Laryngeal reconstruction following vertical partial laryngectomy

Microsurgical laryngotracheal reconstruction

Laryngotracheal reconstruction using free-tissue transfer represents one of the new challenges for the head and neck reconstructive surgeon. This article reviews the anatomy and physiology of the larynx and trachea and discusses the clinical context of laryngotracheal reconstruction, particularly with regard to malignant tumors involving the larynx and cervical trachea. It reviews the free-tissue reconstructive options, including the free forearm flap, the temporoparietal flap, and the two-staged procedure described by Delaere.

Laryngeal reconstruction by platysma myofascial flap after vertical partial laryngectomy

BACKGROUND

Many methods of glottic reconstruction have been described for patients undergoing vertical partial laryngectomy to reestablish the glottic integrity.

METHODS

Fifteen patients with T2 squamous cell carcinoma of the glottis were included in this prospective clinical trial. All patients were treated by vertical partial laryngectomy with laryngeal reconstruction by platysma myofascial flap. The surgical procedure and flap design were described. Vocal function was assessed by videolaryngostroboscopy and subjective and objective voice analysis before and after surgery.

RESULTS

Complete neoglottic closure and acceptable voice quality were obtained by platysma myofascial flap in all cases. No statistically significant difference was found between the preoperative and postoperative acoustic parameters.

CONCLUSIONS

Platysma myofascial flap provides the basic requirements for laryngeal reconstruction with its own favorable characteristics and also allows complete glottic closure without interfering with respiration and deglutition. This technique may be an effective alternative achieving an acceptable quality of voice.

Anatomical study of meandering and functions of human intralaryngeal artery

In recent years, partial laryngectomy and partial reconstruction are increasingly intended for conservation of functions of phonation and swallowing. In partial reconstruction, it is important to comprehend morphological characteristics of the blood vessels distributed in the larynx, but there have been only few reports discussing detailed information about them. Previous reports on laryngeal blood vessels have shown that branches of some arteries show remarkable "meandering". In the present study, we devised a method for objectively determining the morphological nature, "meandering" and assessed functions of the arteries. Intralaryngeal arteries were excised from the larynx of cadavers prepared for practice in anatomy, and images of the "meandering" artery were analyzed with NIH Image. The extent of "meandering" was expressed mainly as the ratio of the total length of the blood vessel to the distance between the starting point and the end point of meandering. The results showed that there was a significant difference in the extent of meandering between superior posterior and medial posterior branches of superior laryngeal artery. These arteries, which were distributed in the arytenoid region, were found to be of primary importance in partial laryngectomy and partial reconstruction of the larynx.

Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas

A cohort of 101 patients with previously untreated glottic cancer (15 Tis, 66 T1a, and 20 T1b) who underwent endoscopic CO2 laser excision between January 1995 and December 1997 was prospectively analyzed. The depth and extension of the excision were graded according to the European Laryngological Society Classification including 5 types of cordectomy. All patients were subsequently examined every 2 months for a period ranging from 30 to 66 months (mean, 48 months). The rates of 5-year overall survival, disease-free survival, ultimate local control with laser alone, and laryngeal preservation were 85%, 87%, 93%, and 95%, respectively. Sixty-nine patients underwent, at least 1 year after surgery, videolaryngostroboscopy combined with perceptual and objective evaluation of the voice, and spirometry. Acoustic parameters were compared with those obtained in a matched control group by Kruskal-Wallis test. No statistically significant difference was found (p > .05) between patients submitted to subepithelial (type I) and subligamental (type II) cordectomies and controls.

Combined buccal mucosa island and sternohyoid flaps: a new technique of hemilaryngeal reconstruction studied in a canine model

No single method of reconstruction has proven ideal for all patients with defects following vertical hemilaryngectomy. In this report, we detail a new technique for hemilaryngeal reconstruction involving the use of a pedicled buccal mucosa island flap supplied by the facial artery and vein. The buccal flap was used to resurface a transversely oriented sternohyoid myofascial flap. The reconstructive outcome was analyzed in 4 animals, 3 of which survived the early postoperative period. Videoendoscopy and stroboscopy were performed to analyze the laryngeal configuration and vibration. Each subject was decannulated and had a competent airway free of aspiration. After sacrifice of the animals, whole organ axial sections were made at multiple levels. Endoscopic and histologic findings documented that this technique produced an appropriate neocord position. Laryngeal stroboscopy in each animal showed bilateral mucosal traveling waves, with entrainment of the reconstructed neocord mucosa and native vocal cord mucosa. We conclude that the layered reconstructive technique described, compared to traditional methods of reconstruction, more closely replicates the structure of the excised tissue in hemilaryngeal reconstruction, potentially resulting in an improved voice outcome.

