Reconstructive laryngectomy. Report on the first 35 cases

[The one-stage technology of epiglottis function and voice reconstruction after total laryngectomy with the sternohyoid myocutaneous flap]

Objective:To investigate the clinical effect of one-stage sternohyoid musculocutaneous flap after total laryngectomy for reconstruction of epiglottis function and vocalization. Methods:A retrospective analysis of 8 patients who underwent total laryngectomy from November 2019 to September 2020. The sternohyoid myocutaneous flap was designed after total laryngectomy. The lower edge of the flap was sewed with the posterior upper edge of the tracheostomy opening, and the lateral and medial edges of the flap were anastomosed to create a vocal tube. The lateral edge of the upper end of tube was sutured with the anterolateral wall of the hypopharynx, then made full use of residual epiglottis and tongue root tissue to reconstruct epiglottis function. Results:None of the 8 patients had serious complications after total laryngectomies. Fifteen months after operation,the vocal tube flaps survived and had intact structure under fiberoptic laryngoscope. All patients could speak clearly and forcefully, and the swallowing function was intact. Conclusion:The use of adjacent myocutaneous flap to construct the vocal canal and reconstruct the epiglottis function is a simple and effective technique that can be completed in one stage and improve the voicing of patients undergoing total laryngectomy.

Neoglottis reconstruction with sternohyoid muscles on upper-tracheal orifice after laryngectomy

Ideal speech restoration remains a difficult challenge for patients undergoing laryngectomy so far. Our aim was to explore the feasibility of neoglottic reconstruction with sternohyoid muscles on upper-tracheal orifice after total laryngectomy which can obtain relatively ideal voice rehabilitation. Fifteen male patients are laryngectomized, of whom eight with standard total laryngectomy and seven underwent nonstandard total laryngectomy with epiglottis conserved. After laryngectomy, the upper margin of the anterior hypopharyngeal mucosa (postcricoid mucosa) was stitched to the posterior margin of upper-tracheal orifice and a triangle-shaped neoglottis on upper-tracheal orifice was reconstructed using bilateral sternohyoid muscles near the hyoid bone which were sutured to the posterior wall and bilateral of upper-tracheal orifice. Then tracheolingual root anastomosis was done and reconstruction surgery was completed. Finally, a satisfactory voice was achieved in 14 of 15 patients except one whose neoglottis is stenosed and 11 cases had no severe complications including aspiration erroneous deglutition. The stomach catheters were removed successfully from 4 to 6 weeks after surgery in 11 cases, respectively. The neoglottis had to be closed in three patients because of aspiration problem. One neoglottis was closed 3 weeks after surgical reconstruction because of tracheal rings tear which created a bigger neoglottis. One neoglottis was removed 32 moths after total laryngectomy due to big neoglottis. Another one was closed 3 weeks after surgery by reason of the fear of aspiration without psychological preparation. Therefore, it is feasible to use the sternohyoid muscles for creation of a neoglottis on upper-tracheal orifice and provide an alternative surgical method of the voice restoration for the patients after laryngectomy.

[Surgical voice restoration following total laryngectomy]

In spite of the progress made in organ-preserving therapy modalities, including endoscopic or external partial laryngectomies, radiotherapy or chemoradiation in many patients with advanced laryngeal and hypopharyngeal carcinomas, total laryngectomy remains the only safe possibility for long lasting local tumour control. The existing strategies for a sufficient restoration of voice following total laryngectomy are still controversial. Besides the strictly conservative methods of esophageal voice and electronic devices, different surgical procedures are carried out worldwide. At present, the exclusively surgical voice shunt techniques are only offered in a few very specialized centres. In Germany, three surgical methods are in use: (1) microvascular laryngoplasty according to Hagen (> 300 cases), (2) the "jejunal speaking siphon" according to Ehrenberger modified by Remmert (> 60 cases), and (3) the modified Asai-technique according to Maier and Weidauer (> 80 cases).

Primary tracheoesophageal shunt operation for postlaryngectomy speech with sphincter mechanism

This paper describes a primary voice restoration technique designed to eliminate the problem of aspiration commonly encountered in rehabilitation procedures following laryngectomy. This technique, utilized in 16 patients, consists of a unique combination of tracheal flap for voice production and bilateral esophageal constrictor muscle flaps to prevent aspiration. Fourteen patients developed satisfactory tracheoesophageal speech; of them 12 had normal deglutition without problems of aspiration. On radiographic examination, the bilateral esophageal muscle flaps, in combination with the dilatation and elevation of the cervical esophagus, provide a sphincter mechanism that prevents tracheal reflux during deglutition.

Recent advances in surgery of the larynx and trachea

Recent advances in surgery of the larynx and trachea have occurred in the general areas of diagnosis, pretreatment nutritional therapy, surgical technique, and reconstruction. In diagnosis the routine use of the flexible fiberoptic laryngoscope in the office and the use of computerized tomography have been valuable. The addition of enteral and parenteral nutrition therapy in selected patients with laryngeal cancer has been an advance. In the area of surgical technique, section of the recurrent nerve for the treatment of abductor laryngeal spastic dysphonia has proved successful. In the area of reconstruction the use of the epiglottic flap for repair of the larynx after near-total laryngectomy for glottic cancer and the use of the pectoralis major myocutaneous flap for one-stage pharyngoesophageal reconstruction have been significant advances. An increase in the number of patients with chronic lung disease has created a new interest in tracheal fenestration.

An endoscopic technique for restoration of voice after laryngectomy

Reports of restoration of voice after total laryngectomy include diversion of exhaled pulmonary air though planned or spontaneous fistulae with a variety of modified tracheal cannulas and valves. Limitations of these techniques include aspiration, scar closure of the shunts, wound complications, and failure to achieve voice consistently. We report a two-year experience with an endoscopic method using a unique valved prosthesis eliminating complicated surgical reconstructions, aspiration, and stenosis. Fifty-four of 60 patients (90%) achieved fluent voices with one deglutition problem. Radiation therapy preceded voice restoration in 63% of the patients and radical neck dissection in 72%. The endoscopic procedure, hospitalization and period of speech therapy are short and constitute a cost-effective voice rehabilitation program. The results of this simple method and lack of complications are encouraging.