Partial Laryngectomy: Analysis of Associated Swallowing Disorders Arthur W. Weaver, MD, Allen Park, Michigan
Susan M. Fleming, PhD, Allen Park, Michigan
Partial laryngectomy with preservation of speech function has gained acceptance as a method of management for selected laryngeal lesions. Often, however, the benefits realized in conservation of voice are associated with an accompanying disorder of deglutition. Cineradiographic studies indicate that a majority of patients having had supraglottic laryngectomy will experience some problem with postoperative aspiration [1,2]. Definitive guidelines have yet to be fully established that will reliably identify those patients who may be expected to benefit from conservative laryngectomy while still retaining satisfactory swallowing function. Material and Methods An analysis of swallowing function was made on thirtyeight patients treated by partial laryngectomy. These were selected from 240 patients who had recently undergone surgery for laryngeal cancer at the Veterans Administration Hospital, Allen Park, Michigan, and the Detroit Medical Center Hospitals. Only those patients were selected for evaluation for whom a sufficiently detailed record of postoperative deglutition function could be concurrently or retrospectively obtained to permit accurate rating of this function for both liquids and solids. Patients for this study were grouped according to the surgical procedure appropriate for their anatomic defects as follows: (1) Hemilaryngectomy. The typical resection included the true cord, false cord, and ventricle and superior laryngeal nerve unilaterally with preservative of the epiglottis. (Figure 1.) (2) Unilateral supraglottic laryngectomy. This resection included the epiglottis, one false cord, and the aryepiglottic fold along with the ipsilateral superior laryngeal nerve. (Figure 2.) From the Departments of Surgery and Otolaryngology. Wayne State University School of Medicine, and the Veterans Administration Hospital, Allen Park, Michigan, and the Detroit Medical Center Hospitals, Detroit, Michigan. Reprint requests should be addressed to Arthur W. Weaver, MD, Surgical Section (112). Veterans Administration Hospital, Allen Park, Michigan 48101. Presented at the Joint Meeting of the American Society for Heed and Neck Surgery and the Society of Head and Neck Surgeons, Toronto, Ontario, Canada, May 29-31, 1978.
486
(3) Bilateral supraglottic laryngectomy. This resection typically included both false cords, both aryepiglottic folds, and one or both superior laryngeal nerves. (Figure 3.) Additional defects, such as extension of the resection into the pyriform sinus or base of the tongue, were also evaluated for any of the above procedures. Method. Most of the patients underwent concurrent evaluation of swallowing function by our deglutition therapist. Evaluations of the remaining patients were made retrospectively from hospital charts and clinic records. When necessary, this information was supplemented by phone interviews with patients or their family members. Swallowing function was rated on a scale from 1 to 5: 1, no swallowing problems; 2, mild dysphagia; 3, moderate dysphagia or aspiration; 4, severe dysphagia or aspiration; 5, inability to swallow. This rating was made six weeks postoperatively and at the time of optimal swallowing function. For most patients this functional plateau was reached approximately six months to one year postoperatively.
Figure 1. Hemilaryngectomy defines an anatomic defect which typically includes the true and false cords and aryeplglottic fold unilaterally. The ipsilateral superior laryngeal nerve Is removed while the bpiglottis is spared.