Biological repair of thyroid cartilage defects by osteogenic protein-1 (bone morphogenetic protein-7) in dog

The efficacy of human recombinant osteogenic protein-1 (OP-1; bone morphogenetic protein-7) in regeneration of dog larynx was examined by treating thyroid cartilage defects (1.5 cm2) in dogs with thyroid allografts covered with host perichondrium or fascia. Prior to implantation allografts were frozen, thawed and demineralized. The treatment groups were as follows: I--Allograft control implant (n = 3); II--Implants coated with 500 micrograms OP-1 (n = 4); III--Implants coated with 100 micrograms OP-1 (n = 3); IV--Implants coated with 500 micrograms OP-1 and covered with neck fascia (n = 3); and V--Implants extracted with 1 M NaCl and guanidine hydrochloride, and coated with 500 micrograms OP-1 (n = 4). Dogs were sacrificed four months following surgery. Each larynx was removed, carefully dissected and a three-dimensional reconstruction of the defect area was performed on serial sections. The results revealed that the implants of control dogs remained intact with no apparent reduction in size and new tissue formation. OP-1 enriched thyroid allografts, dose dependently induced bone, cartilage and ligament-like structures comprising up to 80% of the total regenerated defect area. Boundaries of the defects healed by formation of new bone when bone resided within the old thyroid cartilage layers. Old cartilage not containing bone within its layers healed by complete integration with newly formed cartilage. Both new bone and cartilage were embedded into layers of new ligament-like tissue which expressed specific morphologic and molecular markers. The three newly formed tissues were tightly connected into a "bone-cartilage-ligament continuum" of tissues, suggesting that OP-1 served as a multiple tissue morphogen in this specific microenvironment.

Vocal function after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap: durational and frequency measures

OBJECTIVE

Compare vocal function following vertical partial laryngectomy (VPL) with or without glottic reconstruction by false vocal fold (FVF) mucosal flap.

STUDY DESIGN

Twenty-seven patients with Tla squamous cell carcinoma (SCC) of the glottis were included in a prospective randomized clinical study. All patients were treated by frontolateral partial laryngectomy (FLPL). Glottic reconstruction with FVF mucosal flap was performed in 14 patients at the time of the FLPL, whereas 13 patients had standard FLPL.

METHODS

Objective voice assessment was based on computerized acoustic recordings performed before and 1 year after surgery. When possible, additional recordings were performed at 3 months, 6 months, and 2 years postoperatively. Incidence of postoperative granuloma and anterior neoglottic web were noted. Repeated analysis of variance (ANOVA) was used to compare the durational (maximum phonation time, speech rate) and frequency measurements (average fundamental frequency [Fo], standard deviation of Fo, jitter, shimmer, noise-to-harmonics ratio, degree of voice breaks) between patients with or without glottic reconstruction, postoperative granuloma, and anterior neoglottic web. Linear regression was used to study the evolution over time of the durational and frequency measurements.

RESULTS

Frequency measurements improved with time and were significantly better in patients treated with glottic reconstruction. In addition, glottic reconstruction decreased incidence of postoperative granuloma and anterior neoglottic web.

CONCLUSIONS

The FVF mucosal flap technique can improve vocal results in selected cases of Tla SCC of the glottis when FLPL is the adequate surgical treatment. false vocal folds; glottic reconstruction; vertical partial laryngectomy; vocal function.

Acoustic assessment of voice signal deformation after partial surgery of the larynx

OBJECTIVE

The main objective of the present study was to assess the degree of voice signal impairment among patients who had undergone partial surgery of the larynx due to cancer of this organ. Such on evaluation may be helpful in the selection of the optimal surgical technique for the treatment of tumors displaying a varying degree of local advancement.

METHODS

A prospective examination was carried out among 128 patients. Additionally a comparative study of the control group consisting of 36 healthy males was carried out. Acoustic tests were carried out in an echo-free chamber. The temporal changes in the value of acoustic pressure of the uttered text were registered. The 'distance' between the normal speech signal and the pathological voice has been established.

RESULTS

The values of the fundamental frequency increase together with an increase of the range of resection of anatomical structures. The biggest differences in the value of results describing the distance from the standard were observed after hemilaryngectomy. The shortest distance from the acoustic standard was observed after chordectomy. No significant differences in the degree of voice signal impairment among patients who had undergone extended chordectomy and hemilaryngectomy were observed.

CONCLUSION

The above findings can be of help in arriving at an optimum solution in cases of partial surgery of the larynx. The problem is particularly important in situations where there is the choice between different types of surgery.

Tracheal autotransplantation: a reliable reconstructive technique for extended hemilaryngectomy defects

OBJECTIVES

Current surgical treatment for a glottic cancer with significant subglottic extension is a total laryngectomy. The objective of this study was to expand laryngeal conservation procedures by using a reconstructive technique that allows for the repair of hemicricolaryngectomy defects.

STUDY DESIGN

After resection of the ipsilateral thyroid, cricoid, and arytenoid for advanced T3 glottic cancer, the laryngeal defect was reconstructed by means of an autotransplanted segment of trachea in four patients. The reconstruction consisted of a transferable patch that was constructed from a segment of revascularized cervical trachea.

