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Conservation laryngeal surgery

Conservation laryngeal surgery. Reference. Cummings otolaryngology head and neck surgery, 5 th edition , chapter 110 ; conservation laryngeal surgery P. 1539-1562 Cummings otolaryngology head and neck surgery, 4 th edition

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Conservation laryngeal surgery

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  1. Conservation laryngeal surgery

  2. Reference • Cummings otolaryngology head and neck surgery, 5thedition , chapter 110 ; conservation laryngeal surgery P. 1539-1562 • Cummings otolaryngology head and neck surgery, 4th edition • BaileyBJ.AtlasofHead & NeckSurgeryOtolaryngologyOtolaryngology.4thEdition. • BaileyBJ.Head & NeckSurgery – Otolaryngology.5thEdition • Atlas of head and neck surgery. 2nd edition; 1999

  3. Introduction Conservation laryngeal surgery • Preserve speech and swallow function without permanent tracheostomy • high local control rate same total laryngectomy

  4. 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

  5. Laryngeal framework

  6. Cricoid cartilage • Only complete skeletal ring of airwaycompare with signet ring • Allow for decanulation after conservation laryngeal surgery

  7. 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

  8. Epiglottis • Petiole เกาะกึ่งกลางของ thyroid cartilageโดยมี fibrous tissue ประสานไปกับ Broyles’ ligament. • Suprahyoid • Infrahyoidfenestration • CA supraglottic may invade preepiglotticspacethroughthe fenestration

  9. Condensations of fibrous tissue of larynx

  10. Conuselasticus( Triangular membrane ) • Arise from sup. portion of cricoidcartilageto join with inferomedial part of vocal ligament of vacal cord

  11. 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

  12. Quadrangular membrane • 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

  13. 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

  14. 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

  15. Preepiglottic space • Ant. surface; thyrohyoid m. • Sup. surface; hyoepiglotticligament,valleculae • Post. surface; epiglottis • Inf. surface; thyroepiglottic ligament • Contain lymphatic tissue, • vessels, fat. • CA supraglottisinvasion • to this space through • fenestration of epiglottis

  16. Paraglottic space • Inferomedial ; conuselasticus • 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.

  17. Lymphatic drainage • Lymphatic drainage sparse anteriorly and at glottis • Rich lymphatics in supraglottis, subglottis, posterior half • Barriers to spread • ConusElasticus inferiorly • Quadrangular Membrane laterally • Thyrohyoid Membrane superiorly

  18. Preoperative evaluation • Assess oncologic of primary site, regional nodes, and distant sites (TNM staging) • Assess patient's ability (medical undergo surgery and postop.) • Patient and family insight, emotional state, and ability and willingness to postop. Rehab.

  19. 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.

  20. 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

  21. 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

  22. AJCC Staging Glottic cancer

  23. AJCC Staging Supraglottic cancer

  24. 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 breathbetter 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

  25. Endoscopic Surgery Open Surgery Conservation laryngeal surgery

  26. Glottic cancer Transoral laser microsurgery • Extended • FRONTOLATERAL VERTICAL HEMILARYNGECTOMY • Anterior frontal vertical hemilaryngectomy • POSTEROLATERAL VERTICAL HEMILARYNGECTOMY. • EXTENDED VERTICAL HEMILARYNGECTOMY. • Vertical partial laryngectomy • Verticalhemilaryngectoym Horizontal Partial Laryngectomies • Supracricoid Partial Laryngectomy with • Cricohyoido-Epiglottopexy (SCPL with CHEP) EXTENDED PROCEDURES.

  27. Supraglottic cancer Transoral laser microsurgery • EXTENDED PROCEDURES • ARYTENOID, ARYEPIGLOTTIC FOLD, OR SUPERIOR MEDIAL • PYRIFORM INVOLVEMENT FROM SUPRAGLOTTIC CARCINOMA. • BASE OF TONGUE EXTENSION FROM SUPRAGLOTTIC CARCINOMA. Horizontal Partial Laryngectomies • SupraglotticLaryngectomy SupracricoidLaryngectomy with Cricohyoidopexy (CHP) EXTENDED PROCEDURES.

  28. Endoscopic laser surgery

  29. 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

  30. Classification by European laryngological society 2007

  31. Type I Type II Type IV Type III

  32. Type Vb Type Va Type Vd Type Vc

  33. Cordectomy type VI

  34. Classification by European laryngological society for supreglottic CA

  35. Endoscopic cordectomy Reference : www. medscape.com

  36. TLM for T1 glottic cancer

  37. Endoscopic laser surgery for T2 supraglottic cancer Pre-treatment Post-resection

  38. Open conservation laryngeal surgery

  39. Indications • Early glottic cancer (T1 and T2 stages) • Select cases T3 lesions • Not be appropriate in cases of recurrent glottic carcinomas

  40. 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

  41. Laryngofissure & cordectomy For midcord mobile T1 CA glottic cannot resect endoscopic because of anatomic constraint preventing adequate laryngoscopic exposure

  42. 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

  43. Surgical technique

  44. Surgical technique (2)

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