Preservation of the superior laryngeal nerve in supraglottic and supracricoid partial laryngectomy

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.

Preservation of Internal Branch of Superior Laryngeal Nerve during Surgery for Hypopharyngeal Cancer

OBJECTIVES

This study was performed to evaluate the significance of intraoperative preservation of the internal branch of the superior laryngeal nerve (ibSLN) during surgery for hypopharyngeal squamous cell carcinoma (HSCC).

METHODS

Twelve patients with HSCC underwent surgery between January 2017 and December 2018. Sensation in the hypopharyngeal mucosa was tested using a flexible laryngeal endoscope on postoperative day 5.

RESULTS

Surgeries were successfully performed in 10 patients with HSCC arising from the internal wall of the pyriform fossa and in 2 patients with HSCC arising from the posterior wall of the hypopharynx. The main trunk of the ibSLN was preserved in all patients. Testing of sensation in the hypopharyngeal mucosa revealed the presence of the cough reflex in all patients. All patients achieved a full normal oral diet at a median of 8.5 days (range, 6-11 days) and removal of the tracheal tube at a median of 10 days (range, 7-12 days).

CONCLUSIONS

Our results showed that preservation of the ibSLN during surgery for HSCC is feasible and important in the recovery of sensation in the hypopharyngeal mucosa.

CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO₂ laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan-Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3-4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO₂ laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Comparison of Functional Outcomes after Endoscopic versus Open-Neck Supraglottic Laryngectomies

Objectives:

Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL.

Methods:

We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson χ2 tests.

Results:

Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the Two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001).

Conclusions:

Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.

Is partial laryngectomy safe forever?

OBJECTIVES

Over past decades, function-preserving surgery has been oncologically effective for specific types of laryngeal cancer. Although safe short-term swallow function has been reported, swallow safety during long-term survival has received less attention. The purpose of this report is to highlight potential consequences of late dysphagia and chronic aspiration after partial laryngectomy.

METHODS

A retrospective case series was performed. The head and neck cancer database from Yale-New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11-15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included.

RESULTS

Primary treatment was open supraglottic laryngectomy with adjuvant radiation therapy (n=2) and vertical hemilaryngectomy (n=1). All patients demonstrated locoregional control and preservation of swallow function for >10 years postoperatively. Due to late dysphagia and chronic aspiration, two patients required completion laryngectomy 11 and 15 years postoperatively and the third patient will require this 14 years postoperatively.

CONCLUSIONS

Successful swallowing after function-preserving laryngeal surgery may not last forever despite adequate control of cancer. Three patients presented with aspiration 11-15 years after partial laryngectomy and required definitive completion laryngectomy. This observation may affect preoperative counseling and consideration for longer post-operative follow-up. The data encourage a larger sample size.

FEESST in the rehabilitation of dysphagia after partial laryngectomy

OBJECTIVES

We describe the role of the laryngeal adductor reflex (LAR) and fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in the rehabilitation of patients with oropharyngeal dysphagia after partial laryngectomy.

METHODS

Ten patients with a mean age of 64 years (range, 45 to 72 years) were included in the study. Seven patients underwent supraglottic laryngectomy, and 3 had supracricoid laryngectomy. Six patients underwent additional radiotherapy (RT), and 8 had functional neck dissection (ND). FEESST was performed on each patient in order to establish a swallowing rehabilitation program.

RESULTS

In 2 patients, not submitted to either ND or RT, the LAR was preserved; in 6 patients, who underwent both procedures, the LAR was delayed or absent. In 2 patients who underwent ND but not RT, the LAR was preserved in 1 case and delayed in the other. The patients with an absent LAR presented severe aspiration, whereas in those with a preserved LAR, no penetration was found. Moderate aspiration was found in the remaining patients. In the patients with a reduced or absent LAR, tactile and chemical sensory stimulation was added to the rehabilitation program.

CONCLUSIONS

FEESST represents a useful tool in everyday clinical practice for the planning of swallowing rehabilitation after partial laryngectomy.

The Supraglottic Nerve Supply: An Anatomic Study With Clinical Implications

OBJECTIVES

To describe the course of the superior laryngeal nerve (SLN) and its branches, in particular, with regard to supraglottic motor and sensory functions.

METHODS

In 30 normal human hemilarynges, the SLN with its internal (intSLN) and external branch (extSLN) were dissected under microsurgical conditions and marked with acrylic dye. All anatomic structures of the larynges (muscles, cartilages, and ligaments) were dissected in detail.

RESULTS

The intSLN subdivides into three branches. The superior branch (I) runs to the lingual (extralaryngeal) part of the epiglottis and sends small fibers through the epiglottic foramina to the laryngeal surface. The middle branch (II) runs through the aryepiglottic fold into the ventricular fold, and the inferior branch (III) to the piriform sinus and to the postcricoid region, forming various anastomoses (e.g., ansa galeni) with the recurrent laryngeal nerve (RLN). The extSLN runs to the cricothyroid muscle (CT) and sends a branch through the CT along the lower rim of the thyroid cartilage into the larynx and up to the ventricular fold. This ventricular branch is a potential candidate for the innervation of the ventricular muscle (VM).

CONCLUSIONS

Our results may contribute to a better understanding of supraglottic actions that provide primary functions of the larynx (such as swallowing, coughing, and breathing). An enhanced knowledge of neurolaryngology also provides a basis for interpreting disorders or paralyzes following surgical treatments (e.g., thyroid surgery, partial laryngectomy) and helps to lower the risks.

