Larynx and trachea
INTRODUCTION
The larynx is one of the most important organs in the upper
aerodigestive tract, providing communicative skills through the
production of sound. Any anatomic or physiologic disturbance in
the larynx may impact not only on the quality of the voice but
also on the function of swallowing, due to the harmonious
relationship between the larynx and pharynx during the
pharyngeal phase of deglutition. The larynx begins at the tip of
the epiglottis cephalad and ends at the lower border of the cricoid
cartilage caudad (Fig. 8.1). Anterosuperiorly it is related to the
base of the tongue via tlie muscular attachments to the hyoid
bone and the thyrohyoid membrane. Its lower border is con-
tinuous with the cervical trachea (Fig. 8.2). Peripherally it is in
juxtaposition to the base of the tongue, hypopharynx and cervical
esophagus (Fig. 8.3). The laryngeal framework is made up of the
hyoid bone and the thyroid, cricoid, arytenoid, cuneiform and
corniculate cartilages. Although epiglottis does not form the
framework of the larynx, it consists of the epiglottic cartilage
covered by mucous membrane.
The larynx is divided into supraglottic, glottic and subglottic
regions. These anatomic divisions are based on embryologic dev-
Fig. 8.2 The anatomic relationships of the
arynx.
Fig. 8.1 The anatomic limits of the larynx.
8
elopment and have important clinical implications. Lymphatic
drainage of the supraglottic larynx is very rich compared with the
scanty lymphatic network in the submucosal plane of the true
vocal cords. The patterns of regional spread of laryngeal cancer
therefore depend on the site of origin and the local extent of the
primary tumor.
Each of the three regions of the larynx is divided into various
sites (Fig. 8.4). The sites in the supraglottic region are: the
laryngeal surface of the epiglottis, aryepiglottic folds, arytenoids,
ventricular bands or false vocal cords and ventricles which are
potential spaces between the false and true vocal cords. In the
glottic larynx, the right and left vocal cords and anterior com-
missure represent the three designated sites. The subglottic region
is generally considered as one site and is divided into its right and
left lateral walls.
The surface mucosa of the larynx consists of squamous epi-
thelium with interspersed mucous glands. The true vocal cords are
lined by stratified squamous epithelium. The sensory nerve supply
to the supraglottic larynx is provided by the internal laryngeal
branch of the superior laryngeal nerve. Intrinsic musculature of
the larynx derives its innervation from the recurrent laryngeal
nerve except the cricothyroid muscle which is innervated by the
external laryngeal branch of the superior laryngeal nerve.
Fig. 8.3 The peripheral relationship of the
larynx to the base of the tongue, hypopharynx
and cervical esophagus.
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Fig. 8-4 The anatomic regions and sites of the larynx.
Fig. 8.5 Estimate of new cases and deaths for cancer of the larynx in
USA in 2002.
Squamous cell carcinomas comprise over 9 5 % of primary
malignant t u m o r s o f t h e l a r y n x . The r e m a i n i n g are t u m o r s arising
from the m i n o r salivary glands, n e u r o e p i t h e l i a l t u m o r s , soft tissue
tumors a n d , rarely, c a r t i l a g i n o u s t u m o r s arising f r o m the laryngeal
framework.
In 2002 the A m e r i c a n Cancer Society estimated a p p r o x i m a t e l y
8900 new cases of cancer of the l a r y n x in t h e USA. Death rate
estimates vary d e p e n d i n g on the site a n d stage of t h e p r i m a r y
tumor. However, o v e r a l l , 3 7 0 0 cause-specific deaths were esti-
mated tor 2002 in t h e U n i t e d States ( F i g . 8 . 5 ) . W o r l d w i d e , t h e
incidence o f laryngeal cancer varies i n d i f f e r e n t c o u n t r i e s ( F i g .
8.61. Spain has by far t h e highest i n c i d e n c e of laryngeal cancer
in the w o r l d . It is i n t e r e s t i n g to n o t e t h a t t h e i n c i d e n c e of
supraglottic a n d g l o t t i c cancer is not t h e same in each c o u n t r y .
268
Fig. 8.6 World incidence of cancer of the larynx (incidence per 100,000
population).
Spain has t h e highest i n c i d e n c e of s u p r a g l o t t i c cancer ( F i g . 8.7)
w h i l e I t a l y has the highest incidence of g l o t t i c carcinoma i F i g .
8 . 8 ) . These v a r i a t i o n s in t h e i n c i d e n c e rates m a y be a reflection of
lifestyle a n d habits of p a t i e n t p o p u l a t i o n in different nations, as
w e l l as o t h e r e n v i r o n m e n t a l factors.
Generally, g l o t t i c cancer is by far t h e most c o m m o n site for
p r i m a r y m a l i g n a n t t u m o r s in t h e l a r y n x . T h e site d i s t r i b u t i o n is
s h o w n i n F i g . 8 . 9 . W h e n lesions o f the l a r y n x are described, i t i s
advisable to d o c u m e n t t h e m by a p h o t o g r a p h or to depict them
on a d r a w i n g to precisely demarcate the site as w e l l as the local
e x t e n t o f t h e l e s i o n . I t i s v i t a l l y i m p o r t a n t t o specifically designate
t h e site of o r i g i n of the p r i m a r y lesion w i t h its local extension to
adjacent sites w i t h i n the same region of t h e l a r y n x or f r o m one
region to t h e o t h e r regions. B u l k y lesions m a y e x t e n d b e y o n d the

Fig. 8.7 World Incidence of carcinoma of the supraglottic larynx
(incidence per 100,000 population).
Fig. 8.8 World incidence of carcinoma of the glottic larynx (incidence
per 100,000 population).
larynx i n t o the adjacent base of the t o n g u e , p y r i f o r m sinus,
pharyngeal w a l l or post-cricoid region.
The natural history of laryngeal cancer is dictated by its site of
origin and its p r o c l i v i t y to disseminate to the regional l y m p h a t i c s .
The supraglottic l a r y n x has a rich l y m p h a t i c n e t w o r k leading to
early dissemination of p r i m a r y lesions to the regional l y m p h
nodes. In contrast, the true vocal cords are practically d e v o i d of
lymphatic n e t w o r k u n d e r the mucosa a n d therefore vocal cord
cancers rarely present w i t h regional l y m p h a t i c metastasis at the
time of diagnosis a n d t r e a t m e n t . Staging of p r i m a r y t u m o r s of t h e
larynx is dependent on the surface extent of the lesion to various
Fig. 8.9 The site distribution of cancer of the larynx.
Fig. 8.10 The stage distribution of patients with supraglottic carcinoma.
Fig. 8.11 The stage distribution of patients with glottic carcinoma.
sites w i t h i n the same region of the l a r y n x or f r o m one region to
the o i l i e r region of the larynx or its extension beyond the larynx
to adjacent a n a t o m i c regions as well as on the m o b i l i t y of the
vocal cords. Fixation of the vocal cords signifies a deeply invasive
lesion. The stage d i s t r i b u t i o n of patients w i t h supraglottic
carcinoma a n d g l o t t i c c a r c i n o m a at the t i m e of presentation at
M e m o r i a l Sloan-Kettering Cancer O u t e r is s h o w n in Figs 8.10
a n d 8 . 1 1 . Nearly 7 5 % of patients w i t h g l o t t i c carcinoma have
localized disease at the t i m e of diagnosis, in contrast to nearly
7 0 % o f patients w i t h supraglottic c a r c i n o m a w h o have advanced
disease at presentation.
269
CLINICAL CHARACTERISTICS AND DIAGNOSIS
Patients with primary tumors of the larynx usually present with
complaints of hoarseness of voice, discomfort in the throat,
dysphagia, odynophagia, sensation of something stuck in I he
throat, occasional respiratory obstruction, hemoptysis, or with
referred pain in the ipsilateral ear. The diagnosis in most instances
is made by a thorough clinical examination which includes mirror
examination of the larynx for adequate assessment of the surface
extent of the primary tumor and mobility of the vocal cords (Fig.
8.12). Fiberoptic nasolaryngoscopic or rigid telescopic examin-
ation provides an excellent overview of the larynx and pharynx
and has the capability of close-up views and photographic docu-
mentation. When describing a laryngeal lesion, it is vitally
important to specifically designate the site of origin with its local
Fig. 8.12 Mirror examination of the larynx provides a comprehensive
view of the larynx and pharynx.
Fig. 8.13 Endoscopic view of the normal larynx.
270
extension to adjacent sites or regions. The clinical appearance of a
normal larynx seen through a rigid telescope is shown in Fig.
8.13. This view of the normal larynx clearly gives adequate
visualization of all the anatomic sites of the supraglottic and
glottic larynx as well as the hypopharynx. The dynamic function
of the larynx should also be observed and recorded by asking the
patient to phonate. During phonation, the vocal cords adduct
wiih the pyriform sinuses opening up showing their apices. Symp-
toms such as those described above are often seen with certain
benign lesions of the larynx. Several examples of primary tumors
of the larynx as well as benign lesions of the vocal cords are shown
in Fig.s 8.14-8.32. The mobility of the vocal cords and adequacy
of the airway must be accurately recorded. In addition to this,
direct laryngoscopy with the use of an operating microscope is
often required for accurate assessment of the extent of the primary
lesion, particularly small primary tumors of the vocal cords. The
Fig. 8.14 Benign mucosal polyp on the free edge of the anterior third ol
the right vocal cord.
Fig. 8.1S Benign mucosal polyp near the vocal process on the right
vocal cord.
Fig. 8.16 Bilateral mucosal pseudopolyps of the vocal cords. Fig. 8.17 Fibrous polyp of the right vocal cord.

Fig. 8.18 Post-intubation granuloma of the posterior third of the left Fig. 8.19 Granuloma of the left vocal cord seen through the microscope.
vocal cord.

Fig. 8.20 Teflon granuloma of the right vocal cord post-injection of Fig. 8.21 Squamous papilloma of the right aryepiglottic fold.
Teflon paste for paralyzed vocal cord.

271
Fig. 8.22 Hyperkeratosis of the right vocal cord. Fig. 8 . 2 i Carcinoma in situ presenting as a keratotic nodule of the right
vocal cord.

Fig. 8.24 Superficial carcinosarcoma of the left true vocal cord. Fig. 8.2S Papillary squamous carcinoma of the left true vocal cord.

Fig. 8.26 Ulcerated squamous cell carcinoma of the right vocal cord, Fig. 8.27 Ulcerated carcinoma of the right vocal cord, viewed during
viewed during quiet breathing. phonation.

272

Fig. 8.28 Ulcerated exophytic keratotic squamous carcinoma of the right
vocal cord.
Fig. 8. JO Papillary verrucous carcinoma of the right arytenoid.
Fig. 8.J2 Squamous carcinoma of the left arytenoid.
U LARYNX AND TRACHEA
Fig. 8.29 Squamous carcinoma of the left vocal cord with fixation.
Fig. 8.31 Squamous carcinoma of the right aryepiglottic fold.
most i m p o r t a n t features to lie assessed d u r i n g endoscopic examin-
a t i o n under general anesthesia include accurate documentation of
the site of o r i g i n of the p r i m a r y tumor, a n d its local extensions.
For vocal cord lesions, this includes supraglottic or subglottic
extension of the p r i m a r y t u m o r , a n d i n v o l v e m e n t of the anterior
commissure. Use of various telescopes (0°, 30°, 70° and 120°) pro-
vide an excellent a n d detailed view of the lesion. For supraglottic
lesions, extension of the t u m o r b e y o n d the larynx i n t o the
adjacent base of the tongue, h y p o p h a r y n x , or post-cricoid region
should he assessed. For lesions i n v o l v i n g the laryngeal surface of
the epiglottis, its inferior extent in relation to the anterior com-
missure is very i m p o r t a n t . Accurate evaluation of the primary
t u m o r in this manner is v i t a l l y i m p o r t a n t for consideration of any
surgical procedure w i t h conservation of the f u n c t i o n of speech,
e.g. various types of partial laryngectomies.
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RADIOGRAPHIC EVALUATION
Radiographic assessment of the larynx is vitally important tor
delineating the extent of a tumor since it may influence the
choice of treatment. Radiographic examination of the larynx
ranges from non-invasive to very invasive studies. A laryngogram
is rarely indicated since it is an invasive study with potential com-
plications. Information derived from a laryngogram can usually
be safely obtained from non-invasive studies and therefore a
laryngogram is usually not recommended.
HIGH KV SOFT TISSUE FILMS
High KV soft tissue films of the larynx obtained in posteroanterior
and lateral projections are readily available and provide valuable
information regarding the extent of the lesion, due to the soft
tissues and cartilage being contrasted against the air spaces giving
an air contrast study. These films should be obtained if CT scan or
VIRI is not available.
Fig. 8.33 Telescopic
view of a bulky
obstructing lesion of
the supraglottic larynx.
Fig. 8.34 High KV film
(posteroanterior
projection).
274
Some examples of high KV films demonstrating laryngeal
tumors are shown here. The telescopic view of a bulky obstructing
lesion of the supraglottic larynx is shown in Fig. 8.33. By
mirror or telescopic examination, the vocal cords could not be
seen. The inferior extent of the tumor could also not be assessed
by telescopic examination. A high KV film in a posteroanterior
projection of the same patient shows the lesion confined to the
supraglottic larynx, involving the left aryepiglottic fold, with the
inferior border of the tumor well above the left false vocal cord
(Fig. 8.34). The lateral high KV film clearly shows the tumor
involving mostly the suprahyoid portion of the laryngeal
surface of the epiglottis with a generous margin between the
lower border of the tumor and the anterior commissure
(Fig. 8.35). This film also shows that the tumor is pedunculated
with an air space between the bulk of the tumor and the
laryngeal surface of the epiglottis. The surgical specimen from the
same patient removed after a supraglottic partial laryngectomy
confirms the radiographic findings seen on the high KV films
(Fig. 8.36). Note the pedunculated tumor arising from the left
aryepiglottic fold involving mostly the suprahyoid portion of
the epiglottis.
Fig. 8.35 Lateral high
KV film.
Fig. 8.36 The surgical
specimen of the tumor
shown in Fig. 8.33.
mm.
 Fig. 8.J7 Lateral high Fig. 8.19
KV film showing Anteroposterior
destruction of thyroid projection of high KV
cartilage. film of the larynx
showing a subglottic
tumor on the right
side.

Fig. 8.40 Axial view of

CT scan of the larynx
showing a tumor of
the cricoid cartilage.

Fig. 8.38 The surgical

specimen of the tumor
shown in Fig. 8.J7.

Fig. 8.41 The surgical

specimen of total
laryngectomy done for
chondrosarcoma of the
cricoid cartilage, shown
on the CT scan in
Fig. 8.40.

A lateral high KV film often shows cartilage invasion by destruc-

tion of the 'figure of eight' sign which is the anterior margin of the
thyroid lamina. The lateral high KV film of a patient with trans-
glottic carcinoma shows significant cartilage destruction with
erosion extending posteriorly (Fig. 8.37). The surgical specimen
of the same patient shown in Fig. 8.38 confirms an extensive,
deeply infiltrating tumor involving the base of the epiglottis and
the anterior commissure, with extension to the subglottic region
and destruction of the true and false vocal cords on both sides.
CT SCANS
A CT scan with intravenous contrast is usually the first, and often
the only, radiographic study required to assess a laryngeal tumor.
The CT scan is quite accurate in assessment of laryngeal lesions,
particularly with reference to tumor extension in the paraglottic
space and invasion of cartilage and adjacent soft tissues. In
addition, a CT scan provides an added benefit of radiographic
evaluation of cervical lymph nodes.
In Fig. 8.39, an anteroposterior projection of a high KV film of
the larynx of a patient with chondrosarcoma of the larynx is
shown. Note the presence of a bulky homogeneous lesion arising
from the right hemilarynx with compromise of the airway. An
axial view of the CT scan of the larynx performed through the
subglottic region shows the tumor arising from the right side of
the cricoid cartilage and projecting into the subglottic airway
(Fig. 8.40). The surgical specimen following total laryngectomy
shows a bulky submucosal tumor arising from the right side of the
subglottic region and extending across the anterior midline to the
left side (Fig. 8.41). Note the degree of airway compromise due to
the bulk of the lesion on both sides of the midline.

275
 Another patient with a chondrosarcoma of the cricoid cartilage
presented with respiratory obstruction. A CT scan in axial view
without contrast shows a cartilaginous tumor arising from the
cricoid cartilage and presenting anteriorly causing compromise of
the airway (Fij>. #.42). Endoscopic view of the same patient under
general anesthesia shows a bulky submucosal multilobulatcd
tumor arising from the cricoid cartilage and the region of the
crico-arytenoid joint on the left-hand side with compromise of
the airway (Fig. 8.43).
Occasionally a C\ scan will detect an unsuspected second
primary tumor or, more importantly, enlarged cervical lymph
nodes which are clinically not palpable. An example of this is

Fig. 8.42 CT scan in the axial view showing a chondrosarcoma of the

cricoid cartilage encroaching upon the airway.

Fig. 8.43 Endoscopic view of the tumor shown in Fig. 8.42.

276
shown in a patient whose telescopic view of the larynx is shown in
H g . 8.44. A primary tumor is seen arising from the left aryepiglottic
fold and hoth pyriform sinuses open well and appear to he clear.
The same patient's CT scan, however, at the level of the thyrohyoid
membrane, shows the presence of one lesion on the aryepiglottic
fold with what appears to he a second lesion on the lateral wall of
the pyriform sinus (Fig. 8.45). The surgical specimen of the same
patient after a supraglottic partial laryngopharyngectomy shows
iwo separate primary lesions: one on the aryepiglottic fold, and a
second on the lateral wall of the pyriform sinus which was
clinically not appreciated (Fig. 8.46). Thus, CT scans of the larynx
are recommended particularly when conservation surgery of the
larynx is under consideration.

Fig. 8.44 Telescopic view of the larynx showing a tumor of the

aryepiglottic fold.

Fig. 8.46 The surgical specimen of the tumors shown in Fig. 8.44.

Fig. 8.45 CT scan showing one lesion on the aryepiglottic fold and a
second lesion on the lateral wall of the pyriform sinus.

277
MRI SCANS

Magnetic resonance images of the larynx have an added ability to

provide three-dimensional images in axial, coronal and sagittal
planes lo further demonstrate local extension of a laryngeal
lesion. This is of particular value In assessing subglottic extent of
the t u m o r f r o m a p r i m a r y lesion of the vocal cords. M H I is a n o n -
invasive test a n d is usually c o m p l e t e d w i t h i n a matter of m i n u t e s .
The MRI scans of a patient w h o had previously u n d e r g o n e
radiation therapy for vocal c o r d cancer w h o n o w presented w i t h
recurrent t u m o r are s h o w n in Figs 8 . 4 7 - 8 . 4 9 . T h e axial v i e w
shows a t u m o r of his right vocal cord w i t h subglottic extension
partially c o m p r o m i s i n g the airway. In coronal v i e w of the MRI
scan, an e x o p h y t i c lesion is clearly seen o b s t r u c t i n g the subglottic
airway. Further v i v i d d e m o n s t r a t i o n of the subglottic t u m o r can
be seen in the sagittal M R I view s h o w i n g a significant o b s t r u c t i o n
produced by the recurrent tumor. T h e surgical specimen of the Fig. 8.49 Sagittal view of the MRI scan shows transglottic tumor.
same patient w h o u n d e r w e n t h e m i l a r y n g e c t o m y shows signifi-
cant subglottic recurrence of his right true vocal cord carcinoma
d i g . 8.50).
An MRI of another patient w i t h a submucosal lesion of the

Fig. 8.50 The surgical specimen of hemilaryngectomy showing

transglottic tumor.

Fig. 8.47 MRI scan in axial view shows tumor of the right vocal cord.

Fig. 8.48 Coronal view of the MRI scan shows subglottic extension of Fig. 8.51 Sagittal view of the MRI scan showing a submucosal lesion of
vocal cord tumor. the infrahyoid portion of the epiglottis.

278
Fig. 8.S2 Axial view of the MRI showing extension into the pre-
epiglottic space.
Fig. 8.53 Endoscopy demonstrates the multilobulated submucosal tumor
of the laryngeal surface of the epiglottis.
infrahyoid portion of the laryngeal surface of the epiglottis is
shown in Fig. 8 . 5 1 . Note the extension of the tumor into the pre-
epiglottic space and its cephalo-caudad extension as well as
posterior projection of the tumor causing compromise of the
airway. Axial view of the MRI scan of the same patient shown in
Fig. 8.52 demonstrates the extension of the tumor into the pre-
epiglottic space at the level of the superior border of the thyroid
cartilage. Rndoscopic view of this patient under general anesthesia
shows the multilobulated submucosal tumor of the laryngeal
surface of the epiglottis (Fig. 8.531. Biopsy of this tumor con-
Fig. 8.S4 Sagittal view of the MRI scan showing a submucosal lesion of
the suprahyoid epiglottis.
Fig. 8.SS Endoscopic examination revealed a smooth submucosal lesion
involving the laryngeal surface of the epiglottis.
firmed this lesion to be an adenoid cystic carcinoma.
Another patient with a submucosal lesion of the suprahyoid
portion of the laryngeal surface of the epiglottis is shown in Fig.
8.54. This sagittal view of the MRI shows a submucosal lesion of
limited extent involving only the suprahyoid portion of the epiglottis
without any extension to the pre-epiglottic space. Endoscopic
examination of the patient shows the lesion to be a smooth
submucosal lesion involving the laryngeal surface of the epiglottis
(Fig. 8.551. This lesion was adequately resected endoscopically
and proved to be a schwannoma of the epiglottis.
279

