Partial laryngectomy: analysis of associated swallowing disorders

Topographic anatomy of the ınternal branch of the superior laryngeal nerve

PURPOSE

The aim of this study was to investigate the surgical and topographical anatomy of the internal branch of the superior laryngeal nerve (ibSLN) in laryngectomy patients.

METHODS

Patients aged 36-90 years old who underwent a total laryngectomy operation with a diagnosis of laryngeal carcinoma participated in the study. Fifteen patients who underwent a total laryngectomy operation between June 2015 and November 2016 were included in the study. A total of 29 superior laryngeal nerves (SLN) of 15 patients were studied. The position of the nerve was photographed before the thyrohyoid membrane (THM) was passed during dissection. The relationship and course of the ibSLN with respect to the superior laryngeal artery (SLA) were observed. The distance to adjacent formations and branching variants were examined along the course of the nerve.

RESULTS

Of the total 29 ibSLN, 17 were divided into three branches and 12 into two branches. In all cases except for one, the ibSLN course after piercing the THM was determined. The ibSLN penetrated the THM at a mean of 12.0 ± 2.61 mm (6-16 mm) from the superior border of the thyroid cartilage. The ibSLN penetrated the THM with a mean distance of 9.34 ± 1.65 (6-12) mm from the inferior border of the hyoid bone.

CONCLUSION

Our study demonstrated the surgical and topographical features of the ibSLN with respect to the THM, and provided a more precise knowledge of its anatomy in laryngectomy patients. It thus may help head and neck surgeons identify this nerve.

Partial laryngectomy after irradiation failure

INTRODUCTION

Radiation therapy is often the first method of treating patients with early cancer of the glottis. There is a substantial failure rate among these patients. Total laryngectomy has usually been the means of treating patients with failure after radiation. In recent decades, partial laryngectomy has been used for salvage in such patients. This article will discuss the use of partial laryngectomy for radiation failure both from the oncologic result as well as the morbidity.

PATIENTS AND METHODS

Between 1984 and 1995, 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with T2 N0) and horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2 N0, and 5 with T2 N1). The mean follow-up was 4.1 years.

RESULTS

Local control was obtained in 77.7% of patients with glottic lesions (T1: 84.6%; T2: 60%, P = NS) and in 55.5% of patients with supraglottic lesions (T1: 66.6%; T2: 50%; P = NS). There was no regional recurrence in the vertical laryngectomy group, whereas the regional control rate in the horizontal-supraglottic laryngectomy group was 77.7%. Distant control was achieved in 94.4% of patients with glottic disease and in 77.7% of patients with supraglottic disease. The overall survival rate for glottic lesions was 88.8% (T1: 92.3%; T2: 80%; P = NS) versus 66.6% for supraglottic lesions (T1: 100%; T2: 50%; P = NS).

CONCLUSION AND SIGNIFICANCE

Vertical laryngectomy was not associated with an increased complication rate. Morbidity in the horizontal-supraglottic laryngectomy group was higher, but a satisfactory functional outcome was obtained in all cases. Therefore, in early laryngeal cancer (glottic T1-T2, supraglottic T1) partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactory; further research is required for developing more efficient complimentary or alternative treatments modalities.

Management of swallowing in supraglottic and extended supraglottic laryngectomy patients

BACKGROUND

Aspiration of food and liquid following supraglottic and supracricoid laryngectomy has been documented and found to be the most frequent major postoperative complication that extends hospitalization. The advantages as well as disadvantages of discharging a patient with percutaneous endoscopic gastrostomy (PEG) placement and home therapy versus an aggressive in-hospital dysphagia management program remain controversial. The present investigation examines an aggressive in-patient postoperative dysphagia management program following decannulation.

METHODS

Twenty-one patients participated in a four-part dysphagia management program following decannulation: patient education, indirect therapy, swallowing evaluation, and nutrition education.

