OtolaryngologyHead and Neck Surgery SEPTEMBER 1990

VOLUME 103

NUMBER 3

ORIGINAL ARTICLES Laser epiglottectomy: Endoscopie technique and indications STEVEN M . ZEITELS, MD, CHARLES W. VAUGHAN, MD, FACS, GERARD F. DOMANOWSKI, MD, NABIL S. FULEIHAN, MD, and GEORGE T. SIMPSON II, MD, FACS, Boston, Massachusetts

Endoscopie epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques and the C0 2 laser. Depending on the indications, the removal may be partial or complete. Indi­ cations for 51 epiglottectomfes included treatment of supraglottic airway obstruction— 30 cases; discovery of benign or malignant neoplasm (diagnosis and staging)—20 cases; treatment of malignant neoplasm—7 cases; glottic visualization—4 cases; and treatment of chronic inflammatory conditions—1 case. It is not unusual for a patient to have more than one Indication for this procedure. Some epiglottlc cancers invade the pre-eplglottic space. This crucial information may not be detectable by MRI or CT scanning techniques. Laser epiglottectomy provides a method to explore and perform a biopsy of the pre-epiglottic space and thereby stage these lesions accurately. There are no significant problems with postoperative alimentation, airway, or voice. Any form of primary or adjuvant therapy can be started without delay, (OTOLARYNGOL HEAD NECK SURG 1990;103:337.)

Jackson and Jackson1 described an endoscopie approach for microcontrolled excision of early supraglottic cancer in 1939 in which they cut around the

Ë from the Sections of Otolaryngology (Drs. Zeitels, Vaughan, and Fuleihan) and Pathology (Dr. Domanowski) Boston Veter-

tumor with a basket punch. If there was no evidence of cancer in the punch specimens, the excision was considered curative. The C0 2 laser was used in microlaryngeal surgery in the early 1970s at Boston Univer­ sity.2·3 Endoscopie laser epiglottectomy (epiglottidec­ tomy) using the C0 2 laser has been performed at Boston University since 1973 and was first described by .. Vau

, . . . -, . . . . , „,, · r ^ τ- · i · i g h a n i n h l S Candidate s Thesis for the Tnological

an's Administration Medical Center, and the Departments of

Society in 1978.4 In 1983, Davis et al.- reviewed our

Otolaryngology-Head and Neck Surgery (Drs. Zeitels, Vaughan, Fuleihan, and Simpson) and Pathology (Dr. Domanowski), Boston University School of Medicine. for ^resented at the Annual Meeting of the American Laryngological

experience with 20 patients. The indications in that series included airway palliation before definitive thern e o p i a s m ( 6 p a tients), improved visualization . . . . , ... ... ' , , t . .

Association, West Palm Beach Fla., April 25, 1988. Submitted for publication Feb. 14, 1989; revision received Feb. 6, 1990; accepted Feb. 12, 1990. Reprint requests: Steven M. Zeitels, MD, Department of Otolaryn-

BoSn ÎJaAssachusetts

E y e and Ear Infirmar



243 Charles S t

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of the

g l o t t l s i n P i o u s l y treated cancer patients with severe supraglottic edema (6 patients), removal of benign epiglottic lesions (4 patients), and excisional bi-

opsy in selected early epiglottic cancers (4 patients).

The surgical technique typically required a modified

*Dr.°S e ls is aÏo'currently in practice at the Department of Oto-

L

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laryngology, Harvard Medical School. 23/1/20158

Mueller Co., McGaw Park, 111.), a very uncommon instrument. Some points of technique were not clearly

Suspension apparatus (BE 860, Baxter V.

