Phonatory mechanisms after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap

[Laryngeal-preservation surgery in laryngeal cancer]

After oral cavity and pharyngeal cancer, laryngeal cancer is the third most common malignant tumor in the head and neck region. According to the current German S3 guideline on the diagnosis, treatment, and follow-up of laryngeal cancer, larynx-preserving surgical interventions are part of the standard treatment of this disease, even in advanced tumor stages. However, in order to achieve the desired function-preserving effect, an exact indication is of crucial importance. In this article, the most important larynx-preserving interventions and their indications but also the respective contraindications are presented, with the aim of illuminating the surgical treatment options up to just before total laryngectomy.

Open Partial Laryngectomies: History of Laryngeal Cancer Surgery

Historically, surgery was the first-choice therapy for early, intermediate and advanced laryngeal squamous cell carcinoma (LSCC). Partial laryngeal surgery has evolved in recent decades and was influenced by many historic events and the development of new technologies. Partial laryngectomies may be performed by open, endoscopic or transoral robotic approaches. In this historic paper, we describe the evolution of open partial laryngectomy techniques, indications and surgical outcomes. Since the first partial laryngectomy in 1788, many U.S., U.K. and European surgeons, including Henry Sands, Jacob da Silva Solis-Cohen and Theodor Billroth, performed this surgical procedure under local anesthesia for tuberculosis, cancer or syphilis. Partial laryngectomy gained reputation in the medical community in 1888 due to the laryngeal cancer and death of the prince of Prussia, Frederick III. Frederick III's death represented the turning point in the history of partial laryngectomies, calling attention to the importance of semiotics, biopsy and early diagnosis in laryngeal cancers. Hemi-laryngectomy was indicated/proposed for lateral laryngeal tumors, while thyrotomy was indicated for cancers of the middle part of the vocal fold. The second landmark in the history of partial laryngectomies was the discovery of cocaine, novocaine and adrenaline and the related development of local anesthetic techniques, which, together with the epidemiological and hygienic advances of the 19th century, allowed for better perioperative outcomes. General anesthesia was introduced in the second part of the 20th century and further improved the surgical outcomes. The diagnosis of laryngeal cancer was improved with the development of X-rays and direct laryngoscopies. The 20th century was characterized by the development and improvement of vertical partial laryngectomy procedures and the development of horizontal partial laryngectomies for both supraglottic and glottic regions. The history and the evolution of these techniques are discussed in the present historical paper.

Viscoelastic properties of human aryepiglottic fold and ventricular fold tissues at phonatory frequencies

OBJECTIVE

The purpose of this study was to quantify the viscoelastic shear properties of the human ventricular fold (or false vocal fold) mucosa and aryepiglottic fold mucosa at frequencies of phonation.

METHODS

Linear viscoelastic shear properties of the mucosa of false vocal fold and aryepiglottic fold specimens from seven cadaveric subjects were determined as functions of frequency (5-250 Hz) and compared to those of the true vocal fold cover. Measurements of elastic shear modulus (G') and dynamic viscosity (η') were made with a controlled-strain simple-shear rheometer. Linear least-squares regression was conducted to curve-fit log G' and log η' versus log frequency, and statistical analysis was performed with one-way analysis of variance.

RESULTS

All specimens showed similar frequency dependence of the viscoelastic functions G' and η', with G' gradually increasing with frequency and η' monotonically decreasing with frequency. The magnitudes of G' and η' of the false fold mucosa were generally higher than those of the aryepiglottic fold mucosa and true vocal fold cover, but there were no significant differences in G' and η' among the false fold, aryepiglottic fold, and true vocal fold.

CONCLUSION

The false vocal fold and aryepiglottic fold mucosa showed similar frequency dependence and a similar range of tissue viscoelastic behavior as the true vocal fold. These preliminary findings suggested that such tissues could become candidates for the replacement of the true vocal fold lamina propria in patients with significant tissue loss and deficiencies, for those requiring laryngeal reconstruction following partial laryngectomy or airway reconstruction.

LEVEL OF EVIDENCE

NA. Laryngoscope, E296-E301, 2018.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Voice Outcome of Modified Frontolateral Partial Laryngectomy in Excised Canine Larynges and Finite Element Model

OBJECTIVE

To evaluate vocal parameters after modified frontolateral partial laryngectomy (MFLPL) and frontolateral partial laryngectomy (FLPL) in both excised canine and finite element models.

STUDY DESIGN

FLPL and MFLPL were compared, using a prospective paired case control laboratory study with excised canine larynx and computational modeling.

SETTING

Basic science study conducted in university laboratory.