RESULTS

Eleven patients achieved functional swallowing goals prior to discharge with no reports of pneumonia or rehospitalization over a 3-month follow-up period. Six patients were discharged with a tracheostomy and duo tube; five of these patients were started on an oral diet the same day of decannulation. Four patients decannulated prior to discharge did not achieve functional swallowing.

CONCLUSION

Certain patients can achieve functional swallowing goals prior to discharge and avoid the cost and surgical placement of a PEG. This group required an additional 2 to 3 days of hospitalization; however, the usual and customary charges for aggressive dysphagia management in this group were exceeded by charges for PEG placement and in-home therapy according to pricing guidelines for the hospital where these patients were treated. Specific patient profiles of those who were unsuccessful relate to extent of surgery, ie, supraglottic + base of tongue (SUPRA + BOT) and supraglottic + vocal fold (SUPRA + VF) resection, and non-compliance. Complicated patients often require longer rehabilitation and may benefit from a PEG at the time of surgery.

Anatomy of the human internal superior laryngeal nerve

The mucosa of the larynx contains one of the most dense concentrations of sensory receptors in the human body. This sensitivity is used for reflexes that protect the lungs, and even momentary loss of this function is followed rapidly by life-threatening pneumonia. The internal superior laryngeal nerve (ISLN) supplies the innervation to this area, and, to date, the distribution and branching pattern of this nerve is unknown. Five adult human larynges were processed by using Sihler's stain, a technique that clears soft tissue while counterstaining nerves. The whole-mount specimens were then dissected to demonstrate the branching of the ISLN from its main trunk down to the level of terminal axons. The human ISLN is divided into three divisions: The superior division supplies mainly the mucosa of the laryngeal surface of the epiglottis; the middle division supplies the mucosa of the true and false vocal folds and the aryepiglottic fold; and the inferior division supplies the mucosa of the arytenoid region, subglottis, anterior wall of the hypopharynx, and upper esophageal sphincter. Several dense sensory plexi that cross the midline were seen on the laryngeal surface of the epiglottis and arytenoid region. The human ISLN also appears to supply motor innervation to the interarytenoid (IA) muscle. A detailed map is presented of the distribution of the ISLN within the human larynx. The areas seen to receive the greatest innervation are the same areas that have been shown by physiological experiments to be the most sensate: the laryngeal surface of the epiglottis, the false and true vocal folds, and the arytenoid region. The observation that the human ISLN appears to supply motor innervation to the IA muscle is contrary to current concepts of the ISLN as a purely sensory nerve. These findings are relevant to understanding how the laryngeal protective reflexes work during activities like swallowing. The nerve maps can be used to guide surgical attempts to reinnervate the laryngeal mucosa when sensation is lost due to neurological disease.

Functional outcome and prognosis factors after supracricoid partial laryngectomy with cricohyoidopexy

A retrospective analysis of the medical records and operative files of 124 patients who consecutively underwent supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP) was undertaken. The objective of this study was to analyze the postoperative course and functional results of SCPL-CHP. The mean duration of follow-up was 7 years (range 1 to 20 years). The postoperative mortality was 1.6%. The average times until tracheostomy and nasogastric feeding tube removal were 8 and 22 days, respectively. All patients but 1 were decannulated. The rate of pneumonia from aspiration was 11.5%. Completion total laryngectomy and permanent gastrostomy were required in 2.5% and 2.5% of patients, respectively. Overall normal swallowing without permanent gastrostomy and respiration without tracheostomy were achieved by the first postoperative year in 91% and 99.1% of patients, respectively. Univariate analysis of the potential correlation between various variables and the duration of the tracheostomy and nasogastric feeding tube, the incidence and causes of mortality, the incidence and type of the various complications, the recovery of swallowing, and the length of hospitalization is presented. The report also discusses the management and follow-up care.

Dysphagia following head and neck cancer surgery

Surgical resection of head and neck cancer results in predictable patterns of dysphagia and aspiration due to disruption of the anatomic structures of swallowing. Common procedures undertaken in the treatment of head and neck cancer include tracheostomy, glossectomy, mandibulectomy, surgery on the palate, total and partial laryngectomy, reconstruction of the pharynx and cervical esophagus, and surgery of the skull base. An overview is presented of normal swallowing physiology, as well as swallowing perturbations that are frequently encountered in postoperative head and neck cancer patients.

