Supracricoid Partial Laryngectomy

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Supracricoid Partial Laryngectomy

• Karen Stierman, M.D.
• Shawn Newlands, M.D.
• March 14, 2001

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Supracricoid Laryngectomy

• Horizontal partial laryngectomy
• Conservation not conservative
• Introduced by Majer and Reider, 1959
• Refined by Labayle, Bistmuth, Piquet
• Introduced in U.S. in 1990s

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Types of SCL

• Based on reconstructive technique
• Supracricoid laryngectomy with cricohyoidopexy(SCL
  -CHP) for supraglottic lesions
• Supracricoid laryngectomy with cricohyoidoepiglott
  opexy(SCL-CHEP)for glottic lesions

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Anatomy

• Pre-epiglottic space defined superiorly by
  hyopepiglottic ligament, anteriorly by the
  thyrohyoid membrane, inferiorly by the
  thyroepiglottic ligament, and posteriorly by the
  epiglottis
• Paraglottic space bounded by quadrangular
  membrane, medial piriform sinus wall, conus
  elasticus, and thyroid cartilage

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Route of Spread

• Pressman dye studies showed supraglottis distinct
  from glottis
• Supraglottic cancer can spread transglottically
  through medial surface of thyroid ala
• Can also spread via anterior commissure/pre-epiglo
  ttic space to involve glottis and thyroid
  cartilage.
• Supraglottic contraindicated in above cases but
  SCL is still an option

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Supracricoid laryngectomy

• Remove the entire supraglottis, false and true
  vocal cords and the thyroid cartilage including
  the paraglottic/preepiglottic space
• Up to one arytenoid can be resected
• Phonatory and swallowing function saved

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Indications for SCL

• Cancer that
• 1. Involves the glottis and anterior commissure
• 2. Invades the ventricle
• 3. Is associated with impaired vocal cord
  mobility
• 4. Invades the thyroid cartilage
• 5. Has paraglottic/transglottic invasion
• 6. Has moderate preepiglottic space invasion

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Contraindications for SCL

• True hemilaryngeal fixation(vc arytenoid)
• Base of tongue involvement
• Massive preepiglottic space or vallecular
  invasion
• Cricoid cartilage involvement(10mm anterior / 5
  mm posterior)
• Interarytenoid involvement
• Extensive thyroid cartilage involvement
• Inability to adhere to post-operative care

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Contraindications of SCL

• Age alone is not a contraindication
• GERD
• Inability to perform supraglottic swallow
• Inadequate pulmonary reserve/FEV1lt50

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Selection criteria for SCL

• AJCC staging system not foolproof must consider
  each case individually
• SCL have been performed on lesions in T1b-T4
  range with T2 and T3 tumors being most common
• Not just for advanced tumors consider in cases of
  VPL
• Consider other options
• TL
• XRT Differences in local control rate more
  defined with larger tumors

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Preoperative Assessment

• History and Physical Exam
• Fiberoptic laryngoscopy v.c. mobility/site of
  fixation
• Labs and CXR to rule out metastasis
• CT or MRI
• Staging panendoscopy arytenoid mobility
• /- Pulmonary function tests, Videostrobe

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Preoperative counseling

• Go over all options
• Dysphagia NGT, possible PEG, Swallowing
  rehabilitation
• Tracheostomy
• Voice

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Neck Dissection

• Controversial
• N0 - II,III,IV
• N - MRND or RND
• Vincentiis presence of N2 disease is relative
  contraindication for SCL-CHP

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Post-operative care

• Cuffless trach tube at end of procedure vs.
  deflate cuff on POD1
• Lack of cuff preserves active cough reflex
• First attempt at decannulation is POD 3
• Early decannulation allows elevation of neolarynx
  and encourages mobilization of arytenoid
• Once decannulated, pt encouraged to swallow
  secretions supraglottic swallow
• Once tolerating pureed diet NGT removed

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Local Recurrence

• 1998 study Laccourreye
• Symptoms Dyspnea, dysphonia, otalgia,
  odynophagia, neck mass
• Laryngoscopy submucosal mass, cricoid stenosis,
  fixation of arytenoid, ulceration of c-a region
• CT lysis of cricoid, invasion of c-a
  region,preepiglottic, paraglottic space
• Tx chemo/xrt or TL

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Quality of Life SCL vs TL

• Weinstein, et. Al
• SCL better than TL in areas of physical function,
  general health, vitality, social function,
  emotional limitations, and physical health
  summary, eating, pain and voice related quality
  of life

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Conclusion

• Controversial
• Patient selection key
• Preoperative counseling important