CLINICAL RECORD
The Journal of Laryngology & Otology (2015), 129, 101–105. © JLO (1984) Limited, 2014 doi:10.1017/S0022215114003235
Salvage supracricoid laryngectomy after failed radiotherapy and partial laryngectomy M NAKAYAMA, S MIYAMOTO, S OKABE, M OKAMOTO Department of Otorhinolaryngology – Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
Abstract Background: A case of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed radiation therapy and vertical partial laryngectomy had successful oncological and functional outcomes. This is the first reported application of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after the failure of two major treatments. Case report: A 65-year-old man was referred for salvage supracricoid laryngectomy with cricohyoidoepiglottopexy. The right recurrent hemilarynx was successfully resected. After pexis, the right lobe of the thyroid gland was repositioned to overlap and reinforce the pexis gap and fill the devoid portion of the strap muscular closure. Multiple scattered foci (recurrent tumour–node–metastasis stage T2) were identified around the arytenoid cartilage and beneath the musculocutaneous flap. Four years after supracricoid laryngectomy with cricohyoidoepiglottopexy, the patient’s recovery was following a favourable course and he had satisfactory laryngeal function. Conclusion: Appropriate case selection and proficient surgical skills were essential for a successful outcome. Head and neck surgeons should not be afraid to adopt functional preservation open surgical procedures in well-selected and wellmotivated patients. A requirement for more challenging surgical procedures and meticulous rehabilitation processes should not exclude appropriate treatments from a surgeon’s repertoire. Key words: Laryngeal Cancer; Organ Preservation
Introduction
Case report
Supracricoid laryngectomy with cricohyoidoepiglottopexy is functional organ preservation surgery suitable for early-tointermediate and selected advanced laryngeal cancers. In 1959, the Austrians, Majer and Rieder, reported the initial concept of supracricoid laryngectomy; in the 1970s and 1980s, Piquet and Laccourreye, from France, promoted the clinical use of supracricoid laryngectomy.2,3 Today, supracricoid laryngectomy with cricohyoidoepiglottopexy has become one of the major surgical options for larynx preservation worldwide.4–6 In this surgical procedure, approximately three-quarters of the larynx, including the bilateral glottis and paraglottic spaces (except for one or two arytenoids), is removed.7 The major advantage of this procedure is the associated high control rate for the primary cancer.6,8 Supracricoid laryngectomy with cricohyoidoepiglottopexy can be utilised for salvage after radiotherapy (RT) failure, but has rarely been performed after partial laryngectomies:9 there is only one case report of the use of this technique for salvage after failure of vertical partial laryngectomy.10 We report a case of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed RT (primary failure) and vertical partial laryngectomy (secondary failure), with successful oncological and functional outcomes. A literature search indicated this to be the first report of the clinical application of this surgical procedure after the failure of two major treatments.
Primary and secondary treatments In October 2002, a 58-year-old male company executive was diagnosed with a right glottic squamous cell carcinoma (tumour–node–metastasis (TNM) stage T1aN0M0) at his local hospital. He subsequently had a complete response to RT (62.2 Gy). In April 2006, approximately three and a half years after RT, the first local recurrence (T1aN0M0) developed in the posterior portion of the right vocal fold. He subsequently underwent vertical partial laryngectomy at the same hospital. According to his attending surgeon, the entire right vocal fold had been invaded by the recurrent cancer. It was therefore removed, along with adjacent false vocal folds and subglottic tissue. The defect of the right hemilarynx was reconstructed and primary closure was performed using a sternohyoid muscular flap covered with a local skin strip. Temporary tracheostomy was performed at the time of vertical partial laryngectomy, and was closed three months later. The vertical partial laryngectomy wound developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, resulting in a temporary fistula that required six months to close with local treatment.