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HYPOEPIGLOTTIC LIGAMENT

Fig. 1. Sagittal view demonstrates partial or total eplglottectomy (dotted lines) and restricted operative mobility of the epiglottis by the endotracheal tube and cottonoid.

described and subsequent depictions in the litera­ ture by others are very different from our pro­ cedure.6·7 The purpose of this article is to describe a relatively easy technique that uses commonly available micro­ surgery instruments and to discuss further our indica­ tions for and our experience with carbon dioxide laser epiglottectomy at Boston University. TECHNIQUE

Anesthesia is by inhalation agents with muscle re­ laxant and the airway is maintained by a foil-protected red rubber endotracheal tube. The tube and its cuff are further protected by a wet cottonoid (Fig. 1). The wid­ est bore, tubed laryngoscope, such as the Jako or the Kleinsasser, is used.* This can expose only part of the operative site. It is held in place by a suspension device (such as the Boston University Suspension) and must be repositioned throughout the procedure. The oper­ ating microscope, fitted with a 400-mm objective lens, straight oculars, and 20 x eyepieces affords excellent visualization. An attached C0 2 laser with a laser-aiming device, standard microsurgical instruments, and a ♦(Please refer to our Drug/Device Capsule in this is for our use of the adjustable supraglottiscope).

monopolar electrocautery complete the instrumen­ tation. Before any excision is begun, each pharyngoepiglottic fold is grasped with a cup or an alligator forceps and a coagulating current is applied (Fig. 2, A). This controls the major arterial supply to the operative site (an unnamed branch of the superior laryngeal artery). The C02 laser is used to "cut" through each fold at the lateral edges of the epiglottis (Fig. 1). With the tissue on maximum traction, these cuts are connected across the vallecular surface of the epiglottis (Fig. 2, B). By continuing to follow the limits of the epiglottis, an en bloc excision may be accomplished if the epiglottis is unusually small. Most often there is too much tissue and the operation is performed more easily by removing the epiglottis in sections (one or two sections for partial excision, three sections for total excision) (Figs. 1, 3, and 4). Careful dissection along the anterior surface of the epiglottis facilitates biopsies of the pre-epiglottic space and avoids significant bleeding (Fig. 5). If nec­ essary, the petiole can be excised. The tissue defect heals by secondary re-epithelialization, without primary closure. TECHNICAL CONSIDERATIONS

Exposure of the operative site. The Lynch sus­ pension apparatus provides an excellent view from the lips to the glottis, with the exception of the epiglottis, which it hides because its blades are too long, having been designed to fit within the glottis. We have used shortened blades that reach only into the vallecula, thus allowing the epiglottis to fall into the field of view. However, visualization remains poor. The Lynch ap­ paratus has no posterior wall to hold the endotracheal tube out of the way and it has no self-contained light. Tubed laryngoscopes displace the endotracheal tube posteriorly, between the arytenoids, out of the field of view, and carry excellent light. Unfortunately, even the widest bore, tubed laryngoscope (the "adult" Jako) is too narrow to include the entire operative field during epiglottectomy; thus the tubed scope must be reposi­ tioned frequently.5 The endotracheal tube, even though displaced pos­ teriorly, presents difficulties. Its bulk inhibits manip­ ulation of the epiglottis so that traction and exposure are less than ideal. The tube lies directly under the operative site, but its exact position remains unknown until the epiglottis has been largely removed. Thus, it is at constant risk of being struck by the laser beam. Flammable tubes must be carefully protected by the surgeon's constant concern for the tube, by meticulous wrapping, and by interposing wet cottonoids between the tube and the epiglottis. However, this adds further bulk and operative difficulty (Figs. 1 and 4).

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Volume 103 Number 3 September 1990

, . , ^ , ««« Laser epiglottectomy 339

Flg. 2. The supraglottic larynx viewed through a tubed laryngoscope: A, The pharyngoepiglottic fold Is grasped with a cup forceps and a coagulating current is applied. The lateral vallecular incision Is made. B, The laryngoscope is reposltioned and the medial vallecular incision is made. C, The opposite pharyngoepiglottic fold is grasped with a cup forceps, a coagulating current is applied, and the vallecular incision is completed.