Fig. 8.56 Axial view o( the CT scan of a patient showing tumor in the
subglottic region.
Fig. 8.57 Total laryngectomy specimen of the patient shown in Fig. 8.56.
Fig. 8 . 5 6 shows an axial CT scan of a patient w h o had
previously undergone endoscopic excision f o l l o w e d by external
radiotherapy for a left g l o t t i c c a r c i n o m a . T h e radiologic extent of
recurrent t u m o r in the left subglottic region was i n d i c a t i v e of t h e
actual extent o f t u m o r f o u n d i n t h e t o t a l l a r y n g e c t o m y specimen
(Fig. 8.57).
Both CT scans a n d MKI scans have the added advantage of
providing assessment ot regional l y m p h a t i c s of the neck, particu-
larly for patients in w h o m regional l y m p h nodes are c l i n i c a l l y not
palpable.
280
TREATMENT COALS
T h e p r i m a r y goal for t h e t r e a t m e n t o l t u m o r s o f t h e l a r y n x i s
clearly c o n t r o l of the cancer. However, w h e n feasible, not only
preservation of the f u n c t i o n of speech but also the q u a l i t y of the
speech a n d n o r m a l s w a l l o w i n g m e c h a n i s m as well as avoidance of
tracheostomy are desirable secondary goals, f o r patients present-
i n g w i t h early-Stage disease, the goal of treatment is preservation
of t h e voice w i t h m i n i m a l sequelae of t r e a t m e n t . Select patients
w i t h locally advanced t u m o r s of the l a r y n x may he candidates lor
sophisticated c o n s e r v a t i o n laryngeal procedures. However, patient
selection a n d expertise in t h e t e c h n i c a l aspects of t h e surgical
procedure as w e l l as an expert r e h a b i l i t a t i o n team are essential for
the successful o u t c o m e of such an a p p r o a c h . The disturbance in
d e g l u t i t i o n resulting f r o m e x t e n d e d partial laryngectomy requires
a vigorous r e h a b i l i t a t i v e effort to restore s w a l l o w i n g w i t h o u t
a s p i r a t i o n . On the o t h e r h a n d , for patients w i t h advanced disease,
l a r y n g e c t o m y f o l l o w e d by postoperative radiation therapy is con-
sidered standard surgical treatment at this t i m e . There is increasing
interest in the use of systemic c h e m o t h e r a p y w i t h the aim of
preservation of the l a r y n x in patients w h o w o u l d otherwise need
t o t a l laryngectomy. W i t h i n the past ten years, c o n v i n c i n g data has
become available f r o m prospective r a n d o m i z e d trials supporting
the role of n e o a d j u v a n t c h e m o t h e r a p y f o l l o w e d by radiotherapy
for larynx preservation. C u r r e n t l y there is increasing interest in
the use of c o n c u r r e n t c h e m o t h e r a p y a n d radiotherapy for larynx
preservation. Preliminary data indicate that the concurrent regimen
is superior to t h e sequential neoadjuvant r e g i m e n . However, the
t o x i c i t y of the c o n c u r r e n t approach is q u i t e h i g h a n d this regimen
remains i n v e s t i g a t i o n a l . Patients w h o require t o t a l laryngectomy
w i t h p h a r y n g e c t o m y need appropriate reconstructive efforts to re-
establish the c o n t i n u i t y of the a l i m e n t a r y tract a n d restore the
ability to swallow by mouth. In those patients who are not candidates
for a n y voice preserving procedures, consideration should be given
to i m m e d i a t e tracheoesophageal p u n c t u r e for voice rehabilitation.
W h e n the e n d points of t r e a t m e n t , i.e. c o n t r o l of cancer and
q u a l i t y of voice, are comparable, the least expensive a n d least
m o r b i d treatment s h o u l d be chosen. I his is particularly applicable
in situations w i t h very early vocal cord cancers where endoscopic
laser excision provides e q u a l l y g o o d disease c o n t r o l a n d an accept-
able q u a l i t y of voice in c o m p a r i s o n to external radiation therapy
w h i c h is expensive a n d takes a p p r o x i m a t e l y 6-7 weeks for its
delivery. A similar argument can be made lor patients w h o are
t e c h n i c a l l y considered to be candidates for an extended voice-
saving operative procedure such as a subtotal laryngectomy. The
operative m o r b i d i t y in terms of delay in s w a l l o w i n g and the
rehabilitative efforts necessary have to be weighed against a total
l a r y n g e c t o m y w i t l i an i m m e d i a t e tracheoesophage.il puncture for
voice r e h a b i l i t a t i o n . These are i m p o r t a n t factors w h i c h should be
included w i t h i n the l o n g - t e r m goals for treating patients w i t h
cancer of the l a r y n x .
TREATMENT ALTERNATIVES
T h e standard o p t i o n s o t t r e a t m e n t i n t h e management o f larynx
cancer are surgery, radiotherapy, chemotherapy, or a c o m b i n a t i o n
of these modalities of t r e a t m e n t . In a d d i t i o n to this, very early
lesions may be managed by endoscopic excision using laser, w i t h
respectable c o n t r o l rates. Single m o d a l i t y treatment is considered
adequate l o r early staged t u m o r s w h i l e advanced stage lesions
require a combination of surgery and radiotherapy or chemo-
therapy, radiotherapy, and possibly salvage surgery.
FACTORS AFFECTING CHOICE OF TREATMENT
Tumor Factors
The tumor factors that influence the choice of initial treatment
arc related to the site and T-Stage of the primary tumor as well as
the mobility of the vocal cord and invasion of the cartilaginous
framework of the larynx. Extensive tumors with fixation of the
vocal cord and invasion of the cartilage framework are not suitable
for cure by radiotherapy. In contrast, early and superficial lesions
of the supraglottic larynx and most early lesions of the true vocal
cord are suitable for radiotherapy with a curative intent.
Exophytic lesions are considered to be more radiation responsive
compared to endophytic lesions. Tumors of the vocal cord with
significant subglottic disease are considered less suitable for radio-
therapy. Squamous cell carcinoma by far predominates all histo-
logic variants. However, tumors of the minor salivary glands
and other epithelial lesions or soft tissue somatic lesions are not
suitable for radiotherapy and are considered surgical candidates.
Patient Factors
Patient factors pertaining to age and general medical condition are
vitally important in terms of the ability of the patient to with-
stand surgery. Nearly all patients undergoing any type of con-
servation surgical procedure for supraglottic tumors, aspirate
varying amounts of their own saliva. Thus, patients with poor
pulmonary reserve are considered unsatisfactory candidates for
conservation surgery. Very elderly and medically unfit patients are
also not suitable for major conservation surgical procedures since
their ability to recuperate from such procedures is very poor. In
addition to this, the occupation of the patient, personal pref-
erence and ability to comply with the prescribed treatment
program are all important considerations in making selection of
initial therapy. Very elderly patients with poor renal function are
not considered candidates for larynx preserving treatment pro-
grams with systemic chemotherapy with cis-platinum followed by
radiotherapy.
Physician Factors
Tor successful outcome of a therapeutic program, expertise in the
field of the chosen therapy is essential. If radiotherapy is
employed as the initial treatment, expertise in contemporary
radiation techniques with appropriate treatment planning to deliver
the desired dosage ami minimize sequelae of treatment is essen-
tial. Similarly, surgical expertise in various aspects of conservation
laryngeal procedures and an expert rehabilitation team are required
for a satisfactory oncologic ami functional outcome following treat-
ment. Patients with advanced tumors requiring multimodal therapy
are best managed by a multidisciplinary team providing a com-
prehensive treatment program with the availability of expertise in
various disciplines essential for such a therapeutic strategy.
SELECTION OF INITIAL THERAPY
The choice of initial treatment depends on the various factors
mentioned above, including knowledge and expertise on the part
of the treating physician regarding the biological behavior of the
tumor, its anticipated response to the therapy employed and the
functional outcome as it relates to patient occupation and satis-
faction to restore the quality of life. Clearly the therapeutic
strategy will be different for patients with supraglottic tumors and
glottic tumors. Surgery is preferred as initial therapy for T, and T.
squamous carcinomas of the supraglottic larynx in patients who
present with N„ or \, neck disease. Surgery is also recommended
for primary tumors of the supraglottic larynx with extension to
the base of the tongue or to the hypopharynx. On the other hand,
radiotherapy in combination with surgery is recommended for
very small primary tumors of the supraglottic larynx with bulky-
neck metastasis. The neck will require a combination of surgery
and adjuvant postoperative radiation therapy while the primary
tumor may be treated definitively with external irradiation. Clearly,
all patients with early supraglottic tumors and poor pulmonary
reserve are candidates for radiotherapy.
lor early staged carcinomas of the glottic larynx, one may employ
endoscopic resection or radiotherapy. Although endoscopic resec-
tion is expeditious and cost effective, the quality of voice may not
be as good as with radiotherapy. Therefore, radiotherapy is pre-
ferred, particularly in those instances where the primary lesions
are exophytic without significant subglottic or supraglottic exten-
sion and without extension to the anterior commissure or the
arytenoid.
Radiotherapy is considered the preferred treatment for those
lesions which involve both vocal cords which are mobile. On the
other hand, bilateral vocal cord lesions which are strictly exophytic
and keralolic in nature involving only the mucosa can be best
managed by endoscopic laser excision which avoids the need to
irradiate the entire larynx and provides excellent local control of
well differentiated hyperkeratotic lesions and in situ carcinomas.
Squamous carcinoma of the vocal cords staged as T. presents a
spectrum of different clinical situations requiring due diligence in
the selection of initial therapy. Patients with reduced mobility of
the vocal cord or fixed vocal cord are best treated by a vertical
partial laryngectomy, as long as the tumor is confined to one side
of the larynx. If the quality of voice is a critically important issue
for the patient and the control rates by surgery and radiotherapy
are comparable, then radiotherapy may be chosen as initial treat-
ment. Select patients who fail external radiotherapy and whose
persistent tumor is still amenable to a voice-saving surgical pro-
cedure are candidates for partial laryngectomy. Select patients
with advanced stage supraglottic or glottic tumors are candidates
for a conservation surgical procedure followed by postoperative
radiation therapy- Most other patients with advanced stage lesions
will either require total laryngectomy or may be candidates for
larynx preservation with a multimodal treatment program con-
sisting of chemotherapy and radiotherapy.
Patients with a supraglottic cancer and a clinically N„ neck
require consideration of ipsilatcral jugular node dissection with
primary tumors on one side of the midline. Primary lesions
crossing the midline should be considered candidates for bilateral
jugular node dissections (Levels II, III and IV). Patients with
clinically palpable neck metastasis require a comprehensive neck
dissection. Patients with cancer of the glottic larynx and a
clinically negative neck are simply observed since the incidence of
occult metastases is very low.
PREOPERATIVE PREPARATION
All patients undergoing surgery for laryngeal cancer should have
assessment of preoperative pulmonary functions. This is particu-
281
larly important for those who have a history of chronic obstruc-
tive pulmonary disease and are being considered for conservation
surgery. Preoperative counseling regarding postoperative pulmonary
care and breathing exercises is vitally important. Consultation and
counseling from a speech pathologist is essential for patients who
are likely to undergo a total laryngectomy. Alternatives regarding
speech rehabilitation are discussed at this meeting. A preoperative
visit reduces the patient's anxiety and apprehension regarding loss
of speech following surgery.

DIRECT LARYNGOSCOPY AND SUSPENSION

MICROLARYNCOSCOPY

The need to accurately assess the extent of a primary tumor of the

larynx before selection of treatment cannot be over-emphasized.
The accuracy of diagnosis and selection of treatment directly
depend on the extent of the primary tumor. Direct laryngoscopy
is best done under general anesthesia, either with a small endo-
tracheal tube or with jet ventilation and complete relaxation to Fig. 8.59 The |ako laryngoscope.
permit adequate assessment of the larynx ami hypopharynx. The
instrument set-up for direct laryngoscopy is shown in Fig. 8.58.
The appropriate choice of laryngoscopes should be available in the
operating room to meet with the demands of varying con-
figurations of larynges and locations of lesions. A fiberoptic light
source is ideal to permit satisfactory visualization. Appropriate
biopsy forceps and appropriate suction tips should also be avail-
able for routine endoscopic assessment. The most frequently used
laryngoscope at present is the lako laryngoscope which provides
binocular vision and a wide-field view of the larynx (Fig. 8.S9).
The laryngoscope carries dual light carriers, channels for which
are built within the walls of the laryngoscope. However, the Dedo
laryngoscope (Fig. 8.60) is preferred because it is somewhat
narrower at its tip but it does not quite provide binocular vision.
The Dedo laryngoscope is required for those patients where the
interior of the larynx is narrow for the Jako laryngoscope or where
assessment of the anterior commissure is important. On the other
hand, newer bivalved laryngoscopes are preferred for endoscopic
laser excisions of larger laryngeal and pharyngeal lesions (Fig.
8.61). When endoscopic assessment requires the use of an operating

Fig. 8.60 The Dedo laryngoscope.

Fig. 8.S8 Instrument set-up tor direct laryngoscopy. Fig. 8.61 The bivalved laryngoscope.

282
microscope, llu-n ilic view of the larynx must be continuous and
should be available with a hands-free set-up. The instrumentation
necessary for suspension microlaryngoscopy and endoscopic
microlaryngeal surgery is shown in H g . 8.62. Suspension of the
larynx requires the use of a Louis arm. The endolaryngeal micro-
surgical instruments are ultra-line long instruments with a working
distance of 27 cm. Several set-ups of microsurgical biopsy forceps,
manipulators, scalpels, dissectors and scissors are commercially
available (Figs 8.65-8.65).
The optimal equipment necessary for microlaryngoscopy should
have a binocular microscope with video camera attachment and a
still camera attachment, or online digital storage capability in a
computer as well as the capability of attachment of a carbon
dioxide laser ( I ' i g . 8.66). The operating microscope provides a
binocular view of the endoscopic field and, when attached with a
video monitor, permits significant enlargement of the operative
field with the ability to demonstrate endolaryngeal microsurgery
on a video screen.

Fig. 8.62 Instrumentation for suspension laryngoscopy and

endolaryngeal microsurgery.

Fig. 8.66 The electrically controlled operating microscope with attached

Fig. 8 . 6 i Various types of microlaryngeal biopsy forceps. still and video cameras and laser assembly.

283
 Detailed endoscopic evaluation of the i n t e r i o r of the l a r y n x
requires the use of telescopes (0°, 3 0 ° , 70° a n d 120°) ( F i g . 8 . 6 7 ) to
accurately evaluate the a n t e r i o r c o m m i s s u r e , the ventricles, a n d
the subglottic region. The details of the views o b t a i n e d t h r o u g h
telescopes of various angles are s h o w n in F i g s 8 . 6 8 - 8 . 7 1 . Such
detailed evaluation of a laryngeal lesion is crucial, regardless of t h e
treatment selected. If the patient is suitable for endoscopic surgery,
then such a procedure begins after p h o t o d o c u m e n t a t i o n of the
lesion. On the o t h e r h a n d , if the patient is to have o t h e r treatment
(e.g. radiotherapy, c h e m o / r a d i o t h e r a p y , or partial l a r y n g e c t o m y ) ,
then after adequate photo documention, the procedure
terminated.
The set-up lor endolaryngeal microsurgery in a patient w i t h the
larynx suspended is s h o w n in F i g . 8 . 7 2 . T h e patient is placed in
the supine p o s i t i o n u n d e r general anesthesia w i t h a n oral e n d o -
tracheal lube. T h e head is e x t e n d e d to p r o v i d e a direct axial v i e w
Fig. 8.68 Endoscopic view of a recurrent squamous carcinoma of
the right vocal cord with an edematous left vocal cord through a
0° telescope.
284
of the l a r y n x . T h e laryngoscope is i n t r o d u c e d i n t o the larynx a n d
suspended w i t h t h e Louis a r m resting over the M a y o stand fixed
to t h e o p e r a t i n g table. Resting the distal e n d of the Louis arm on
the M a y o stand or a fixed table type of device attached to the
o p e r a t i n g table avoids u n d u e pressure on the anterior chest wall
of the p a t i e n t . After an adequate v i e w of the i n t e r i o r of the larynx
is o b t a i n e d , t h e l a r y n x is suspended. T h e o p e r a t i n g microscope is
t h e n b r o u g h t i n t o the field a n d a p p r o p r i a t e l y adjusted to gain
g o o d b i n o c u l a r v i s i o n of the l a r y n x . T h e o p e r a t i n g microscope has
a beam splitter w i t h a v i d e o camera a t t a c h m e n t to provide an
is instant m a g n i f i e d v i e w of the i n t e r i o r of the l a r y n x on a television
screen. Such m a g n i f i c a t i o n a l l o w s excellent assessment of the
laryngeal lesion a n d also offers a m p l e o p p o r t u n i t y for teaching to
resident staff and for viewing by nurses, anesthesiologists,
students a n d o t h e r observers.
At this p o i n t , the patient is ready either for endoscopic micro-
Fig. 8.67 Rigid telescopes used to evaluate the larynx.
Fig. 8.69 Endoscopic view of a recurrent squamous carcinoma of
the right vocal cord with an edematous left vocal cord through a
30' telescope.
laryngeal surgery or endoscopic laser surgery of the larynx. The
placement of various personnel and equipment in the operating
room during endoscopic laryngeal surgery is shown In Fig. 8.73.
The surgeon sits at the head end of the operating tabic with the
assisting nurse on his right-hand side. The instrument table is on
the surgeon's right-hand side between him and the scrub nurse.
The operating microscope is placed on the surgeon's left-hand side
as depicted in K g . 8.73. The laser equipment is placed on the
right-hand side of t h e o p e r a t i n g table. The television m o n i t o r is
Fig. 8.70 Endoscopic view of a recurrent squamous carcinoma of
the right vocal cord with an edematous left vocal cord through a
70° telescope.
Fig. 8.71 Endoscopic view of a recurrent squamous carcinoma of
the right vocal cord with an edematous left vocal cord through a
120 telescope.
placed near the foot e n d of the table d i r e c t l y across a n d just to the
right of the operating table lo provide an easy view for the surgeon.
T h e anesthetic t u b i n g c o n n e c t e d to the endotracheal tube rests
a l o n g the patient's outstretched left a r m . T h e anesthesiologist stays
on the patient's l e f t - h a n d side for easy access to the intravenous
l i n e a n d anesthesia e q u i p m e n t . Since endoscopic surgery is a one-
m a n procedure, surgical assistants are n o t necessary but the endo-
scopic procedure can be v i v i d l y d e m o n s t r a t e d to the resident staff
a n d students o n the video m o n i t o r .
Fig. 8.72 The endolaryngeal microsurgery set up.
Fig. 8.7J The placement of personnel and equipment in the operating
room for endolaryngeal microsurgery: 1. Anesthesia machine; 2.
Microscope; 3. Laser; 4. Video monitor; 5. Waste basket. AN: Anesthetist;
S: Surgeon; N: Nurse.
285
ENDOLARYNGEAL MICROSURGERY - EXCISION OF A
VOCAL CORD POLYP
An endoscopic view of the larynx as soon through the operating
microscope with a 40x magnification shows a mucosal polyp
involving the middle third of the left true vocal cord (Fig. 8.74).
The remaining larynx is unremarkable. The polyp is grasped with
an angled biopsy forceps as shown in Fig. 8.7S and, using an
angled scissors with its tip to the right, t h e mucosal polyp is
excised in toto. No attempt should he made to excise any part of
the underlying musculature otherwise the quality of voice could
he adversely affected. Excision of the polyp in progress is shown
in Fig. 8.76. Every attempt must he made to remove the entire
specimen in one piece. The whole specimen should he fixed in a
Fig. 8.74 Endoscopic view of the larynx Fig. 8.75 The mucosal polyp is grasped with a
showing a mucosal polyp on the free edge of biopsy forceps and excised w i t h a curved
the left vocal cord. scissors.
Fig. 8.77 Hemostasis
with a cotton pledget.
286
paraffin block for accurate histologic processing alter its orien-
tation by the operating surgeon lor the pathologist, regarding its
anterior, posterior, superior, and inferior margins. Ilemostasis is
obtained by gentle pressure with a cotton pledget soaked in
adrenaline in saline solution (Fig. 8.77). Bleeding from tiny
vessels is usually controlled in this manner (Fij>. 8.78i. Ilemostasis
of minor bleeding can be secured by cauterization with silver
nitrate or with the use of a low power C O , laser.
During endoscopic laryngeal surgery, t h e patient receives 4 mg
of Decadron which is continued every six hours and is tapered
off over the next 48 hours. The purpose of steroids is to reduce
laryngeal edema and occasional respiratory difficulty in the
immediate postoperative period. The patient is permitted regular
diet by m o u t h but is advised to remain on voice rest until satis-
factory epithelialization of the operated vocal cord takes place.
Fig. 8.76 Only the mucosa is excised, without
any underlying muscle.
Fig. 8.78 The surgical
defect.
Generally voice rest is recommended for approximately one week
following vocal cord surgery.
Various other benign and early malignant lesions of the larynx
are considered suitable for management through endoscopic
microlaryngeal surgical techniques. Use of the carbon dioxide
laser may be considered appropriate under select circumstances
for benign lesions and on some patients with malignant disease.
The reader is referred to many excellent textbooks on endoscopic
microsurgery of the larynx for that purpose.
ENDOLARYNGEAL MICROSURGERY - EXCISION OF
KERATOSIS OF THE VOCAL CORD WITH THE
HYDRODISSECTION TECHNIQUE
Mucosal lesions of the true vocal cord which arc relatively flat
require special attention during microlaryngeal surgery. Since
these lesions do not have an exophytic component, they are
difficult to grasp and lift away from the underlying submucosa of
the true vocal cord. Thus, if the lesion is grasped and excision is
performed in the usual manner, the probability of sacrifice of the
Fig. 8.79 Endoscopic view of the larynx showing superficial keratosis of
the anterior third of the left vocal cord.
Fig. 8.80 A long mediastinal needle is used for saline injection.
underlying vocaliS muscle is high. Therefore, lesions such as these
are excised endoscopically using the hydrodissection technique.
The patient shown in Fig;. 8.79 has superficial keratosis of the left
true vocal cord in its anterior third. The lesion is flat and has
minimal exophytic component. In order to lift the lesion from the
underlying vocalis muscle, normal saline with epinephrine
(adrenaline) is injected in the submucosal plane. A long
mediastinal no. 25 gauge needle is attached to a 5 ml syringe.
One milliliter of epinephrine (1:50 ()(>()), is mixed with 5 ml of
normal saline solution. The needle is introduced through the
laryngoscope and the saline solution is injected in the submucosal
plane of the anterior half of the left true vocal cord (Fig. 8.80).
The injected amount should be just sufficient to elevate the lesion.
Over injection should be avoided, otherwise it will distort the
anatomy. Note that the lesion is now lifted from the underlying
vocalis muscle and is easy to grasp and excise without sacrifice of
normal tissue (Fig. 8.81).
The lesion is grasped with a small biopsy forceps and retracted
towards the midline. A curved scissors with the ti|> to the right is
used to excise the lesion in a monobloc fashion (Fij». 8.821. Every
attempt must be made to excise the lesion in one piece. The
Fig. 8.81 Adequate injection of saline into the submucosal plane lifts up
the lesion from the underlying vocalis muscle.
Fig. 8.82 The lesion is excised in a monobloc fashion.
287
surgical delect following excision of t h e lesion is seen in Fig.
8.83. Hemostasis for minor bleeding points is controlled with
cotton pledgets soaked in epinephrine in saline solution. It further
bleeding is encountered, it may be controlled with either silver
nitrate cauterization or electrocautery or carbon dioxide laser.
LARYNGOFISSURE WITH CORDECTOMY
The optimal treatment for most patients with early staged
squamous cell carcinoma of t h e glottic larynx confined to the true
vocal cord is definitive radiation therapy. However, there are
instances when radiation therapy is not feasible or is unacceptable
to t h e patient. Under those circumstances, surgical treatment
would be indicated. This may be accomplished via an endoscopic
resection or laser excision or an open procedure. On the other
hand, when external irradiation has failed to control localized car-
cinoma of the true vocal cord, then endoscopic resection, laryngo-
lissure with cordectomy or partial laryngectomy remains the only
viable option lor that patient.
A telescopic view of the larynx of a patient with carcinoma of
the right true vocal cord which has remained persistent following
definitive external irradiation is shown in I ij>. 8.8S. I his tumor

Fig. 8.83 The surgical defect.

CONSERVATION SURGERY FOR GLOTTIC CANCER

A vertical partial laryngectomy is indicated for primary tumors of

the vocal cord that extend to i n v o k e the supraglottic larynx or
the anterior commissure or with significant subglottic extension.
Patients with reduced mobility of the involved vocal cord, those
who have failed previous radiation therapy for a locally advanced
lesion which still remains confined to one side of the larynx, and
select patients with fixed vocal cord lesions are also considered
for a vertical partial laryngectomy. There are certain criteria
pertaining to the tumor which must be met before a patient is
considered suitable for a vertical partial laryngectomy. These are
shown in Fig- 8.84 and are general guidelines in the selection of
a lesion suitable for vertical partial laryngectomy. However, these
criteria are not absolute and t h e indications for partial
laryngectomy may be extended. Several technical variations of
vertical partial laryngectomy are demonstrated here. Fig. 8.8S Telescopic view of the larynx

Fig. 8.84 Criteria for the selection of a lesion

suitable for vertical partial laryngectomy.

288
was i n i t i a l l y staged as a T| t u m o r of the true vocal cord c o n f i n e d
to its free edge. The vocal cord is fully m o b i l e a n d the p r i m a r y
t u m o r remains c o n f i n e d to the true cord w i t h no subglottic exten-
sion or extension to the a n t e r i o r c o m m i s s u r e or the supraglottic
larynx. T h i s lesion is suitable for endoscopic surgical excision or
via laryngofissure and cordectomy.
Detailed endoscopic assessment of the lesion is essential before
e m b a r k i n g on this surgical procedure. Endoscopy s h o u l d ideally
be d o n e i m m e d i a t e l y before surgery. Endotracheal i n t u b a t i o n
t h r o u g h the l a r y n x s h o u l d be avoided leaving the lesion u n d i s -
turbed for endoscopic assessment. A p r e l i m i n a r y tracheostomy is
performed u n d e r local anesthesia to establish an airway. General
anesthesia is t h e n i n d u c e d . The t r a c h e o s t o m y s h o u l d be per-
formed caudad to the level of the isthmus of t h e t h y r o i d g l a n d .
After general anesthesia is i n d u c e d , appropriate endoscopy is
performed to accurately assess the e x t e n t of the t u m o r , its
subglottic extension a n d e x t e n s i o n to the a n t e r i o r c o m m i s s u r e or
the ventricle.
In Fig. 8 . 8 6 , the surface markings of the t h y r o i d n o t c h a n d the
cricoid cartilage w i t h the proposed l i n e of i n c i s i o n for exposure of
the larynx to p e r f o r m laryngofissure a n d c o r d e c t o m y are s h o w n .
Note the endotracheal l u b e in the trachea, w h i c h is w e l l below the
level of the c r i c o i d cartilage to a v o i d c o m m u n i c a t i o n between the
Fig. 8.86 Proposed line ol incision and the surface markings of the
thyroid and cricoid cartilages.
Fig. 8.87 Exposure of the thyroid cartilage and cricothyroid membrane
in the midline.
surgical w o u n d a n d the tracheostomy w o u n d . The skin incision
for exposure of the l a r y n x extends f r o m the lateral aspect of the
t h y r o i d l a m i n a on the right side up to the lateral aspect of the
t h y r o i d l a m i n a o n the left.
The skin incision is made w i t h a scalpel and it is deepened
t h r o u g h the platysma w i t h an electrocautery. The upper and lower
skin flaps are elevated deep to the platysma. Excessive mobiliz-
a t i o n of t h e s k i n flaps must be a v o i d e d , but they must be suf-
ficiently elevated to p r o v i d e exposure ol the entire thyroid
cartilage a n d the c r i c o t h y r o i d m e m b r a n e I Pig. 8 . 8 7 ) . The fascia in
the m i d l i n e is incised w i t h an electrocautery a n d the strap muscles
on b o t h sides are retracted laterally exposing the p e r i c h o n d r i u m
over the m i d l i n e o f the t h y r o i d cartilage (Pig. 8 . 8 8 1 .
It is unnecessary to detach the s t e r n o t h y r o i d muscle from the
t h y r o i d cartilage since the e n t i r e operative procedure is endo-
laryngeal. Excessive m o b i l i z a t i o n of the soft tissue attachments on
the f r a m e w o r k of the larynx s h o u l d be avoided since it may
jeopardize the b l o o d s u p p l y a n d increase the risk of necrosis,
particularly in the irradiated l a r y n x .
Using an electrocautery w i t h a needle t i p , an incision is now
made in the p e r i c h o n d r i u m of t h e t h y r o i d lamina in the midline
e x t e n d i n g f r o m the t h y r o i d n o t c h t o the c r i c o t h y r o i d membrane
(Fig. 8.89). F o l l o w i n g this, the edges of the external peri-
Fig. 8.88 The perichondrium is exposed by retracting the strap muscles.
Fig. 8.89 Midline
thyrotomy shown in a
model.
289
chondriurrj are elevated from the thyroid cartilage on both sides
using a fine periosteal elevator (Fig. 8.90). Elevation is made
approximately S mm from the midline on each side. This will
permit sufficient exposure of the thyroid cartilage for its division
in the midline with a saw without lacerating the edges of the
perichondrium, which will be used as a separate layer during
closure.
Using a sagittal power saw, the thyroid cartilage is divided in the
midline (Fig. 8.91). Extreme care should he taken to avoid
lacerating the mucosa of the larynx with the power saw. If the
power saw is used delicately, the give of the cartilage will he
appreciated as soon as its division is complete. Laryngeal double
hooks are now used to retract the laminae of the thyroid cartilage
on each side, which puts the mucosa of the interior of the larynx
to stretch. It is now incised with an electrocautery, using a needle
tip, which will permit entry into the interior of the larynx.
In Fig. 8.92, the double hooks are used to retract each
hemilarynx, providing a view of the tumor of the right true vocal
cord. Further incision on the mucosa of the base of the epiglottis
in the midline should he avoided since it will not provide any
Fig. 8.90 Elevation of the edges of the external perichondrium.
Fig. 8.91 Division of the thyroid cartilage in the midline with a power
saw.
290
additional exposure. At this point, the interior of the larynx is
irrigated with saline and any blood clots or mucous are suctioned
out to provide accurate surface assessment of the extent of the
tumor. A deep right-angled retractor is now: placed cephalad to
provide additional exposure of the supraglottic larynx (Fig. 8.93).
Excellent exposure of the tumor of the right vocal cord is thus
obtained. The anterior commissure has been divided exactly in
the midline with a normal-appearing left vocal cord and some-
what bulky, tumor-bearing right vocal cord.
Using the electrocautery, an incision is made in the mucosa of
the right hemilarynx encompassing the primary tumor with
generous mucosal margins (Fig. 8.94). The right true and false
vocal cords are included in the surgical specimen with a cuff of
mucosa of the subglottic region (Fig. 8.95). The mucosal incision
is deepened through the underlying soft tissues and musculature
of the right hemilarynx. A serrated scissors with an angle on its
flat is now used to excise the surgical specimen (Fig. 8.96). The
scissors with its flat blades is introduced into the larynx through
the site of the laryngofissure. The surgical specimen is grasped
with a toothed forceps and is lifted up permitting the scissors to
Fig. 8.92 Tumor of the right true vocal cord is seen on retraction of the
thyroid laminae.
Fig. 8.9J Retraction of the supraglottic larynx brings the tumor into
view.