The American Journal of Surgery
Partial Laryngectomy
Results
Hemilnryngectomy. Eleven patients were evaluated for swallowing function after hemilaryngectomy. Seven of these showed no difficulty in swallowing either liquids or solids at either the initial or subsequent evaluation. These were therefore given a rating of 1 on the deglutition scale. Two patients had initial problems with swallowing but reached a trouble-free status within a few months. An early second primary tumor of the hypopharynx developed in one patient, which made final evaluation impossible. Satisfactory swallowing failed to develop in only one patient with hemilaryngectomy: This patient,, a fifty-four year old white male, underwent preoperative cobalt therapy, 5,200 rads, followed by hemilaryngectomy for a T2 Nl MO lesion of the right true and false cords and ventricle. This was accompanied by radical neck dissection. His recovery was complicated by a laryngeal cutaneous fistula which was eventually closed using a nape of the neck flap. After closure of the fistula, feedings were begun, and the patient experienced some difficulty with aspiration. Subcutaneous tumor seeding of the neck shortly developed, and chemotherapy was begun. He never rt’covered satisfactory swallowing prior to his death. It should be noted that this was the only patient in the hemilaryngectomy group to receive radiotherapy. With this one exception, all evaluated patients with hemilaryngectomy did well. Supraglottic Laryngectomy. Unilateral Twenty-three patients underwent resection which included the epiglottis, one false cord, and the aryepiglottic fold. Also included was the ipsilateral superior laryngeal nerve. All of these patients had some initial difficulty in swallowing (rated 2, 3, 4, or 5 on the deglutition scale). Only seven of these patients were eventually rated 1 (no evident dysphagia for both solids and liquids). Sixteen patients in this group have continued with at least some chronic swallowing disability. Twelve of these have had minimal trouble (rated 2 on the deglutition scale). Four patients have had significant difficulty persisting beyond six months (rated 3,4, or 5). The two patients (rated 4 and 5) had both required resection of a portion of the base of the tongue along with the supraglottic resection. The patient who was rated 5 (complete failure to swallow) had also received postoperative radiotherapy. Bilateral Supraglottic Laryngectomy. Only four patients underwent removal of the epiglottis along with both aryepiglottic folds and false cords. In three of these patients, one superior laryngeal nerve was preserved. None of these patients were able to return to completely normal swallowing. All except one, however, were able to maintain their weight and eat
Volume 136, October 1976
Figure 2. Unilateral supraglottic laryngectomy describes resection which includes the epiglottis, one false cord, aryepiglottic fold, and superior laryngeal nerve. The contralateral superior laryngeal nerve is spared.
with tolerable aspiration. One patient in whom both superior laryngeal nerves were removed had total failure to swallow. He also received postoperative radiotherapy. Radiotherapy. Approximately half our patients had either preoperative or postoperative radiotherapy associated with their supraglottic laryngectomy. The mean rating for optimal swallowing function obtained by the nonirradiated patients was 1.59 on our deglutition scale. The mean rating obtained by the irradiated group was 2.50. The number of pa--
Figure 3. Bilateral supraglottic taryngectomy describes removal of the entire supraglottis. Hopefully, one superior laryngeal nerve may be preserved.
467
Weaver and Fleming
C
D
Figure 4. A, fhe malignant lesion involves epigioMis and the aryepigiottic fold and extends along the pharyngoepigloffic fold into the vailecuia and pyriform sinus. B, Note fixation of aryienoid and true cord in abduction foiiowing resecflon of supragiottic lesion. Food is easliy aspirated through an incompetent glottis. C, the cord and arytenoid are freed by sharp dissection. This reopens the obliterated sinus. D, Ihe silicone stent is transfixed by nonabsorbable sutures. This keeps the sinus patent until epifheiiaiization can occur.
tients in each group was too small to draw significance from this study. The figures do agree, however, with our clinical observation on a much larger group of patients that radiotherapy is a distinct det.riment to swallowing function. In this study, all patients with complete failure to swallow (1 with hemilaryngectomy, 1 with unilateral laryngectomy, and 1 with bilateral laryngectomy) underwent radiotherapy. Cricomyotomy. Only five patients from our group of thirty-eight patients with partial laryngectomy underwent cricomyotomy included with the initial operative procedure. Again, this group is too small for statistical evaluation. One patient from this group, however, had total failure to swallow (after unilateral supraglottic resection, 20 per cent base of tongue resection, and postoperative irradiation) and another had severe postoperative swallowing problems. There was no evidence that cricomyotomy was beneficial to the five patients in whom it was performed. This agrees with the observation of Bocca [3] who discontinued use of this procedure when after a trial period it seemed that cricomyotomy failed to
Figure 5. The Siiastic steni is held in place by sutures passed through the skin of the r&k overiylng the pyriform sinus and tied over piedgets.