Accepted for publication 28 May 2014
Peri-operative course In December 2009, approximately three and a half years after vertical partial laryngectomy, a second local recurrence
First published online 30 December 2014
102 (T2N0M0) developed at the posterior portion of the reconstructed right musculocutaneous flap. Total laryngectomy was recommended by the attending surgeon, but the patient rejected this option because of the associated functional defects. He was then referred to our clinic (approximately 500 km from his local hospital) for possible functional organ preservation treatment. The 65-year-old patient attended our clinic in January 2010. He had quit smoking seven years previously and maintained a moderate pulmonary status, with blood gases at 73 torr (in room air). He exercised regularly and maintained an excellent physical condition for his age (Figure 1a). Laryngoscopy findings revealed an exophytic recurrence at the post-inferior portion of the reconstructed right musculocutaneous flap. Restricted mobility was identified in the right arytenoid (Figure 1b, c). Contrast computed tomography (CT) revealed enhancement to the right hemilarynx (Figure 1d); the left hemilarynx was intact. Based on these findings, supracricoid laryngectomy with cricohyoidoepiglottopexy was considered a suitable treatment option; however, the possibility of intra-operative conversion to total laryngectomy was discussed when obtaining informed consent. Supracricoid laryngectomy with cricohyoidoepiglottopexy was performed in February 2010. For this, a T-shaped skin incision was designed to include the vertical partial
M NAKAYAMA, S MIYAMOTO, S OKABE et al.
laryngectomy and tracheostomy wound scars. The right sternohyoid muscle was missing following vertical partial laryngectomy. The right scarred hemilarynx was carefully resected, along with the left glottis and the remaining portion of thyroid cartilage (Figure 2a). The entire right arytenoid except for the corniculate cartilage was then removed. Nine marginal strips surrounding the resected larynx were submitted for frozen pathological analysis: all margins were tumour negative. Before pexis, the right corniculate cartilage and surrounding pharyngeal mucosa were retracted forward and sutured to the inner edge of the cricoid cartilage to create appropriate airway narrowing of the neoglottis (Figure 2b). After pexis, the right lobe of the thyroid gland was elevated with superior thyroid vessels and relocated so as to overlap and reinforce the pexis gap (Figure 2c) and fill the devoid portion of the strap muscular closure (Figure 2d). Macroscopic observation showed the recurrent cancer to be located at the post-inferior portion of the reconstructed musculocutaneous flap (Figure 3a). Microscopic observation identified moderate- to well-differentiated squamous cell carcinoma at the posterior edge, with multiple foci scattered around the arytenoid cartilage and beneath the musculocutaneous flap (Figure 3b). Abscess formation with extensive fibrosis and a foreign body reaction was noted surrounding the recurrent foci.
FIG. 1 Clinical evaluation of the patient at the initial visit in January 2010. (a) Scarring at the anterior neck resulting from vertical partial laryngectomy and tracheostomy. (b) A distant view of the glottis (black arrow indicates whitish musculocutaneous flap resulting from vertical partial laryngectomy at the right glottis). (c) A close-up view of the glottis (white arrow denotes a recurrent tumour at the right posterior glottis). (d) Tumour enhancement in the right hemilarynx, as revealed by contrast computed tomography.
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FIG. 2 Intra-operative images of supracricoid laryngectomy with cricohyoidoepiglottopexy showing electric cautery directed at the scarred area situated between right hemilarynx (posterior end of the paraglottic space) and pyriform sinus (indicated by finger) (a), right corniculate reconstruction before pexis (b), repositioning of the right lobe of the thyroid gland to overlap and reinforce the pexis gap (c) and use of the right lobe to fill the devoid portion of strap muscular closure (d, white arrow).
Post-operative course The immediate post-supracricoid laryngectomy course was uneventful until the end of the first week, when increased purulent secretion was observed at the T-shaped skin junction and tracheal stoma. An MRSA infection was identified and subsequently treated with an anti-MRSA antibiotic agent. Hyperbaric oxygen therapy was provided for 30 days starting post-surgery day 12. With meticulous local treatment, the infected wound healed completely by postsurgery day 60, and the patient was discharged. After complete healing of the neoglottis (Figure 4), two operations were required to close the tracheal stoma because of local wound infection. In-patient swallowing rehabilitation was provided in September 2010 and the treatment course was completed in October 2010, approximately eight months after supracricoid laryngectomy with cricohyoidoepiglottopexy. In February 2014, four years after supracricoid laryngectomy with cricohyoidoepiglottopexy, the patient had recovered well and had satisfactory laryngeal function. At 2 years postsupracricoid laryngectomy, he spoke with a hoarse voice and had a grade of hoarseness in rough, breathy, asthenic, and strained scales (‘GRBAS’) score of 22 201 and a maximum phonation time of 12 seconds. At four years post-supracricoid laryngectomy, videofluoroscopic swallowing analysis revealed a favourable swallowing outcome for both jelly and liquid iohexol contrast agent (Figure 5). The patient currently has no dietary restrictions and enjoys dining in public. He has resumed his work as a company executive and enjoys coaching a junior league baseball team. FIG. 3 Pathological findings. (a) A supracricoid laryngectomy-resected specimen revealing local recurrence in the post-inferior portion of the whitish musculocutaneous flap. (b) H&E staining of a specimen taken from the slice shown by the dotted line in (a) showing exophytic recurrence with multiple foci scattered beneath the musculocutaneous flap (black arrows; low power view).