METHODS

FLPL and MFLPL were performed serially on 9 excised canine larynges. The excised larynx bench apparatus was used to collect phonation threshold pressure (PTP) and high-speed video data. A finite element model was built to compare a normal vocal fold with applied tension, a cut fold with no applied tension (simulating FLPL), and a cut fold with applied tension (simulating MFLPL). Stress values and distributions across the 3 conditions were computed.

RESULTS

The mean PTP increase after MFLPL (15.45-17.46 cmH2O) was not statistically significant. In the excised canine model, fundamental frequency (F0) showed a significant increase for the MFLPL (P = .039). Differences in vibration amplitudes were not statistically significant. Von Mises stress distribution was most similar between the MFLPL model and the normal fold. Maximum von Mises stresses at the midline were 17.56, 21.63, and 5.10 kPa for the normal, MFLPL, and FLPL, respectively, and 47.57, 63.98, and 101.97 kPa at the peripheries.

CONCLUSIONS

From these results, we conclude that MFLPL has the potential to give a better voice outcome while avoiding tracheotomy in partial laryngectomy patients. In vivo study in canines to examine the healing process would lend further evidence-based support for this surgical method.

A modified false vocal fold flap for functional reconstruction after frontolateral partial laryngectomy: a comparison with conventional open resection and laser cordectomy

OBJECTIVE

To describe a modified flap technique (MFT) involving the use of a false vocal fold flap for glottic reconstruction and the removal of arytenoid cartilage and to compare it with conventional frontolateral partial laryngectomy (FLPL) and laser cordectomy (LC).

METHODS

Twenty-eight MFT, 13 FLPL and 12 LC patients completed a standardised questionnaire for assessing aspiration, respiration, quality of life, and subjective voice quality. We analysed vocal function in terms of roughness, breathiness and hoarseness, measured voice range profiles, and performed videoendoscopy.

RESULTS

No patient reported respiratory problems. Aspiration occurred in 33.3% (MFT), 41.6% (FLPL) and 16.6% (LC). Voice quality was rated as good/satisfactory by 17 MFT patients (62%), satisfactory/sufficient by 69% of FLKT patients, and sufficient/poor by 75% of LC patients.

CONCLUSIONS

The modified false vocal fold flap effectively covers defects and creates a neocord that ensures good phonatory rehabilitation and has positive effects on postoperative quality of life.

Traditional transcutaneous approaches in head and neck surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Vertical partial hemilaryngectomy with reconstruction by false cord imbrication

BACKGROUND

To evaluate global survival, disease-free period, complications, evolution and function in vertical partial hemilaryngectomy (VPHL) plus reconstruction with false cord.

METHODS

Descriptive and retrospective study. In aertiary care medical center in Mexico City. Eight patients with early diagnosis of early glottic cancer (T1 and T2), treated with VPHL plus reconstruction with false cord imbrication.

RESULTS

Fifty percent of the patients were clinical stage I, 37.5% stage II and 12.5% stage III. Nasogastric tube was not placed and oral feeding was reinitiated within 3 days on average. Tracheostomy was removed after an average of 2.1 days. Average hospital stay was 3.3 days. Average of the PSS-HNC (Performance Status for Head and Neck Cancer) and Karnofsky Performance Status evaluation was 91 to 97 and 100 at 1 year of evaluation. Voice evaluation demonstrated normal voice in 87.5% of patients. Intensity was below normal with improvement on annual evaluation. Global survival was 100% and disease-free period was 71% at 3 years.

CONCLUSIONS

VPHL with reconstruction by false cord imbrication is an excellent therapeutic option for early glottic cancers. Multiple functional advantages are demonstrated without sacrificing oncological control as well as providing an audible and intelligible voice. In cases of recurrence, various management options are available.

Glottal reconstruction with a tissue engineering technique using polypropylene mesh: a canine experiment

OBJECTIVES

The larynx must be resected in some cases of cancer or stenosis, and various techniques are generally employed to fill the resulting defect. No ideal way, however, has been established to restore vocal function after this form of insult. The aim of this preliminary feasibility study in a canine model was to investigate the effectiveness of a polypropylene-based tissue engineering approach to repair a partial glottal defect.

METHODS

Eight dogs were used in this study. A laryngeal defect involving resection of the left vocal fold was created through a thyroid cartilage window. A scaffold made of polypropylene and collagen was preclotted and wrapped with autologous fascia lata, inserted through the window, and sutured to the laryngeal defect in 5 dogs. The defect was reconstructed with an adjacent sternohyoid muscle flap in 3 control dogs. The surgical site was evaluated 3 months after operation by fiberscopic examination, computed tomographic imaging, histologic evaluation, and study of excised larynges.