Fig. 8.95 The mucosal incision is made around the vocal cord tumor.
Fig. 8.96 Excision of the surgical specimen is done with a scissors.
divide the u n d e r l y i n g m u s c u l a t u r e . Brisk h e m o r r h a g e f r o m the
branches Of the superior laryngeal artery is lo be expected hut can
be easily c o n t r o l l e d w i t h a p p r o p r i a t e hemostasis.
In F i g . 8 . 9 7 , the surgical delect f o l l o w i n g removal of the right
true vocal c o r d , r i g h t false c o r d a n d adjacent mucosa is s h o w n .
Note a p o r t i o n of the a r y t e n o i d cartilage exposed posteriorly in
Fig. 8.97 The surgical defect.
Fig. 8.98 Three drill holes are made in the thyroid laminae.
t h e surgical defect a m i the stumps o f the r e m a i n i n g musculature
of the right h e m i l a r y n x . Frozen sections must n o w he obtained
f r o m the mucosal a n d soft tissue margins of the surgical defect to
ensure adequacy of t u m o r resection. The w o u n d is irrigated w i t h
Bacitracin s o l u t i o n . Three d r i l l holes are made on each thyroid
l a m i n a adjacent to t h e m i d l i n e ( F i g . 8 . 9 8 ) . These w i l l be used for
r e a p p r o x i m a t i o n of the t h y r o i d cartilage in the m i d l i n e for repair
of t h e laryngorissure. No a t t e m p t is made to achieve mucosal
coverage on t h e raw area at the site of the cordectomy.
Primary closure of the mucosa f r o m the supraglottis larynx to
t h e subglottic l a r y n x is n o t possible due to r i g i d i t y of the laryngeal
f r a m e w o r k a n d the size of t h e mucosal defect. A skin graft is
unnecessary a n d i m p r a c t i c a l for f i x i n g in this area and muscle or
skin flaps often prove to be t o o bulky, a n d occasionally c o m -
promise the airway. Therefore, it is preferable to leave the raw area
at the site of c o r d e c t o m y o p e n to granulate in and epilhclializc by
secondary i n t e n t i o n . The t h y r o i d l a m i n a e on b o t h sides are
reapproximated in the midline using 2-0 Vicryl interrupted
sutures. Non-absorbable sutures are not recommended as they
o f t e n f o r m suture g r a n u l o m a s r e q u i r i n g secondary removal.
In F i g . 8 . 9 9 , the t h y r o i d cartilage is s h o w n reapproximated.
C h r o m i c catgut sutures are used to reapproximate the crico-
thyroid membrane. The previously elevated p e r i c h o n d r i u m on
each side is n o w sutured in the m i d l i n e w i t h 3-0 c h r o m i c catgut
291
Fig. 8.99 Reapproximated thyroid cartilage. Fig. 8.102 Suturing of the platysma.

Fig. 8.100 Suturing of the perichondrium

Fig. 8.103 Closure of the skin incision.

Fig. 8.101 Suturing of the sternohyoid muscle.

interrupted sutures (Fig. 8.IOO). Following closure of the peri-

chondrium, the strap muscles are reapproximated in the midline.
This is also done with 3-0 chromic catgut interrupted sutures,
approximating the fascia on the medial aspect of the sternohyoid
muscle on one side to thai on the other (Fig. 8.101). However, is sutured with 3-0 chromic catgut interrupted sutures {Fig.
before complete closure of the strap muscles in the midline, a 8.l()2i. The skin incision is closed witli 5-0 nylon interrupted
Penrose drain is inserted deep to the fascia of the si rap muscles sutures (Fig. 8.10.3). A number six tracheostomy tube is
and brought out laterally through the neck incision. The platysma introduced.

292
Fig. 8.105 View of the larynx one year following surgery. Fig. 8.106 Telescopic view of a primary carcinoma of the right true vocal
cord.

The surgical specimen shows residual carcinoma of the right

true vocal cord involving ils middle third (Fig. 8.1041. The
metallic hook retracts the false vocal cord showing the superior
extension of the tumor and the negative mucosa of the ventricle.
A postoperative view of the larynx obtained approximately one
year following surgery shows very satisfactory healing of the right
hemilarynx (Fig. 8.105). Note the complete epitheliali/ation
with a hand of scar tissue formed at the level of Ihe true vocal cord
seen during phonation. Laryngofissure and cordectomy is an
adequate operative procedure for a localized superficial lesion of
the true vocal cord which is mobile. If the lesion, however, deeply
infiltrates the vocalis muscle or extends to involve the anterior
commissure or Ihe opposile vocal cord, or if there is significant
subglottic extension, then a vertical partial laryngectomy should
be performed.

VERTICAL (ANTEROLATERAL) PARTIAL LARYNGECTOMY

(HEMILARYNCECTOMY) FOR RECURRENT CARCINOMA
OF THE VOCAL CORD
Fig. 8.107 The vocal cord during phonation.

Carcinoma of the mobile vocal cord with extension to the false

cord can be treated definitively by external irradiation. In some
patients, however, radiation therapy fails to control the tumor and
surgical treatment is necessary. The patient shown here had a
primary carcinoma of the right true vocal cord which extended
from the anterior commissure to the vocal process and involved
the right ventricle and false vocal cord (Fig. 8.106). The mobility
of the vocal cord, however, was unaffected, as seen in Fig. 8.107,
where complete adduction is demonstrated during phonation.
External irradiation was initially used as definitive treatment in
this patient with apparent control of his cancer. However,
approximately I I months after completion of radiotherapy, local
recurrence developed manifesting in the anterior half of the right
vocal cord (Fi>>. 8.108). Al Ihis point, surgical resection is the
only viable option. Ihe recurrent tumor, however, is still suitable
for a conservation procedure on Ihe larynx. It must, however, be
emphasized th.it (he extent of surgical resection in this clinical
selling should conform lo the initial extent of the tumor, prior to
external irradiation.
A preliminary tracheostomy is performed under local anesthesia
and general anesthesia is then induced and adequate endoscopic
assessment of the lesion is performed to accurately delineate the
extent of recurrent tumor. The skin ol the neck is prepared with
antiseptic solution and isolated with sterile drapes (Fig. 8.109).
The surface markings of the hyoid bone, the superior border of the
thyroid cartilage and the cricoid cartilage are shown. The incision
for partial laryngectomy is placed approximately at Ihe middle of
the vertical height of the thyroid cartilage through a skin crease
in Ihe neck. The skin incision is deepened through Ihe platysma
(Fig. 8.110). The upper and lower skin flaps are elevated deep to
the platysma to expose the prelaryngeal strap muscles from the
thyrohyoid membrane to the cricothyroid membrane (Fig.
8.111). The fascia in the midline between Ihe strap muscles is

293
 now incised with an electrocautery until the plane of the thyroid
cartilage is reached (Fig. 8.112).
The strap muscles on b o t h Sides are retracted to expose the
m i d l i n e of the t h y r o i d cartilage ( F i g . 8 . 1 1 3 ) . The b l o o d supply to
the t h y r o i d cartilage is p r o v i d e d by the b l o o d vessels in the peri-
c h o n d r i u m . Unnecessary elevation of the p e r i c h o n d r i u m should,
therefore, be avoided to reduce the risk of necrosis of the remain-
i n g radiated larynx f o l l o w i n g surgery. Using an electrocautery
w i t h a l i n e needle l i p , an i n c i s i o n is made in the perichondrium
o f the t h y r o i d cartilage i n t h e a n t e r i o r m i d l i n e e x t e n d i n g f r o m the
t h y r o i d n o t c h to the c r i c o t h y r o i d m e m b r a n e ( F i g . 8 . 1 1 4 ) . Using
a line periosteal elevator, the p e r i c h o n d r i u m of the right ala of
the t h y r o i d cartilage is elevated up to the poslerior margin of the
t h y r o i d cartilage ( F i g . 8 . 1 1 5 ) . In order to accomplish this, the
p e r i c h o n d r i u m w i l l have to be detached superiorly f r o m the upper
border of the t h y r o i d cartilage a n d i n t e r i o r l y f r o m the crico-
thyroid membrane.
C h r o m i c catgut tagging sutures are n o w applied to the upper
and lower edges of the elevated p e r i c h o n d r i u m a n d these are left
long for retraction ( F i g . 8 . 1 1 6 ) . A sagittal power saw w i t h a right-
angled blade is n o w used to p e r f o r m laryngolissure t h r o u g h the
Fig. 8.108 Recurrence in the anterior half of the right vocal cord after
anterior m i d l i n e as s h o w n in the model ( F i g . 8 . 1 1 7 ) . Ihe thyroid
radiotherapy as initial treatment.

Fig. 8.109 Surface markings of the hyoid bone, thyroid and cricoid Fig. 8.111 Elevation of the upper and lower skin flaps.
cartilages and the outline of skin incision.

Fig. 8.110 The skin incision is deepened through platysma. Fig. 8.112 The fascia in the midline is incised.

294
cartilage is divided from its notch up to the cricothyroid mem- is divided, a give is felt and the saw should then cease (Fig.
brane with the saw, sparing the underlying soft tissues and 8.1191. Right-angled double hooks arc now used to retract the
mucosa (Fig. 8.118). As soon as Ihe full thickness of the cartilage divided Ihyroid cartilage on each side exposing the underlying

Fig. 8.113 The strap muscles are retracted laterally. Fig. 8.116 The perichondrium is tagged with sutures and retracted
laterally.

Fig. 8.117 Model

showing midline
thyrotomy.

Fig. 8,115 The perichondrium of the right ala of the thyroid cartilage is Fig. 8.118 Division of the thyroid cartilage with a power saw.
elevated up to its posterior border.

295
soli tissues (l-'is- 8 . 1 2 0 ) . As these are retracted laterally, a deficiency
i n the mucosa o f t h e subglottic region becomes a p p a r e n t . A n
electrocautery w i t h a needle t i p is n o w used to enlarge the
o p e n i n g in the subglottic mucosa ( F i g . 8 . 1 2 1 ) . A hemostat is
inserted t h r o u g h this o p e n i n g . T h e o p e n e d h e m o s t a t is used as a
guide for d i v i s i o n of the r e m a i n i n g soft tissues a n d mucosa of the
larynx i n the anterior m i d l i n e ( F i g . 8 . 1 2 2 ) . The d o u b l e h o o k s are
Fig. 8.119 The full thickness of the cartilage is divided.
Fig. 8.120 The divided thyroid cartilage is retracted laterally.
Fig. 8.121 The opening in the subglottic mucosa is enlarged with an
electrocautery.
296
used again to retract each h a l f of the l a r y n x f u r t h e r ( F i g . 8.123),
p r o v i d i n g a v i e w of t h e i n t e r i o r of the l a r y n x . N o t e the recurrent
t u m o r w h i c h is m o s t l y submucosal w i t h a b u l k y vocal cord on the
right side. A close-up v i e w of the surgical field shows that the
t u m o r u l c e r a t i o n at the superior surface of the true vocal cord is
posterior to t h e l i n e of d i v i s i o n of t h e mucosa at the anterior
commissure (Fig. 8 . 1 2 4 ) .
Fig. 8.122 A hemostat is used to facilitate division of laryngeal mucosa.
Fig. 8.123 The interior of the larynx is exposed
Fig. 8.124 Close-up view of the surgical field.
 LARYNX AND TRACHEA

A deep right-angled retractor is now Introduced through the

laryngotomy site and the supraglottic larynx is retracted cephalad
(lis- 8.125). Using the electrocautery, the cricothyroid membrane
is n o w divided along the lower border of the t h y r o i d cartilage
d i g . 8.126). Under direct v i s i o n , the mucosa of the subglottic
larynx is also incised along the c r i c o t h y r o i d membrane up to the
posterior m i d l i n e (Pig. 8 . 1 2 7 ) . Soft tissue attachments at the
upper border ol the t h y r o i d cartilage on the right side are d i v i d e d
next (Fig. 8.128).
A mucosal incision in the rij^Iit h c m i l a r y n x encompassing the
t u m o r w i t h adequate margins is s h o w n in the model (Fig. 8 . 1 2 9 ) .
This incision is made on the false vocal cord, the right arytenoid
and (he posterior edge of the right vocal cord at the m i d l i n e c o n -
necting the mucosal incision in the subglottic region w i t h an elec-
trocautery (Fig. 8 . 1 3 0 ) . Finally; a serrated scissors w i t h an angle
on the flat is used to excise the surgical specimen of the right
hemilarynx, encompassing the entire ala of t h e t h y r o i d cartilage Fig. 8.127 Incision of the mucosa of the subglottic larynx
on the right-hand side along w i t h all the soft tissues and the
overlying mucosa ( F i g . 8 . 1 3 1 ) . The superior h o r n of the t h y r o i d
cartilage w i l l have to be d i v i d e d for the removal of the t h y r o i d ala
(Fig. 8 . 1 3 2 ) . T h e extent of t h y r o i d cartilage resection is s h o w n in
the model (Fig. 8 . 1 3 3 ) . A serrated scissors is used again for

Fig. 8.128 Division o( soft tissue attachments at the upper border of the
thyroid lamina.

Fig. 8.125 The supraglottic larynx is retracted cephalad with a right-

angled retractor.

Fig. 8.129 Model

showing the mucosal
incision.

Fig. 8.126 The cricothyroid membrane is divided to mobilize the lower

border of the specimen.

297
excision through the cricoarytenoid junction and the remaining
muscular attachments of the inferior constrictor muscle at the
posterior edge of the thyroid ala (Fig. 8.134). Brisk hemorrhage
from the branches of the superior laryngeal artery is encountered
but is easily controlled once the specimen is removed. In Fig.
8.135, the surgical defect following excision of the right hemi-
larynx extending from the right aryepiglottic fold cephalad up to
the superior border of the cricoid cartilage caudad is shown.
A close-up view of the surgical field with the left ala of the
thyroid cartilage retracted shows the normal left vocal cord, ven-
tricle and false cord (Fig. 8.136). On the other side, the surgical
defect shows stumps of the laryngeal muscles attached to the
cricoid cartilage as well as the stump of the right inferior con-
strictor muscle (Fig. 8.137). No attempt is made to obtain
mucosal closure of the surgical defect. The raw area granulates and
spontaneously epithelializes satisfactorily in every instance but
may take longer in patients who have received previous radiation Fig. 8.132 Superior horn of the thyroid cartilage is also divided with a
scissors.

Fig. 8.130 Mucosal incision on the false vocal cord.

Fig. 8.131 The posterior attachments of the specimen are divided with a
scissors. Fig. 8.134 Excision through the cricoarytenoid junction

298
therapy. A nasogastric feeding tube is i n t r o d u c e d prior to the placed to o b t a i n a watertight p e r i c h o n d r i a ! closure ( l i s . 8.139).
closure of the i n c i s i o n . The strap muscles are ^ a p p r o x i m a t e d next in the m i d l i n e . A
Closure begins w i t h reapproximation of the p e r i c h o n d r i u m Penrose d r a i n is placed deep to the strap muscles and brought out
from the r i g h t - h a n d side to the p e r i c h o n d r i u m of the left-hand on the left side as seen in F i g . 8 . 1 4 0 . A second Penrose drain is
side (Fig. 8 . 1 3 8 ) . Several i n t e r r u p t e d c h r o m i c catgut sutures are placed superficial to the strap muscles a n d brought out at the

Fig. 8.135 The surgical defect following excision of the right Fig. 8.138 Reapproximation of the perichondrium.
hemilarynx.

Fig. 8.139 Watertight perichondria! closure.

Fig. 8.137 The detached inferior constictor muscle is seen in the surgical Fig. 8.140 One Penrose drain is placed deep to the strap muscles.
defect.

299
other end of the incision. The platysma is closed with interrupted
chromic catgut sutures (Fig. 8.141). I*he skin incision is closed
with interrupted nylon sutures dig. 8.142).
The surgical specimen of righl hemilaryngectomy with removal
of the entire lamina of the t h y r o i d cartilage is s h o w n in
Fig. 8 . 1 4 3 . Note the right vocal cord t u m o r w i t h significant
subglottic extension excised w i t h satisfactory mucosal margins. A
metallic hook retracting the right false vocal cord shows that the
hulk of the t u m o r is in a submucosal fashion o c c u p y i n g the
ventricle.
In the postoperative period, n u t r i t i o n is m a i n t a i n e d t h r o u g h
the nasogastric feeding tube. Clearance of p u l m o n a r y secretions is
maintained t h r o u g h the tracheostomy. A moderate degree of
serosanguinous drainage is to he expected f r o m the drains a n d (In-
Fig. 8.141 Another drain is placed deep to the platysma.
Fig. 8.142 Closure of the skin incision.
300
patient m a y expectorate blood-stained secretions for the first
48 hours due to o o z i n g f r o m t h e raw area. Most patients will be
able to swallow semi-solid a n d l i q u i d food by the end ol one week,
w h e n the nasogastric feeding tube is r e m o v e d . T h e tracheostomy
tube may be removed soon thereafter. A satisfactory laryngeal air
passage should be confirmed, however, by telescopic examination
p r i o r to removal of the tracheostomy tube.
A postoperative endoscopic view of the larynx three months
f o l l o w i n g surgery shows satisfactory healing of the surgical defect
on the r i g h t - h a n d side ( F i g . 8 . 1 4 4 ) . Note the prolapse of the
mucosa of the a r y t e n o i d towards the glottis due to resection of
the a r y t e n o i d . H i e prolapsed mucosa m a y create compromise
of the airway in some patients, r e q u i r i n g its excision to improve
the airway.
Fig. 8.143 The surgical specimen.
Fig. 8.144 Endoscopic view ot the larynx three months following
surgery.
VERTICAL PARTIAL LARYNGECTOMY (ANTERIOR) FOR n o t c h and the cricoid cartilage are s h o w n in Fix- H. 146 w i t h the
ANTERIOR COMMISSURE LESION i n c i s i o n along an upper neck skin crease. The skin incision is
deepened t h r o u g h the platysma a n d the upper and lower skin
flaps are elevated ( T i g . 8 . 1 4 7 ) .
Primary carcinoma of the g l o t t i c l a r y n x arising at the anterior
the larynx is exposed from the thyrohyoid membrane down to
commissure, or carcinoma of the true vocal cord w i t h extension to
the c r i c o t h y r o i d m e m b r a n e . The fascia in the m i d l i n e between the
the anterior c o m m i s s u r e , requires resection of the anterior
strap muscles is incised ( F i g . 8 . 1 4 8 1 . A plane is n o w developed
commissure in c o n j u n c t i o n w i t h the i n v o l v e d true vocal c o a l . The
between the t h y r o i d cartilage a n d the strap muscles p e r m i t t i n g
endoscopic picture of tile larynx ot a patient with primary
t h e m to he retracted laterally ( F i g . 8 . 1 4 9 1 . The p e r i c h o n d r i u m is
carcinoma arising at the anterior commissure is s h o w n in Fig.
incised in the m i d l i n e w i t h an electrocautery (Fig. 8. ISO). It is then
8.14S. Note the t u m o r extends to i n v o l v e the left a n d r i g h t true
elevated w i t h a tine periosteal elevator to expose approximately
vocal cords. Accurate endoscopic assessment of this t u m o r requires
6 mm of the ala of the t h y r o i d cartilage on the right-hand side
an operating microscope a n d angled telescopes. A tracheostomy
( F i g . 8 . 1 5 1 ) . A suture is taken t h r o u g h the edge of the elevated
under local anesthesia is p e r f o r m e d first a n d general anesthesia is
p e r i c h o n d r i u m as a tag f o r subsequent i d e n t i f i c a t i o n d u r i n g repair
administered thereafter. The surface markings of the thyroid

Fig. 8.145 Endoscopic Fig. 8.147 The upper

picture ot the larynx and lower skin flaps
showing carcinoma of are elevated.
the anterior
commissure.

Fig. 8.146 The surface Fig. 8.148 The fascia is

markings of the incised in the midline.
thyroid notch and the
cricoid cartilage, and
outline of the skin
incision.

301
of the larynx ( F i g . 8 . 1 5 2 ) . On the left side, the p e r i c h o n d r i u m is
elevated f u r t h e r back to expose the anterior half of the ala of the
t h y r o i d cartilage. The cartilage cuts, based on the endoscopic
assessment of the t u m o r are s h o w n on the m o d e l in F i g . 8 . 1 5 3 .
Using the electrocautery, vertical lines are m a r k e d on the t h y r o i d
cartilage at the proposed site of d i v i s i o n ( F i g . 8 . 1 5 4 ) . These lines
are drawn based on the endoscopic assessment of the extent of the
t u m o r and its lateral e x t e n s i o n on each vocal c o r d . M o r e cartilage
w i l l have to be resected on the left side because of i n v o l v e m e n t of
the a n t e r i o r h a l f of the left vocal c o r d . A lesser w i d t h of the
cartilage needs excision on the r i g h t - h a n d side due to lesser extent
o f i n v o l v e m e n t o f the r i g h t vocal c o r d .
A power sagittal saw is n o w used a n d t h e t h y r o i d cartilage is
d i v i d e d t h r o u g h the previously marked lines f r o m its superior
border up to the c r i c o t h y r o i d m e m b r a n e ( F i g . 8 . 1 5 5 ) . Every
a t t e m p t must he made to a v o i d laceration of the soft tissues and

Fig. 8.149 The strap muscles are retracted Fig. 8.150 The perichondrium is incised in the Fig. 8.151 Elevation ot the perichondrium.
laterally. midline.

Fig. 8.152 A suture is taken through the edge Fig. 8.153 The proposed cartilage cuts outlined Fig. 8.154 Vertical lines of division are marked
of the elevated perichondrium. on a model. on the thyroid cartilage.

302
mucosa of the interior of the larynx with the power saw. As soon
as the cartilage division is complete, a give is felt in the soft
tissues. A similar cut is made on the left side. Using a double hook,
the lower border of the cartilaginous component of the surgical
specimen is retracted cephalad and entry is made in the subglottic
region of the larynx through the cricothyroid membrane (Fig.
8.156). With continued retraction cephalad, a further view of the
interior of the larynx is obtained. Under direct vision mucosal
incisions are placed on the vocal cords securing adequate margins
lFig. 8.157). A serrated angled scissors is now used to divide the
musculature of the vocal cords on both sides and the specimen is
removed (Fig. 8.158). The surgical defect shown in Fig. 8.1S9
demonstrates the stumps of the vocal cords on both sides and the
intcr-arytenoid mucosa. A close-up examination of the larynx
shows that approximately one-half of the right vocal cord and
one-third of the left vocal cord remain (Fig. 8.160). Note that
both arytenoids and the remaining supraglottic larynx are intact.
To ensure adequate function of the remaining vocal cords, it is
essential to restore their bow string configuration. A drill hole
is made through the remaining ala of the thyroid cartilage on each
side at the level of the vocal cords. A 4-0 Vicryl suture is now taken
through this hole and through the full thickness of the stump of
the vocal cord. When this suture is tied, it approximates the
stump of the vocal cord to the cut end of the thyroid cartilage,

Fig. 8.155 Division of the thyroid cartilage Fig. 8.156 Cephalad retraction of the lower Fig. 8.157 Mucosal incisions on the vocal cords
with a power saw. border of the surgical specimen. are made with the specimen retracted
cephalad.

Fig. 8.158 The specimen is removed by division Fig. 8.159 The surgical defect. Fig. 8.160 Close-up view of the remaining
of remaining attachments. larynx.