Discussion Supracricoid laryngectomy with cricohyoidoepiglottopexy is by far the most radical open surgical procedure for functional organ preservation in glottic cancer. It is reported to be more beneficial than conventional partial laryngectomy for local
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FIG. 4 Images showing neoglottis four years post-supracricoid laryngectomy: (a) Respiratory phase; (b) Phonetic phase.
control.5,8 It can also be used as salvage surgery following RT failure. In our institute, both oncological and functional outcomes have been satisfactory and did not vary between patients undergoing primary and salvage surgery.9 Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy is applicable to all recurrent tumour stages and is the most effective for unfavourable T2 and T3a tumours.9 Despite this positive evidence, the application of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after RT and vertical partial laryngectomy failure was unprecedented. A final decision to use this surgical procedure was based on clinical evaluations, including targeted CT imaging and a patient interview. During the supracricoid laryngectomy with cricohyoidoepiglottopexy procedure, the right scarred hemilarynx was carefully resected, along with the left glottis and the remaining portion of the thyroid cartilage. Fortunately, there was no extralaryngeal extension of the cancer. The surgical margins of the resected specimen were negative in all directions owing to the radical nature of supracricoid laryngectomy, including the
ability to remove the paraglottic space en bloc.7 The entire ipsilateral arytenoid cartilage can also be removed, but it is crucial to preserve and reconstruct the corniculate cartilage,11 which ensures proper airway narrowing of the neoglottis. In consequence of the previous MRSA infection following vertical partial laryngectomy, we repositioned the right lobe of the thyroid gland to overlap and reinforce the pexis gap. The right lobe also perfectly filled the devoid portion to achieve strap muscular closure. When the ipsilateral thyroid lobe is resected for oncological reasons, the contralateral lobe can be used for the same purpose. In this case, susceptibility to MRSA infection was recognised and anticipated. Therefore, when increased purulent secretion was observed, bacterial cultures and additional anti-MRSA treatment were promptly introduced. Hyperbaric oxygen therapy is also reported to facilitate wound healing.12 Various surgical complications are reported to be associated with supracricoid laryngectomy with cricohyoidoepiglottopexy.13 Therefore, for successful surgery, it is important to promptly detect and correctly manage all complications.
FIG. 5 Images of videofluoroscopic swallowing analysis four years post-supracricoid laryngectomy. No mis-swallowing was observed for jelly (a) or liquid iohexol (b).
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• Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed radiation therapy and vertical partial laryngectomy had successful oncological and functional outcomes • This is the first case report of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy performed after the failure of two major treatments • Appropriate case selection and proficient surgical skills were key to a successful outcome In addition to a favourable oncological outcome, supracricoid laryngectomy with cricohyoidoepiglottopexy can be used to achieve a functional outcome comparable with that of vertical partial laryngectomy.8 Special attention must be paid to cases involving extended resection of the arytenoid or cricoid cartilage, which may compromise laryngeal function and require prolonged recovery.14,15 This patient attained a satisfactory functional outcome, but the recovery process took longer than eight months. However, this long recovery period was expected and had been discussed preoperatively with both the patient and his family.
Conclusion Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy was successfully applied after failure of two major treatments (RT and vertical partial laryngectomy). Appropriate case selection and proficient surgical skills were key to a successful outcome for this patient. To make a final decision in such highly challenging cases, the patient benefit should be prioritised over clinical interests. Conversion to total laryngectomy should always be discussed with the patient and viewed as an oncological backup. Head and neck surgeons should not be afraid to adopt functional preservation open surgical procedures in wellselected and well-motivated patients. A requirement for more challenging surgical procedures and meticulous rehabilitation processes should not exclude appropriate treatments from a surgeon’s repertoire.
