Conservation laryngeal surgery
Reference
• Cummings otolaryngology head and neck
surgery, 5thedition , chapter 110 ; conservation
laryngeal surgery P. 1539-1562
• Cummings otolaryngology head and neck
surgery, 4th edition
• Bailey BJ. Atlas of Head & Neck Surgery
Otolaryngology Otolaryngology. 4th Edition.
• Bailey BJ. Head & Neck Surgery –
Otolaryngology. 5th Edition
• Atlas of head and neck surgery. 2nd edition; 1999
Introduction
Conservation laryngeal surgery
 Preserve speech and swallow function without
permanent tracheostomy
 high local control rate same total laryngectomy
Principles of organ preservation surgery
• First principle: Local control
• Second principle: Accurate assessment of
three-dimensional extent of tumor
• Third principle: Cricoarytenoid unit is basic
functional unit of larynx (swallowing ,
Respiration,Phonation and airway protection)
• Fourth principle: Resection of normal tissue to
achieve an expected functional outcome
Laryngeal framework
•Only complete skeletal ring of airway
compare with signet ring
•Allow for decanulation after conservation
laryngeal surgery
Cricoarytenoid unit
•fundamental functional unit of the
larynx
•one arytenoid cartilage with its
associated cricoarytenoid
musculature and recurrent and
superior laryngeal nerves
•Preservation of one cricoarytenoid
unit with the associated cricoid ring
allows for speech and swallowing
without a permanent tracheostomy.
Cricoid , Arytenoid
Muscle: PCA, LCA, interarytenoid
Nerve: SLN, RLN
•Petiole เกาะกึง่ กลางของ
thyroid cartilage โดยมี
fibrous tissue ประสานไป
กับ Broyles’ ligament.
•Suprahyoid
•Infrahyoidfenestration
•CA supraglottic may
invade preepiglottic space
through the fenestration
Condensations of fibrous tissue of
larynx
•Arise from sup. portion of
cricoid cartilage to join with
inferomedial part of vocal
ligament of vacal cord
Condensations of fibrous tissue of larynx
•temporary barrier for the spread of early glottic carcinoma
•But for larger cancer ,gateway to subglottic and extralaryngal
spreading
•Sup. border of membrane is
free
and oblique and thickening to
form aryepiglottic fold.
•Inf. ; extend from infr point of
epiglottis this attach to thyroid
cartilage to insert arytenoid
•Inf. border are thickening
to form vestibular fold;
a part of false vocal cord
Broyles ligament: or anterior commissure tendon, devoid of
perichondrium
Thyrohyoid membrane: extension out of the larynx through the thyrohyoid
membrane alone is rare, typically seen when cancer exit larynx through upper
portion of thyroid cartilage
Hyoepiglottic ligament
•Resilient barrier to
malignant spread from
the supraglottis to BOT
•When cancer confined
to laryngeal membranes
does not clinically invade
the suprahyoid epiglottis
Ant. surface; thyrohyoid m.
Sup. surface; hyoepiglottic ligament,valleculae
Post. surface; epiglottis
Inf. surface; thyroepiglottic ligament
•Contain lymphatic tissue,
vessels, fat.
•CA supraglottis invasion
to this space through
fenestration of epiglottis
•Inferomedial ; conus elasticus
•Anterolateral ; thyroid ala,
abut preepiglottic space
•Superomedial ; quadrangular
membrane
•Posterior ;medial wall of
pyriform
•Inferior ; adjacent to
cricothyroid m.
•Tumor invade to extralarynx
through cricothyroid m.
Lymphatic drainage
• Lymphatic drainage sparse
anteriorly and at glottis
• Rich lymphatics in
supraglottis, subglottis,
posterior half
• Barriers to spread
1) Conus Elasticus inferiorly
2) Quadrangular
Membrane laterally
3) Thyrohyoid Membrane
superiorly
Preoperative evaluation
1) Assess oncologic of primary site, regional
nodes, and distant sites (TNM staging)
2) Assess patient's ability (medical undergo
surgery and postop.)
3) Patient and family insight, emotional state,
and ability and willingness to postop.
Rehab.
Oncologic assessment
• Degree of airway impairment and voice quality
• Arytenoid and vocal cord mobility
– Glottic CA :
• Impaired mobility TVC may be result of
superficial TA invasion or bulk on surface of
cord in exophytic lesion
• Fixed TVC most common results from
extensive invasion of TA m.
