Treatment of vocal cord carcinoma by vertical hemilaryngectomy

Transoral robotic vertical partial laryngectomy (hemilaryngectomy) extended to the hypopharynx

Locally advanced laryngeal cancers treatment often involves total laryngectomy, which some patients are unwilling to undergo, even if this choice reduces their survival probability. Therefore, the objective of laryngeal oncologic surgery is not only to remove the tumor, but also to preserve the organ and its functions. To overcome these concerns, several partial laryngectomy techniques have been developed. This article describes the surgical technique and a case study of a 64-year-old male patient with locally advanced laryngeal squamous cell carcinoma who underwent vertical partial laryngectomy extending to the subglottis and hypopharynx using transoral robotic surgery (TORS) with a da Vinci Single Port surgical robot. The video and article provide a detailed description of the surgical technique, which resulted in successful tumor removal with excellent oncological and functional outcomes.

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.

Hemicricoidectomy for voice rehabilitation following hemilaryngectomy with ipsilateral arytenoid removal

The purpose of this article is to describe an approach to reconstruction of the larynx after vertical partial laryngectomy with removal of the ipsilateral arytenoid cartilage. This method addresses the problem of postoperative posterior glottal incompetence (aphonia with or without aspiration). The technique involves resection of the ipsilateral half of the cricoid cartilage, use of an inferiorly based strap muscle flap for vocal fold reconstruction, and placement of a customized stent. This technique may be used at the time of the primary cancer extirpation or as a secondary rehabilitative procedure. Generally, patients who have undergone this procedure have had minimal postoperative breathiness with good phonatory and airway function. We recommend this reconstructive technique for patients with large posterior defects following hemilaryngectomy.

Laryngeal reconstruction following vertical partial laryngectomy

Laryngeal reconstruction following vertical partial laryngectomy (VPL) with arytenoidectomy was studied in 30 dogs. Variations of a superiorly based thyroid cartilage flap (TCF) were used for reconstruction. In addition, sternohyoid muscle reconstruction and endolaryngeal muscle coverage were studied. Larynges were recovered after a 6-month period in 28 surviving dogs and were analyzed by endoscopic photographs and axial whole-organ sections. Endoscopic assessment (n = 18) demonstrated good results for arytenoid replacement (100%), pseudocord position (94%), pseudocord development (94%), and airway patency (100%). Arytenoid replacement was judged as completely (78%) or partially (22%) replaced. This was accomplished by a pseudocord extending to the cricoid in the horizontal plane. Pseudocord position was judged as normal (83%) or paramedian (11%), with the remainder lateralized (6%). Pseudocord development was judged as complete (72%) or partial (22%), with the remainder poor (6%). Reviewing both endoscopic photographs and gross sections (n = 28), airways were all normal without laryngeal or tracheal stenosis. Histologic assessment (n = 24) also demonstrated good results for arytenoid replacement (79%), pseudocord position (87%), and TCF survival in the glottic plane (79%). Arytenoid replacement was judged as complete (62%) or partial (17%), with the remainder poor (21%). Pseudocord position was judged as normal (50%) or paramedian (37%), with the remainder lateralized (13%). TCF survival was judged as total (63%) or partial (16%). Although not present in the glottic plane in the remaining cases (21%), a portion of the TCF was always present in the supraglottic region. The TCF was largely replaced by bone in the region of the pseudocord, and was covered by nonkeratinizing stratified squamous epithelium and a thick fibrous layer. Breakdown over the TCF was infrequent, with a small focus of granulation tissue over cartilage present in 1 (4%) of 24 cases. Clinically insignificant granulation tissue was present in a total of 6 (25%) cases. In the other 5 cases, this was over muscle or over permanent sutures. Focal cartilage necrosis was present in 2 (8%) of 24 cases, and was localized, self limiting, and deep to the endolaryngeal surface. When the TCF failed to survive histologically, poorer results for arytenoid replacement and pseudocord position generally resulted. However, this apparent difference was not statistically significant due to small sample sizes and variability in results. Other factors that may have kept this difference from becoming larger were thought to be contraction of th e normal cord towards the operated side with fore-shortening of the glottis, and medial rotation and ossification of the posterior thyroid ala remnant.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.