Acknowledgements This study was supported by a Grant-in-Aid for Scientific Research (C) award from the Ministry of Education, Culture, Sports, Science and Technology of Japan (24592608: 2012–2015), and a grant from the Kanagawa Health Foundation (2013–2014). References 1 Majer EH, Rieder W. Technique of laryngectomy permitting the conservation of respiratory permeability (cricohyoidopexy) [in French]. Ann Otolaryngol 1959;76:677–81 2 Piquet J, Chevalier D. Subtotal laryngectomy with cricohyoidoepiglotto-pexy for the treatment of extended glottic carcinomas. Am J Surg 1991;162:357–61
3 Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidoepiglottopexy: A partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99:421–6 4 Sperry SM, Rassekh CH, Laccourreye O, Weinstein GS. Supracricoid partial laryngectomy for primary and recurrent laryngeal cancer. JAMA Otolaryngol Head Neck Surg 2013; 139:1226–35 5 Zhang S, Lu Z, Chen L, Lou X, Ge P, Song X et al. Supracricoid partial laryngectomy cricohyoidoepiglottopexy (SCPL-CHEP) versus vertical partial laryngectomy for the treatment of glottic carcinoma. Eur Arch Otorhinolaryngol 2013;270:1027–34 6 Nakayama M, Okamoto M, Miyamoto S, Yokobori S, Takeda M, Masaki T et al. Supracricoid laryngectomy with cricohyoidoepiglotto-pexy or cricohyoido-pexy: Experience on 32 patients. Auris Nasus Larynx 2008;35:77–82 7 Kim M, Sun D, Park K, Cho K, Park Y, Cho S. Paraglottic space in supracricoid laryngectomy. Arch Otolaryngol Head Neck Surg 2002;128:304–7 8 Laccourreye O, Laccourreye L, Garcia D, Gutierrez-Fonseca R, Brasnu D, Weinstein G. Vertical partial laryngectomy versus supracricoid partial laryngectomy for selected carcinomas of the true vocal cord classified as T2N0. Ann Otol Rhinol Laryngol 2000;109:965–71 9 Nakayama M, Okamoto M, Hayakawa K, Ishiyama H, Kotani S, Miyamoto S et al. Clinical outcome of supracricoid laryngectomy with cricohyoidoepiglottopexy: radiation failure versus previously untreated patients. Auris Nasus Larynx 2013;40: 207–10 10 Luna-Ortiz K, Nuñez-Valencia E, Carmona-Luna T. Supracricoid partial laryngectomy as salvage for recurrent carcinoma of the larynx initially treated by vertical partial hemilaryngectomy. Case report [in Spanish]. Cir Cir 2008;76:333–7 11 Loyo M, Laccourreye O, Weinstein G, Helsingr C. Corniculate reconstruction after arytenoid resection in supracricoid laryngectomy. Laryngoscope 2014;124:472–5 12 Nakayama M, Okamoto M, Seino Y, Miyamoto S, Matsuki T, Ogawa A. Delayed wound infection after supracricoid partial laryngectomy following failure of high dose radiation. Eur Arch Otorhinolaryngol 2011;268:273–9 13 Naudo P, Laccourreye O, Weinstein G, Jouffre V, Laccourreye H, Brasnu D. Complications and functional outcome after supracricoid laryngectomy with cricohyoidoepiglottopexy. Otolaryngology Head Neck Surg 1998;118:124–9 14 Park J, Joo Y, Cho K, Kim N, Kim M. Functional and oncologic results of extended supracricoid partial laryngectomy. Arch Otolaryngol Head Neck Surg 2011;137:1124–9. 15 Laccourreye O, Ross J, Brasnu D, Chabardes E, Kelly J, Laccourreye H. Extended supracricoid partial laryngectomy with tracheocricohyoidoepiglottopexy. Arch Otolaryngol 1994; 114:669–74 Address for correspondence: Dr M Nakayama, Department of Otorhinolaryngology – Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 252-0374, Japan Fax:+81–42–778–8441 E-mail: [email protected] Dr M Nakayama takes responsibility for the integrity of the content of the paper Competing interests: None declared
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The Journal of Laryngology & Otology (2015), 129, 101–105. © JLO (1984) Limited, 2014 doi:10.1017/S0022215114003235
Salvage supracricoid laryngectomy after failed radiotherapy and partial laryngectomy M NAKAYAMA, S MIYAMOTO, S OKABE, M OKAMOTO Department of Otorhinolaryngology – Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
