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Supracricoid Partial Laryngectomy

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Preoperative Assessment. History and Physical Exam ... Preoperative counseling. Go over all options ... selection key. Preoperative counseling important ... – PowerPoint PPT presentation

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Title: Supracricoid Partial Laryngectomy


1
Supracricoid Partial Laryngectomy
  • Karen Stierman, M.D.
  • Shawn Newlands, M.D.
  • March 14, 2001

2
Supracricoid Laryngectomy
  • Horizontal partial laryngectomy
  • Conservation not conservative
  • Introduced by Majer and Reider, 1959
  • Refined by Labayle, Bistmuth, Piquet
  • Introduced in U.S. in 1990s

3
Types of SCL
  • Based on reconstructive technique
  • Supracricoid laryngectomy with cricohyoidopexy(SCL
    -CHP) for supraglottic lesions
  • Supracricoid laryngectomy with cricohyoidoepiglott
    opexy(SCL-CHEP)for glottic lesions

4
Anatomy
  • Pre-epiglottic space defined superiorly by
    hyopepiglottic ligament, anteriorly by the
    thyrohyoid membrane, inferiorly by the
    thyroepiglottic ligament, and posteriorly by the
    epiglottis
  • Paraglottic space bounded by quadrangular
    membrane, medial piriform sinus wall, conus
    elasticus, and thyroid cartilage

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Route of Spread
  • Pressman dye studies showed supraglottis distinct
    from glottis
  • Supraglottic cancer can spread transglottically
    through medial surface of thyroid ala
  • Can also spread via anterior commissure/pre-epiglo
    ttic space to involve glottis and thyroid
    cartilage.
  • Supraglottic contraindicated in above cases but
    SCL is still an option

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Supracricoid laryngectomy
  • Remove the entire supraglottis, false and true
    vocal cords and the thyroid cartilage including
    the paraglottic/preepiglottic space
  • Up to one arytenoid can be resected
  • Phonatory and swallowing function saved

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Indications for SCL
  • Cancer that
  • 1. Involves the glottis and anterior commissure
  • 2. Invades the ventricle
  • 3. Is associated with impaired vocal cord
    mobility
  • 4. Invades the thyroid cartilage
  • 5. Has paraglottic/transglottic invasion
  • 6. Has moderate preepiglottic space invasion

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Contraindications for SCL
  • True hemilaryngeal fixation(vc arytenoid)
  • Base of tongue involvement
  • Massive preepiglottic space or vallecular
    invasion
  • Cricoid cartilage involvement(10mm anterior / 5
    mm posterior)
  • Interarytenoid involvement
  • Extensive thyroid cartilage involvement
  • Inability to adhere to post-operative care

13
Contraindications of SCL
  • Age alone is not a contraindication
  • GERD
  • Inability to perform supraglottic swallow
  • Inadequate pulmonary reserve/FEV1lt50

14
Selection criteria for SCL
  • AJCC staging system not foolproof must consider
    each case individually
  • SCL have been performed on lesions in T1b-T4
    range with T2 and T3 tumors being most common
  • Not just for advanced tumors consider in cases of
    VPL
  • Consider other options
  • TL
  • XRT Differences in local control rate more
    defined with larger tumors

15
Preoperative Assessment
  • History and Physical Exam
  • Fiberoptic laryngoscopy v.c. mobility/site of
    fixation
  • Labs and CXR to rule out metastasis
  • CT or MRI
  • Staging panendoscopy arytenoid mobility
  • /- Pulmonary function tests, Videostrobe

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Preoperative counseling
  • Go over all options
  • Dysphagia NGT, possible PEG, Swallowing
    rehabilitation
  • Tracheostomy
  • Voice

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Neck Dissection
  • Controversial
  • N0 - II,III,IV
  • N - MRND or RND
  • Vincentiis presence of N2 disease is relative
    contraindication for SCL-CHP

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Post-operative care
  • Cuffless trach tube at end of procedure vs.
    deflate cuff on POD1
  • Lack of cuff preserves active cough reflex
  • First attempt at decannulation is POD 3
  • Early decannulation allows elevation of neolarynx
    and encourages mobilization of arytenoid
  • Once decannulated, pt encouraged to swallow
    secretions supraglottic swallow
  • Once tolerating pureed diet NGT removed

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Local Recurrence
  • 1998 study Laccourreye
  • Symptoms Dyspnea, dysphonia, otalgia,
    odynophagia, neck mass
  • Laryngoscopy submucosal mass, cricoid stenosis,
    fixation of arytenoid, ulceration of c-a region
  • CT lysis of cricoid, invasion of c-a
    region,preepiglottic, paraglottic space
  • Tx chemo/xrt or TL

32
Quality of Life SCL vs TL
  • Weinstein, et. Al
  • SCL better than TL in areas of physical function,
    general health, vitality, social function,
    emotional limitations, and physical health
    summary, eating, pain and voice related quality
    of life

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Conclusion
  • Controversial
  • Patient selection key
  • Preoperative counseling important
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