303
m a k i n g it taut ( l i s . 8 . 1 6 1 ) . Similar t i g h t e n i n g of the vocal c o r d is
performed on the opposite side.
To reconstruct the a n t e r i o r c o m m i s s u r e a n d prevent an a n t e r i o r
web, a laryngeal keel is used. A Silastic keei s i m i l a r to Ihe o n e
s h o w n in F i x . X. 162 is preferable for restoration of the a n t e r i o r
commissure. T h e keel is placed between t h e cut edges of t h e t h y r o i d
cartilage and retained in position by anchoring it to the remaining
ala on each side w i t h 2-0 c h r o m i c catgut. Sutures a n ' passed t h r o u g h
the h o r i z o n t a l flange of the keel a n d t h e n the ala of i h e t h y r o i d
cartilage on one side and then through the vertical flange of the
keel and out through Ihe other side of the thyroid cartilage and
the keel as s h o w n in I ij{. 8 . 1 6 3 . I h e vertical flange of t h e keel
remains between the t w o reconstructed s l u m p s of Ihe vocal cords
and Ihe t w o cut ends of the t h y r o i d cartilage ( F i g . 8 . 1 6 4 ) . The
Fig. 8.161 The stump of the led vocal cord is Fig. 8.162 A Silastic keel,
anchored to the thyroid cartilage.
Fig. 8.164 The vertical flange of the keel Fig. 8.16S The ends of the nylon suture
remains between the anterior ends of the vocal applied to the keel are kept long.
cords.
304
catgut sutures are tied over the flat surface of the keel. A heavy
n y l o n s u l u r c is passed f r o m o n e e n d of t h e flat surface of the keel
t h r o u g h its vertical flange a n d o u l f r o m the o t h e r side of the flat
surface. The ends of this n y l o n suture are kept l o n g a n d brought
out t h r o u g h Ihe skin i n c i s i o n ( F i g . 8 . 1 6 5 ) . Placing a n y l o n suture
in t h e keel in t h i s f a s h i o n facilitates its easy removal under local
anesthesia as an o u t p a t i e n t procedure. Alternatively, the keel may
be r e m o v e d endoscopically, in w h i c h case the n y l o n suture is
unnecessary b u t the palient w i l l require general anesthesia for
direct laryngoscopy a n d its r e m o v a l .
F o l l o w i n g i n s e r t i o n of the keel, the p e r i c h o n d r i u m is sutured
over t h e keel w i t h i n t e r r u p t e d c h r o m i c catgut sutures. The strap
muscles are r e a p p r o x i m a t e d in t h e m i d l i n e as s h o w n in Fig.
8 . 1 6 6 . Note the l o n g ends of the n y l o n suture from the keel which
Fig. 8 . 1 6 } The Silastic keel is fixed to the
thyroid laminae with an absorbable suture.
Fig. 8.166 The strap muscles are
reapproximated in the midline.
arc brought out t h r o u g h the m i d l i n e closure. The platysma is closed
with interrupted chromic catgut sutures. A Penrose drain is placed
deep to the platysma and is brought out through the skin incision
w h i c h is closed w i t h fine n y l o n sutures ( F i g . 8 . 1 6 7 ) . An anterior
view ol the surgical specimen shows the external aspect of t i l e
thyroid cartilage i n the m i d l i n e , w h i c h f o r m s the deep m a r g i n o l
(he t u m o r ( F i g . 8 . 1 6 8 ) . H i e t u m o r is not seen f r o m this view. A
posterior v i e w of the specimen shows the e x o p h y t i c p o l y p o i d
t u m o r o f the anterior c o m m i s s u r e i n ( h e center w i t h the s t u m p s
of the left and right vocal cords w h i c h are clear of (he t u m o r ( F i g .
8.169). The t u m o r appears to he arising f r o m the superior surfai e
of the anterior commissure a n d (he (rue vocal cords.
Postoperatively, the tracheostomy tube is retained u n t i l t h e keel
is removed. Clear liquids a n d a soft diet are p e r m i t t e d a p p r o x i -
mately 48 hours f o l l o w i n g surgery. If satisfactory healing is observed
Fig. 8.167 A Penrose drain is placed and the Fig. 8.168 Anterior view of the surgical
incision is closed. specimen.
Fig. 8.170 Endoscopic
view of the larynx
during breathing, six
months after surgery.
by fiberoptic laryngoscopy, t h e n (he keel is removed al a p p r o x i -
mately three to four weeks. Under local anesthesia, the center of
the i n c i s i o n is reopened. The n y l o n suture anchored to the keel is
f o l l o w e d up to the keel by b l u n t dissection w i t h a liemostat. A
g e n t l e p u l l on the n y l o n suture dislodges the keel, w h i c h is
delivered outside. The s k i n incision is t h e n closed in t w o layers.
Alternatively, if the n y l o n suture is not used, (he keel may be
r e m o v e d endoscopically. A postoperative v i e w ol (he recon-
structed l a r y n x f o l l o w i n g resection of ( h e anterior commissure at
a p p r o x i m a t e l y six m o n t h s is seen d u r i n g quiet breathing in F i g .
8 . 1 7 0 . A l t h o u g h (he anteroposterior d i m e n s i o n of the glottis is
foreshortened, (he airway is q u i t e adequate. D u r i n g p h o n a t i o n ,
satisfactory a d d u c t i o n of (he vocal cords is seen w i t h a well-
constructed anterior c o m m i s s u r e ( F i g . 8 . 1 7 1 ) . The quality of
voice in this patient is quite g o o d .
Fig. 8.169 Posterior view of the surgical
specimen.
Fig. 8.171 Endoscopic
view ot the larynx
during phonation.
305
SUPRACRICOID SUBTOTAL LARYNGECTOMY WITH
CRICOHYOIDOEPIGLOTTOPEXY (CHEP)
Invasive carcinomas of the true vocal cord which extend across
the midline through the anterior commissure to the opposite
vocal cord are sometimes not suitable lor a conventional antero-
lateral vertical partial laryngectomy. These tumors are best man-
aged by a conservation surgical procedure which comprehensively
removes the entire glottic region on both sides in a monobloc
fashion. The surgical procedure encompasses the entire thyroid
cartilage along with both true vocal cords and both false vocal
cords and may include one arytenoid. The patient whose endo-
scopic photograph of the larynx is shown here had received
external irradiation as definitive treatment for invasive carcinoma
of the glottic larynx involving both vocal cords (Fig. 8. 172). Both
vocal cords were mobile although minimal subglottic disease was
appreciated on the left-hand side as well as in the anterior mid-
line. The extent of his recurrent cancer could be easily encom-
Flg. 8.17J A transverse incision is placed at the level of the cricothyroid
membrane.
306
passed with a subtotal laryngectomy w i t h a supracroid
cricohyoidolepiglottopexy (CHEP). If, however, the laryngeal
tumor extends to involve the infrahyoid portion of the epiglottis
or false vocal cords, then the epiglottis cannot be preserved and
therefore the operation required is supracricoid subtotal
laryngectomy with cricohyoidopexy (CHI').
The operative procedure is performed under general endo-
tracheal anesthesia. Detailed endoscopic evaluation is performed
to assess the feasibility of the operation. A transverse incision is
placed at the level of the cricothyroid membrane and the skin
incision is deepened through the platysma (Fig. 8.173). Upper
and lower skin flaps are elevated deep to the platysma to expose
the strap muscles in the midline. The upper skin flap is elevated to
expose the liyoid bone and the lower skin flap is elevated to expose
the isthmus of the thyroid gland and the proximal trachea (Fig.
8.174). The midline fascia is incised and the strap muscles are
retracted laterally to expose the thyroid cartilage and the cricoid
cartilage (Fig. 8.175). The isthmus of the thyroid gland is divided
in the midline to expose the proximal trachea and a low tracheo-
Fig. 8.174 Upper and lower skin flaps are elevated.
stomy through the third or fourth tracheal ring is performed in
the operative field. The orotracheal tube is removed and anesthesia
is switched over to an endotracheal tube through the tracheostomy.
The sternohyoid muscles on both sides are detached from the
hyoid and are retracted laterally ( H g . 8.176).
Using sharp double hooks, the thyroid cartilage is retracted to
the patient's right-hand side to expose the posterior edge of the
left thyroid lamina (Fig. 8.1771. The inferior constrictor muscle
along the oblique line of the thyroid cartilage is transected all the
way up to the superior horn of the thyroid cartilage. A similar
procedure is repeated on the opposite side. The superior laryngeal
neurovascular pedicle is identified and the superior laryngeal
artery and vein are divided and ligated, carefully preserving the
superior laryngeal nerve (Fig. 8.178). The cricothyroid muscles
are then carefully transected anteriorly to expose the cricothyroid
membrane which is incised to gain entry into the subglottic
region of the larynx (Fig. 8.179). The entire thyroid cartilage is
removed, including its superior horns, but the inferior horns are
Fig. 8.177 The inferior constrictor muscle on the left side is detached
from the thyroid cartilage.
preserved to protect the recurrent laryngeal nerves (Fig. 8.180).
The inferior cornu of the thyroid cartilage is transected on the side
opposite the tumor to avoid injury to the recurrent laryngeal
nerve during excision of the thyroid cartilage. On the other hand,
the inferior cornu on the side of the bulkier component of the
tumor is disarticulated to allow the paraglottic space to be com-
pletely removed. One may elevate the mucosa of the subglottic
region on the more involved side to obtain a wider margin.
The thyrohyoid membrane is incised next and divided to gain
entry into the supraglottis- region. The epiglottis is transected at its
base near the petiole. The larynx is thus entered into just superior
to the false vocal cords (Fig. 8.181). Under direct vision now a
mucosal incision is placed just anterior to the arytenoid, pre-
serving the vocal process, this incision is continued interiorly up
to the superior border of the cricoid cartilage. The mucosal incision
is shown on the model in Fig. 8.182. The lateral cricoarytenoid
muscle can be spared on the side opposite to the tumor to retain
anterior motion of the remaining arytenoid. On the dominant
Fig. 8.178 The superior laryngeal artery and vein are divided but the
nerve is preserved.
Fig. 8.179 The cricothyroid muscle is divided to gain entry into the
larynx through the cricothyroid membrane.
307
 Fig. 8.180 Cartilage Fig. 8.182 Mucosal
cuts shown on a model incisions are placed so
to demonstrate that as to excise the entire
the superior laryngeal thyroid cartilage
pedicle is divided preserving its inferior
protecting the nerve. horns and the cricoid
cartilage.

Fig. 8.18) Mucosal incisions are placed anterior to the arytenoids up to

the cricothyroid membrane.

Fig. 8.181 The epiglottis is divided above the false vocal cords to gain
entry into the supraglottic region.

side, mucosal incision may be placed directly over the arytenoid

conserving the posterior mucosa. Both these vertical incisions arc-
then carried anteriorly to meet w i t h the incision in the crico-
thyroid membrane by a right-angled turn from the medial aspect
of the incision to the lateral. In this patient, however, t h e t u m o r
involved o n l y the anterior t w o - t h i r d s of b o t h the vocal cords a n d
therefore both arytenoids could be preserved ( l ; i g . 8 . 1 8 3 ) . The
mucosal incisions are then connected and a full-thickness
resection of the entire t h y r o i d cartilage w i t h the g l o t t i c l a r y n x is
performed in a m o n o b l o c fashion. The surgical field f o l l o w i n g
removal ot the specimen is s h o w n in Fix- 8 . 1 8 4 . At this j u n c t u r e , Fig. 8.184 The surgical defect following removal of the tumor.

308
Ihe p y r i f o r m sinuses s h o u l d be chocked to be sure t h a i there are
no accidental perforations. The r e d u n d a n t mucosa o v e r l y i n g the
arytenoid is utilized to cover the denuded cricoid cartilage,
particularly on the side of a r y t e n o i d resection if such is p e r f o r m e d .
Frozen sections are obtained f r o m the margins of the surgical
defect to ensure adequacy of resection.
Repair of the surgical defect is simple. The l a r y n x is closed using
three n o . 0 Vicryl sutures. These stitches encircle the c r i c o i d a n d
traverse t h r o u g h the pre-epiglottic space e n c i r c l i n g the h y o i d
bone. An anterior m i d l i n e suture is placed a n d one lateral suture
on each side is applied I F i g . 8 . 1 8 5 ) . A t t e n t i o n s h o u l d be paid to
carefully avoid the lateral sutures e n c i r c l i n g the superior laryngeal
nerves. Once these sutures are tied, the cricoid comes i n t o contact
w i t h the h y o i d ( F i g . 8 . 1 8 6 ) . The tracheostomy site has auto-
matically moved cephalad due to this closure. T h e strap muscles
are reapprOXimated in the m i d l i n e a n d to the h y o i d b o n e ( F i g .
8.187). The tracheostomy is n o w switched over t h r o u g h a separate
incision t h r o u g h the lower skin f l a p to isolate the tracheostomy
wound from the operative i n c i s i o n ( F i g . 8 . 1 8 8 ) . I h e r e m a i n i n g
incision is closed in t w o layers w i t h a small Penrose d r a i n in the
subcutaneous plane.
External v i e w of the surgical specimen shows complete excision
of the entire t h y r o i d cartilage in a m o n o b l o c fashion ( F i g . 8.189).
Posterior view of the surgical specimen w i t h the vocal cords retracted
shows c o m p l e t e m o n o b l o c excision of Ihe glottic carcinoma
i n v a d i n g b o t h vocal cords w i t h subglottic extension. The entire
paraglottic space on b o t h sides is resected in a m o n o b l o c fashion
w i t h adequate superior a n d inferior mucosal and soft tissue mar-
gins ( F i g . 8 . 1 9 0 ) .
Postoperative care of the patient requires the use of a nasogastric
feeding tube to m a i n t a i n n u t r i t i o n . Tracheostomy is retained to
facilitate clearance of p u l m o n a r y secretions u n t i l the patient is able
lo manage his o w n saliva and secretions. Once Ihe patient is able to
breathe t h r o u g h the n a t u r a l passages, the tracheostomy tube is
plugged. If the patient can tolerate p l u g on the tracheostomy tube
w i t h o u t a n y respiratory difficulties, t h e n the tracheostomy tube is
removed. Oral a l i m e n t a t i o n is begun o n c e the patient is able to
swallow his saliva w i t h o u t aspiration. Usually w i t h i n !s-4 weeks,
the patient is able to tolerate a soft diet. Over the next few weeks,
the patient is able lo advance to a regular diet and all types of fluids.
Postoperative endoscopic view of the reconstructed larynx during
quiet b r e a t h i n g is s h o w n in F i g . 8 . 1 9 1 . Note that the laryngeal

Fig. 8.185 Closure is performed with three Vicryl sutures between the
hyoid and the cricoid.

Fig. 8.186 Cricohyoidoepiglottopexy completed.

309
airway is now transversely oriented. During phonation, the sound surgical procedure permitting monobloc resection of the
arytenoids adducl permitting closure of the airway to produce entire glottic larynx for those lesions which involve both vocal
sound and prevent aspiration ( H g . 8.192). SupiacriCiod subtotal cords and manifest paraglottic extension.
laryngectomy with cricohyoidoepiglottopcxy is an oncologically

Fig. 8.187 The strap muscles are reapproximated in the midline. Fig. 8.188 Tracheostomy is transferred to a separate incision in the
lower neck.

Fig. 8.189 Anterior Fig. 8.190 Posterior

view of the surgical view of the surgical
specimen. specimen.

Fig. 8.191 Fig. 8.192

Postoperative Postoperative
endoscopic view of the endoscopic view of the
larynx during larynx during
breathing. phonation.

310
CONSERVATION SURGERY FOR SUPRAGLOTTIC CANCER
Primary tumors of the supraglottic larynx produce minimal symp-
toms initially such as soreness in the throat or a sensation of dis-
comfort in the throat. Changes in the quality of voice are late to
occur, secondary to extension of the tumor to the glottic larynx.
Bulky supraglottic tumors may cause stridor due to respiratory
obstruction, or occasionally difficulty in swallowing. External
irradiation as definitive treatment for a supraglottic lesion is not
as successful as for early lesions of the vocal cords. Radiation
portals by necessity are large, resulting in post-irradiation dryness,
which is a somewhat disabling sequela of treatment. Iollow-up
evaluation of the larynx in some patients is difficult due to
persistent laryngeal edema.
On the other hand, surgical treatment of tumors of the supra-
glottic larynx creates a significant physiologic disturbance in the
act of deglutition. Almost every patient aspirates to a varying degree
following a supraglottic partial laryngectomy. Most patients, how-
ever, handle this physiologic disturbance with little difficulty
and are able to tolerate most types of foods without significant
pulmonary complications. Aspiration of saliva to a varying degree
is almost uniform but this is tolerated well within the pulmonary
reserve of most patients. Patients with poor pulmonary functions,
those with an advanced degree of emphysema, and those of
advanced age are poor candidates for a supraglottic partial
laryngectomy. Likewise patients who are poorly motivated and
unable to understand the complexity of their problem and the
rigorous effort necessary for postoperative recovery are not ideal
candidates for this surgical procedure. Patient participation and
effort are essential in rehabilitation following supraglottic partial
laryngectomy for a successful outcome.
Several criteria related to tumor factors must be met in the selec-
tion of patients who are otherwise considered suitable candidates
for a supraglottic partial laryngectomy. These are described in Fig.
8.193. These criteria provide good general guidelines in the selec-
tion of patients whose tumors are suitable for a supraglottic partial
laryngectomy, but the indications for the operation expand as
the experience of the operating surgeon increases. A supraglottic
partial laryngectomy may also be necessary for surgical treatment
of highly selected patients with primary tumors of the base of the
tongue with secondary extension to the supraglottic larynx, tumors
of the pyriform sinus involving its medial wall, and bulky tumors of
the pharyngeal wall with secondary extension to the supraglottic
larynx.
Fig. 8.193 Criteria for the selection of a lesion suitable for supraglottic partial laryngectomy.
SUPRAGLOTTIC (HORIZONTAL) PARTIAL
LARYNGECTOMY
The operative procedure described here is in a patient with a
primary squamous cell carcinoma of the aryepiglottic fold. An
endoscopic view of the supraglottic larynx shows the tumor
arising from the tip of the epiglottis with extension to the left
aryepiglottic fold, with the glottis open during quiet breathing
(Fig. 8.194). During phonation, however, as shown in Fig. 8.195,
the glottis closes well and brings into view both vocal cords which
are clear of tumor and maintain normal mobility. The lower extent
of the tumor on the laryngeal surface of the epiglottis is better
appreciated during phonation.
A C7T scan of the larynx taken through the suprahyoid region
shows the tumor involving the entire thickness of the epiglottis
with involvement of its cartilage (Fig. 8.1961.
As mentioned earlier in this chapter, endoscopic evaluation of
the lesion immediately prior to surgery is mandatory for an accurate
assessment of the extent of the lesion. A preliminary tracheo-
stomy is performed under local anesthesia and an endotracheal
tube is introduced into the distal trachea. After adequate relax-
ation is obtained under general anesthesia, endoscopy is performed
to examine the tumor and its extensions to various sites within
the larynx and adjacent regions. The skin of the neck is then
prepared with antiseptic solution and isolated with sterile drapes.
The surface markings of the hyoid bone and the thyroid notch are
shown (Fig. 8.197). The skin incision is taken through an upper
neck skin crease at the level of the thyrohyoid membrane as
shown by the dotted line extending from the anterior border of
the sternomastoid muscle on one side to the anterior border of the
sternomastoid muscle on the other side. The skin incision is
deepened through the platysma to expose the strap muscles (Fig.
8.198). The upper skin flap is elevated to expose the hyoid bone
and the attachments of the suprahyoid muscles (Fig. 8.199). The
lower skin flap is sufficiently elevated to expose the thyroid
cartilage. P.levation of the skin flaps to this extent exposes the
medial aspect of the carotid sheath on both sides.
Attention is now focused on the region of the thyrohyoid
membrane. The strap muscles are detached from the hyoid bone
on both sides to expose the thyrohyoid membrane (Fig. 8.200).
The stumps of the strap muscles are tagged with a chromic catgut
suture and retracted laterally exposing the thyrohyoid membrane
and the upper border of the thyroid cartilage. In Fig. 8.201 two
hemostats are used to demonstrate the vertical height of the
311
 •
Fig. 8.194 Telescopic view of the supraglottic larynx during breathing.
Fig. 8.196 CT scan of
the larynx showing
tumor of the left
Fig. 8.195 Telescopic view of the larynx during phonation.

aryepiglottic fold.

Fig. 8.197 Surface markings of the hyoid bone and the thyroid notch
with the incision outlined.

Fig. 8.198 The skin incision is deepened through the platysma. Fig. 8.199 The upper and lower skin flaps are elevated.

312

Fig. 8.200 The strap muscles are detached from the hyoid bone.
Fig. 8.201 Hemostats used to demonstrate the vertical height of the
thyroid cartilage.
Fig. 8.202 The incision in the thyroid cartilage curves cephalad to reach
the superior border of the thyroid cartilage.
t h y r o i d cartilage. O n e l i e m o s t a l is placed at the t h y r o i d n o t c h a n d
the other at the c r i c o t h y r o i d m e m b r a n e . T h e anterior c o m m i s s u r e
is located exactly at the m i d p o i n t of the vertical height of the
anterior m i d l i n e of the t h y r o i d cartilage. Excision of the upper
third of the ala of the cartilage on each side can therefore be safely
p e r f o r m e d w i t h o u t risk of inadvertent i n j u r y to the anterior c o m -
missure. An i n c i s i o n in the p e r i c h o n d r i u m of the t h y r o i d cartilage
is m a d e a l o n g the proposed l i n e of d i v i s i o n of the t h y r o i d carti-
lage w i t h an electrocautery using a needle tip. Note that w h i l e the
i n c i s i o n is progressing posteriorly, it curves cephalad to reach the
superior border of the t h y r o i d cartilage ( F i g . 8 . 2 0 2 ) .
The s u p r a h y o i d muscles are detached f r o m the upper border of
the central t h i r d of t h e h y o i d h o n e to denude it completely. The
d e t a c h m e n t of the s u p r a h y o i d muscles extends laterally over the
h y o i d bone up to the lesser cornua on each side. The central t h i r d
of the h y o i d b o n e w i l l be resected to a c c o m p l i s h a monobloc
excision of the pre-epiglottic space. Therefore, using an electro-
cautery, the proposed l i n e of d i v i s i o n of the h y o i d bone is marked
o u t , r e m a i n i n g just lateral to the lesser c o r n u a on each side as
s h o w n i n the model ( F i g . 8 . 2 0 3 ) .
If the p r i m a r y t u m o r of the SupraglOttiC larynx extends well
posteriorly a l o n g the a r y e p i g l o t t i c fold up to the arytenoids, then
the resection of the h y o i d b o n e on that side should be taken
further posteriorly, even up to a n d i n c l u d i n g the whole greater
Fig. 8.203 The line of
transection of the
thyroid cartilage and
hyoid bone are shown
in the model.
Fig. 8.204 On the side
of invasion of the
aryepiglottic fold the
hyoid bone may be
excised up to its
posterior border.
cornua if indicated ( T i g . 8 . 2 0 4 1 . In that setting, the ipsilateral
Superior laryngeal nerve is sacrificed, resulting in a somewhat
increased postoperative m o r b i d i t y due to aspiration. In this patient,
however, the lesion is relatively central a m i therefore both superior
laryngeal nerves can be spared. It is i m p o r t a n t to reiterate that the
BIS
Fig. 8.20S Drill holes on each side of the midline on the remaining Fig. 8.207 Division of the thyroid cartilage with a saw.
thyroid cartilage are marked.

Fig. 8.206 Multiple drill holes are made for resuspension of the larynx. Fig. 8.208 Division of the hyoid bone with a bone cutter.

superior laryngeal nerves enter the larynx t h r o u g h the t h y r o h y o i d

membrane at an angle. The course of t h e superior laryngeal nerve
extends from the superior aspect of the carotid sheath r u n n i n g
medially and caudad to enter t h e t h y r o h y o i d m e m b r a n e .
Before division of the t h y r o i d cartilage, m u l t i p l e d r i l l holes are
made near the upper border ot the t h y r o i d cartilage that w i l l
remain in the l a r y n x ( F i g . 8 . 2 0 5 1 . A right-angled d r i l l w i t h a very
fine drill bit is best suited for this. A p p r o x i m a t e l y four to live d r i l l
holes are made on each side of the m i d l i n e ( F i g . 8 . 2 0 6 ) . T h e y are
used for resuspension of the r e m a i n i n g l a r y n x to the base of the
tongue t o restore t h e a n a t o m i c a n d p h y s i o l o g i c r e l a t i o n s h i p o f
the base of the t o n g u e to the l a r y n x . A right-angled saw is next
used to divide the t h y r o i d cartilage t h r o u g h the proposed l i n e of
transection ( I ' i g . 8 . 2 0 7 ) . Extreme care s h o u l d be taken so that
o n l y the cartilage is d i v i d e d a n d the i n t e r n a l soft tissues a n d
mucosa are not lacerated. As soon as the t h y r o i d cartilage is
divided, a give is felt a n d the saw s h o u l d t h e n cease.
Alter division of t h e t h y r o i d cartilage on b o t h sides is c o m - Fig. 8.209 The upper part of the thyroid cartilage is retracted cephalad
pleted, a bone cutter is used to d i v i d e the h y o i d b o n e t h r o u g h the to expose the soft tissues.
previously marked sites o f d i v i s i o n ( F i g . 8 . 2 0 8 ) . D i v i s i o n o f t h e
framework ot the l a r y n x to excise the surgical specimen is n o w
complete. Note that u p t o this p o i n t d i v i s i o n o f the h y o i d b o n e U s i n g a right-angled d o u b l e h o o k , the d i v i d e d upper part of the
and t h y r o i d cartilage i s d o n e w i t h o u t h a v i n g the t u m o r u n d e r t h y r o i d cartilage is retracted cephalad to put the internal soft
direct vision. Accurate preoperative endoscopic assessment of the tissues on a stretch ( F i g . 8 . 2 0 9 ) . U s i n g an electrocautery w i t h a
extent of the t u m o r is therefore essential before surgery begins. needle tip, the intralaryngeal soft tissues a n d mucosa are incised

314
Fig. 8.210 The intralaryngeal soft tissues and mucosa are incised to gain
entry into the larynx.
Fig. 8.212 The thyrohyoid membrane is divided up to the vallecula.

Fig. 8.211 Division of the mucosa of the false vocal cords to separate
the lower border of the specimen.

to gain access to the interior of the larynx (Fig. 8.210). Division

of the mucosa of the false vocal cords now continues posteriorly
(Fig. 8.211). As the mucosal incision and soft tissue division
progress posteriorly, with gentle traction, the specimen becomes
mobilized cephalad. A right-angled retractor will facilitate gentle
traction on the specimen. All Adair clamp may also be used to
grasp the divided portion of the central third of the hyoid bone to
provide traction. Further division of the thyrohyoid membrane
and the soft tissue attachments at the level of the divided hyoid
bone continues cephalad on the contralateral side as shown in
Fig. 8.212. The plane of transection lor supraglottic resection is
shown in the model in Fig. 8.213.
The oropharynx is entered by dividing the mucosa of the right
vallecula. At this point, the mucosal incision through the right
false vocal cord is completed by connecting it with the incision in
the right vallecula, allowing rotation of the specimen towards the
left side (Fig. 8.214). Rotation of the specimen brings the primary
tumor into view. A close-up view of the rotated specimen shows
the interior of the larynx and the oropharynx, demonstrating the Fig. 8.214 Mucosal incision in the vallecula is connected to the mucosal
surface extent of the tumor on the laryngeal surface of the epiglottis incision on the false vocal cord.

315
and the left aryepiglottic f o l d ( F i g . 8 . 2 1 5 ) . A Richardson retractor
is n o w used to retract t h e base of t h e t o n g u e c e p h a l a d , s t r e t c h i n g
the glossoepiglottic f o l d , w h i c h facilitates its d i v i s i o n t o w a r d the
left side. This w i l l free up the t i p of the e p i g l o t t i s w h i c h is n o w
delivered in the w o u n d , a i d i n g further m o b i l i z a t i o n of the specimen
(Fig. 8.216).
N o w , u n d e r direct v i s i o n , u s i n g a n electrocautery w i t h a needle
tip, a mucosal incision is placed a r o u n d the visible t u m o r w i t h
adequate margins on the left side of the l a r y n x . R e m a i n i n g soft
tissue attachments to the t h y r o h y o i d m e m b r a n e a n d the left
vallecula are d i v i d e d a n d the surgical specimen is r e m o v e d . Hrisk
hemorrhage f r o m branches of t h e superior laryngeal a r t e r y is to be
expei ted d u r i n g d i v i s i o n of the t h y r o h y o i d m e m b r a n e . I hese are,
Fig. 8.21 S Close-up view of the rotated specimen shows the tumor on
the left aryepiglottic fold.
Fig. 8.217 The surgical defect showing Fig. 8.218 The true vocal cords and transected
arytenoids. false vocal cords are seen.
316
however, promptly clamped and ligaled. The surgical defect
f o l l o w i n g removal o f t h e specimen i s s h o w n i n F i g . 8 . 2 1 7 .
Transected false cords on b o t h sides s h o w t h e i r superior surfaces,
d e n u d e d of mucosa, but the mucosa over b o t h arytenoids remains
intact. If the l a r y n x is viewed f u r t h e r d o w n by anterior traction on
the t h y r o i d cartilage, t h e true vocal cords become visible ( F i g .
8 . 2 1 8 1 . N o t e that a generous m a r g i n of n o r m a l mucosa still
remains above the vocal cords f o l l o w i n g removal of the specimen.
Closure of the surgical defect begins by a p p r o x i m a t i o n of the
mucosal edge of the medial wall ol the p y r i f o r m sinus to the remain-
i n g mucosa of the false vocal cord ( F i g . 8 . 2 1 9 ) . Interrupted
sutures w i t h 4-0 c h r o m i c catgut are taken t o a p p r o x i m a t e these
mucosal edges, ('overage of the d e n u d e d false cords in their
Fig. 8.216 The epiglottis is delivered in the wound to facilitate resection
of the tumor under vision.
Fig. 8.219 Mucosa of the pyriform sinus is
sutured to the mucosa of the false vocal cord.
posterior hall is easily accomplished but the anterior hall is left
open to granulate. The completed suture line of the false cords is
shown in F i g . 8 . 2 2 0 . A nasogastric feeding tube is n o w inserted.
Mucosal closure of the rest of the surgical defect is not possible
and unnecessary. The o n l y area where mucosal closure m a y be
attempted is at the lateral edges of the surgical defect near the
stumps o f t h e h y o i d h o n e . Perhaps t w o o r t h r e e i n t e r r u p t e d
sutures between the cut edges of the lateral pharyngeal w a l l m a y
be taken on each side. No a t t e m p t is made to a p p r o x i m a t e the
mucosa o f t h e base o f t h e t o n g u e t o t h e mucosa o f t h e l a r y n x .
Closure of the r e m a i n i n g defect is d o n e w i t h n o . 0 c h r o m i c
catgut i n t e r r u p t e d sutures b e g i n n i n g at the lower e n d t h r o u g h the
previously d r i l l e d holes i n t h e t h y r o i d cartilage ( F i g . 8 . 2 2 1 ) . A t
the upper e n d , the sutures pass t h r o u g h the musculature of the
base of the tongue. A p p r o x i m a t i n g the stumps of the musculature
Of (he base of the t o n g u e to t h e r e m a i n i n g t h y r o i d cartilage p r o -
duces a shelf of o v e r h a n g i n g muscles of the base of the t o n g u e
Fig. 8.220 The completed suture line of the Fig, 8.221 Suture between the thyroid
false cords. cartilage and muscles of the base of the
tongue.
Fig. 8.223 All sutures
are placed first and
then tied sequentially.
w i t h its c o v e r i n g mucosa on the anterior part ol the glottis. This
shelf effect provides p r o t e c t i o n to the glottis d u r i n g d e g l u t i t i o n .
Note a c o m p l e t e d suture in F i g . 8 . 2 2 2 s h o w i n g the placement of
the suture t h r o u g h the muscles of the base of the tongue.
All sutures are taken in a similar fashion t h r o u g h each of the
d r i l l holes in the t h y r o i d cartilage and the base of the tongue.
T h e y are not l i e d at t h i s p o i n t but h e l d l o n g u n t i l all of t h e m are
placed, a n d then they are tied sequentially ( F i g . 8.2231. The
i n t e r i o r of the l a r y n x is irrigated o n c e again and hemostasis is
r e c o n f i r m e d . A l l the suspension sutures h e l d t i l l n o w are tied
starting f r o m one e n d to the other. As this closure progresses, the
l a r y n x gets reattached to the base of the tongue, restoring its
a n a t o m i c r e l a t i o n s h i p o f suspension f r o m t h e tongue for satis-
factory physiologic f u n c t i o n d u r i n g the act of swallowing.
In F i g . 8 . 2 2 4 , all sutures are seen tied in place w i t h suspension
of the larynx to t h e base of the t o n g u e completed. The sternohyoid
a n d S t e r n o t h y r o i d muscles detached f r o m the central t h i r d of the
Fig. 8.222 A completed suture.
Fig. 8.224 Completed
closure.
317
hyoid bone are now sutured to the detached mylohyoid muscle
with interrupted catgut sutures (Fig. 8.225). This second layer of
muscular closure also restores the anatomic attachments of the
strap muscles to the base of the tongue al the site of the resected
hyoid bone (Fig. 8.226). A Penrose drain inserted in a plane
between the strap muscles and the larynx is brought out through
one lateral end of the skin incision (Fig. 8.227). A second Penrose
drain is placed superficial to the strap muscles but deep to the
platysma and is brought out through the opposite end of the skin
incision (Fig. 8.228). The platysma is closed with interrupted
chromic catgut sutures and the skin is closed with nylon sutures.
The specimen demonstrates the primary tumor of the tip of the
epiglottis and left aryepiglottic fold seen from an anterior view
(Fig. 8.229). Note a monobloc resection of the supraglotlic larynx
and the pre-epiglottic space with the hyoid bone as its anterior
margin and the resected portion of the thyroid cartilage at its
inferior margin. Thus a satisfactory soft tissue resection of the pre-
epiglottic space is achieved. On the posterior surface of the
epiglottis, the bulk of the primary tumor is seen occupying the left
aryepiglottic fold and the laryngeal surface of the epiglottis with a
generous inferior mucosal margin and generous soft tissue and
mucosal margins laterally (Fig. 8.230).
Postoperatively intensive pulmonary care is essential since in
the immediate postoperative period the patient will aspirate his
own secretions. Frequent suctioning through the tracheostomy
lube is indicated to evacuate pulmonary secretions. Nasogastric
lube feedings, however, may begin as early as 24 hours following
surgery. As healing progresses, most patients begin lo swallow
(heir own saliva with minimal aspiration by the end of the first
week. At this point, the tracheostomy tube may either be corked

Fig. 8.225 The sternohyoid and sternothyroid Fig. 8.226 The anatomic attachments of the Fig. 8.227 A Penrose drain is placed deep to
muscles are sutured to the detached mylohyoid strap muscles are restored to the base of the the strap muscles.
muscle. tongue.