produce any benefit. It also supports our previous experience that secondary cri6omyotomy seldom produces any benefit for dysphagia unless definite cricopharyngeal spasm can be demonstrated by cineradiography. Evaluation
of Swallowing
Disorders
Every patient who fails to develop satisfactory swallowing function after head and neck cancer surgery deserves a careful evaluation to determine the reason for this difficulty. Our evaluation included a careful observation of the patient by the physician or trained deglutition therapist during one or several feeding sessions. The patient’s ability to remove food from the mouth to the oropharyngeal port, drooling, head and body position, lift of the larynx, and degree of aspiration should be noted. Special attention should be given to the patient’s mental attitude. Often, encouragement and optimism are the major contributions from the therapist. The cineradiogram is valuable for diagnosis and documentation of specific disorders. We have found the flexible bronchoscope also to be extremely valuable for use in evaluating postoperative dysphagia. The scope may be passed to the level of the soft palate through a locally
The American Journal of Surgery
Partial Laryngectomy
nasal passage. The examiner then observes the swallowing mechanism while the patient attempts to swallow a small quantity of liquid or solid food. Visualization may also be obtained through the tracheal st.oma, if one exists, by passing the bronchoscope in a retrograde fashion to view the undersurface of the vocal cords. The upper trachea should he previously sprayed with small amounts of local anesthetic through the stoma. No local anesthesia should be used in the pharynx or on the upper surface of the vocal cords in either of these examinations. Evaluation of the swallowing mechanism using the flexible endoscope supplemented by careful physical and cineradiographic examination usually permits a definitive evaluation of any postoperative swallowing disorder. Many of these deglutition problems can be surgically corrected. The scope of this paper permits description of only one of these problems and its surgical correction.
anesthetized
The Obliterated
Pyriform Sinus
Malignant lesions of the supraglottic area frequently extend along the pharyngoepiglottic fold as well as the aryepiglottic fold. (Figure 4A.) Surgical removal of such a lesion requires resection of a portion of the pyriform sinus and vallecula along with the supraglottic larynx on the side of the lesion. Mucosal closure of this area frequently obliterates the opening of the pyriform sinus and may fix the arytenoid cartilage and ipsilateral cord in abduction. With no epiglottis to divert the food from the laryngeal introitus, there is now a direct shot for food and liquids into a larynx which is unable to achieve complete glottic closure. (Figure 4B.) Surgically opening the obliterated pyriform sinus with freeing of the arytenoid cartilage has enabled several of our patients to overcome severe swallowing disability. This operation can be done transorally through an operating laryngoscope. Microlaryngeal scissors and sharp dissector are used to free the arytenoid and true cord from the pharyngeal wall and to reestablish the pyriform sinus opening. (Figure 4C.) The raw area of the newly opened pyriform sinus is then stented with a silicone keel. This keel is to be held in place by nonabsorbable sutures passed from the lateral neck. The suture is passed by a swaged straight cutting needle through the skin of the neck into the reopened sinus. The needle is then withdrawn through the laryngoscope, passed through the silicone keel, and reinserted through the new sinus back into the lateral neck. (Figure 4D.) Two such sutures are used to fix the keel in the depths of the wound. These sutures are then tied over cotton or Silastic@ pledgets to fix the keel in place until epitheliahzation has occurred in three or four weeks. Volume 136, October 1976
(Figure 5.) Tracheostomy is recommended for those patients whose tracheal stoma has been allowed to close. Most of these patients, however, because of their swallowing difficulty, will still have an established tracheostomy at the time of surgery.
Conclusions
Patients with apparently similar anatomic defects as a result of partial laryngectomy frequently demonstrate significantly different swallowing abilities. Our study suggests, however, that certain categorization is possible by which one may reasonably anticipate the degree of postoperative dysphagia likely to follow definable surgical resections: (1) Hemilaryngectomy with preservat.ion of the epiglottis rarely produces significant, swallowing dysfunction. (2) Radiation, either preoperatively or postoperatively, combined with supraglottic resection greatly interferes with both early and ultimate swallowing ability. AL1patients with total failure to swallow fell in this category. (3) A patient having bilateral supraglottic resection which includes both superior laryngeal nerves is not likely to achieve satisfactory swallowing. (4) Cricomyotomy was not shown to produce observable benefit to the few patients in whom it was used. (5) Careful evaluation of all patients with continuing swallowing dysfunction should be made to determine if surgical rehabilitation is possible. One such procedure, reestablishment of the pyriform sinus. is described.
Summary
Evaluation of postoperative swallowing ability in thirty-eight patients having had partial laryngectomy indicates that there are marked differences in the degree of dysphagia among individuals with similar surgical defects. This variation in swallowing disability, however, appears to have definable limits. Rehabilitation is possible for many patients disabled by postoperative dysphagia. A transoral surgical technic for reconstruction of the obliterated pyriform sinus is described. References 1. Staple TW, Ogura JH: Cineradiography of the swallowing mechanism following supraglottic subtotal laryngectomy. Radiology 87 (2): 226, 1966. 2. Litton WB, Leonard JR: Aspiration after partial laryngectomy: cineradiography studies. Laryngoscope 79(5): 887, 1969. 3. Bocca E: Supraglottic cancer. Laryngoscope 85(8): 1318, 1975.