Fig. 3. Anteroposterlor view demonstrates partial or total seg­ mentai excision of the epiglottis (dotted lines).

HemostasiS. The C0 2 laser provides a dry operative field during most of the procedure; however, branches of the superior laryngeal vasculature are consistently encountered in the pharyngoepiglottic folds and occa­ sionally elsewhere. Bleeding from these vessels is con­ trolled by grasping them with an alligator forceps and

Fig. 4. The dissection is carried along the anterior aspect of the epiglottis, exposing the pre-epiglottic space. The superior epiglottis is removed in one or two pieces.

applying a coagulating electric current. An alternative, occasionally quicker method uses a "Bellina Coagulat­ ing Forceps" (Pilling no. 50-6483, Pilling Co., Phila­ delphia, Pa.), which has its cup filled in and blackened. The bleeding vessel is grasped with the "cup" and the

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PRE-EPIGLOTTIC SPACE PETIOLE

Flg. 5. Biopsy Is performed on the pre-eplglottic space and the petiole is removed if necessary.

laser beam is directed onto the blackened cup, which becomes hot and coagulates the vessel (Fig. 2, A and C). Visualization. The dry operativefieldresulting from use of the C02 laser makes the resection possible. The operating microscope improves the accuracy of the pro­ cedure. With experience, normal structures, such as arteries, nerves, muscle, bone, cartilage, etc., are clearly delineated, and abnormalities—both benign and malignant—are easily defined. Cancer diagnosis. With a dry surgical field and a magnified view, gross cancer can be identified and fol­ lowed to its limits. Surgical margins must be controlled histologically and frozen section examination of the wound margins is used to determine the final limits of resection. Permanent section examination of the spec­ imen is used to confirm the diagnosis of cancer and to evaluate the completeness of its removal.8 Specimen orientation. The multiple tissue frag­ ments resulting from the resection cannot be thrown casually into a bottle and sent to pathology if infor­ mation about the margins is important. They should be reconstituted (sewn back together, for instance) and

carefully described to the pathologist, and any critical margins should be jointly selected for sectioning. POSTOPERATIVE MANAGEMENT

Airway protection. After epiglottectomy, the air­ way is always more open than the preoperative airway if the vocal cords and/or subglottic areas are not in­ advertently traumatized. A single bolus of dexamethasone sodium phosphate (Decadron) 1.0 mg/7.5 kgm (10 mg in the adult), administered intravenously before induction of anesthesia, inhibits traumatic edema of the vocal folds. Tracheotomy is not needed. Alimentation. "The epiglottis is a degenerate organ in man and serves only a minor protective role during swallowing".9 Its absence produces few problems in an otherwise normal larynx with a normal swallowing sys­ tem. The usual postoperative alimentation is ad libitum. Pre-existing problems with aspiration may become im­ proved if related to the presence of an interfering mass, now removed. Aspiration may become worse if there are underlying neuromuscular defects, other loss of glottic tissue, or upward restriction of the laryngotracheal complex, secondary to a tracheotomy tube.

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Volume 103 Number 3 September 1990

Laser eplglottectomy 341

Fig. 6. Photomicrograph displays microinvasion Into the pre-epiglottic space through preformed pathways. The preformed pathways originally contained mucous glands and have been replaced with squamous cell carcinoma (Hematoxylin-eosin stain; original magnification x 40.)

Communication. Speech and voice are unaffected, except that "muffling" and "hot potato" sounds resulting from abnormal supraglottic mass may be relieved. Voice rest postoperatively is not required. Analgesia. Pain is usually mild in the immediate postoperative period and responds to simple analgesics such as acetaminophen (Tylenol), four times every 4 to 6 hours. Pain may worsen and require narcotic control if the wound becomes secondarily infected, but this is uncommon. Antacids and H2 blockers are used to avoid delayed healing in any patient suspected of reflex. Periopera­ tive antibiotics are not used. Further Therapy

Primary or adjuvant therapy may be started as soon as the need is determined. Further surgery using open approaches can be performed, even at the same "sit­ ting". Radiation therapy and/or chemotherapy need not be delayed. Laser surgery may be repeated as often as necessary, whenever necesssary, even after radiation therapy. INDICATIONS

Fifty-one laser epiglottectomies were performed and some patients had multiple indications for the procedure.