METHODS

During a 14-day period, a 4-cm segment of cervical trachea was wrapped by a free radial forearm fascial flap. In the second stage, the glottic cancer was removed and the cervical trachea was isolated on its fascial blood supply and transformed into a patch that was used to repair the extended hemilaryngectomy defect. Two different patch designs were used. Two patients underwent reconstruction with a patch augmented at the glottic level (group A); two patients underwent reconstruction without glottic augmentation on the patch (group B). Tracheal continuity was restored by an end-to-end reanastomosis. The postreconstruction morphology of the two patch designs was compared with the preoperative laryngeal morphology.

RESULTS

The autotransplantation technique led to complete restoration of the subglottic airway lumen in all four patients. Although the anterior-posterior glottic diameter was reduced by 36% in group A patients and by 43.5% in group B patients, a sufficient glottic airway lumen was obtained. The glottic sphincteric function was restored in both groups.

CONCLUSIONS

Tracheal autotransplantation may be used reliably to repair hemicricolaryngectomy defects. Augmentation of the patch at the level of the glottis is not essential for successful rehabilitation.

Vocal function following vertical hemilaryngectomy: comparison of four reconstruction techniques in the canine

The goals of laryngeal reconstruction have been prevention of aspiration, production of a functional voice, and maintenance of an adequate airway for decannulation. A number of procedures for partial laryngeal reconstruction have accomplished these objectives. However, few studies have attempted to compare patients' vocal characteristics following different reconstruction procedures. In this study, an in vivo canine model was used to compare acoustic and aerodynamic measures of vocal function for the following vertical hemilaryngectomy reconstruction techniques: 1) a superiorly based sternohyoid muscle flap, 2) a modified epiglottic laryngoplasty, 3) a new procedure using a layered vascularized buccal mucosal flap and a transversely oriented sternohyoid muscle flap, and 4) hemilaryngeal transplantation combined with arytenoid adduction. Hemitransplantation provided the most efficient phonation of the four techniques. The vascularized buccal mucosa flap produced the best phonation of the autologous tissue techniques examined. Both vascularized buccal mucosa flap and hemilaryngeal transplantation subjects demonstrated a mucosal wave on stroboscopy. The results indicate that vocal function will improve as the layered structure of the vocal fold is more accurately replicated in a reconstructed hemilarynx. Endoscopic findings and whole organ sections are presented.

Reconstruction with composite nasal septal cartilage and auricular cartilage in extended partial laryngectomy

Several reconstruction techniques have been employed following partial laryngectomy in order to improve laryngeal function. We report 12 cases in which composite nasal septal cartilage and auricular cartilage were used. We decannulated the patients in an average of 19 days. Following the reconstruction we obtained a satisfactory phonatory function and swallowing. Six patients completed a follow-up period of three years without presenting any recurrences or mortality. Our experience with reconstruction using composite nasal septal and auricular cartilage following partial laryngectomy proved effective.

A combined endoscopic Co2 laser and external approach for treatment of glottic cancer involving the anterior commissure: an animal study

Endoscopic laser resection usually has been discouraged for anterior commissure (AC) carcinoma because of inadequate exposure and close proximity to underlying cartilage. A new technique combining endoscopic CO2 laser incision and an external approach, creating a window in the thyroid cartilage, was tested in this in vivo study of six dogs. An en bloc specimen including adjacent cartilage was excised while preserving the thyroid framework. The glottic reconstruction was accomplished with external placement of a sternohyoid muscle flap, by either using a bipedicled muscle flap with overlying skin or a unipedicled muscle flap with a graft of free mucosa. The results showed a satisfactory anatomic reconstruction and acceptable functions. The bipedicled muscle flap was superior to the unipedicled muscle flap due to a better AC reconstruction. It is believed that this new combined technique may overcome limited access with endoscopic technique and excessive cartilage resection with the external partial laryngectomy.

"Window" laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery

Endoscopic laser resection of early laryngeal carcinoma is an increasingly used treatment modality; however, the limited exposure achieved and the alteration of vocal function are still major problems. A new surgical procedure, "window" laryngoplasty, has been devised and tested in an in vivo study in 6 canines with 50 days' survival. The right vocal cord was incised endoscopically with the carbon dioxide laser, and the en bloc specimen with adjacent thyroid cartilage was removed through a window approach made in the thyroid cartilage. A sternohyoid muscle flap based superiorly was inserted into the cartilaginous window to reconstruct a pseudocord with coverage of either mucosa or fascia. A diode laser soldering technique was used to secure the mucosal graft in place. Epithelial transplantation can be accomplished externally with precise endoscopic guidance for reliable placement of the pseudocord. The results show that the new technique, a combination of endoscopic and open approaches, may be a better treatment choice than standard vertical partial laryngectomy in selected patients. Advantages of this technique include adequate en bloc resection, including adjacent cartilage for pathologic evaluation, preservation of the integrity of most of the laryngeal framework, avoidance of tracheotomy, and better functional results.