489
Susan M. Fleming, PhD, Allen Park, Michigan
Partial laryngectomy with preservation of speech function has gained acceptance as a method of management for selected laryngeal lesions. Often, however, the benefits realized in conservation of voice are associated with an accompanying disorder of deglutition. Cineradiographic studies indicate that a majority of patients having had supraglottic laryngectomy will experience some problem with postoperative aspiration [1,2]. Definitive guidelines have yet to be fully established that will reliably identify those patients who may be expected to benefit from conservative laryngectomy while still retaining satisfactory swallowing function. Material and Methods An analysis of swallowing function was made on thirtyeight patients treated by partial laryngectomy. These were selected from 240 patients who had recently undergone surgery for laryngeal cancer at the Veterans Administration Hospital, Allen Park, Michigan, and the Detroit Medical Center Hospitals. Only those patients were selected for evaluation for whom a sufficiently detailed record of postoperative deglutition function could be concurrently or retrospectively obtained to permit accurate rating of this function for both liquids and solids. Patients for this study were grouped according to the surgical procedure appropriate for their anatomic defects as follows: (1) Hemilaryngectomy. The typical resection included the true cord, false cord, and ventricle and superior laryngeal nerve unilaterally with preservative of the epiglottis. (Figure 1.) (2) Unilateral supraglottic laryngectomy. This resection included the epiglottis, one false cord, and the aryepiglottic fold along with the ipsilateral superior laryngeal nerve. (Figure 2.) From the Departments of Surgery and Otolaryngology. Wayne State University School of Medicine, and the Veterans Administration Hospital, Allen Park, Michigan, and the Detroit Medical Center Hospitals, Detroit, Michigan. Reprint requests should be addressed to Arthur W. Weaver, MD, Surgical Section (112). Veterans Administration Hospital, Allen Park, Michigan 48101. Presented at the Joint Meeting of the American Society for Heed and Neck Surgery and the Society of Head and Neck Surgeons, Toronto, Ontario, Canada, May 29-31, 1978.
486
(3) Bilateral supraglottic laryngectomy. This resection typically included both false cords, both aryepiglottic folds, and one or both superior laryngeal nerves. (Figure 3.) Additional defects, such as extension of the resection into the pyriform sinus or base of the tongue, were also evaluated for any of the above procedures. Method. Most of the patients underwent concurrent evaluation of swallowing function by our deglutition therapist. Evaluations of the remaining patients were made retrospectively from hospital charts and clinic records. When necessary, this information was supplemented by phone interviews with patients or their family members. Swallowing function was rated on a scale from 1 to 5: 1, no swallowing problems; 2, mild dysphagia; 3, moderate dysphagia or aspiration; 4, severe dysphagia or aspiration; 5, inability to swallow. This rating was made six weeks postoperatively and at the time of optimal swallowing function. For most patients this functional plateau was reached approximately six months to one year postoperatively.
Figure 1. Hemilaryngectomy defines an anatomic defect which typically includes the true and false cords and aryeplglottic fold unilaterally. The ipsilateral superior laryngeal nerve Is removed while the bpiglottis is spared.
The American Journal of Surgery
Partial Laryngectomy
Results
Hemilnryngectomy. Eleven patients were evaluated for swallowing function after hemilaryngectomy. Seven of these showed no difficulty in swallowing either liquids or solids at either the initial or subsequent evaluation. These were therefore given a rating of 1 on the deglutition scale. Two patients had initial problems with swallowing but reached a trouble-free status within a few months. An early second primary tumor of the hypopharynx developed in one patient, which made final evaluation impossible. Satisfactory swallowing failed to develop in only one patient with hemilaryngectomy: This patient,, a fifty-four year old white male, underwent preoperative cobalt therapy, 5,200 rads, followed by hemilaryngectomy for a T2 Nl MO lesion of the right true and false cords and ventricle. This was accompanied by radical neck dissection. His recovery was complicated by a laryngeal cutaneous fistula which was eventually closed using a nape of the neck flap. After closure of the fistula, feedings were begun, and the patient experienced some difficulty with aspiration. Subcutaneous tumor seeding of the neck shortly developed, and chemotherapy was begun. He never rt’covered satisfactory swallowing prior to his death. It should be noted that this was the only patient in the hemilaryngectomy group to receive radiotherapy. With this one exception, all evaluated patients with hemilaryngectomy did well. Supraglottic Laryngectomy. Unilateral Twenty-three patients underwent resection which included the epiglottis, one false cord, and the aryepiglottic fold. Also included was the ipsilateral superior laryngeal nerve. All of these patients had some initial difficulty in swallowing (rated 2, 3, 4, or 5 on the deglutition scale). Only seven of these patients were eventually rated 1 (no evident dysphagia for both solids and liquids). Sixteen patients in this group have continued with at least some chronic swallowing disability. Twelve of these have had minimal trouble (rated 2 on the deglutition scale). Four patients have had significant difficulty persisting beyond six months (rated 3,4, or 5). The two patients (rated 4 and 5) had both required resection of a portion of the base of the tongue along with the supraglottic resection. The patient who was rated 5 (complete failure to swallow) had also received postoperative radiotherapy. Bilateral Supraglottic Laryngectomy. Only four patients underwent removal of the epiglottis along with both aryepiglottic folds and false cords. In three of these patients, one superior laryngeal nerve was preserved. None of these patients were able to return to completely normal swallowing. All except one, however, were able to maintain their weight and eat
Volume 136, October 1976
Figure 2. Unilateral supraglottic laryngectomy describes resection which includes the epiglottis, one false cord, aryepiglottic fold, and superior laryngeal nerve. The contralateral superior laryngeal nerve is spared.