Fig. 8.228 A second penrose drain is placed Fig. 8.229 Anterior view of the surgical Fig. 8.230 Primary tumor on the posterior
under the platysma. specimen shows the lingual surface of the surface of the epiglottis.
epiglottis.

318
or removed to assist w i t h further progress in s w a l l o w i n g . It is
preferable to keep the tracheostomy tube in w i t h a cork, a l l o w i n g
access to the tracheobronchial tree in the event of massive
aspiration o n c e the patient starts t a k i n g f o o d by m o u t h .
I n i t i a l l y the patient is given pureed a n d semi-solid f o o d . Clear
liquids are not p e r m i t t e d u n t i l later, since t h e i r aspiration in t h e
early postoperative period is almost u n i f o r m . Once the p a t i e n t
masters semi-solid f o o d , t h e n he gradually advances to l i q u i d s by
m o u t h . A m a j o r i t y of the patients w i l l be able to swallow most
types of foods by the e n d of t h e t h i r d week f o l l o w i n g surgery. The
nasogastric feeding tube m a y n o w be r e m o v e d . Nearly all patients
w i t h a supraglottic partial l a r y n g e c t o m y aspirate t h e i r o w n saliva
Fig. 8.231
Postoperative
endoscopic view of the
larynx during
breathing.
Fig. 8.232 Endoscopic
view of the larynx
during phonation.
Fig. 8.233 The base of
the tongue moves
posteriorly as the
larynx is lifted up,
exaggerating the shelf
effect to protect the
glottis during
swallowing.
in v a r y i n g a m o u n t s . Most, however, handle this degree of aspir-
a t i o n w i t h i n the physiologic l i m i t s of t h e i r p u l m o n a r y reserve
without any symptoms.
A postoperative endoscopic v i e w of the larynx d u r i n g quiet
b r e a t h i n g is s h o w n in F i g . 8 . 2 3 1 . Note the relationship between
the base of t h e t o n g u e a n d the r e m a i n i n g l a r y n x . The mucosal
c o n t i n u i t y between the base of the t o n g u e a n d the anterior pari "I
the glottis is n o t seen due to the shelf effect of the musculature
of the base of the t o n g u e w h i c h overhangs on the anterior aspect
of the glottis. D u r i n g p h o n a t i o n , b o t h vocal cords adduct normally
w i t h satisfactory closure of the glottis ( F i g . 8 . 2 3 2 ) . D u r i n g the act
of s w a l l o w i n g , the base of the t o n g u e o v e r h a n g i n g the glottis
moves posteriorly as the l a r y n x is elevated, exaggerating the shell
effect to protect the glottis a n d t h u s prevent aspiration ( F i g .
8 . 2 3 3 ) . This particular result can be achieved if meticulous atten-
t i o n to detail is paid to placement of sutures in the musculature of
the base of the t o n g u e at the t i m e of closure of the surgical defect.
Supraglottic ( h o r i z o n t a l ) partial laryngectomy is thus a tech-
nically simple operative procedure w h i c h provides an oncologically
sound surgical resection for t u m o r s ol the supraglottic larynx. II
allows a satisfactory restoration of the a n a t o m i c c o n t i n u i t y of the
upper aerodigeslive tract c o m b i n e d w i t h restoration of the physio-
logic aspects of the pharyngeal phase of d e g l u t i t i o n .
SUPRAGLOTTIC RESECTION FOR OTHER TUMORS
T h e f o l l o w i n g situations s h o w v a r y i n g applications of supraglottic
partial l a r y n g e c t o m y as an appropriate surgical procedure under
select circumstances. In F i g . 8 . 2 3 4 the endoscopic view of a bulky
pedunculated o b s t r u c t i n g lesion of the supraglottic larynx is seen,
liiopsy of this lesion c o n f i r m e d that this was an adenoid cystic
c a r c i n o m a of m i n o r salivary g l a n d o r i g i n . The lesion is confined
to the supraglottic l a r y n x . The surgical specimen of supraglottic
Fig. 8.234 Endoscopic view of a bulky pedunculated obstructing lesion
of the supraglottic larynx.
319
Fig. 8.235 The surgical specimen of Fig. 8.236 Left oblique view of the surgical Fig. 8.237 Postoperative telescopic view of the
supraglottic partial laryngectomy. specimen. larynx.

Fig. 8.238 Primary carcinoma of the lingual Fig. 8.239 Postoperative view of the larynx Fig. 8.240 Endoscopic view of the larynx
surface of the epiglottis. during quiet breathing. during phonation.

partial laryngectomy viewed f r o m the laryngeal aspect is s h o w n in
F i g . 8 . 2 3 5 . Note the n u i l t i l o b u l a t c d nature o f the p r i m a r y t u m o r
arising from the left a r y e p i g l o t t i c fold a n d the laryngeal surface
of the epiglottis. The specimen demonstrates adequate mucosal
margins, particularly on its superior a n d i n f e r i o r aspects. In F i g .
8.236. a left o b l i q u e v i e w of the specimen shows the lateral aspect
o f the primary tumor along the left aryepiglottic fold with
monobloc resection of the pre-epiglotlic space. T h e h y o i d hone
w h i c h forms the a n t e r i o r m a r g i n of the pre-epiglottic space a n d
the resected p o r t i o n of the t h y r o i d cartilage w h i c h f o r m s the
lower b o u n d a r y of the pre-epiglottic space have been r e m o v e d en
Woe by the supraglottic partial l a r y n g e c t o m y . A postoperative
telescopic v i e w of (he l a r y n x shows t h e n o r m a l arytenoids w i t h a
well-healed scar b e t w e e n t h e base of t h e t o n g u e a n d the
remaining t h y r o i d cartilage ( F i g . 8 . 2 3 7 1 .
A primary c a r c i n o m a of the lingual surface of the epiglottis
resected by a supraglottic partial l a r y n g e c t o m y in c o n j u n c t i o n
w i t h resection of the adjacent base of the t o n g u e is s h o w n in F i g .
8 . 2 3 8 . Note the small p r i m a r y t u m o r on the l i n g u a l aspect of the
e p i g l o t t i s w i t h a generous cuff of n o r m a l mucosa and u n d e r l y i n g
musculature of the base of the t o n g u e as soft tissue margins. A
postoperative v i e w of the same patient is s h o w n in F i g . 8 . 2 3 9
d u r i n g quiet b r e a t h i n g . D u r i n g p h o n a t i o n , a d d u c t i o n o f the vocal
cords w i t h satisfactory a p p o s i t i o n is observed ( F i g . 8 . 2 4 0 ) .
A p r i m a r y c a r c i n o m a of the base of the t o n g u e secondarily
i n v o l v i n g the l i n g u a l aspect of the e p i g l o t t i s is s h o w n in a lateral
projection of a h i g h KV soft tissue f i l m ( F i g . 8 . 2 4 1 1 . Surgical
excision of this t u m o r required a supraglottic partial laryngectomy
in c o n j u n c t i o n w i t h resection of a generous p o r t i o n of the base of
I he t o n g u e ( F i g . 8 . 2 4 2 1 . W h e n a significant a m o u n t of the base
of the t o n g u e is resected, increased difficulties in swallowing
s h o u l d be a n t i c i p a t e d . This p r o b l e m becomes m o r e significant and
o f t e n produces p r o l o n g e d m o r b i d i t y w h e n the hypoglossal nerve
as well as the superior laryngeal nerve on the same side require
sacrifice.
Supraglottic partial l a r y n g e c t o m y is also feasible in select
patients w h o have previously failed external i r r a d i a t i o n employed
as i n i t i a l d e f i n i t i v e treatment for l i m i t e d lesions of the supraglottic

320
 Fig. 8.241 Lateral Fig. 8.243 Endoscopic
projection of a high KV view of the larynx
soft tissue film showing showing recurrent
a primary carcinoma of carcinoma of the
the base of the tongue. epiglottis.

Fig. 8.242 Surgical Fig. 8-244 Surgical

specimen of the base specimen of
of the tongue with supraglottic partial
supraglottic partial aryngectomy.
laryngectomy.

larynx. An endoscopic v i e w of the supraglottic l a r y n x of such a Fig. 8.24S Endoscopic

view of the larynx
patient shows an ulcerated, m o s t l y e n d o p h y t i c lesion of the
showing carcinoma of
laryngeal surface of the epiglottis ( F i g . 8 . 2 4 3 ) . This lesion has the left arytenoid.
recurred w i t h i n six m o n t h s f o l l o w i n g c o m p l e t i o n o f external
irradiation. In such situations, if patient selection is appropriate
and o t h e r criteria f o r selection of t h e operative procedure are
followed, t h e n a satisfactory o p e r a t i o n can be performed w i t l l a
predictably successful o u t c o m e . The specimen of the supraglottic
larynx of the same patient is s h o w n in F i g . 8 . 2 4 4 d e m o n s t r a t i n g
adequate resection w i t h negative mucosal a n d soft tissue margins.

EXTENDED SUPRAGLOTTIC PARTIAL LARYNGECTOMY

WITH HEMILARYNGECTOMY

Primary t u m o r s o l the supraglottic larynx, w h i c h extend lo

involve the medial w a l l of the p y r i f o r m sinus or e x t e n d to i n v o l v e
the false a n d the true vocal cords on the same side, require an
exlended operation to o b t a i n an o n c o l o g i c a l l y s o u n d surgical w h i c h does not o p e n d u r i n g p h o n a t i o n . A l t h o u g h the m o b i l i t y o f
specimen. An endoscopic v i e w of the l a r y n x of a patient w i t h the vocal cords is n o r m a l , the t u m o r clearly extends to involve the
primary squamous cell c a r c i n o m a of the left arytenoid and superior surface of the left true vocal cord.
adjacent supraglottic l a r y n x is s h o w n in Fij>. 8 . 2 4 5 . N o t e t h e The posteroanterior p r o j e c t i o n of a h i g h KV f i l m of the larynx
bulky nature o f t h e p r i m a r y t u m o r w i t h significant t h i c k e n i n g o f shows a large p r i m a r y t u m o r i n v o l v i n g the left bemilarynx in a
the aryepiglottic f o l d a n d the m e d i a l w a l l of t h e p y r i f o r m sinus transglottic fashion with significant submucosal transglottic

321
Fig. 8.246 Posteroanterior projection of a high Fig. 8.247 The interior of the larynx with the
KV film of the larynx showing a large primary specimen rotated to the left side clearly shows
tumor involving the left hemilarynx. the tumor.
Fig. 8.249 Close-up
view of the primary
tumor of the arytenoid
and laryngeal surface
of the epiglottis.
extension of disease (Fig. 8.246). Note the distortion of the
'Gothic' arch in the subglottic region. The tumor also extends in
a submucosal fashion to obliterate the left pyriform sinus,
obscuring its air column. At endoscopy, however, the apex of the
pyriform sinus was seen to be free of tumor involvement and
therefore the patient was considered suitable for an extended
supraglottic resection with hemilaryngeclomy. The initial steps of
the surgical procedure are similar to those for a supraglottic
resection.
The interior of the larynx with the specimen rotated to the left
side is shown in Fig. 8.247. The strap muscles have been
detached and entry is made in the larynx through the thyrohyoid
membrane and the right vallecula. The true surface extent of the
primary tumor is appreciated at this point and it mandates the
need for a hemilaryngeclomy to encompass the entire tumor in a
monobloc fashion. Therefore, using a sagittal saw, the thyroid
cartilage is divided in the anterior midline. Division of the larynx
through the anterior commissure permits further left lateral
rotation of the specimen (Fig. 8.2481. Separation of the mobilized
left thyroid cartilage from the cricothyroid membrane permits
322
Fig. 8.248 Division of the larynx through the
anterior commissure permits further left lateral
rotation of the specimen.
Fig. 8.2S0 The surgical
defect.
further rotation of the left hemilarynx, laterally exposing the
tumor.
In a close-up view, the primary tumor of the arytenoid and
laryngeal surface of the epiglottis is seen with its extension to
involve the false cord and the superior surface of the left true vocal
cord (Fig. 8.2491. The left arytenoid is, therefore, disarticulated
from the cricoid cartilage and a full-thickness resection of the
medial wall of the pyriform sinus in conjunction with the left
hemilarynx is performed. Following removal of the specimen, the
surgical defect shows the remaining right hemilarynx with its
intact ala of the thyroid cartilage (Fig. 8.250). Frozen section
studies are obtained from the margins of the surgical defect to
ensure a satisfactory surgical resection.
Reconstruction of the surgical defect following this extensive
resection is rather simple. A nasogastric feeding tube is inserted.
The exposed musculature of the pharyngeal wall on the left side is
left open to heal by secondary intention. The previously detached
strap muscles of the left side are sutured to the mylohyoid muscle
to provide anterior soft tissue closure. Strap muscles from the right
side are approximated in the midline to the medial edge of the
 Fig. 8.251 The
specimen of the
supraglottic and left
hemilarynx.
Fig. 8.2S2
Postoperative
endoscopic view of the
larynx.
strap muscles f r o m the left side. R e m a i n i n g closure is p e r f o r m e d
in layers. A Penrose d r a i n is placed superficial to the strap muscles.
T h e specimen o f t h e supraglottic a n d left h e m i l a r y n x d e m o n -
strates satisfactory excision of a b u l k y p r i m a r y t u m o r of the
arytenoid w i t h extension to the left true vocal cord a n d the medial
wall of the left p y r i f o r m sinus ( F i g . 8 . 2 5 1 ) .
Significant s w a l l o w i n g d i f f i c u l t i e s a n d aspiration are to he
expected in the postoperative p e r i o d . Satisfactory e p i t h e l i a l i z a t i o n
of the raw areas by secondary i n t e n t i o n takes a p p r o x i m a t e l y three
to four weeks. The need for p r o l o n g e d nasogastric t u b e feedings
should therefore be a n t i c i p a t e d . A percutaneous gastrostomy m a y
be considered in this s i t u a t i o n d u e to the need for p r o l o n g e d
n u t r i t i o n a l support.
A postoperative endoscopic v i e w of t h e l a r y n x demonstrates
edematous right a r y t e n o i d w i t h satisfactory h e a l i n g of the base of
the tongue and the r e m a i n i n g l a r y n x on the r i g h t - h a n d side ( F i g .
8.2S2). On the left side, the raw area left o p e n has e p i t h e l i a l i z e d
nicely w i t h a band of scar at the level of the true vocal c o r d . This
scar provides adequate soft tissue for a p p o s i t i o n by the r i g h t vocal
cord d u r i n g p h o n a t i o n a n i l assists in s w a l l o w i n g by restoring
satisfactory competency of the g l o t t i s .
WIDE-FIELD TOTAL LARYNGECTOMY
W h e n a conservation o p e r a t i o n on the larynx is not feasible due
to t h e local extent of the t u m o r or the patient's i n a b i l i t y to
recuperate alter an extended conservation procedure, then total
l a r y n g e c t o m y s h o u l d be considered. Those t u m o r s w h i c h are
considered unsuitable for treatment by external irradiation or
chemo/radiotherapy combination for larynx preservation and
those w h i c h r e m a i n persistent or recur after chemoradiotherapy
are also situations w h e r e t o t a l l a r y n g e c t o m y is indicated.
The general i n d i c a t i o n s for c o n s i d e r a t i o n of total laryngectomy
are: (1) advanced cancers of the l a r y n x or h y p o p h a r y n x w i t h
i n v a s i o n of the t h y r o i d cartilage a n d extralaryngeal soft tissues;
a n d (2) t u m o r s that have failed the larynx preservation treatment
programs of radiotherapy a n d c h e m o / r a d i o t h e r a p y .
Whenever total laryngectomy is considered for a primary
c a r c i n o m a of the l a r y n x , the o p e r a t i o n of choice is a wide-field
total laryngectomy. This encompasses the entire larynx w i t h its
attached prelaryngeal strap muscles a n d the l y m p h nodes in the
jugular c h a i n (Levels I I , III a n d IV) on the ipsilateral side as well as
the l y m p h nodes in the tracheoesophageal groove on the same
side. For lesions w h i c h i n v o l v e the g l o t t i c l a r y n x w i t h significant
subglottic e x t e n s i o n , ipsilateral t h y r o i d l o b e c t o m y should be per-
f o r m e d to facilitate adequate clearance of ipsilateral tracheo-
esophageal g r o o v e l y m p h nodes. If the laryngeal lesion requiring
t o t a l l a r y n g e c t o m y extends on b o t h sides of the m i d l i n e , then
bilateral jugular n o d e dissection (Levels I I , 111 a n d IV) should be
p e r f o r m e d . If metastatic nodes are palpable, t h e n a modified
radical neck dissection preserving the accessory nerve should be
performed.
The operative procedure described here is on a patient w i t h a
large t u m o r of the right vocal cord w i t h fixation of the right hemi-
larynx. There was significant submucosal extension of disease
i n v a d i n g the medial w a l l of the right p y r i f o r m sinus. A CT scan of
the larynx showed t h y r o i d cartilage i n v a s i o n . At endoscopy, the
t u m o r was f o u n d to be i n v o l v i n g the anterior commissure w i t h
significant subglottic disease. There were no c l i n i c a l l y palpable
cervical l y m p h nodes.
The patient is placed on the o p e r a t i n g table under general
endotracheal anesthesia t h r o u g h an orotracheal tube and the
head a n d neck area is isolated in the usual fashion. A transverse
incision placed over an upper neck skin crease approximately at
the level of t h e t h y r o h y o i d m e m b r a n e is most suitable for the
necessary exposure ( F i g . 8 . 2 5 3 ) . The i n c i s i o n extends from the
anterior border of the trapezius muscle on o n e side to the anterior
border of the trapezius muscle on the opposite side. A circular disc
of skin a p p r o x i m a t e l y 2.5 cm in diameter is marked in the supra-
sternal n o t c h at t h e site of the proposed p e r m a n e n t tracheostome.
The skin i n c i s i o n is deepened t h r o u g h the platysma to expose the
prelaryngeal strap muscles in the central c o m p a r t m e n t . The upper
neck flap is elevated cephalad to expose the h y o i d bone and the
attached s u p r a h y o i d muscles. The lower skin flap is elevated up to
the suprasternal n o t c h ( F i g . 8 . 2 5 4 ) . The anterior jugular veins
encountered d u r i n g e l e v a t i o n of the skin flaps are divided and
I i gated.
M o b i l i z a t i o n of the l a r y n x begins superiorly by detaching the
muscles attached to the upper surface of the h y o i d bone (Fig.
8 . 2 5 5 ) . The h y o i d is grasped w i t h an Adair c l a m p a n d , using an
electrocautery, all t h e s u p r a h y o i d muscles are detached from the
m i d l i n e up to t h e t i p of the greater cornua on b o t h sides. Note the
l i n g u a l artery on the right side w h i c h is exposed to the risk of
323
 Fig. 8.253 Transverse
incision placed over
upper neck skin crease.
The tracheostome is
outlined.
Fig. 8.255 Mobilization of the larynx begins by Fig. 8.256 The superior thyroid artery near its
detaching the suprahyoid muscles. superior laryngeal branch is shown by a
hemostat.
inadvertent injury if sufficient tare is not taken during this part of
the operative procedure.
Dissection now proceeds to isolate the rij>lit superior thyroid
artery and its superior laryngeal branch as it enters the thyrohyoid
membrane. The hemostat shown in Fig. 8.256 is holding the
fascia over the superior thyroid artery near ils superior laryngeal
branch. This vessel is identified, carefully dissected, divided between
clamps and ligated. Most of the hloocl supply to the larynx is
derived front the superior laryngeal arteries. Early identification,
division and ligation of this vessel will therefore minimize hemor-
rhage during mobilization of the larynx.
Since this patient requires a right thyroid lobectomy, the superior
thyroid artery is divided near its origin ami ligated (Fig. 8.257).
The hemostat still remains applied to the distal stump of the
superior thyroid artery which is now retracted with the specimen.
The sternomastoid muscle is retracted laterally lo expose the
carotid sheath near the carotid bulb. Deep jugular lymph nodes al
Levels II, III and IV are dissected and mobilized towards the
specimen. The superior belly of the omohyoid muscle in the lower
324
Fig. 8.254 The upper
and lower skin flaps
are elevated to get
exposure from the
hyoid to the
suprasternal notch.
Fig. 8.257 The superior thyroid artery is
divided near its origin and ligated.
part ol the exposed surgical held is divided to gain further access
to the cricothyroid region and the tracheoesophageal groove on
the right side. A close-up view of the surgical field at this point
demonstrates the right thyroid lobe mobilized medially with
clearance of the lymph nodes at levels III and IV exposing the
right common carotid artery I Fig. 8.2581.
As dissection proceeds toward the suprasternal notch, the
sternomastoid muscle is retracted laterally and the sternohyoid
and sternothyroid muscles arc divided as low in the neck as
possible (Fig. 8.259).
Hie surgical field now shows the strap muscles of both sides
divided low in the neck (Fig. 8.260). Their stumps retract
cephalad immediately upon division. Gentle traction is applied to
the larynx towards the chin with an Adair clamp holding the
hyoid hone. The inferior thyroid artery on the right-hand side is
now divided and ligated. All the capsular vessels of the righi
thyroid lobe are divided and ligated. Finally the isthmus of the
thyroid gland is separated from the trachea by blunt dissection.
Two Kocher clamps are applied to the isthmus and it is divided in
 Fig. 8.260 The cervical Fig. 8.261 The stump
trachea is exposed by of the trachea attached
division of the thyroid to the larynx is
isthmus. retracted cephalad.

between. The s l u m p of the left lobe of the t h y r o i d g l a n d is suture Using an electrocautery, Ihe subcutaneous tissues and underlying
ligated w i t h c o n t i n u o u s i n t e r l o c k i n g 3-0 c h r o m i c catgut .suture. platysma are d i v i d e d a n d the skin disc is removed. Adequate
This w i l l provide adequate hemostasis f r o m the cut surface of the hemostasis is achieved at the cut edge of the skin. An incision is
isthmus. made in the anterior tracheal w a l l at a desired level depending
Division of the isthmus of Ihe t h y r o i d gland exposes the cervical u p o n the lower extent of the t u m o r in the l a r y n x . The trachea is
trachea <Fig. 8.2601. The strap muscles on the left side are separated divided obliquely leaving a short anterior w a l l and a long
from the anterior surface o f t h e left lobe U p t o t h e t h y r o h y o i d posterior w a l l . This bevel-shaped s t u m p of t h e trachea provides a
membrane, t h e left lobe is t h e n separated f r o m the trachea, larger circumference for the p e r m a n e n t tracheostome. I h e stump
preserving the superior t h y r o i d vessels. Several small vessels on of the trachea attached to the larynx is retracted cephalad w i t h a
the posterior capsule of the left lobe require l i g a t i o n , t h e separated h o o k ( F i g . 8 . 2 6 1 1 . I h e distal trachea is sutured lo the skin edges
left lobe is n o w retracted laterally. Superior laryngeal vessels a n d o f the p e r m a n e n t tracheostome w i t h i n t e r r u p t e d n y l o n sutures.
nerves on the left side are divided a n d ligated as described previously. Anesthesia is n o w transferred f r o m the orotracheal tube to a direct
The inferior constrictor muscle is detached f r o m the posterior endotracheal tube introduced t h r o u g h the permanent tracheostome.
edge of the t h y r o i d cartilage bilaterally w i t h I h e electrocautery. D u e t o t h e beveled nature o f t h e tracheal s t u m p Ihe permanent
The o u t l i n e d disc of s k i n in Ihe suprasternal n o t c h is n o w tracheostome becomes oval in shape. T h e retracted upper part of
excised. I h e circular skin incision is taken w i t h a scalpel a n d the the transected trachea gives an intraluminal view which
center of Ihe skin disc is grasped w i t h a h e m o s t a t a n d p u l l e d . demonstrates subglottic extension o f t u m o r o n the patient's right-