Abstract Background: A case of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed radiation therapy and vertical partial laryngectomy had successful oncological and functional outcomes. This is the first reported application of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after the failure of two major treatments. Case report: A 65-year-old man was referred for salvage supracricoid laryngectomy with cricohyoidoepiglottopexy. The right recurrent hemilarynx was successfully resected. After pexis, the right lobe of the thyroid gland was repositioned to overlap and reinforce the pexis gap and fill the devoid portion of the strap muscular closure. Multiple scattered foci (recurrent tumour–node–metastasis stage T2) were identified around the arytenoid cartilage and beneath the musculocutaneous flap. Four years after supracricoid laryngectomy with cricohyoidoepiglottopexy, the patient’s recovery was following a favourable course and he had satisfactory laryngeal function. Conclusion: Appropriate case selection and proficient surgical skills were essential for a successful outcome. Head and neck surgeons should not be afraid to adopt functional preservation open surgical procedures in well-selected and wellmotivated patients. A requirement for more challenging surgical procedures and meticulous rehabilitation processes should not exclude appropriate treatments from a surgeon’s repertoire. Key words: Laryngeal Cancer; Organ Preservation
Introduction
Case report
Supracricoid laryngectomy with cricohyoidoepiglottopexy is functional organ preservation surgery suitable for early-tointermediate and selected advanced laryngeal cancers. In 1959, the Austrians, Majer and Rieder, reported the initial concept of supracricoid laryngectomy; in the 1970s and 1980s, Piquet and Laccourreye, from France, promoted the clinical use of supracricoid laryngectomy.2,3 Today, supracricoid laryngectomy with cricohyoidoepiglottopexy has become one of the major surgical options for larynx preservation worldwide.4–6 In this surgical procedure, approximately three-quarters of the larynx, including the bilateral glottis and paraglottic spaces (except for one or two arytenoids), is removed.7 The major advantage of this procedure is the associated high control rate for the primary cancer.6,8 Supracricoid laryngectomy with cricohyoidoepiglottopexy can be utilised for salvage after radiotherapy (RT) failure, but has rarely been performed after partial laryngectomies:9 there is only one case report of the use of this technique for salvage after failure of vertical partial laryngectomy.10 We report a case of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed RT (primary failure) and vertical partial laryngectomy (secondary failure), with successful oncological and functional outcomes. A literature search indicated this to be the first report of the clinical application of this surgical procedure after the failure of two major treatments.
Primary and secondary treatments In October 2002, a 58-year-old male company executive was diagnosed with a right glottic squamous cell carcinoma (tumour–node–metastasis (TNM) stage T1aN0M0) at his local hospital. He subsequently had a complete response to RT (62.2 Gy). In April 2006, approximately three and a half years after RT, the first local recurrence (T1aN0M0) developed in the posterior portion of the right vocal fold. He subsequently underwent vertical partial laryngectomy at the same hospital. According to his attending surgeon, the entire right vocal fold had been invaded by the recurrent cancer. It was therefore removed, along with adjacent false vocal folds and subglottic tissue. The defect of the right hemilarynx was reconstructed and primary closure was performed using a sternohyoid muscular flap covered with a local skin strip. Temporary tracheostomy was performed at the time of vertical partial laryngectomy, and was closed three months later. The vertical partial laryngectomy wound developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, resulting in a temporary fistula that required six months to close with local treatment.