with tolerable aspiration. One patient in whom both superior laryngeal nerves were removed had total failure to swallow. He also received postoperative radiotherapy. Radiotherapy. Approximately half our patients had either preoperative or postoperative radiotherapy associated with their supraglottic laryngectomy. The mean rating for optimal swallowing function obtained by the nonirradiated patients was 1.59 on our deglutition scale. The mean rating obtained by the irradiated group was 2.50. The number of pa--
Figure 3. Bilateral supraglottic taryngectomy describes removal of the entire supraglottis. Hopefully, one superior laryngeal nerve may be preserved.
467
Weaver and Fleming
C
D
Figure 4. A, fhe malignant lesion involves epigioMis and the aryepigiottic fold and extends along the pharyngoepigloffic fold into the vailecuia and pyriform sinus. B, Note fixation of aryienoid and true cord in abduction foiiowing resecflon of supragiottic lesion. Food is easliy aspirated through an incompetent glottis. C, the cord and arytenoid are freed by sharp dissection. This reopens the obliterated sinus. D, Ihe silicone stent is transfixed by nonabsorbable sutures. This keeps the sinus patent until epifheiiaiization can occur.
tients in each group was too small to draw significance from this study. The figures do agree, however, with our clinical observation on a much larger group of patients that radiotherapy is a distinct det.riment to swallowing function. In this study, all patients with complete failure to swallow (1 with hemilaryngectomy, 1 with unilateral laryngectomy, and 1 with bilateral laryngectomy) underwent radiotherapy. Cricomyotomy. Only five patients from our group of thirty-eight patients with partial laryngectomy underwent cricomyotomy included with the initial operative procedure. Again, this group is too small for statistical evaluation. One patient from this group, however, had total failure to swallow (after unilateral supraglottic resection, 20 per cent base of tongue resection, and postoperative irradiation) and another had severe postoperative swallowing problems. There was no evidence that cricomyotomy was beneficial to the five patients in whom it was performed. This agrees with the observation of Bocca [3] who discontinued use of this procedure when after a trial period it seemed that cricomyotomy failed to
Figure 5. The Siiastic steni is held in place by sutures passed through the skin of the r&k overiylng the pyriform sinus and tied over piedgets.
produce any benefit. It also supports our previous experience that secondary cri6omyotomy seldom produces any benefit for dysphagia unless definite cricopharyngeal spasm can be demonstrated by cineradiography. Evaluation
of Swallowing
Disorders
Every patient who fails to develop satisfactory swallowing function after head and neck cancer surgery deserves a careful evaluation to determine the reason for this difficulty. Our evaluation included a careful observation of the patient by the physician or trained deglutition therapist during one or several feeding sessions. The patient’s ability to remove food from the mouth to the oropharyngeal port, drooling, head and body position, lift of the larynx, and degree of aspiration should be noted. Special attention should be given to the patient’s mental attitude. Often, encouragement and optimism are the major contributions from the therapist. The cineradiogram is valuable for diagnosis and documentation of specific disorders. We have found the flexible bronchoscope also to be extremely valuable for use in evaluating postoperative dysphagia. The scope may be passed to the level of the soft palate through a locally
The American Journal of Surgery
Partial Laryngectomy
nasal passage. The examiner then observes the swallowing mechanism while the patient attempts to swallow a small quantity of liquid or solid food. Visualization may also be obtained through the tracheal st.oma, if one exists, by passing the bronchoscope in a retrograde fashion to view the undersurface of the vocal cords. The upper trachea should he previously sprayed with small amounts of local anesthetic through the stoma. No local anesthesia should be used in the pharynx or on the upper surface of the vocal cords in either of these examinations. Evaluation of the swallowing mechanism using the flexible endoscope supplemented by careful physical and cineradiographic examination usually permits a definitive evaluation of any postoperative swallowing disorder. Many of these deglutition problems can be surgically corrected. The scope of this paper permits description of only one of these problems and its surgical correction.