325
Fig. 8.262 Mobilization of the larynx in the
post-crkoid region continues cephalad.
Fig. 8.263 The circular defect in the anterior
pharyngeal wall following removal of the
larynx.
Fig. 8.264 The circular pharyngeal defect is
converted to two elliptical defects by the
application of a suture between the midline of
the base of the tongue and anterior esophageal
wall.

hand side. The proximal trachea and larynx are dissected from the
cervical esophagus by sharp dissection which is facilitated by
cephalad traction on the tracheal stump. This dissection is best
done with an electrocautery to minimize blood loss.
Further mobilization of the larynx in the post-cricoid region
continues cephalad (Fig. 8.262). By applying continuous
moderate traction on the stump of the trachea, the plane between
the larynx and the esophageal mucosa easily separates with I he
electrocautery. Note that entry is not yet made in the pharynx
since mobilization of the larynx from all its external attachments
should be done before the pharynx is entered. Finally entry is
made in the pharynx either through the vallecula or the post-
cricoid region depending on the location of the primary tumor for
which total laryngectomy is undertaken. If the primary tumor is
completely endolaryngeal, then entry in the pharynx is made
through the vallecula. On the other hand if the primary tumor is
supraglottic in nature with involvement of the aryepiglottic fold
or tip of the epiglottis, then entry in the pharynx is best made
through the post-cricoid region.
After opening the mucosa to enter the pharynx, the mucosal
incision is continued along the periphery of the larynx, until the
opening is large enough to permit introduction of a retractor in
the pharynx. Subsequent removal of the larynx by division of its
mucosal attachments is completed under direct vision. The
surgical field with a defect in the anterior wall of the pharynx as a
result of removal of the larynx is shown in Fig. 8.263. If any of
the mucosal margins appear to be close to the primary tumor,
then they must be examined histologically to rule out microscopic
spread of tumor. A nasogastric feeding tube is inserted at this time.
If an immediate tracheo-esophageal puncture (T'KI'l is planned,
then it is performed at this time. It is important to avoid
unnecessary dissection in the tracheo-esophageal plane, posterior
to the tracheostome. A right-angled hemostat (Mixlcr clamp) is
introduced through the pharyngeal defect into the cervical
esophagus. Its tip is pushed through the anterior esophageal wall
behind the tracheostome to point through the membranous
trachea in the tracheostome at the 12 o'clock position approxi-
mately 8 mm from the tracheo-cutaneous suture line. With a no.
15 scalpel, the membranous trachea is incised and the tip of the
clamp is pushed through. The clamp is opened approximately
3-4 mm to enlarge the opening. A #14 red rubber catheter is
introduced through this opening and passed into the distal
esophagus. The outer end of the catheter is secured with a silk
suture to the skin of the subclavicular region.
A pharyngeal defect of these dimensions is quite suitable for
primary closure. The pharynx should be preferably closed in a
transverse fashion. Closure begins with a 2-0 chromic catgut
suture taken through the mucosa and muscle of the midline of the
base of the tongue and the mucosa of the anterior wall of the
cervical esophagus. An anterior pull on this suture, which is still
untied, divides the pharyngeal defect into equal halves on each
side. Note that the circular pharyngeal delect seen in Fig. 8.263
is now converted to two elliptical defects by the application of the
midline inverting suture (Fig. 8.2641. The pharyngeal defect on
each side of this midline suture is closed with 2-0 chromic catgut
interrupted inverting sutures. The closure should begin at the
lateral edges of the delect and it should proceed towards the
midline. Careful attention should be paid to invert the mucosal
edges as each suture is tied during this closure. Mucosal prolapse
through the suture line may cause delayed healing and a potential
for fistula formation. Meticulous attention should therefore be
paid while tying the knots to ensure that the edges of the mucosa
do get inverted and buried under the suture.
The pharyngeal closure is thus completed (Fig. 8.26S). Note
that the closure has no tension. The surgical field following
closure of the pharynx is irrigated with Bacitracin solution.
Suction drains are placed lateral to the pharynx and are brought
out through separate stab incisions in the skin. The platysma is
closed with interrupted chromic catgut sutures and the skin is
closed with interrupted nylon sutures.

326
 Fig. 8.265 The Fig, 8.266 The surgical
pharyngeal closure is specimen.
completed.

Fig. 8.267 The appearance of the tracheostome three months following

surgery.

The surgical specimen demonstrates a transglottic t u m o r of the
right hemilarynx w i t h significant submucosal e x t e n s i o n in the
supraglottic larynx a n d medial w a l l of the right p y r i f o r m sinus
(Fig. 8.266). The specimen is d i v i d e d in the posterior m i d l i n e
showing the i n t e r i o r of the l a r y n x as w e l l as invasion of the
thyroid cartilage. Note the significant subglottic extension of t u m o r
on the r i g h t - h a n d side.
Postoperative care after total l a r y n g e c t o m y requires nasogastric
tube feedings w h i c h m a y begin w i t h i n 24 hours. Suction drains
are removed w h e n they cease to f u n c t i o n . If the neck flaps a n d
skin incision arc w e l l healed, oral fluids a n d a pureed diet m a y be
started in seven to eight days. Sutures on the tracheostome are
removed at t w o weeks. Esophageal speech t r a i n i n g m a y begin as
early as three weeks after surgery. If an i m m e d i a t e TEP is per-
f o r m e d , t h e n the red rubber catheter is r e m o v e d on the t e n t h day
a n d replaced w i t h a voice prosthesis (Blom-Singer or I'rovox). TEP
speech t r a i n i n g m a y begin as early as three weeks following
surgery.
The postoperative appearance of the patient approximately
three m o n t h s f o l l o w i n g surgery shows a well-healed scar in the
central c o m p a r t m e n t of the neck w i t h the tracheostome of a very
satisfactory size a n d shape properly placed in the suprasternal
n o t c h ( F i g . 8 . 2 6 7 ) . It is preferable not to use a n y laryngectomy
tube in the tracheostome in either the i m m e d i a t e postoperative
period or later o n . If the p e r m a n e n t tracheostome is large enough,
t h e n a l a r y n g e c t o m y tube is unnecessary.

327
EXTENDED TOTAL LARYNGECTOMY FOR PRIMARY The specimen shows the external appearance of Ihe larynx,
CARCINOMA OF THE SUBGLOTTIC LARYNX p r o x i m a l trachea a n d the left lobe of the t h y r o i d along w i t h the
jugular c h a i n of l y m p h nodes removed f r o m Ihe left side of Ihe
neck d i g . 8 . 2 7 3 ) . A n e n d - o n v i e w t h r o u g h the distal stump o f
Primary t u m o r s of the subglottic l a r y n x carry a h i g h p o t e n t i a l of (he transected trachea shows the p o l y p o i d t u m o r of the subglottic
extension to the p r o x i m a l trachea a n d therefore require t r a n - region p r o j e c t i n g in the l u m e n ( F i g . 8 . 2 7 4 ) . The specimen alter
section of the trachea q u i t e l o w in Ihe neck. T h e p o t e n t i a l for d i v i s i o n t h r o u g h the posterior m i d l i n e demonstrates a polypoid
metastases to l y m p h nodes in the tracheoesophageal groove a n d t u m o r p r i m a r i l y arising f r o m (he left side of Ihe subglottic larynx
superior m e d i a s t i n u m is also h i g h a n d therefore the operative w i t h extension l o i n v o l v e the right subglottic region and proximal
procedure demands clearance of these first echelon l y m p h nodes trachea ( F i g . 8 . 2 7 5 ) .
w i t h total laryngectomy. In order to a c c o m p l i s h this, the s k i n
The postoperative appearance of the patient a p p r o x i m a t e l y six
incision employed s h o u l d permit satisfactory exposure of tin-
m o n t h s after surgery shows a well-healed scar on the neck, w i t h
superior m e d i a s t i n u m . An endoscopic v i e w of the l a r y n x of a
the p e r m a n e n t tracheostome situated q u i t e low in Ihe superior
patient w i t h p r i m a r y a d e n o i d cystic c a r c i n o m a of the subglottic
m e d i a s t i n u m b e h i n d the m a n u b r i u m sterni ( F i g . 8 . 2 7 6 ) . Note
region is shown in Fix- 8 . 2 6 8 . Note the presence of a p o l y p o i d
that the skin edges are b r o u g h t over the m a n u b r i u m and in the
t u m o r obstructing the subglottic region. A coronal t o m o g r a m of
m e d i a s t i n u m clown lo the trachea, where Ihe p e r m a n e n t stoma is
the larynx clearly shows the subglottic t u m o r on the left-hand
created. Occasionally the skin edges m a y be unable lo reach the
side b e g i n n i n g a p p r o x i m a t e l y at the level of the undersurface of
s t u m p of the trachea. Under those circumstances, i h e m a n u b r i u m
the true vocal cord a n d e x t e n d i n g d o w n to i n v o l v e the p r o x i m a l
m a y have lo be resected or a circular n o t c h created al its superior
trachea (Fig. 8 . 2 6 9 1 . In such a s i t u a t i o n , whenever possible, a
border w i t h a burr for insertion of Ihe s l u m p of the trachea, w h i c h
preliminary tracheostomy s h o u l d be avoided since access to the
c a n t h e n be b r o u g h t (o the surface for anastomosis w i t h the skin
trachea distal to the t u m o r under local anesthesia m a y be d i f f i c u l t .
edges.
The patient is therefore placed u n d e r general endotracheal
anesthesia t h r o u g h a small endotracheal tube carefully i n t r o d u c e d
under direct vision t h r o u g h the l a r y n x i n t o the distal trachea. Fig. 8.268 Endosco|
Rough attempts at forceful i n t u b a t i o n must be avoided, since that view o( the larynx,
m a y produce trauma and hemorrhage, and precipitate an | showing subglottic
emergent life-threatening situation. Very s k i l f u l endotracheal tumor.
intubation is therefore v i t a l l y important. Alternatively, jet
v e n t i l a t i o n may be used a n d endotracheal i n t u b a t i o n avoided
altogether.

A U-shaped incision is preferred for this operative procedure

w i t h an anterior apron flap a p p r o a c h . T h e i n c i s i o n begins near the
angle of the m a n d i b l e on o n e side a n d follows t h e a n t e r i o r border
of the sternomastoid muscle up to the suprasternal n o t c h where a
circular disc of skin is excised at t h e site of the proposed per-
manent tracheostome ( F i g . 8 . 2 7 0 ) . A similar incision f o l l o w s the
sternomastoid muscle on Ihe o t h e r side up to the angle of the
mandible. The upper a n d lower skin flaps are elevated alter
excision of the circular disc of skin to p r o v i d e adequate exposure
of Ihe root of the neck a n d the superior m e d i a s t i n u m .
The rest of the operative procedure is exactly s i m i l a r to that
described (or total laryngectomy. The trachea s h o u l d be transected
well below the i n f e r i o r border o f I h e tumor, this should be
ascertained prior to d i v i s i o n of Ihe trachea either by careful review Fig. 8.269 Corona
tomogram of the
of the radiographs or careful endoscopic assessment lo avoid
larynx showing
inadvertent e n t r y at the site of the t u m o r . subglottic tumor.
The surgical field is s h o w n f r o m the anterior aspect after
removal of the specimen in Fig. 8 . 2 7 1 . Note that the left t h y r o i d
lobe is removed w i t h the p r i m a r y t u m o r but the right lobe is
preserved. The l y m p h nodes a l o n g Ihe left carotid sheath a n d the
tracheoesophageal groove l y m p h nodes on b o t h sides are cleared
all the way d o w n to the superior m e d i a s t i n u m . The trachea is
transected quite low in the superior m e d i a s t i n u m . The surgical
field viewed f r o m Ihe head of Ihe o p e r a t i n g table l o o k i n g clown
i n t o the superior m e d i a s t i n u m is s h o w n in F i g . 8 . 2 7 2 . I b i s v i e w
clearly demonstrates the left c a r o t i d artery al its o r i g i n f r o m the
arch of the aorta, the upper thoracic esophagus b e h i n d the s l u m p
of the trachea a n d adequate clearance of the superior mediastinal
l y m p h nodes. Skin edges f r o m the upper a n d lower flaps are
brought d o w n i n t o the superior m e d i a s t i n u m a n d sutured t o Ihe
trachea for creation oi the tracheostome.

328
Fig. 8.270 The skin incisions are outlined. Fig. 8.271 The surgical field from the anterior Fig. 8.272 The surgical field viewed from the
aspect following removal of the larynx. head of the operating table.

Fig. 8.27J Anterior view of the surgical Fig. 8.274 End-on view through the distal Fig. 8.275 The surgical specimen after division
specimen. stump of the transected trachea. through the posterior midline.

Fig. 8.276 The appearance of the patient six months after surgery
showing a mediastinal tracheostome.

329
TOTAL LARYNGECTOMY WITH RADICAL NECK
DISSECTION
Primary tumors of the larynx with clinically apparent cervical
lymph noile metastases require a comprehensive neck dissection
with wide-field total laryngectomy. The patient shown here has
locally advanced primary carcinoma of the larynx with clinically
obvious cervical lymph node metastases at Levels II and III. The
largest palpable mass is approximately 2.S cm in diameter and
the smaller lymph nodes are palpated at Level III in the neck. Ihe
incision planned lor radical neck dissection and total laryngectomy
is shown in Fig. 8.277. It begins at the mastoid process and
follows an upper neck skin crease at the level of the thyrohyoid
membrane and extends across the midline up to the contralateral
sternomastoid muscle. A vertical curvaceous component of this
incision begins at a point posterior to the carotid sheath on the
transverse incision and extends up to the clavicle. The site of the
Fig. 8.277 The incision is outlined for radical neck dissection and total
laryngectomy.
Fig. 8.278 The skin flaps are elevated and posterior triangle neck
dissection is completed first.
330
permanent tracheostome is marked in Ihe suprasternal notch.
The operation begins with the patient under general endo-
tracheal anesthesia. Neck dissection is started in the usual fashion
in the posterior triangle of the neck mobilizing all Ihe tibrofatty
tissues and lymph nodes anteriorly. The accessory nerve should be
dissected and preserved if it is not involved by metastatic nodes.
The subsequent steps of the operative procedure are discussed
here. The exposed field in Fig. 8.278 shows completed dissection
of the posterior triangle with the anterior skin flap elevated and
retracted with sharp rake retractors. Ihe sternomastoid muscle is
detached from the manubrium and the clavicle, exposing the under-
lying strap muscles and carotid sheath (Fig. 8.279). Ihe internal
jugular vein is divided between clamps and ligated. Ihe thoracic
duct is also divided and ligated. The vagus nerve and the phrenic
nerve are seen as the surgical specimen is mobilized cephalad over
the scalene muscles (Fij>. 8.280). Meticulous attention should be
paid at this point to obtain absolute hemostasis at the root of the
neck, particularly from branches of the thyrocervical trunk.
Fig. 8.279 The sternomastoid muscle is detached from the manubrium
and the clavicle and the carotid sheath are exposed.
Fig. 8.280 The vagus nerve and the phrenic nerve are seen as dissection
proceeds cephalad.
 The transverse cervical artery is identified, divided and ligated
(Fig. 8.281). The inferior thyroid artery should also be identified
at this point and divided and ligated. Attention is now focused on
the central compartment of the neck. The strap muscles on both
sides are divided (Fig. 8.282). The right sternomastoid muscle is
retracted laterally to expose Ihe carotid sheath on the right-hand
side. Note the exposed internal jugular vein which will form the
right lateral boundary of the surgical field for completion of a
wide-field total laryngectomy. The strap muscles are retracted
cephalad to expose the thyroid gland.
The lymph nodes in the pretracheal space and tracheo-
esophageal groove are dissected on both sides and reflected
cephalad to remain in continuity with the larynx (Fig. 8.283). All
accessible lymph nodes in the central compartment must be
cleared for prevention of parastomal recurrence. Meticulous atten-
tion, however, should be paid not to disturb the posterior aspect
of the thyroid lobe on the contralateral side to prevent injury to
Fig. 8.283 The lymph nodes in the pretracheal space and
the parathyroid glands (Fig. 8.284).
tracheoesophageal groove are dissected on both sides and reflected
A close-up view of the surgical field shows complete clearance of cephalad.
the tracheoesophageal groove on the left-hand side (Fig. 8.285).

Fig. 8.281 The transverse cervical artery is identified, divided and Fig. 8.284 The thyroid lobe on the contralateral side is carefully
ligated. preserved with intact parathyroid glands.

Fig. 8.282 The strap muscles on both sides are divided. Fig. 8.285 Close-up view of the surgical field showing clearance of
tracheoesophageal groove lymph nodes.

331
The isthmus ol the t h y r o i d g l a n d is exposed at this p o i n t in front (Hg. 8.288). I he upper skin flap is elevated last a n d the
ol the p r o x i m a l trachea. It is n o w dissected f r o m the trachea and sternomastoid muscle is detached f r o m the mastoid process.
the cricoid cartilage a n d is d o u b l y clamped a m i d i v i d e d . T h e r i g h t Clearance of Level I l y m p h nodes is also c o m p l e t e d , still leaving
thyroid lobe is separated from the trachea a n d larynx and t h e specimen attached m e d i a l l y to the l a r y n x a n d p h a r y n x . The
retracted laterally preserving both the inferior and superior superior t h y r o i d artery is d i v i d e d a m i tied. Note the hypoglossal
thyroid arteries. The s t u m p of the isthmus of the t h y r o i d g l a n d is nerve adjacent to the t e n d o n of the digastric muscle.
suture ligated for hemostasis ( F i g . 8 . 2 8 6 ) . The superior laryngeal A t t e n t i o n is n o w focused on the upper part ot the central
vessels on the right-hand side are d i v i d e d , permitting the c o m p a r t m e n t of the neck. The upper skin flap is retracted w i t h a
specimen to be retracted to the left. In this p h o t o g r a p h a Kocher sharp retractor a n d the c o i n e r of the i n c i s i o n on the right-hand
clamp is seen h o l d i n g the s t u m p of the i s t h m u s of the left lobe of side is retracted laterally to p r o v i d e the necessary exposure ( F i g .
the t h y r o i d g l a n d . Clearance of the deep jugular l y m p h nodes on 8 . 2 8 9 ) . T h e s u p r a h y o i d muscles are detached f r o m the superior
the right side is nearly complete at this p o i n t . aspect of the h y o i d b o n e With an electrocautery. The h y o i d is
In a close-up v i e w of the surgical f i e l d , the laryngeal branch of grasped w i t h a n Adair c l a m p t o p r o v i d e t r a c t i o n o n the specimen.
the right superior t h y r o i d artery is clearly seen e n t e r i n g the larynx I he greater cornua of the h y o i d b o n e on b o t h sides are denuded
( H g . 8 . 2 8 7 ) . It should lie carefully i d e n t i f i e d , d i v i d e d a n d ligated by d e t a c h i n g all the muscular a t t a c h m e n t s f r o m their superior and
to m i n i m i z e blood loss d u r i n g m o b i l i z a t i o n of the l a r y n x . H a v i n g lateral aspects ( F i g . 8 . 2 9 0 ) .
completed m o b i l i z a t i o n of the r i g h t - h a n d side of the l a r y n x , At this p o i n t , the trachea is transected in the lower part ol the
dissection of the neck proceeds cephalad on the l e f t - h a n d side surgical field at the appropriate level a n d anesthesia is switched
until complete clearance of the carotid sheath is a c c o m p l i s h e d over w i t h an endotracheal tube in the distal trachea. Entry is made

Fig. 8.286 The stump of the isthmus of the thyroid gland is suture Fig. 8.288 Dissection of the neck proceeds cephalad on the left-hand
ligated on the right-hand side. side.

Fig. 8.287 Close-up view of the surgical field shows completed Fig. 8.289 The upper skin flap is retracted with a sharp retractor to
mobilization ot the larynx on the right-hand side. expose the hyoid bone and suprahyoid muscles.

332
i n the p h a r y n x e i t h e r t h r o u g h t h e vallecula o r f r o m t h e post-
cricoid region d e p e n d i n g u p o n the location of the p r i m a r y t u m o r .
Mucosal incisions a r o u n d the l a r y n x are c o m p l e t e d after d i v i s i o n
Of the interior c o n s t r i c t o r muscle, t h e specimen is n o w c o m -
pletely treed up a n d is r e m o v e d . It consists of the l a r y n x , the left
lobe of the t h y r o i d g l a n d , deep jugular l y m p h nodes f r o m the
right side, tracheoesophageal groove l y m p h nodes on b o t h sides,
and the contents of the f u l l y dissected neck of t h e left side.
I he surgical field f o l l o w i n g r e m o v a l of the specimen is s h o w n
i n Fig. 8 . 2 9 1 . N o t e the p h a r y n g e a l defect i n t h e center o f the
field. T h e left c o m m o n carotid artery is s k i r t i n g the left lateral
border of the p h a r y n g e a l defect. On the r i g h t - h a n d side of t h e
esophagus, the r e m a i n i n g t h y r o i d lobe w i t h the superior t h y r o i d
artery is clearly seen. In t h e u p p e r part of t h e surgical field on t h e
right side, the s u b m a n d i b u l a r salivary g l a n d is e v i d e n t . On t h e left
in the lower part of the posterior t r i a n g l e of the neck, the p h r e n i c
nerve and the brachial plexus are seen.
Fig. 8.290 The greater cornua of the hyoid bone on both sides are
denuded by detaching all the muscular attachments from their superior
and lateral aspects.
T h e p e r m a n e n t t r a c h e o s t o m e is n o w created. A circular disc of
skin is excised f r o m the suprasternal n o t c h . The s t u m p of the
trachea is sutured w i t h t h e skin edges of this circular delect w i t h
i n t e r r u p t e d n y l o n sutures. Four q u a d r a n t sutures are applied first
to accurately m a t c h t h e circumference of the transected trachea to
the circumference of the circular skin defect ( F i g . 8 . 2 9 2 ) . The
r e m a i n i n g sutures are placed between each quadrant suture to
o b t a i n a w a t e r t i g h t closure. Accurate a p p r o x i m a t i o n of the skin
edges to the mucosal edges is essential to prevent any skin
i n v e r s i o n or exposure of the cartilage of the trachea. The ends of
these n y l o n sutures are left at least one i n c h l o n g to facilitate their
r e m o v a l . Short ends often get buried u n d e r the skin due to edema
in the postoperative period leading to the d e v e l o p m e n t of suture
g r a n u l o m a s a n d p o t e n t i a l s t o m a l stricture.
Alter c o m p l e t i o n of the tracheostome, the pharyngeal defect is
closed w i t h a single layer of i n t e r r u p t e d 2-0 c h r o m i c catgut
i n v e r t i n g sutures ( F i g . 8 . 2 9 3 1 . W h e n e v e r possible, a transverse
Fig. 8.292 Four quadrant sutures are applied first on the tracheostome.
Fig, 8.29J The pharyngeal defect is closed with interrupted chromic
catgut sutures.
333
closure is performed. Occasionally a T-shaped suture line is u n a v o i d - REPAIR OF SUBGLOTTIC STENOSIS
able. However, a suture l i n e u n d e r tension must be avoided at all
times, or else w o u n d b r e a k d o w n a n d fistula are likely. If adequate
Subglottic stenosis resulting from a n y e t i o l o g y is a surgical
tissue is unavailable, a flap s h o u l d be used for repair.
p r o b l e m w i t h a variety of different surgical techniques available
Two Hemovac drains are placed in the left side of the neck a n d
for its repair. These i n c l u d e endoscopic maneuvers as well as open
one is placed lateral to the esophagus on t h e r i g h t side. They are
Operative procedures. The operation described here is one m e t h o d
introduced t h r o u g h separate stab incisions. The w o u n d is irrigated
of excision a n d repair of the stenosed area. The endoscopic view
w i t h Bacitracin solution a n d the i n c i s i o n is closed w i t h 3-0
of the l a r y n x of a patient w i t h m i d l i n e g r a n u l o m a is s h o w n in
chromic catgut i n t e r r u p t e d sutures for platysma a n d 5-0 n y l o n for
Fig. 8 . 2 9 S . This patient h a d previously u n d e r g o n e repeated endo-
skin. Careful a t t e n t i o n s h o u l d be paid to the placement of the
tracheal i n t u b a t i o n s tor bronchoscopic e x a m i n a t i o n s as well as
suction drains w h i c h s h o u l d n o t dislodge a n d lie d i r e c t l y over the
v e n t i l a t o r y support w i t h p r o l o n g e d i n t u b a t i o n s d u r i n g episodes o f
suture line of the p h a r y n x or adjacent to the carotid artery. T h e y
respiratory difficulties. At the t i m e of this presentation, he had
nun be retained in their desired p o s i t i o n w i t h loops of c h r o m i c
significant respiratory stridor due to an area of concentric stenosis
catgut sutures taken t h r o u g h the u n d e r l y i n g musculature of the
w h i c h c o u l d be easily seen in the subglottic region. A t t e m p t s at
posterior triangle of the neck on the l e f t - h a n d side a n d t h r o u g h
management of this stenotic area by endoscopic laser excision had
the soft tissues on the r i g h t - h a n d side ( F i g . 8 . 2 9 4 1 .
failed on t w o previous occasions.
The postoperative care for the patient undergoing total
laryngectomy and radical neck dissection is similar to the previous C o r o n a l t o m o g r a m s ot the l a r y n x s h o w a concentric stricture
Operative procedures. A l a r y n g e c t o m y tube is usually unnecessary a p p r o x i m a t e l y at the level ot the lower border of the cricoid
in the tracheostome, w h i c h is left o p e n a n d protected o n l y w i t h cartilage ( F i g . 8 . 2 9 6 ) . An endoscopic e x a m i n a t i o n under general
a gauze covering its surface. Suction drains are r e m o v e d w h e n anesthesia w i t h a 0° telescope passed t h r o u g h the g l o t t i s i n t o the
drainage ceases a n d the skin flaps appear w e l l healed a n d are
adherent to the u n d e r l y i n g soft tissues.
II the skin flaps remain d o w n a n d h e a l i n g of the w o u n d appears Fig. 8.295 Endoscopic
to be satisfactory, the patient may take clear liquids by m o u t h on view of the larynx
the seventh postoperative day. f o l l o w i n g this, the diet is advanced showing subglottic
gradually u n t i l the patient is able to tolerate a regular diet by stenosis.
mouth.
All sutures on the p e r m a n e n t tracheostome are not r e m o v e d at
the same t i m e . At the e n d of o n e week, every o t h e r suture is
removed and the r e m a i n i n g sutures are r e m o v e d over the next
several days to prevent d i s r u p t i o n of the m u c o c u t a n e o u s suture
line. If the sutures at this site are left for a l o n g t i m e , they develop
suture granulomas w h i c h m a y eventually lead to d e v e l o p m e n t of
stomal stenosis.