Normal laryngeal valving patterns during three breath-hold maneuvers: a pilot investigation

Synchronized videonasendoscopy and respiratory recordings were conducted in six healthy male subjects to evaluate activity of the arytenoid cartilages, true vocal folds, false vocal folds, and epiglottis during repeated trials of three breath-hold maneuvers: EASY hold, INHALE HARD hold, and INHALE/EXHALE HARD hold. Five of the six subjects demonstrated maximal laryngeal valving on the HARD breath-hold conditions. One subject showed maximal laryngeal valving on the EASY hold condition, and rarely demonstrated any medial displacement or contact of the laryngeal valves on either effortful breath-hold maneuver. Arytenoid approximation and true vocal fold closure were produced consistently by the majority of subjects on all breath-hold maneuvers, but false vocal fold approximation and anterior arytenoid tilting were accomplished by the majority of subjects only during the effortful breath-hold conditions. Intratrial and intersubject variation indicated that presence or degree of laryngeal valving cannot be assumed during a breath-hold maneuver. We conclude that videonasendoscopy has merit in assessing a patient's laryngeal valving ability and progress in effectively using a breath-hold maneuver for safe swallowing function.

Modification of compensatory swallowing in a supraglottic laryngectomy patient

Results are presented for repeated videofluoroscopic and scintigraphic examinations of a supraglottic laryngectomy patient, illustrating the successful use and later changes in a compensatory swallow. Issues in patient management are outlined, stressing the importance of interaction between radiologists and dysphagia therapists in the rehabilitation of such patients.

The incidence of communication disorders in dysphagic patients

A retrospective study investigated the incidence and types of communication problems in 115 patients referred for swallowing difficulties. Each patient had a bedside swallowing evaluation completed as well as a screening of communication abilities. A formal speech-language evaluation was done when warranted and possible. Of the 115 patients, 93 had suspected swallowing problems based on the bedside evaluation done by the speech-language pathologist. Videofluoroscopy was performed on 85 of these patients. A significant positive correlation was found between communication impairments and both suspected and videofluoroscopically confirmed dysphagia. Cognitive problems were the most frequent communication impairment with dysarthria being second. Neurological diseases were the most common medical diagnoses in patients with swallowing difficulties. The case is presented for the speech-language pathologist to be the primary diagnostician and manager of both communication and oral-pharyngeal swallowing disorders whether they co-occur or not.

Radiographic evaluation of the free jejunal graft

Jejunal autotransplantation is an increasingly popular method of reconstructive surgery for the upper aerodigestive tract following laryngopharyngectomy. From 1977 to 1985, 55 free jejunal grafts were performed on 49 patients. Thirty patients (61%) experienced reconstructive complications including graft failure in 6, fistula in 18, and strictures in 10. Postoperative dysphagia occurred in 26 patients (53%). The cause of the dysphagia is often complex and related to a number of factors that are discussed. While jejunal autotransplantation is successful in selected patients, complications are not infrequent. The radiologist plays an important role in the evaluation and follow-up of these patients.

Swallowing problems in patients with head and neck cancer:

The restoration of swallowing skills in head and neck cancer surgery patients demands a two-pronged approach: thorough and systematic evaluation and simple, fundamental treatments. Therapists should begin with an assessment of their own biases and their knowledge of head and neck cancer and its surgeries. The patients themselves should be evaluated presurgically-to determine food preferences, other medical conditions, nutritional status, and current swallowing abilities, and postsurgically-to assess facial symmetry, oral mobility and strength, saliva management, aspiration risk, and altered swallowing skills. Treatment approaches should generally be basic, stressing oral exercises, positioning techniques, the use of feeding aids, and teaching the supraglottic swallow. Attention to special considerations, like problems with cuffed tracheostomies and the controversies over using variable food consistencies, will refine the treatment.