Accepted for publication 28 May 2014
Peri-operative course In December 2009, approximately three and a half years after vertical partial laryngectomy, a second local recurrence
First published online 30 December 2014
102 (T2N0M0) developed at the posterior portion of the reconstructed right musculocutaneous flap. Total laryngectomy was recommended by the attending surgeon, but the patient rejected this option because of the associated functional defects. He was then referred to our clinic (approximately 500 km from his local hospital) for possible functional organ preservation treatment. The 65-year-old patient attended our clinic in January 2010. He had quit smoking seven years previously and maintained a moderate pulmonary status, with blood gases at 73 torr (in room air). He exercised regularly and maintained an excellent physical condition for his age (Figure 1a). Laryngoscopy findings revealed an exophytic recurrence at the post-inferior portion of the reconstructed right musculocutaneous flap. Restricted mobility was identified in the right arytenoid (Figure 1b, c). Contrast computed tomography (CT) revealed enhancement to the right hemilarynx (Figure 1d); the left hemilarynx was intact. Based on these findings, supracricoid laryngectomy with cricohyoidoepiglottopexy was considered a suitable treatment option; however, the possibility of intra-operative conversion to total laryngectomy was discussed when obtaining informed consent. Supracricoid laryngectomy with cricohyoidoepiglottopexy was performed in February 2010. For this, a T-shaped skin incision was designed to include the vertical partial
M NAKAYAMA, S MIYAMOTO, S OKABE et al.
laryngectomy and tracheostomy wound scars. The right sternohyoid muscle was missing following vertical partial laryngectomy. The right scarred hemilarynx was carefully resected, along with the left glottis and the remaining portion of thyroid cartilage (Figure 2a). The entire right arytenoid except for the corniculate cartilage was then removed. Nine marginal strips surrounding the resected larynx were submitted for frozen pathological analysis: all margins were tumour negative. Before pexis, the right corniculate cartilage and surrounding pharyngeal mucosa were retracted forward and sutured to the inner edge of the cricoid cartilage to create appropriate airway narrowing of the neoglottis (Figure 2b). After pexis, the right lobe of the thyroid gland was elevated with superior thyroid vessels and relocated so as to overlap and reinforce the pexis gap (Figure 2c) and fill the devoid portion of the strap muscular closure (Figure 2d). Macroscopic observation showed the recurrent cancer to be located at the post-inferior portion of the reconstructed musculocutaneous flap (Figure 3a). Microscopic observation identified moderate- to well-differentiated squamous cell carcinoma at the posterior edge, with multiple foci scattered around the arytenoid cartilage and beneath the musculocutaneous flap (Figure 3b). Abscess formation with extensive fibrosis and a foreign body reaction was noted surrounding the recurrent foci.
FIG. 1 Clinical evaluation of the patient at the initial visit in January 2010. (a) Scarring at the anterior neck resulting from vertical partial laryngectomy and tracheostomy. (b) A distant view of the glottis (black arrow indicates whitish musculocutaneous flap resulting from vertical partial laryngectomy at the right glottis). (c) A close-up view of the glottis (white arrow denotes a recurrent tumour at the right posterior glottis). (d) Tumour enhancement in the right hemilarynx, as revealed by contrast computed tomography.
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FIG. 2 Intra-operative images of supracricoid laryngectomy with cricohyoidoepiglottopexy showing electric cautery directed at the scarred area situated between right hemilarynx (posterior end of the paraglottic space) and pyriform sinus (indicated by finger) (a), right corniculate reconstruction before pexis (b), repositioning of the right lobe of the thyroid gland to overlap and reinforce the pexis gap (c) and use of the right lobe to fill the devoid portion of strap muscular closure (d, white arrow).
Post-operative course The immediate post-supracricoid laryngectomy course was uneventful until the end of the first week, when increased purulent secretion was observed at the T-shaped skin junction and tracheal stoma. An MRSA infection was identified and subsequently treated with an anti-MRSA antibiotic agent. Hyperbaric oxygen therapy was provided for 30 days starting post-surgery day 12. With meticulous local treatment, the infected wound healed completely by postsurgery day 60, and the patient was discharged. After complete healing of the neoglottis (Figure 4), two operations were required to close the tracheal stoma because of local wound infection. In-patient swallowing rehabilitation was provided in September 2010 and the treatment course was completed in October 2010, approximately eight months after supracricoid laryngectomy with cricohyoidoepiglottopexy. In February 2014, four years after supracricoid laryngectomy with cricohyoidoepiglottopexy, the patient had recovered well and had satisfactory laryngeal function. At 2 years postsupracricoid laryngectomy, he spoke with a hoarse voice and had a grade of hoarseness in rough, breathy, asthenic, and strained scales (‘GRBAS’) score of 22 201 and a maximum phonation time of 12 seconds. At four years post-supracricoid laryngectomy, videofluoroscopic swallowing analysis revealed a favourable swallowing outcome for both jelly and liquid iohexol contrast agent (Figure 5). The patient currently has no dietary restrictions and enjoys dining in public. He has resumed his work as a company executive and enjoys coaching a junior league baseball team. FIG. 3 Pathological findings. (a) A supracricoid laryngectomy-resected specimen revealing local recurrence in the post-inferior portion of the whitish musculocutaneous flap. (b) H&E staining of a specimen taken from the slice shown by the dotted line in (a) showing exophytic recurrence with multiple foci scattered beneath the musculocutaneous flap (black arrows; low power view).