Treatment of supraglottic obstruction of the air­ way (30 patients). Airway obstruction caused by be­ nign and malignant tumors, by inflammatory processes, by congenital and traumatic deformities, and by chronic edema postradiation therapy can be relieved by endo­ scopie excision of the obstructing tissue. The ability to reestablish easily an airway seriously obstructed with cancer, without resorting to tracheotomy, is particularly helpful. This is not an infrequent event in our particular patient population. It requires intubation (usually when the patient is awake). The practical advantages of this approach are: (1) elimination of the possible compli­ cations from tracheotomy, with subsequent delayed laryngectomy; (2) the opportunity for planned preopera­ tive chemotherapy or radiation therapy; and (3) better nutritional and psychologic preparation of the patient for surgery.I0 Diagnosis and staging of supraglottic carci­ noma (20 patients). Supraglottic neoplasms are dif­ ficult to assess, especially those that arise in the area of the epiglottis. The view is, at best, a tangential one. The cartilage is thin with many preformed pathways, so that apparently minor tumors often invade the preepiglottic space (Fig. 6). Infiltration through these fenestrations by carcinoma is unpredictable. As illustrated in Fig. 7, two pathways one millimeter apart, with carcinoma on the anterior surface of the epiglottis, may

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Fig. 7. Photomicrograph displays consecutive preformed pathways—one with invasion (B) and one without Invasion ^ — d e s p i t e adjacent carcinoma on the laryngeal surface of the epiglottis (Hematoxylin-eosln stain; original magnification x 40.)

Table 1. Patients treated with laser epiglottectomy alone Patient no.

Stage

Followup (mo)

1

T2

28

2

T1

25

3 4 5 6

T1 T2 T1 T1

92 25 70 9

7

T1

14

Current status Dead: lung cancer NED in larynx Lost to followup NED NED NED NED Dead: cardiac arrest NED in larynx NED

Disease-free Interval (mo) 28 25 92 25 70 9 14

NED, No evidence of disease.

show dramatically different infiltration. This unpre­ dictability at a microscopic level illustrates the ease with which so-called early supraglottic cancers may be understaged. Computerized axial tomography and mag­ netic resonance imaging are not helpful in definitively evaluating early invasion of the pre-epiglottic space, nor is endoscopy. This important information can be discovered reliably only at the time of resection of the tumor. The resection may therefore be thought of as an

"excisional biopsy". The C02 laser and the operating microscope permit an excisional biopsy to be attempted transorally. If tumor is found in the pre-epiglottic space, the attempt at complete resection should be considered unsuccessful and the effort should be abandoned. How­ ever, the knowledge gained is then used to treat the patient appropriately, which in this instance is as a T3 supraglottic carcinoma rather than as a Tl or small T2 lesion.

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Volume 103 Number 3 September 1990