Oncologic assessment
– Supraglottic CA :
• Pseudofixation : arytenoid motion impaired
superiorly causing from "weight impact" of
tumor
• Actual fixation : malignant involvement of
intrinsic laryngeal muscle, cricoarytenoid
joint, or both
Oncologic assessment
• Extensions out of endolarynx :
– Palpate thyroid cartilage for irregularities
– Areas directly above and below thyroid cartilage
• Bulge or mass at level of thyrohyoid membrane may
indicate massive preepiglottic space invasion
• Mass at level of cricothyroid ligament may indicate
delphian lymph node, which indicates subglottic
extension of malignancy
AJCC Staging Glottic cancer
AJCC Staging Supraglottic cancer
Assessment of patient's ability
• Aging and chronic lung obstructive disease increase risk
of postoperative atelectasis/pneumonia
• Lung function test controversy
– Some authers: routinely for all patients
– FEV-1 < 50-60% of expected for age predicts high risk
of pulmonary complications
– Ability to walk up 2 flights of stairs without getting
short of breath better predictor of post-op
complications good candidates for conservation sx
• Good cognitive function, consent for intra-op TLG
• Aim: Good life activity, Good control local
Conservation laryngeal surgery
Endoscopic
Surgery
Open
Surgery
Glottic cancer
Transoral laser microsurgery
•Vertical partial
laryngectomy
•Vertical hemilaryngectoym
Horizontal Partial
Laryngectomies
•Supracricoid Partial
Laryngectomy with
Cricohyoido-Epiglottopexy
(SCPL with CHEP)
•Extended
•FRONTOLATERAL VERTICAL
HEMILARYNGECTOMY
•Anterior frontal vertical
hemilaryngectomy
•POSTEROLATERAL VERTICAL
HEMILARYNGECTOMY.
•EXTENDED VERTICAL
HEMILARYNGECTOMY.
EXTENDED PROCEDURES.
Supraglottic cancer
Transoral laser microsurgery
Horizontal Partial
Laryngectomies
•Supraglottic Laryngectomy
Supracricoid Laryngectomy
with Cricohyoidopexy (CHP)
EXTENDED PROCEDURES
•ARYTENOID, ARYEPIGLOTTIC FOLD, OR
SUPERIOR MEDIAL
PYRIFORM INVOLVEMENT FROM
SUPRAGLOTTIC CARCINOMA.
•BASE OF TONGUE EXTENSION FROM
SUPRAGLOTTIC CARCINOMA.
EXTENDED PROCEDURES.
Principles
• Endoscopic laser resection can encompass smaller lesions without
transgressing tumor
• Larger tumors are best managed with controlled resection in several
pieces
• Image B: Microscopic evaluation of the cut surface
• C, Small vocal fold lesions can be resected as a single specimen with care
to keep a 1- to 3-mm distance about the lesion and to mark it
appropriately to confirm clear margins histologically
Ref: Cumming Figure 100-10
Classification by European laryngological society 2007
Type I
Type II
Type III
Type IV
Type Va
Type Vb
Type Vc
Type Vd
Cordectomy type VI
Classification by European laryngological society for
supreglottic CA
Endoscopic cordectomy
Reference : www. medscape.com
TLM for T1 glottic cancer
Endoscopic laser surgery for T2
supraglottic cancer
Pre-treatment
Post-resection
Indications
• Early glottic cancer (T1 and T2 stages)
• Select cases T3 lesions
• Not be appropriate in cases of recurrent glottic
carcinomas
Contraindications
•
•
•
•
Large T3 or any T4 lesions
Arytenoid fixation (CA joint)
Interarytenoid, postcricoid invasion
Cricoid invasion (subglottic extension >10 mm
anteriorly; >5 mm posteriorly)
• Bulky transglottic lesion
• Massive Pre-epiglottic space invasion
• Lesions extending beyond external thyroid
perichondrium
Laryngofissure & cordectomy
• For midcord mobile
T1 CA glottic
cannot resect endoscopic
because of anatomic
constraint preventing
adequate laryngoscopic
exposure
Laryngofissure & cordectomy
Advantages
• Excellent exposure,
which permits precise
tumor removal and
accurate sampling of
adjacent tissue for F/S
analysis
• Can be extended to
include resection of
adjacent structures
(e.g., underlying
thyroid cartilage).
Disadvantages
• Need for tracheotomy
• Potential problems
with healing may
compromise airway,
voice, and swallowing
• Relies on secondary
intention healing to
create a neocord :
breathy voice
commonly results
Surgical technique
Surgical technique (2)