anesthetized
The Obliterated
Pyriform Sinus
Malignant lesions of the supraglottic area frequently extend along the pharyngoepiglottic fold as well as the aryepiglottic fold. (Figure 4A.) Surgical removal of such a lesion requires resection of a portion of the pyriform sinus and vallecula along with the supraglottic larynx on the side of the lesion. Mucosal closure of this area frequently obliterates the opening of the pyriform sinus and may fix the arytenoid cartilage and ipsilateral cord in abduction. With no epiglottis to divert the food from the laryngeal introitus, there is now a direct shot for food and liquids into a larynx which is unable to achieve complete glottic closure. (Figure 4B.) Surgically opening the obliterated pyriform sinus with freeing of the arytenoid cartilage has enabled several of our patients to overcome severe swallowing disability. This operation can be done transorally through an operating laryngoscope. Microlaryngeal scissors and sharp dissector are used to free the arytenoid and true cord from the pharyngeal wall and to reestablish the pyriform sinus opening. (Figure 4C.) The raw area of the newly opened pyriform sinus is then stented with a silicone keel. This keel is to be held in place by nonabsorbable sutures passed from the lateral neck. The suture is passed by a swaged straight cutting needle through the skin of the neck into the reopened sinus. The needle is then withdrawn through the laryngoscope, passed through the silicone keel, and reinserted through the new sinus back into the lateral neck. (Figure 4D.) Two such sutures are used to fix the keel in the depths of the wound. These sutures are then tied over cotton or Silastic@ pledgets to fix the keel in place until epitheliahzation has occurred in three or four weeks. Volume 136, October 1976
(Figure 5.) Tracheostomy is recommended for those patients whose tracheal stoma has been allowed to close. Most of these patients, however, because of their swallowing difficulty, will still have an established tracheostomy at the time of surgery.
Conclusions
Patients with apparently similar anatomic defects as a result of partial laryngectomy frequently demonstrate significantly different swallowing abilities. Our study suggests, however, that certain categorization is possible by which one may reasonably anticipate the degree of postoperative dysphagia likely to follow definable surgical resections: (1) Hemilaryngectomy with preservat.ion of the epiglottis rarely produces significant, swallowing dysfunction. (2) Radiation, either preoperatively or postoperatively, combined with supraglottic resection greatly interferes with both early and ultimate swallowing ability. AL1patients with total failure to swallow fell in this category. (3) A patient having bilateral supraglottic resection which includes both superior laryngeal nerves is not likely to achieve satisfactory swallowing. (4) Cricomyotomy was not shown to produce observable benefit to the few patients in whom it was used. (5) Careful evaluation of all patients with continuing swallowing dysfunction should be made to determine if surgical rehabilitation is possible. One such procedure, reestablishment of the pyriform sinus. is described.
Summary
Evaluation of postoperative swallowing ability in thirty-eight patients having had partial laryngectomy indicates that there are marked differences in the degree of dysphagia among individuals with similar surgical defects. This variation in swallowing disability, however, appears to have definable limits. Rehabilitation is possible for many patients disabled by postoperative dysphagia. A transoral surgical technic for reconstruction of the obliterated pyriform sinus is described. References 1. Staple TW, Ogura JH: Cineradiography of the swallowing mechanism following supraglottic subtotal laryngectomy. Radiology 87 (2): 226, 1966. 2. Litton WB, Leonard JR: Aspiration after partial laryngectomy: cineradiography studies. Laryngoscope 79(5): 887, 1969. 3. Bocca E: Supraglottic cancer. Laryngoscope 85(8): 1318, 1975.
489
![[Video fluoroscopy of the swallowing act following partial supraglottic laryngectomy].](/assets/img/hold.png)