Discussion Supracricoid laryngectomy with cricohyoidoepiglottopexy is by far the most radical open surgical procedure for functional organ preservation in glottic cancer. It is reported to be more beneficial than conventional partial laryngectomy for local
104
M NAKAYAMA, S MIYAMOTO, S OKABE et al.
FIG. 4 Images showing neoglottis four years post-supracricoid laryngectomy: (a) Respiratory phase; (b) Phonetic phase.
control.5,8 It can also be used as salvage surgery following RT failure. In our institute, both oncological and functional outcomes have been satisfactory and did not vary between patients undergoing primary and salvage surgery.9 Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy is applicable to all recurrent tumour stages and is the most effective for unfavourable T2 and T3a tumours.9 Despite this positive evidence, the application of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after RT and vertical partial laryngectomy failure was unprecedented. A final decision to use this surgical procedure was based on clinical evaluations, including targeted CT imaging and a patient interview. During the supracricoid laryngectomy with cricohyoidoepiglottopexy procedure, the right scarred hemilarynx was carefully resected, along with the left glottis and the remaining portion of the thyroid cartilage. Fortunately, there was no extralaryngeal extension of the cancer. The surgical margins of the resected specimen were negative in all directions owing to the radical nature of supracricoid laryngectomy, including the
ability to remove the paraglottic space en bloc.7 The entire ipsilateral arytenoid cartilage can also be removed, but it is crucial to preserve and reconstruct the corniculate cartilage,11 which ensures proper airway narrowing of the neoglottis. In consequence of the previous MRSA infection following vertical partial laryngectomy, we repositioned the right lobe of the thyroid gland to overlap and reinforce the pexis gap. The right lobe also perfectly filled the devoid portion to achieve strap muscular closure. When the ipsilateral thyroid lobe is resected for oncological reasons, the contralateral lobe can be used for the same purpose. In this case, susceptibility to MRSA infection was recognised and anticipated. Therefore, when increased purulent secretion was observed, bacterial cultures and additional anti-MRSA treatment were promptly introduced. Hyperbaric oxygen therapy is also reported to facilitate wound healing.12 Various surgical complications are reported to be associated with supracricoid laryngectomy with cricohyoidoepiglottopexy.13 Therefore, for successful surgery, it is important to promptly detect and correctly manage all complications.
FIG. 5 Images of videofluoroscopic swallowing analysis four years post-supracricoid laryngectomy. No mis-swallowing was observed for jelly (a) or liquid iohexol (b).
105
CLINICAL RECORD
• Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy after failed radiation therapy and vertical partial laryngectomy had successful oncological and functional outcomes • This is the first case report of salvage supracricoid laryngectomy with cricohyoidoepiglottopexy performed after the failure of two major treatments • Appropriate case selection and proficient surgical skills were key to a successful outcome In addition to a favourable oncological outcome, supracricoid laryngectomy with cricohyoidoepiglottopexy can be used to achieve a functional outcome comparable with that of vertical partial laryngectomy.8 Special attention must be paid to cases involving extended resection of the arytenoid or cricoid cartilage, which may compromise laryngeal function and require prolonged recovery.14,15 This patient attained a satisfactory functional outcome, but the recovery process took longer than eight months. However, this long recovery period was expected and had been discussed preoperatively with both the patient and his family.
Conclusion Salvage supracricoid laryngectomy with cricohyoidoepiglottopexy was successfully applied after failure of two major treatments (RT and vertical partial laryngectomy). Appropriate case selection and proficient surgical skills were key to a successful outcome for this patient. To make a final decision in such highly challenging cases, the patient benefit should be prioritised over clinical interests. Conversion to total laryngectomy should always be discussed with the patient and viewed as an oncological backup. Head and neck surgeons should not be afraid to adopt functional preservation open surgical procedures in wellselected and well-motivated patients. A requirement for more challenging surgical procedures and meticulous rehabilitation processes should not exclude appropriate treatments from a surgeon’s repertoire.