Fig. 8.296 Coronal

tomograms of the
larynx showing a
concentric stricture.

Fig. 8.294 The suction drains are retained in position with loops of
chromic catgut sutures.

334
subglottic region snows a concentric stenotic area w i t h a dense
scar f o r m i n g its edges ( F i g . 8 . 2 9 7 ) . N o r m a l tracheal rings are seen
distal to the stenosed area. T h e surgical procedure consists of
excision of the concentric stricture a n d adjacent n o r m a l mucosa
and repair of the denuded area w i t h a mucosal graft supported by
a T-tube stent.
The patient is placed u n d e r general endotracheal anesthesia
w i t h a very small endotracheal tube placed distal to the stenosed
subglottic region. T h e surface markings of the t h y r o i d cartilage,
cricoid cartilage a n d the suprasternal n o t c h are s h o w n w i t h the
line of proposed i n c i s i o n for exposure of the subglottic region
(Fig. 8 . 2 9 8 | . The skin i n c i s i o n is deepened t h r o u g h t h e platysma
and the upper and l o w e r skin flaps are elevated. T h e strap muscles
are separated in the m i d l i n e a n d retracted laterally to expose the
isthmus of the t h y r o i d g l a n d ( F i g . 8 . 2 9 9 ) .
A close-up view of the surgical field w i t h retraction of the strap
muscles on each side shows the isthmus of the t h y r o i d o v e r l y i n g
the region of the cricoid cartilage a n d the first t w o tracheal rings
( F i g . 8 . 3 0 0 ) . Note the r e l a t i o n s h i p of the c r i c o t h y r o i d muscle just
cephalad to the i s t h m u s of the t h y r o i d g l a n d . T h e isthmus is
mobilized f r o m the trachea, d o u b l y c l a m p e d a n d d i v i d e d . T h e
stumps of the i s t h m u s on each side are sutured w i t h c o n t i n u o u s
i n t e r l o c k i n g 3-0 c h r o m i c catgut sutures l o r hemostasis. Retraction
of the right a n d left t h y r o i d lobes laterally provides exposure of
the lower border of cricoid a n d the first l o u r tracheal rings.
The t h y r o i d lobes are further dissected f r o m the trachea on each
side to o b t a i n a d d i t i o n a l exposure ( F i g . 8 . 3 0 1 ) . However, during
this dissection, extreme care s h o u l d be taken not lo continue
m o b i l i z a t i o n up to t h e tracheoesophageal g r o o v e . Kxcessivc lateral
m o b i l i z a t i o n of the t h y r o i d lobes poses the risk of inadvertent
i n j u r y to the recurrent laryngeal nerves in the tracheoesophageal
grooves. Therefore, excessive lateral m o b i l i z a t i o n of the thyroid
lobes s h o u l d be a v o i d e d . Exposure of the anterior t h i r d of the
circumference of the tracheal w a l l is sufficient for the surgical
procedure to be carried o u t .
T h e t h y r o i d lobes are n o w retracted laterally ( F i g . 8.302). In
this close-up view, the area of n a r r o w i n g between (lie cricoid and
t h e second tracheal r i n g is s h o w n . A tracheostomy is now
performed low in the trachea at a p p r o x i m a t e l y the level of the
Fig. 8.299 The strap
muscles are separated
in the midline and
retracted laterally.

Fig. 8.297 Endoscopic

view of the stricture
through a 0" telescope.

Fig. 8.298 The surface Fig. 8 3 0 0 Close-up

markings of the view of the surgical
thyroid cartilage, field showing the
cricoid cartilage and isthmus of the thyroid
the suprasternal notch, gland.
with the line of
proposed incision for
exposure of the
subglottic region.

335
sixth or seventh ring and the anesthesia is transferred to an
endotracheal tube placed in the distal trachea. The orotracheal
tube is removed. T h e trachea is opened in the anterior m i d l i n e by
a vertical incision w h i c h begins at the level of the c r i c o t h y r o i d
membrane, d i v i d i n g the anterior ring of the cricoid cartilage and
also d i v i d i n g the first four rings of trachea ( F i g . 8 . 3 0 3 1 . Retraction
of the cricoid cartilage a n d the tracheal w a l l on each side clearly
demonstrates the area of stricture at the j u n c t i o n of the cricoid
cartilage and the first t w o rings of trachea.
Using an electrocautery, incisions are made c i r c u m f e i e n t i a l l y in
the tracheal mucosa below a n d above the stenotic area. A freer
elevator is used to elevate the area of stenosis submucosally a n d it
is c o m p l e t e l y excised. Several minor bleeding points are
encountered from the tracheal wall d u r i n g this procedure but are
easily c o n t r o l l e d w i t h electrocoagulation. The surgical defect so
created is repaired w i t h a free mucosal graft obtained from Ihe
cheek mucosa.
Alternatively, a mucosal graft can be obtained from Ihe nasal
septum. In Ibis patient, the graft was harvested f r o m the mucosa
of t h e cheek. T h e graft is s h o w n sutured to the edges of the
tracheal mucosa and the mucosa of the subglottic larynx with
i n t e r r u p t e d 4-0 c h r o m i c catgut sutures ( F i g . 8 . 3 0 4 } . Circum-
ferential closure of the denuded area should lie obtained w i t h the
mucosal graft. A close-up v i e w of the surgical field clearly shows
satisfactory repair of Ihe surgical d e l e d w i t h Ihe mucosal graft
( F i g . 8 . 3 0 5 ) . Al this p o i n t , the endotracheal lube is removed from
the tracheostomy she and is replaced by a M o n t g o m e r y T-tube
l l i j ; . 8.306). The vertical a r m of the T-tube remains in the

Fig. 8.301 The thyroid lobes are dissected from Fig. 8.302 The thyroid lobes are retracted Fig. 8.303 The trachea is opened in the
the trachea on each side. laterally to expose the trachea. anterior midline by a vertical incision.

Fig. 8.304 A mucosal Fig. 8.305 Close-up

graft is sutured to the view of the surgical
edges of the tracheal field showing
mucosa and the adequate coverage of
mucosa of the the defect with a
subglottic larynx. mucosal graft.

336
subglottic region a n d distal trachea w h i l e the h o r i z o n t a l a r m TRACHEAL RESECTION FOR STENOSIS OR TUMOR
comes out t h r o u g h the tracheostomy site.
After the tube is i n t r o d u c e d in p o s i t i o n , the trachea is closed
Stenosis of the trachea secondary to any e t i o l o g y may produce
w i t h 3-0 I'rolene i n t e r r u p t e d sutures. T h e i s t h m u s of the t h y r o i d
respiratory difficulties requiring surgical management. While
is replaced back in the m i d l i n e a l t h o u g h no a t t e m p t is m a d e to
short segments of stenosis c a n be managed by endoscopic laser
suture the t w o sides of t h e t h y r o i d g l a n d . T h e strap muscles are
excision, l o n g cicatrical strictures a n d recurrent strictures require
rcapproximated i n the m i d l i n e w i t h i n t e r r u p t e d c h r o m i c catgut
surgical excision. Similarly, t u m o r s of the trachea i n v o l v i n g short
sutures and the skin incision is closed in t w o layers using !?-()
segments are best managed by surgical resection. The most com-
chromic catgut for platysma a n d 5-0 n y l o n for s k i n .
m o n p r i m a r y t u m o r s are a d e n o i d cystic c a r c i n o m a a n d squamous
The postoperative care is similar to a n y laryngeal surgery. No
c a r c i n o m a . T h e c o r o n a l t o m o g r a m o f t h e patient s h o w n i n Fig.
special precautions are necessary for m a n a g e m e n t of the T-tubc.
8 . 3 0 8 demonstrates a strictured area of the trachea beginning at
During suctioning of the tracheostomy, it is important to
a p p r o x i m a t e l y the level of the second a n d e x t e n d i n g up to the
remember that the h o r i z o n t a l a r m of t h e T-tube m a y have to be
seventh tracheal r i n g . The endoscopic appearance of the stricture
tilted cephalad to permit i n t r o d u c t i o n of a s u c t i o n catheter. If this
viewed w i t h a f l e x i b l e b r o n c h o s c o p e passed distal to the true vocal
is not d o n e , the catheter w i l l not negotiate the r i g h t - a n g l e d curve
cords shows a c o n c e n t r i c n a r r o w i n g w i t h o n l y a m i n u t e opening
Of the T-tube. The T-tubc is retained for a p p r o x i m a t e l y three weeks
in the center ( F i g . 8 . 3 0 9 ) . The patient had significant respiratory
when it is r e m o v e d a n d replaced by a regular t r a c h e o s t o m y tube.
d i f f i c u l t y w i t h stridor at rest.
Following this, the patient is gradually weaned from the
tracheostomy by progressive c o r k i n g of the tracheostomy tube.
Eventually the t r a c h e o s t o m y tube can be r e m o v e d in a p p r o x i -
mately four to live weeks.
A postoperative endoscopic telescopic view of the l a r y n x at six Fig. 8.308 Coronal
months f o l l o w i n g surgery is s h o w n in Fig. 8.307. A trans- tomogram of the
laryngeal v i e w of the subglottic region shows t h e area of repaired trachea showing a
stricture w i t h a w i d e o p e n airway. Excision a n d repair of t h e stricture.
submucosal stenosis w i t h a free mucosal graft a n d T-tube stent is
a very satisfactory m e t h o d of repair of small areas of strictures in
the subglottic region. T h e mucosal graft usually takes w e l l a n d
most patients do n o t require a n y f u r t h e r surgical i n t e r v e n t i o n .

Fig. 8.306
Montgomery T-tube.

Fig. 8.307 Telescopic Fig. 8.309 Endoscopic

view of the larynx six appearance of the
months after surgery. stricture.

337
 The surgical procedure planned is a sleeve resection of the
involved segment of trachea and primary anastomosis. The patient
is placed under general endotracheal anesthesia with an endo-
tracheal tube passed distal to the vocal cords but remaining just
proximal to the area of the stricture. Following induction of
anesthesia, the head and neck area is isolated in the usual fashion.
A transverse low cervical skin incision is taken and is deepened
through the platysma. The upper and lower skin flaps are then
elevated.
The strap muscles are separated in the midline with an
electrocautery, exposing the isthmus of the thyroid gland which is
doubly clamped and divided in between (Fig. 8.310). The stumps
of the isthmus are suture ligated with interlocking continuous
chromic catgut sutures for hemostasis. A close-up view of the
surgical field at this point is shown in Fig. 8.311. Hie thyroid
cartilage, the cricothyroid membrane and the cervical trachea
from the first up to the eighth ring are exposed. The area of
narrowing is seen clearly posterior to the isthmus of the thyroid
gland where dissolution of tracheal rings with tracheomalacia
could he palpated.
Prior to proceeding with resection of the trachea, however, it is
vitally important lo identify the recurrent laryngeal nerves lying
in the tracheoesophageal groove on both sides. The strap muscles
are retracted laterally with Richardson retractors to expose the
right and left thyroid lobes which are separated by division of
the isthmus of the thyroid gland (Fig. 8.312). Dissection for
identification of the recurrent laryngeal nerves begins with
mobilization of the thyroid lobe from medial to lateral until the
tracheoesophageal groove is reached. Phe right lobe of the thyroid
gland is retracted laterally with a Richardson retractor and the
trachea is retracted towards the left with a deep right-angled
retractor, demonstrating the tracheoesophageal groove and the
Fig. 8.310 The strap muscles are separated in Fig. 8.311 Close-up view of the surgical field
the midline and the isthmus of the thyroid shows exposure of the stricture.
gland is divided.
338
entry of the recurrent laryngeal nerve in the cricothyroid mem-
brane (Fig. 8.313). Similarly the left recurrent laryngeal nerve is
shown entering the larynx through the cricothyroid membrane
(Fig. 8.314). The blood supply to the thyroid lobes and para-
thyroid glands coming through the superior and inferior thyroid
arteries respectively is thus preserved. The parathyroid glands
located on the posterior capsule of the thyroid lobes are also
retracted laterally in situ.
By alternate blunt and sharp dissection, a plane is now created
between the trachea and esophagus to mobilize the trachea
circumferentially before its resection. The level and length of
resection of the tracheal stricture to be resected is determined by
radiographic assessment preoperativcly as well as by bronchoscope
assessment under anesthesia. The trachea is circumferentially
incised and the anesthesia is switched over with an endotracheal
tube passed directly into the distal tracheal stump (Fig, 8.315).
Before circumferential transection of the trachea, however, it is
important to pass a couple of tagging sutures through the edge of
the distal stump to prevent its retraction into the mediastinum.
The proximal stump of the trachea is lifted with hooks and
rotated cephalad demonstrating the stenosed segment from below
(Fig. 8.316). Very careful and delicate mobilization should be
carried out between the membranous trachea and the cervical
esophagus particularly near the lower border of cricoid to prevent
inadvertent injury to the recurrent laryngeal nerves or the eso-
phagus. After complete mobilization of the pathologic segment of
the trachea, it is divided between the cricoid cartilage and the first
ring and the specimen is delivered. Note that the surgical defect of
the trachea extends from the cricoid cartilage up to its sixth ring
(Fig. 8.317).
Primary anastomosis between the cricoid and distal tracheal
stump will require mobilization of the two ends to achieve the
Fig. 8.312 The right and left thyroid lobes are
separated from the trachea to identify the
recurrent laryngeal nerves.
closure without tension. It is, however, inadvisable to carry out
dissection of the mediastinal trachea since that may jeopardize its
blood supply and even produce stump necrosis. Therefore, minimal,
if any, mobilization of the mediastinal trachea is undertaken. On
the other hand, the larynx is released by a maneuver known as
suprahyoid release, bringing the cricoid cartilage close to the
stump of the trachea. The upper skin flap is elevated further to
expose the hyoid bone and the suprahyoid musculature (Fig.
8.318). With the use of an electrocautery, the suprahyoid muscles
attached to the upper border of the hyoid bone are detached. This
will permit drop of the larynx caudad up to 3 cm, permitting the
cricoid cartilage to come closer to the stump of the trachea,
flexion of the neck also helps in approximation of the cricoid
cartilage to the trachea without tension.

Fig. 8.31 3 The right lobe of the thyroid and Fig. 8.314 The left recurrent laryngeal nerve is Fig. 8.315 The trachea is circumferentially
the trachea are retracted showing the right shown entering the cricothyroid membrane. incised below the stricture.
recurrent laryngeal nerve.

Fig. 8.316 The stenosed segment of the Fig. 8.317 The surgical defect of the trachea. Fig. 8.318 Suprahyoid release permits the
trachea seen from below. larynx to drop caudad to facilitate primary
anastomosis.

339
 Prior to anastomosis, the endotracheal tube is r e m o v e d f r o m the tracheal anastomosis. T h e slrap muscles are reapproximated in the
distal trachea. It is r e i n t r o d u c e d f r o m the oral cavity, past the m i d l i n e . Suction d r a i n s are placed in the w o u n d t h r o u g h separate
larynx i n t o the distal trachea, u n t i l the b a l l o o n of the tube is w e l l stab incisions and the skin incision is closed in layers.
i n t o the thoracic trachea. T h e b a l l o o n i s n o w i n f l a t e d a n d I h c rest T r a c h e o s t o m y is best avoided in this s i t u a t i o n since t h e airway at
of the operative procedure continues. Anastomosis between the this p o i n t is clearly superior c o m p a r e d w i t h its preoperative status.
cricoid cartilage a n d the s l u m p of the trachea is t h e n p e r f o r m e d In order to keep the anastomosis tension-free in the immediate
end-to-end w i t h 3-0 Prolene i n t e r r u p t e d sutures. A single layer of postoperative period, the head s h o u l d be kepi in f l e x i o n . A variety
interrupted Prolene sutures is adequate. (Kither I'rolene or D e x o n of techniques can be e m p l o y e d for that purpose. A halo splint may
may be used for this anastomosis). T h e distance gained by be used or a heavy n y l o n suture m a y be taken f r o m the c h i n to the
suprahyoid release to permit the larynx to d r o p caudad to facilitate anterior chest w a l l ( F i g . 8 . 3 2 1 ) . This w i l l keep the head in flexion
the anastomosis is s h o w n v i v i d l y in F i g . 8 . 3 1 8 . The posterior in the postoperative period u n t i l satisfactory healing is achieved at
sutures between the subglottic mucosa a n d the m e m b r a n o u s the site of the tracheal anastomosis. The chin to chest suture is left
trachea are taken w i t h 3-0 D e x o n as s h o w n in F i g . 8 . 3 1 9 , w h i l e in for at leasl t w o to three weeks. The endotracheal lube may be
the anterior sutures are taken w i t h I'rolene in t h i s p a t i e n t . A close- removed within 24 h o u r s o f surgery. T h e p a t i e n t i s given
up view of the completed anastomosis is s h o w n in F i g . 8 . 3 2 0 . h u m i d i f i e d air to breathe a n d is a l l o w e d to lake liquids by m o u t h
Meticulous a t t e n t i o n should be paid to achieve an airtight w i t h i n 4 8 hours.
anastomosis. The isthmus of the t h y r o i d g l a n d is r e a p p r o x i m a t e d
T h e surgical specimen measures 2.5 cm in l e n g t h a n d consists of
w i t h c h r o m i c catgut sutures anterior to the suture l i n e of the
five tracheal rings ( F i g . 8 . 3 2 2 ) . T h e e n d - o n v i e w of the specimen

Fig. 8.319 The Fig. 8.320 Close-up

posterior sutures view of the completed
between the subglottic anastomosis.
mucosa and the
membranous trachea
are taken with 3-0
Dexon.

Fig. 8.321 Heavy nylon Fig. 8.322 The surgical

suture taken from the specimen.
chin to the anterior
chest wall.

340
clearly shows total excision of a concentric stricture of the trachea
achieved by this sleeve resection technique (Fig. 8.323). The
postoperative high KV film of the trachea in the posteroanterior
projection shows re-establishment of a normal tracheal airway
(Kg. 8.324).
Patients with tracheal tumors present with increasing respir-
atory difficulty, wheezing, and sometimes hemoptysis. The axial
view of the MRI scan of a patient with squamous cell carcinoma
of the trachea is shown in Fig. 8.32S. Note that the tumor has
reduced the airway to approximately 10% of normal. A sagittal
view of the MRI shows the tumor involving approximately six
rings of trachea (Fig. 8.326). General anesthesia for endoscopy
and surgical resection required jet ventilation. The jet ventilation
catheter was passed posterior to the tumor and its tip was placed
distal to the tumor. Endoscopic view of the tumor with a 0°
telescope shows the tumor presenting like a horseshoe, occupying
the anterior three-quarters of the circumference of the trachea
(Fig. 8.327). A sleeve resection of the trachea and primary
anastomosis were performed for this patient. Postoperative MRI
shows a restored normal airway (Fig. 8.328).
Sleeve resection of the trachea with primary anastomosis is a
very safe and satisfactory surgical procedure for excision and
repair of small segments of trachea involved by strictures or
tumor. Primary malignant tumors of the trachea or secondary
invasion of the trachea by cancer of the thyroid gland are among
the other indications for resection of trachea. Prom live to seven
rings of the trachea can be safely resected with primary
anastomosis achieved in most patients via a suprahyoid release.
The operative procedure is easy, safe and well tolerated by patients
with minimal morbidity.

Fig. 8.323 The end-on view of the specimen. Fig. 8.324 A postoperative high KV film of the Fig. 8.325 Axial view of the MRI scan showing
trachea shows a normal airway. squamous carcinoma of the trachea.

Fig. 8.326 Sagittal view of the MRI scan Fig. 8.327 Endoscopic view through a 0' Fig. 8.328 Postoperative MRI scan in the
demonstrates the length of tracheal telescope. sagittal view demonstrates restoration ot the
involvement. airway.

341
RESECTION OF P A R A S T O M A L RECURRENCE
Parastomal recurrence of c a r c i n o m a f o l l o w i n g t o t a l l a r y n g e c t o m y
is most frequently seen as a result of recurrent disease d e v e l o p i n g
in tracheoesophageal groove l y m p h nodes presenting u n d e r the
skill. The parastomal recurrence may manifest as a small m o b i l e
t u m o r mass in t h e superior or lateral aspect of the tracheostome
or may manifest in the lower half of the tracheostome w i t h direct
extension of disease to the mediastinal l y m p h nodes.
f r o m a strictly surgical s t a n d p o i n t , the parastomal recurrence
w h i c h presents adjacent to the upper half of the circumference of
the tracheostome is relatively easy lo manage a n d has a h i g h e r
potential tor c o n t r o l o f disease. O n t h e o t h e r h a n d , those lesions
w h i c h present at the lower half of the circumference of the
tracheostome have reduced m o b i l i t y due to direct e x t e n s i o n of
disease in the m e d i a s t i n u m a n d are less likely lo be amenable to a
satisfactory surgical resection.
The patient s h o w n in F i g . 8 . 3 2 9 has parastomal recurrence
i n v o l v i n g the superolateral aspect of t h e l e f t - h a n d side of the
tracheostome. The t u m o r mass measures 3.5 cm in diameter a n d
is mobile over the deeper soft tissues. A CT scan of the lower part
of the neck shows the t u m o r clearly presenting as a distinct mass
under t h e medial head of t h e s t e r n o m a s t o i d muscle at t h e level of
the tracheostome, w i t h extension of disease outside the capsule
of the metastatic n o d e to i n v o l v e the adjacent soft tissues ( F i g .
8 . 3 3 0 1 . T h e mass is adherent to the sternoclavicular
interiorly.
Fig. 8.329 Patient with
parastomal recurrence
involving the
superolateral aspect of
the left-hand side of
the tracheostome.
Fig. 8.330 CT scan of
the lower part of the
neck.
342
Surgical resection of this t u m o r requires w i d e excision of a
generous p o r t i o n of skin a r o u n d the tracheostome i n c l u d i n g the
m u c o c u t a n e o u s j u n c t i o n of the tracheostome a n d the s t u m p of
t h e distal trachea a s o u t l i n e d i n F i g . 8 . 3 3 1 . N o t e t h e surface
markings of the m a n u b r i u m a n d the sternoclavicular joints on
b o t h sides in relation to the extent of the skin for excision.
The surgical resection entails a t h r o u g h - a n d - t h r o u g h resection
of the s k i n , u n d e r l y i n g soft tissues, distal trachea, a n d all the gross
disease en bloc w i t h the medial t h i r d of the left clavicle and the
m a n u b r i u m sterni. A circular skin incision is taken at the site of
the proposed excision of skin over the parastomal recurrence. A
second m i d l i n e vertical incision is taken f r o m the lower border of
the circular s k i n i n c i s i o n over the m a n u b r i u m sterni. The lower
skin flaps are elevated first. The muscular attachments over the
medial half of the clavicle are detached. The sternomastoid muscle
is detached f r o m its superior surface a n d the subclavius muscle is
detached f r o m its undersurface.
A periosteal elevator is t h e n used to elevate the periosteum of
the medial t h i r d of the clavicle. A Doyen's rib raspatory is now
used to elevate the periosteum of the clavicle circumferentially.
Using a power saw, the clavicle is d i v i d e d . The sternal attachments
of the pectoralis major muscle are t h e n elevated to expose the
m a n u b r i u m . A sternal power saw is n o w used to divide the
sternum at the desired level of resection. Alternatively, a power
d r i l l a n d an olive-shaped burr m a y be used to create a trench along
the r i g h t sternocostal a n d i n f e r i o r m a n u b r i o s t e r n a l joints. This
joint
t r e n c h is created t h r o u g h the outer cortex a n d t h e cancellous part
of the m a n u b r i u m up to its posterior cortex. T h e n , using a
I.ebschc k n i f e , the m a n u b r i u m is d i v i d e d along this t r e n c h .
D i v i s i o n of the m a n u b r i u m a n d the clavicle as performed above
w i l l n o w permit m o b i l i z a t i o n of the surgical specimen a n d entry
I n t o the superior m e d i a s t i n u m . By alternate b l u n t a n d sharp
dissection a n d particularly by delicate sharp dissection b e h i n d the
sternoclavicular j o i n t a n d at the j u n c t i o n of the clavicle and the
first rib, the b o n y c o m p o n e n t of t h e specimen is mobilized.
M e t i c u l o u s a t t e n t i o n s h o u l d be paid d u r i n g this dissection to
a v o i d i n a d v e r t e n t i n j u r y l o the subclavian a n d i n n o m i n a t e veins.
Careful dissection of these veins f r o m the posterior aspect of the
sternoclavicular j o i n t is undertaken first a n d , using a malleable
retractor, these delicate great veins are protected d u r i n g this phase
of the o p e r a t i o n .
Fig. 8.331 The extent of skin resection and the sternoclavicular joints
are outlined.
 Finally the specimen is rotated to the right-hand side and T h e surgical defect created by resection of this parastomal
cephalad to dissect all the mediastinal l y m p h nodes a n d soft recurrence requires coverage of a large area of skin loss and soft
tissues. The specimen n o w remains attached o n l y t h r o u g h the tissue to fill the dead space b e n e a t h . A variety of flaps are available
trachea, w h i c h is d i v i d e d last, distal lo the visible a n d palpable to a c c o m p l i s h this. Prom the simplest to the more c o m p l e x , they
recurrent tumor. T h e endotracheal tube is r e m o v e d , the trachea is
transected to deliver the specimen a n d the endotracheal tube is
reintroduced i n t o the distal trachea.
f o l l o w i n g removal of the specimen, the surgical field shows
adequate clearance of the superior m e d i a s t i n u m ( F i g . 8 . 3 3 2 1 . T h e
confluence of the i n t e r n a l jugular a n d subclavian veins f o r m i n g
the left i n n o m i n a t e v e i n is seen clearly in the f i e l d . A close-up
view of the upper part of the surgical field demonstrates the lower
end of the carotid sheath w i t h the left c o m m o n carotid artery a n d
the internal jugular vein as well as the esophagus ( F i g . 8 . 3 3 3 ) . In
,i close-up view of the superior m e d i a s t i n u m , the i n n o m i n a t e v e i n
and the stump of the trachea are clearly seen ( F i g . 8 . 3 3 4 ) .
The specimen shows a generous p o r t i o n of skin w i t h the
mucocutaneous j u n c t i o n a n d distal trachea resected en bloc w i t h
the m a n u b r i u m a n d the medial h a l f of the left clavicle ( F i g .
8.335). The posterior aspect of the specimen shows all the excised
superior mediastinal l y m p h nodes a l o n g w i t h the s t u m p o f the
trachea, the posterior surface of t h e sternoclavicular j o i n t a n d the
Stump of the attached s t e r n o m a s t o i d muscle ( F i g . 8 . 3 3 6 ) . Fig. 8.334 Close-up view of the superior mediastinum shows the left
innominate vein and the stump ot the trachea.

Fig. 8.332 The surgical field following resection of the tumor. Fig. 8.335 Anterior view of the surgical specimen.