The incidence of the foramen thyroideum in Turkish population

This study was undertaken to investigate the incidence and characteristics of the foramen thyroideum (FT) in Turkish population. A total of 50 cadaver specimens were dissected which were a randomly selected sample of population from the criminal laboratory of the Republic of Turkey's Ministry of Justice (Istanbul). Larynges were dissected with a surgical SMZ 10 Nikon stereomicroscope. Six of the 50 specimens dissected had distinctly identifiable foramina with neurovascular component. One specimen had bilateral foramina, five specimens had unilateral foramina, and two had it in the left side, three in the right. One specimen had a double foramen in the left side. All of them were male and contained neurovascular components. Our data showed 12% incidence of FT in Turkish population.

Organ preservation surgery for intermediate size (T2 and T3) laryngeal cancer

This article discusses the surgical options, both open and endoscopic,developed to preserve voice, maintain swallowing, and avoid permanent tracheotomy in patients with intermediate-sized laryngeal lesions.

Aspectos histomorfométricos do nervo laríngeo superior

Introdução: A laringe desempenha funções primordiais para a manutenção da vida do indivíduo. A perfeita integração entre as suas vias aferentes e eferentes, proporcionada pelo nervo laríngeo superior (NLS) e pelo nervo laríngeo recorrente, evita a aspiração de corpos estranhos e através de reflexos desencadeados pela movimentação da onda mucosa mantém o tônus da musculatura intrínseca da laringe. Distúrbios nessas vias neurais podem predispor à aspiração e pneumonias, bem como podem ser responsáveis por alterações na voz do indivíduo; condições estas mais freqüentes no idoso. Objetivo: Avaliar as características histomorfométricas do NLS em indivíduos idosos e comparar os achados com indivíduos adultos. Material e Método: Um fragmento desse nervo dos lados direito e esquerdo foi obtido a partir de cadáveres durante o exame de necropsia. Foram montados dois grupos de diferentes faixas etárias. Um grupo denominado Adulto composto por 5 indivíduos com média etária de 39,6 anos e um grupo Idoso composto por 6 indivíduos com média etária de 71,7 anos. A avaliação do material foi realizada em microscópio de luz com objetiva de 40 X ligado a um sistema analisador de imagens computadorizado e foram obtidos os principais parâmetros relacionados ao nervo: freqüência das fibras mielínicas, densidade de fibras por mm2 e a área intraperineural. Resultados: Foi observada uma redução estatisticamente significante das fibras mielínicas de menor diâmetro (1 e 2 mm) no grupo Idoso. Não houve diferença na freqüência de fibras mielínicas entre os lados direito e esquerdo, em ambos os grupos. Conclusão: Como funcionalmente as fibras mielínicas de menor diâmetro do nervo laríngeo superior são responsáveis pela sensibilidade da supraglote e pelo reflexo de fechamento glótico, a redução das fibras mielínicas no idoso pode estar relacionada, além de outros fatores, a uma maior predisposição à aspiração e às alterações de voz.

Larynx preservation with supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Correlation of videostroboscopic findings and voice parameters

Classically, the formation of a mucosal wave is dependent on the pliable mucosa present in the vocal fold. The supracricoid partial laryngectomy with cricohyoidoepiglottopexy is an organ preservation surgical technique in which both true vocal folds, both false vocal folds, both paraglottic spaces, and the entire thyroid cartilage are resected. The functional goal is speech and swallowing without a permanent tracheostomy. In an effort to further study voice production in these patients, we performed laryngeal stroboscopy in 5 patients. Analysis was performed with a modified Bless grading system. In addition, speech and voice parameters were also measured and correlated with stroboscopic findings. The key finding in this study was the presence of a periodic mucosal wave on the anterior aspect of the arytenoid cartilage, where it abuts the epiglottic cartilage. Patients with lower periodicity and symmetry scores tended to have lower jitter and shimmer percentages.

Laringectomia supracricóide (chep) para câncer glótico

OBJETIVOS: Com a intenção de se avaliar os resultados funcionais e terapêuticos da laringectomia supracricóide com crico-hióide-epiglote-pexia (CHEP) foram estudados 50 casos de pacientes com carcinoma epidermóide da glote classificados como T2/T3 submetidos a esta técnica em nossa instituição. MÉTODOS: Foi realizada uma análise retrospectiva entre 1996 e 1999. Classificamos 18 pacientes como T2N0M0 e 32 pacientes como T3N0M0. Quarenta e um pacientes foram submetidos a esvaziamento cervical seletivo lateral bilateralmente, quatro foram submetidos ao mesmo esvaziamento unilateralmente, e cinco não foram esvaziados. Analisamos as complicações e a sobrevida livre de doença pelo método de Kaplan-Meyer. RESULTADOS: Dez pacientes tiveram complicações pós-operatórias, dois foram tratados com complementação da laringectomia. Os 48 pacientes restantes mantiveram a via aérea normal, deglutição e a voz. Três pacientes no grupo submetido a esvaziamento cervical apresentaram linfonodo metastático. Quatro pacientes tiveram recidiva da doença, três com recidiva local, sendo dois tratados com laringectomia total e estão vivos e sem doença, o outro com doença avançada alcançou o óbito pela doença. O paciente que teve recidiva no pescoço foi tratado com esvaziamento cervical mais radioterapia e morreu com doença. Dois pacientes tiveram um segundo tumor primário em orofaringe, sendo um tratado com radioterapia paliativa e morreu com doença e o outro tratado com cirurgia está vivo e sem doença. A sobrevida livre de doença em três anos foi de 88% para pacientes T2 e 72% para pacientes T3. CONCLUSÕES: Esta técnica é útil no tratamento de casos selecionados de carcinoma epidermóide da glote T2/T3 sempre se considerando a extensão da doença. A incidência de complicações necessitando laringectomia total de resgate não compromete a funcionalidade desta técnica. A sobrevivência é comparável aos pacientes submetidos a laringectomia total e laringectomia "near-total".