Acknowledgements This study was supported by a Grant-in-Aid for Scientific Research (C) award from the Ministry of Education, Culture, Sports, Science and Technology of Japan (24592608: 2012–2015), and a grant from the Kanagawa Health Foundation (2013–2014). References 1 Majer EH, Rieder W. Technique of laryngectomy permitting the conservation of respiratory permeability (cricohyoidopexy) [in French]. Ann Otolaryngol 1959;76:677–81 2 Piquet J, Chevalier D. Subtotal laryngectomy with cricohyoidoepiglotto-pexy for the treatment of extended glottic carcinomas. Am J Surg 1991;162:357–61
3 Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidoepiglottopexy: A partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99:421–6 4 Sperry SM, Rassekh CH, Laccourreye O, Weinstein GS. Supracricoid partial laryngectomy for primary and recurrent laryngeal cancer. JAMA Otolaryngol Head Neck Surg 2013; 139:1226–35 5 Zhang S, Lu Z, Chen L, Lou X, Ge P, Song X et al. Supracricoid partial laryngectomy cricohyoidoepiglottopexy (SCPL-CHEP) versus vertical partial laryngectomy for the treatment of glottic carcinoma. Eur Arch Otorhinolaryngol 2013;270:1027–34 6 Nakayama M, Okamoto M, Miyamoto S, Yokobori S, Takeda M, Masaki T et al. Supracricoid laryngectomy with cricohyoidoepiglotto-pexy or cricohyoido-pexy: Experience on 32 patients. Auris Nasus Larynx 2008;35:77–82 7 Kim M, Sun D, Park K, Cho K, Park Y, Cho S. Paraglottic space in supracricoid laryngectomy. Arch Otolaryngol Head Neck Surg 2002;128:304–7 8 Laccourreye O, Laccourreye L, Garcia D, Gutierrez-Fonseca R, Brasnu D, Weinstein G. Vertical partial laryngectomy versus supracricoid partial laryngectomy for selected carcinomas of the true vocal cord classified as T2N0. Ann Otol Rhinol Laryngol 2000;109:965–71 9 Nakayama M, Okamoto M, Hayakawa K, Ishiyama H, Kotani S, Miyamoto S et al. Clinical outcome of supracricoid laryngectomy with cricohyoidoepiglottopexy: radiation failure versus previously untreated patients. Auris Nasus Larynx 2013;40: 207–10 10 Luna-Ortiz K, Nuñez-Valencia E, Carmona-Luna T. Supracricoid partial laryngectomy as salvage for recurrent carcinoma of the larynx initially treated by vertical partial hemilaryngectomy. Case report [in Spanish]. Cir Cir 2008;76:333–7 11 Loyo M, Laccourreye O, Weinstein G, Helsingr C. Corniculate reconstruction after arytenoid resection in supracricoid laryngectomy. Laryngoscope 2014;124:472–5 12 Nakayama M, Okamoto M, Seino Y, Miyamoto S, Matsuki T, Ogawa A. Delayed wound infection after supracricoid partial laryngectomy following failure of high dose radiation. Eur Arch Otorhinolaryngol 2011;268:273–9 13 Naudo P, Laccourreye O, Weinstein G, Jouffre V, Laccourreye H, Brasnu D. Complications and functional outcome after supracricoid laryngectomy with cricohyoidoepiglottopexy. Otolaryngology Head Neck Surg 1998;118:124–9 14 Park J, Joo Y, Cho K, Kim N, Kim M. Functional and oncologic results of extended supracricoid partial laryngectomy. Arch Otolaryngol Head Neck Surg 2011;137:1124–9. 15 Laccourreye O, Ross J, Brasnu D, Chabardes E, Kelly J, Laccourreye H. Extended supracricoid partial laryngectomy with tracheocricohyoidoepiglottopexy. Arch Otolaryngol 1994; 114:669–74 Address for correspondence: Dr M Nakayama, Department of Otorhinolaryngology – Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 252-0374, Japan Fax:+81–42–778–8441 E-mail: [email protected] Dr M Nakayama takes responsibility for the integrity of the content of the paper Competing interests: None declared
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