Fig. 8.333 Close-up view of the upper part of the surgical field shows Fig. 8.336 The posterior aspect of the specimen.
the carotid artery and internal jugular vein.

343
are: (1) deltopectoral flap; (2| pectoralis major myocutaneous flap;
and (3) a rectus abdominis myocutaneous free flap. In this patient,
a medially based deltopectoral flap is elevated from the left side
and rotated cephalad and medially to cover the surgical defect.
The tip of the deltopectoral flap is first brought to the surgical
defect and sutured to the stump of the tracheostome. The flap
rotates easily into the space created by resection of the clavicle
and the sternum and helps fill the dead space.
The donor site defect of the deltopectoral flap on the anterior
chest wall is closed primarily by mobilizing the upper and lower
skin flaps. Completed closure of the surgical defect is shown in
Fig. 8 3 3 7 .
The postoperative appearance of the patient approximately six
months following surgery shows well-healed scars (Fig. 8.338).
The deltopectoral flap has provided satisfactory closure of the skin
defect in the mediastinum and has helped to bring a mediastinal
tracheostome to the surface.
Parastomal recurrence of modest dimensions presenting at the
upper half of the circumference of the tracheostome as shown
above is suitable for a relatively conservative surgical resection.
The surgical defect can usually be closed with rotated regional
flaps. The potential for cure in this clinical setting is reasonably
good and the surgical procedure is worthy of consideration.
Fig. 8.337 Completed closure of the surgical defect with a deltopectoral
flap.
Fig. 8.338 Appearance of the patient six months following surgery.
344
RESECTION OF EXTENSIVE PARASTOMAL RECURRENCE
WITH TOTAL PHARYNGOESOPHAGECTOMY
Patients whose parastomal recurrence involves the upper half of
the margin of the tracheostome and extensively invades the
adjacent skin, soft tissues, and the underlying pharynx or
esophagus are candidates who are considered suitable for curative
resection as long as the disease does not invade the carotid sheath
on either side. The patient shown in Fig. 8.339 has extensive
parastomal recurrence with tumor fungating through the skin of
the central compartment of the neck and invading the underlying
pharyngoesophageal junction. The tumor, however, does not
invade the carotid sheath or extend into the mediastinum. The
plan of surgical resection here is to excise a generous portion of
the skin of the neck in conjunction with through-and-through
resection of the soft tissues of the central compartment of the
neck including pharynx, esophagus, distal trachea and all the soft
tissues and lymph nodes in the superior mediastinum iFig.
8.340). Clearance of the neck will include all the tissues from
carotid sheath to carotid sheath.
Fig. 8.339 Preoperative appearance of a patient with extensive
parastomal recurrence.
Fig. 8.340 A generous portion of the skin is excised along with the
tumor and viscera of the central compartment.
 M o b i l i z a t i o n of the surgical specimen in the neck has been RADICAL RESECTION FOR MASSIVE PARASTOMAL
completed w i t h adequate clearance of the t u m o r ( F i g . 8 . 3 4 1 ) . The RECURRENCE
upper thoracic esophagus has been m o b i l i z e d f r o m this exposure.
A laparotomy is performed to m o b i l i z e the stomach and the distal
Parasternal recurrence at the lower half of the tracheostome
thoracic esophagus. Once the esophagus is completely m o b i l i z e d ,
usually has decreased m o b i l i t y a n d presents a difficult technical
it is pulled out of the thoracic cavity along w i t h the s t o m a c h . The
problem. I h e patient s h o w n here had laryngectomy a n d post-
gastroesophageal junction is divided and the specimen is
operative radiotherapy, the portals of w h i c h included the
delivered.
tracheostome. At the t i m e of this presentation, the parastomal
I'haryngogastrostomy is c o m p l e t e d . T h e skin a n d soft tissue
recurrence occupied a p p r o x i m a t e l y three-quarters of the circum-
defect are reconstructed using a pectoralis major m y o c u t a n e o u s
ference of the tracheostome. The disease extended f r o m the
flap. Postoperative appearance of the patient a p p r o x i m a t e l y three
superior m i d l i n e to the e n t i r e left half a n d up to the lower aspect
months following surgery (Fig. 8.342) shows satisfactory
of the right half of the tracheostome. A close-up view shows that
coverage of the soft tissue a n d skin defect w i t h the tracheostome
t h e t u m o r has ulcerated t h r o u g h the mucosa of the trachea.
created low in the suprasternal n o t c h .
M o b i l i t y of the t u m o r mass is restricted due to its adherence to the
If total esophagectomy is felt not to be necessary, t h e n the
u n d e r l y i n g sternoclavicular j o i n t ( F i g . 8 . 3 4 3 ) .
pharyngoesopahgeal junction c a n be reconstructed using a
A c: I scan of the patient taken at the level of the tracheostome
jejunal free flap a n d coverage for the skin can be p r o v i d e d by a
shows t h e presence of recurrent t u m o r on b o t h sides of the
deltopectoral flap or a pectoralis m y o c u t a n e o u s flap. Resections of
trachea w i t h m o r e extensive t u m o r on the left-hand side and
this magnitude are still felt to be curative in some patients but
l y m p h node metastasis in the paratracheal region on the right-
prove to be palliative in most situations.
hand side ( F i g . 8 . 3 4 4 ) .
T h e o p e r a t i o n consists of resection of the parastomal disease
w i t h a generous p o r t i o n of the s u r r o u n d i n g skin and the entire
m a n u b r i u m as w e l l as the medial t h i r d of the clavicle on the left-
h a n d side. T h e marked circular i n c i s i o n shows the extent of skin
to be sacrificed w i t h a m i d l i n e extension over the sternum for

Fig. 8.343 The disease

extended from the
superior midline to the
entire left hall and up
to the lower aspect of
the right half of the
tracheostome.

Fig. 8.341 The surgical defect showing clearance of all tissue from one
carotid sheath to the other.

Fig. 8.344 CT scan of

the neck shows tumor
on both sides of the
tracheostome with
adjacent metastatic
ymph nodes.

Fig. 8.342 Postoperative appearance of the patient three months

following surgery.

345
Fig. 8.345 The incisions are outlined for resection of the tumor, and
sternectomy.
Fig. 8.346 The surgical defect shows the innominate veins, the
innominate artery and the stump of the trachea with the endotracheal
tube.
mediastinal dissection (I-'ig. 8.345). The surgical resection
required mediastinal dissection with careful preservation of the
great vessels. The trachea was resected postero-inferior to the
innominate artery.
The surgical defect with the endotracheal tube is shown in l i g .
8.346. The great vessels that could be demonstrated in the
mediastinum are the left internal jugular, left subclavian and left
innominate vein, which joins with the right innominate vein to
form the superior vena cava. The innominate artery and the right
common carotid artery are also seen in the field with the stump of
the trachea lying deep to the innominate artery. In order to
appreciate the level of transection of the trachea, the endotracheal
tube is momentarily removed in Fig. 8.347 where the extent of
mediastinal resection is fully demonstrated. The stump of the
trachea is clearly seen lying posterior and deep to the innominate
artery in the mediastinum.
Repair of this surgical defect needs not only skin coverage but a
large amount of viable vascularized tissue to fill a huge dead space
created by removal of the tumor. Such tissue can be provided by
either a pectoralis major myocutaneous flap or free flaps such as
the rectus abdominis or latissimus dorsi. Special attention is
required to create a mediastinal tracheostome with a good, viable
346
Fig. 8.347 The endotracheal tube is momentarily removed to show that
the trachea is resected below the innominate artery.
and pliable skin component of the flap reaching the tracheal
stump in the mediastinum.
Major resection for massive parastomal recurrence requiring
mediastinal dissection and resection ot the clavicle, manubrium,
etc., is indicated in select patients who are considered lit to with-
stand such major surgery. Lvery attempt must be made pre-
operative^ to ascertain the feasibility of a satisfactory surgical
resection. Such a major operative procedure is not indicated for
debulking the tumor with a palliative intent. Even in those
patients who have a seemingly satisfactory surgical resection with
negative margins, the potential for long-term cure is small.
VOICE REHABILITATION
Rehabilitation of the voice is essential in those patients where the
quality of voice is altered as a result of surgical procedures on the
larynx. This may be a simple endoscopic excision of a vocal cord
lesion to total laryngectomy. Clearly there are numerous operative
procedures described for reconstruction of the resected portion of
the larynx with claims of varying degrees of success as it relates to
the quality of voice. However, regardless of the type of recon-
structive procedure used to repair a resected portion of the larynx,
predictable quality of the voice is hard to achieve. On the other
hand, predictable improvement in the quality of voice can be
expected for patients with unilateral paralysis of the vocal cord
by mediali/ation procedures. Also, predictable improvement in
restoration of speech can be expected after laryngectomy with
creation of a tracheoesophageal puncture and use of the
Blom-Singei type of prosthesis.
LARYNGOPLASTY
The procedure of laryngoplasty is recommended in those patients
where unilateral paralysis of the vocal cord has taken place for any
reason where the life expectancy of the patient is reasonably good.
A vocal cord paralyzed in the abduction position leads to.an
incompetent glottis with a hoarse and hollow voice. Laryngo-
plasty effectively attains medial shift of the paralyzed vocal cord
allowing adequate apposition by the mobile contralateral vocal
cord and thus improves the quality of voice.
 The operative procedure is usually performed u n d e r local ala of the t h y r o i d cartilage f r o m the m i d l i n e up to the posterior
anesthesia w i t h m i l d sedation. Topical anesthetic is applied to the border of the t h y r o i d l a m i n a is anesthetized.
mucosa of the supraglottic larynx either by a spray or by direct A transverse i n c i s i o n , a p p r o x i m a t e l y .< cm length is placed
instillation of a topical anesthetic agenl in the valleculae, p y r i - e x t e n d i n g f r o m the m i d l i n e o f the t h y r o i d cartilage u p t o its
form sinuses and in the vestibule of the l a r y n x . In a d d i t i o n to this, posterior edge a p p r o x i m a t e l y 5-7 mm superior to the lower border
bilateral superior laryngeal nerve block is p e r f o r m e d by i n j e c t i o n of the t h y r o i d cartilage ( F i g . 8 3 4 9 ) . T h e skin incision is deepened
of approximately 5 ml of l% lidocaine (lignocaine) with t h r o u g h the platysma to expose the strap muscles (Fig. 8.350).
epinephrine on the lateral aspect of the t h y r o h y o i d m e m b r a n e T h e fascia in the m i d l i n e is incised ( F i g . 8 . 3 5 1 ) . Similarly the
where the surface m a r k i n g for the e n t r y of the superior laryngeal p e r i c h o n d r i u m is also incised in the m i d l i n e to expose the under-
nerve into the supraglottic larynx is fairly constant. This is depicted l y i n g t h y r o i d cartilage. I h e p e r i c h o n d r i u m is elevated w i t h a line
on the model where the superior laryngeal nerve is s h o w n periosteal elevator to expose the anterior half of the lamina of the
entering the t h y r o h y o i d m e m b r a n e near the lateral e n d of the t h y r o i d cartilage. A Richardson retractor is used to retract the strap
greater cornua of the h y o i d ( f i g . 8 . 3 4 8 ) . Alter adequate topical muscles a n d the p e r i c h o n d r i u m to expose the t h y r o i d lamina
anesthesia a n d superior laryngeal nerve block are p e r f o r m e d , 1% ( F i g . 8 . 3 5 2 ) . A rectangular w i n d o w in the t h y r o i d cartilage is now
lidocaine is injected t h r o u g h the skin a n d subcutaneous tissues up made using a variable-speed electric d r i l l w i t h an ultra-fine burr
to the lamina of the t h y r o i d cartilage on the side that the surgery ( F i g . 8 . 3 5 3 ) . The p o s i t i o n of this rectangular w i n d o w is critically
is to he performed. An area of skin a n d soil tissues o v e r l y i n g the i m p o r t a n t . I h e rectangle is h o r i z o n t a l l y oriented w i t h its anterior

Fig. 8.348 Model showing the superior f i g . 8.349 The outlines of the thyroid and Fig. 8.350 The skin incision is deepened
laryngeal nerve entering the thyrohyoid cricoid cartilages are shown in relation to the through the platysma.
membrane near the lateral end of the greater skin incision.
cornua of the hyoid.

Fig. 8.351 The fascia in the midline is incised Fig. 8.352 The strap muscles and the Fig. 8.353 A rectangular window in the thyroid
longitudinally along its long axis. perichondrium are retracted to expose the cartilage is made with a drill and a fine burr.
thyroid lamina.

347
border beginning approximately S mm posterior to the midline of
the thyroid cartilage (Fig. 8.354). The lower border of the
rectangular window is approximately S mm from the lower border
of the thyroid cartilage as shown in the model. The high-speed
drill is used with extreme caution to avoid laceration of the inner
perichondrium or the soft tissues in the interior of the larynx,
otherwise a hematoma will invariably lake place and significantly
jeopardize the operative procedure (Fig. 8.355). Once the
cartilage window is created with the drill, a I'enliekl dural elevator
is used to elevate the inner perichondrium and the underlying soft
tissues of the interior of the larynx in all four directions (Fig.
8.356). A freer periosteal elevator is now used to assess the degree
of medial displacement of the vocal cord necessary to achieve the
desired quality of voice. The periosteal elevator is Introduced
through the rectangular window pointing posteriorly and the soft
tissues of the interior of the larynx are shifted medially and the
patient is asked to phonate. When the desired quality of voice is
achieved, an estimate is made regarding the size of the Silastic
Fig. 8.354 The location of the rectangular Fig. 8.35S The cartilage window extends up to
window in the thyroid cartilage. the inner perichondrium.
Fig. 8.357 A solid block of soft Silastic material
is now used to fabricate the wedge-shaped
Silastic shim.
348
wedge necessary to create such displacement of the vocal cord and
to maintain it in that position. A solid block of soft Silastic
material is used to fabricate the wedge-shaped Silastic shim
necessary for medial displacement of the vocal cord (Fig. 8.357).
Alternatively a Dacron (Goretex) ribbon may be used. (Fig.
8.358). The advantage of the ribbon is thai il enables the surgeon
lo customize the quality of voice desired by introducing only the
necessary length of the ribbon to achieve the desired result (Fig.
8.359). The pitch of the voice can be tested with varying lengths
of the ribbon until the exact length necessary to achieve the
desired voice is found.
Using non-toothed line DeBakey forceps, the shim is grasped
with its handle and its posterior portion (the base of the triangular
wedge) is first introduced through the rectangular window toward
the posterior part of the larynx and then the anterior part of the
shim is introduced by compressing the shim and easing it into
the paraglottic space (Fig. 8.360). Once the shim is in position,
its handle is used to adjust its permanent position. The patient is
Fig. 8.356 A Penfield dural elevator is used to
elevate the inner perichondrium and the
underlying soft tissues ot the interior of the
larynx.
Fig. 8.359 Coretex thyroplasty.
now asked again to p h o n a t e to assess the q u a l i t y of voice. If the
voice is still too hollow, t h e n the s h i m is t o o small a n d a bigger
shim w o u l d he necessary. On the o t h e r h a n d , if the voice is t o o
shrill, or the patient finds d i f f i c u l t y w i t h b r e a t h i n g causing stridor,
then the s h i m is too b i g a n d it needs to be t r i m m e d d o w n . W i t h
experience, an appropriate size of the s h i m is fabricated to reach
the desired q u a l i t y of voice w i t h o u t c o m p r o m i s e of the airway
(Fig. K.361). Once the s h i m is properly p o s i t i o n e d , the strap
muscles are allowed to retract back a n d are r e a p p r o x i m a t e d w i t h
interrupted c h r o m i c catgut sutures. The platysma is closed w i t h
interrupted c h r o m i c catgut sutures a n d the skin is closed in the
usual fashion w i t h i n t e r r u p t e d 5-0 n y l o n sutures.
M i n i m a l postoperative care is necessary f o l l o w i n g this pro-
cedure. However, t h e p a t i e n t s h o u l d be carefully observed f o r
several hours for respiratory distress. Occasionally a h e m a t o m a
may occur leading to progressive respiratory difficulty. Previously
irradiated patients m a y d e v e l o p significant laryngeal edema
following this operative procedure and m a y have to be observed
carefully for respiratory c o m p r o m i s e . Significant i m p r o v e m e n t in
the quality of voice s h o u l d be expected in most patients under-
going laryngoplasty.
Fig. 8.360 The posterior part of the shim is introduced by compressing
the shim and easing it into the paraglottic space.
Fig. 8.361 An appropriate size of the shim is fabricated to reach the
desired quality of voice without compromise of the airway.
SECONDARY TRACHEOESOPHAGEAL PUNCTURE
Loss of voice f o l l o w i n g t o t a l laryngectomy is a major functional
disability. In order to achieve a satisfactory voice, esophageal
speech therapy lias been used in the past. However, the quality,
a m p l i t u d e , a m i l e n g t h of the sentences produced by esophageal
speech are far f r o m satisfactory in the m a j o r i t y of patients.
Creation of a fistulous tract between the trachea a n d the
esophagus permits p u l m o n a r y air to be d r i v e n i n t o the pharynx to
p r o v i d e sufficient charge of air c o l u m n to produce speech of high
a m p l i t u d e a n d p i t c h w i t h more words a m i longer sentences per
each charge of air c o l u m n . Delivery of the p u l m o n a r y air i n t o the
p h a r y n x is c o n t r o l l e d by a d u c k b i l l t y p e of prosthesis w h i c h has a
one-way valve p r e v e n t i n g regurgitation of saliva a n d food i n t o the
trachea but p e r m i t t i n g delivery of air i n t o the esophagus freely.
T h e l i l o m - Singer valve is the most popular prosthesis used for
speech r e h a b i l i t a t i o n t h r o u g h tracheoesophageal puncture. The
l'rovox prosthesis is a significant i m p r o v e m e n t over the duckbill
prosthesis a n d can be retained in place up to six m o n t h s w i t h o u t
a change.
The operative procedure can be performed either under general
anesthesia or under local anesthesia w i t h m i l d sedation, l o r satis-
factory performance of the tracheoesophageal puncture, an adequate
tracheostome is essential ( F i g . 8 . 3 6 2 ) . Ideally the tracheostome
Should be of a racquet shape w i t h direct access to the mem-
branous trachea a n d its mucocutaneous j u n c t i o n in the posterior
part of the tracheostome. The location of the tracheoesophageal
p u n c t u r e is a p p r o x i m a t e l y 5 mm below the mucocutaneous
j u n c t i o n . The i n s t r u m e n t s required for the procedure are shown
in F i g . 8 . 3 6 3 . T h e j e s b e r g esophagoscope w i t h distal light is ideal
since it has a w i d e m o u t h w i t h a protective w a l l ( F i g . 8.364). A
Jcsberg esophagoscope is i n t r o d u c e d t h r o u g h the oral cavity and
is rotated 180° to have its ' m o u t h ' face the m e m b r a n o u s trachea
at the superior e n d of the tracheostome ( F i g . 8 . 3 6 5 ) . I he light at
the distal e n d of the esophagoscope readily shows i l l u m i n a t i o n
t h r o u g h the m e m b r a n o u s trachea locating the position of the
esophagoscope ( F i g . 8 . 3 6 6 ) . A n o . 14 gauge angiocath is now
used to make a p u n c t u r e t h r o u g h the m e m b r a n o u s trachea into
t h e esophagus ( F i g . 8 . 3 6 7 ) . L o o k i n g t h r o u g h the esophagoscope,
the t i p of the a n g i o c a t h needle can be seen. T h e posterior lip
of the esophagoscope readily protects inadvertent i n j u r y to the
posterior w a l l of the esophagus by the needle. Using a fine
hemostat, t h e tracheoesophageal p u n c t u r e a r o u n d t h e angiocath
Fig. 8.362 An
adequate tracheostome
is essential.
349
 Fig. 8.366 The light at
the distal end of the
esophagoscope locates
its position.

Fig. 8.363 The instruments required for tracheoesophageal puncture.

Fig. 8.367 A puncture

is made through the
membranous trachea
into the esophagus.

Fig. 8.364 The distal tip of the jesberg esophagoscope.

Fig. 8.368 The

tracheoesophageal
puncture is dilated.

Fig. 8.365 A Jesberg esophagoscope is introduced through the oral

cavity.

is dilated to a c c o m m o d a t e a n o . 14 size red rubber catheter ( F i g .
8.3681. The tip of the red rubber catheter is i n t r o d u c e d t h r o u g h
the tracheoesophageal puncture I n t o the esophagus ( F i g . 8 . 3 6 9 ) .
An alligator forceps is used to grasp the l i p of the red rubber
catheter w h i c h is w i t h d r a w n i n t o the esophagoscope. The distal
end of the red rubber catheter is n o w directed caudad i n t o the
thoracic esophagus a n d the esophagoscope is withdrawn. The
outer e n d of the red rubber catheter is secured to the skin edge
w i t h a silk suture. The red rubber catheter m a y be used as a feeding
lube for the next 2 4 - 4 8 hours.
At 48 hours, the red rubber catheter is r e m o v e d a n d a d u m m y
tracheoesophageal prosthesis is i n t r o d u c e d to gauge the size

350
 Fig. 8.369 A red
rubber catheter is
introduced through the
puncture.
Fig. 8.370 Currently
available voice
prostheses.
(length) of the voice prosthesis. T h e c u r r e n t l y available prostheses
are shown in l i g . 8 . 3 7 0 . After the appropriate type a n d size of
the prosthesis is selected, using an introducer, the prosthesis is
Introduced a n d appropriately p o s i t i o n e d . The patient s h o w n in
F i g . 8 . 3 7 1 has a l o n g - t e r m i n d w e l l i n g prosthesis w h i c h requires
change every 4 - 6 m o n t h s . D u r i n g this phase of the insertion of
Ihe prosthesis, the patient receives i n s t r u c t i o n regarding produc-
tion of tracheoesophageal speech as well as maintenance of
the prosthesis f r o m a q u a l i f i e d speech therapist. Significantly i m -
proved quality of speech is expected in most patients u n d e r g o i n g
tracheoesophageal p u n c t u r e a n d voice prosthesis.
In order to produce speech, the patient has to direct air f r o m the
trachea to the esophagus, r e q u i r i n g occlusion of the tracheostome
during p h o n a t i o n , T h i s requires the use ol a t h u m b or a linger to
occlude the stoma w h i l e the patient is speaking. Most patients get
along well w i t h this t e c h n i q u e . However, if the patient finds use
of Ihe linger to he c u m b e r s o m e , t h e n one-way tracheostome
valves are available w h i c h are applied to the tracheostome for
spontaneous p r o d u c t i o n of speech. These valves are glued to the
skin adjacent to the tracheostome a n d carry a one-way f l i p valve
w h i c h permits i n h a l a t i o n of air t h r o u g h the valve i n t o the
tracheobronchial tree, but d u r i n g e x h a l a t i o n the valve closes itself
and directs the air i n t o (he esophagus t h r o u g h the tracheo-
Fig. 8.371 Patient with
a long-term indwelling
prosthesis which
requires change every
4-6 months.
Fig. 8.372 A stoma
valve facilitates hands-
free tracheo-
esophageal speech.
esophageal prosthesis l l ' i g . 8 . 3 7 2 ) . I h e valve is so calibrated that
d u r i n g quiet b r e a t h i n g , air passage t h r o u g h the valve takes place
in b o t h directions; however, d u r i n g p h o n a t i o n , higher intra-
thoracic pressure is created w h i c h forces the valve to close and
directs t h e a i r i n t o t h e esophagus. The c u r r e n t l y available
tracheostome valves are serviceable but not o p t i m a l and further
technical research i n t o t h e i r d e v e l o p m e n t is required.
RESULTS OF TREATMENT
The results of t r e a t m e n t for cancer of the larynx are directly
dependent on the site of o r i g i n of the p r i m a r y t u m o r and the stage
of disease al the l i m e of diagnosis a n d t r e a t m e n t . The overall live-
year survival f o l l o w i n g t r e a t m e n t for each region of the larynx is
s h o w n i n F i g . 8 . 3 7 3 . Eighty-one percent o f patients w i t h glottic
c a r c i n o m a , 7 7 % w i t h subglottic, a n d 5 1 % w i t h supragloltic carci-
n o m a survive live years. T h e supragloltic larynx has a rich
l y m p h a t i c n e t w o r k leading to an increased incidence of regional
l y m p h n o d e metastasis at the t i m e of diagnosis or subsequent to
the t r e a t m e n l of Ihe p r i m a r y r u m o r w i t h its adverse impact on
prognosis. I h e risk of regional l y m p h node metastasis is lower
f o r ' e n d o l a r y n g e a l ' t u m o r s , i.e. ventricle, false vocal cord, and
351
Fig. 8.373 The overall five-year survival following treatment for each
region of the larynx.

Fig. 8.375 Voice preservation for patients with carcinomas of the

supraglottic larynx over the last 50 years.
Fig. 8.374 The five-year disease-free survival of patients with
supraglottic cancer by stage.

laryngeal epiglottis compared to 'exolaryngeal' tumors, i.e.

aryepiglottic fold and arytenoid. Nearly two-thirds of the patients
with carcinoma of the supraglottic larynx have regional lymph
node metastasis at t h e time of initial treatment. On the other
hand, primary tumors of the glottic larynx have a very low
incidence of regional lymph node metastasis with its favorable
long-term prognosis in most patients.
The live-year disease-free survival of patients with supraglottic
cancer by stage is shown in Fig. 8 . 3 7 4 . Eighty-four percent of
patients with Stage I, 8 3 % with Stage II, and 7 3 % with Stage III
survive five years. In contrast, patients with Stage IV disease have
a 44% probability of five-year survival. At MSKCC, over t h e last
SO years an increasing proportion of patients with carcinoma of
the supraglottic larynx have been able lo retain their function of
Fig. 8.376 The five-year disease-free survival of patients with glottic
speech. As can be seen in Fig. 8.375, voice preservation has risen cancer by stage.
from 5% to 56% for patients with carcinomas of the supraglottic
larynx over the last 50 years. This is attributable to early diagnosis,
appropriate selection of initial therapy, increasing application of
voice conserving surgical procedures on the larynx, and the use of multimodal treatment program consisting of chemotherapy and
a multimodal chemoradiotherapy program in patients with radiotherapy. Those patients who have chemosensitive tumors
advanced disease requiring total laryngectomy. manifesting complete response have nearly a 70% chance of
Patients with carcinoma of t h e glottic larynx have an excellent preserving their larynx without an adverse impact on their
long-term prognosis. Ninety percent of patients with Stage I prognosis. However, when total laryngectomy is unavoidable,
tumors and 85% with Stage II survive for five years (Fig. 8.3761. then the quality of life with relation to speech rehabilitation must
Even with Stage III disease, 7 5 % of the patients survive five years. be addressed. Every effort should be made to restore the function
The live-year survival for Stage IV disease, however, is only 45%. of speech either by aggressive speech therapy with the esophageal
Patients with advanced cancers of the larynx requiring total speech rehabilitation or with the institution of a tracheo-
laryngectomy have the potential of salvaging their larynges by a esophageal puncture and use of a Hlom-Singer prosthesis.

352