RESULTS

On fiberscopic examination, the experimental group implants were completely covered with regenerated mucosa in all cases, and a favorable vocal fold contour was found in 4 of the 5 cases. One case was characterized by a concave vocal fold shape and red granulation. In the control group, the muscle flap was replaced by scarred mucosa with a concave vocal fold contour in 2 cases, and there was soft white granulation at the anterior resected edge in the third case. The histologic data revealed the regeneration of lined epithelium, subepithelial tissue, and muscle structure in both groups. The excised larynx phonatory data revealed reduced vibratory amplitude in the experimental group compared with the control group; however, excised phonation was not achieved in 2 of the 3 cases in the control group.

CONCLUSIONS

This polypropylene-based tissue engineering technique appears to be a viable tool for glottal reconstruction; however, additional refinement is required to maximize long-term phonatory function.

Modified fronto-lateral laryngectomy in treatment of glottic T1(a-b) cancer with anterior commissure involvement

OBJECTIVE

Evaluation of clinical and oncological safety of the modified fronto-lateral laryngectomy in the treatment of T1a-b glottic cancer.

METHODS

Retrospective review of charts of patients managed with classical fronto-lateral laryngectomy or with our modified technique using a cervical fascia flap and a false cord flap to reconstruct the defect.

RESULTS

No recurrence of cancer was observed in the present series and slight dysphonia was present in all cases. The patients managed with classical technique required a revision surgery for granulations or anterior synechia in 4 cases; those managed with modified technique did not need a second intervention.

CONCLUSION

The fronto-lateral laryngectomy should be present in the head-neck surgeon armamentarium. In T1a-b glottic cancer this technique gives a good oncological resection, but the postoperative period requires an intensive rehabilitation process. The modification of the classical technique reduces the incidence of a second intervention.

Modified frontolateral partial laryngectomy without tracheotomy

Objective: To investigate the feasibility of modified frontolateral partial laryngectomy without tracheotomy for patients with early-stage laryngeal cancer or dysplasia of the true vocal cord.

Study Design: After frontolateral partial laryngectomy, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen to suture it to the incisal margin of the uninjured side and to the false vocal cord on the side of the lesion to ensure the safety without tracheotomy. A reverted sternohyoid fascial flap was used to cover the anterior area to form a new laryngeal lumen in the shape of a ladder.

Subjects and Methods: A total of 65 patients with early glottic carcinomas or severe dysplasia of the true vocal cord were treated with modified frontolateral partial laryngectomy without tracheotomy. Ipsilateral false vocal cord flaps and cervical skin flaps were used in 63 patients and two patients respectively to reconstruct the defect.

Results: Deglutition and phonation were fully recovered after 7 to 10 days postsurgery. The only postoperative complication was subcutaneous emphysema noted in nine patients. The 1-, 3-, and 5-year survival rates were all 100 percent.

Conclusion: Modified frontolateral partial laryngectomy without tracheostomy is an effective surgical method for early glottic carcinomas and severe dysplasia of the true vocal cord.

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.

Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience

On the basis of an inception cohort of 270 patients with a previously untreated invasive squamous cell carcinoma of the true vocal cord (232 T N0M0, 35 T2N0M0, and 3 T3N0M0) and a minimum of 3 years of follow-up, the authors analyze the oncological and functional outcomes following frontolateral vertical partial laryngectomy without tracheotomy. The 5-year Kaplan-Meier actuarial survival estimate ranged from 83.1% for T1 tumors to 67.2% for T2 tumors (p = .005). On univariate analysis, a significant statistical relationship was noted between reduced survival and the following variables: increased age, increased Charlson comorbidity index score over grade 0, increased tobacco intake, increased alcohol intake, increased T stage, local failure, nodal failure, and development of a metachronous second primary cancer. The hospital mortality rate was 0.4%. A significant postoperative surgical complication was noted in 49 patients (18.1%). The predominant significant surgical complication was wound infection (19 patients; 7%), followed by seroma and major subcutaneous emphysema. No significant statistical relationship was noted in a comparison of each, significant postoperative complication (including postoperative death) with the variables under analysis. The incidence of secondary tracheotomy was 0.4%. The incidence of completion laryngectomy due to functional problems was 0%. The 5-year Kaplan-Meier actuarial local control estimate was 91% for T1 tumors and 68.7% for T2 tumors (p <.0001). Within the T1 tumors, the 5-year Kaplan-Meier actuarial local control estimate ranged from 96.2% for tumors without anterior commissure involvement to 74.7% for tumors with anterior commissure involvement (p = .0002). On univariate analysis, a significant statistical relationship was noted between an increase in local recurrence and the following variables: increased T stage, anterior commissure involvement, and pathological margin involvement. The overall disease control rate and laryngeal preservation rate were 92.9% and 93.3%, respectively.