Laser epiglortectomy 343

In our institution, T3 supraglottic cancer is treated with open surgery if there is not a medical contrain­ dication to general anesthesia, if there is not unresectable regional metastasis, and if there are no distant métastases. If a patient with early pre-epiglottic space invasion is not considered a candidate for partial sur­ gery, a total laryngectomy is performed. Both necks are treated surgically when there is evidence of cervical metastatic disease. This may be determined by endo­ scopie staging, radiographie imaging, or at the time of laryngectomy, when the skin flap is ra,ised. Radiation to the primary site and/or necks is individualized. Treatment of malignant neoplasm (7 patients). If the excisional biopsy separates the tumor entirely from the patient, no further treatment is necessary. Sat­ isfactory proof of this condition may be difficult be­ cause it relies considerably on the skill and experience of the surgeon in visually detecting cancer under these unusual conditions. Frozen section evaluation of the wound margins should be relied upon only to indicate the presence of tumor. Absence of cancer in the patient may be inferred only when the permanent histologie sections of the specimen reveal its margins to be free of tumor. Followup on this small group of patients is detailed in Table 1. Improvement of glottic visualization (4 pa­ tients). The omega-shaped (infantile) epiglottis, the epiglottis that is "hooded" following trauma, or the edematous epiglottis following radiation therapy, can obscure visualization of the glottis (despite the use of flexible fiberoptic scopes and rigid telescopes), except during direct examination under general anesthesia. Followup of patients after treatment of anterior com­ missure glottic carcinoma can be facilitated by removal of portions of the epiglottis. Two of the four patients had partial epiglottectomy before flexible fiberoptic scopes and rigid telescopes were available. Treatment of chronic inflammatory conditions (1 patient). An individual with a self-induced traumatic epiglottic chondritis and an alcohol-induced bleeding disorder was successfully treated with endoscopie epi­ glottic excision. The epiglottis was completley removed and the patient healed without consequence. Disorders causing intolerable symptoms from nonspecific inflam­ mation of the epiglottis can be relieved by partial epi­ glottectomy. "

SUMMARY

Endoscopie epiglottectomy can be accomplished transorally with minimal morbidity by using the C0 2 laser and standard microlaryngeal surgical techniques. This system is especially useful in the management of cancer arising on the epiglottis because it provides a reliable means of palliating the airway and/or estab­ lishing the cancers local boundaries without resorting to open surgery. Occasionally such efforts may remove the entire tumor and be curative. If not, adjuvant ther­ apy or definitive treatment of any kind can be started without delay. With proper patient selection, there are no significant problems with postoperative alimenta­ tion, airway, or voice. We wish to thank Mr. J. Marshall Dyke for his artistic skill and Ms. Mary T. Burke for her photographic assistance. REFERENCES

1. Jackson C, Jackson CL. Endoscopie removal of cancer of the epiglottis. Cancer of the larynx Philadelphia: WB Saunders Co., 1939;52. 2. Jako GJ. Laser surgery of the vocal cords. Laryngoscope 1972:82:2204. 3. Strong MS, Jako GJ. Laser surgery of the larynx. Ann Otol Rhin Laryngol 1972;81:791. 4. Vaughan CW. Transoral laryngeal surgery using the C0 2 laser: laboratory experiments and clinical experience. Laryngoscope 1978;88:1399-1420. 5. Davis RK, Shapshay SM, Strong MS, Hyams VJ. Transoral partial supraglottic resection using the C0 2 laser. Laryngoscope 1983:93:429-32. 6. Cummings C, Sessions DG, Weymuller EA, Wood P. Transoral subtotal supraglottic laryngectomy with the laser. Atlas of la­ ryngeal surgery 1984;1:264-5. 7. Thawley SE, Sessions DG. Surgical therapy of supraglottic tu­ mors. In: Comprehensive management of head and neck tumors. Philadelphia: WB Saunders, 1987;1:970-1. 8. Vaughan CW. Use of the carbon dioxide laser in endoscopie management of organic laryngeal disease. Otolaryngol Clin North Am 1983;16:849-64. 9. Kirchner JA. Pressman and Kellman's Physiology of the lar­ ynx (Monograph). Washington, D.C.: American Academy of Otolaryngology-Head and Neck Surgery Foundation, 1986; 13-4. 10. Davis RK, Shapshay SM, Vaughan CW, Strong MS. Pretreatment airway management in obstructing carcinoma of the larynx. OTOLARYNGOL HEAD NECK SURG 1981;89:209-14.

11. Ruff T, Bellens EE. Sarcoidosis of the larynx treated with CO, laser. J Otolaryngol 1985;14:245-7.

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Laser epiglottectomy: endoscopic technique and indications.

Endoscopic epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques ...
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