I. GENERAL CONSIDERATIONS

A. Definitions

1. Supraglottic laryngectomy or horizontal partial laryngectomy is an operation to remove the epiglottis, false vocal cords, superior half of the thyroid cartilage. We interpret the term laryngectomy, subtotal supraglottic to represent the standard supraglottic laryngectomy. The term “partial laryngectomy (hemilaryngectomy); horizontal” is interpreted to identify a lesser procedure with only partial removal of the supraglottic structures still designed to encompass a cancer with clear margins. Supraglottic cancer may be resected with clear margins through an external incision or, in selected cases, endoscopically employing a laser. The role for endoscopic laser supraglottic laryngectomy is still being defined.

2. Cancer extending inferiorly from the supraglottis to involve the glottic larynx may be successfully resected with preservation of laryngeal function employing supracricoid laryngectomy (see Supracricoid laryngectomy protocol).

B. Indications for Supraglottic (Horizontal Partial) Laryngectomy

1. Debate continues regarding which cases are best treated with surgery and which with irradiation. Most cancers affecting the supraglottis that can be treated with horizontal partial laryngectomy can also be successfully managed with irradiation as a primary modality, reserving surgical salvage for irradiation failures. The strongest arguments favoring surgery (supraglottic laryngectomy) as a primary treatment can be made for tumors of large volume (ie, with significant pre-epiglottic space involvement or with extension to the base of tongue), for the “radio-resistant” verrucous variant of squamous cell carcinoma, and for patients who prefer to avoid external beam irradiation. Decision making must include the consideration that, unlike irradiation failures of early glottic cancer, most early supraglottic cancers that persist after irradiation are not amenable to function-preserving surgery (ie, supraglottic laryngectomy). The negative impact of irradiation on wound healing and swallowing requires Total laryngectomy for surgical salvage of the large majority of supraglottic cancers that have failed irradiation.

2. Rare cases of superficial squamous cell carcinoma affecting the suprahyoid epiglottis may be treated without addressing potential cervical metastases. The high rate of metastases for all other cases of squamous cell carcinoma affecting the supraglottic larynx warrant elective treatment of the N₀ neck, either through irradiation or selective Levels II, III, and IV neck dissections. Although debate continues regarding the capacity of radiotherapy to address clinically apparent neck metastases, a therapeutic neck dissection is generally recommended for N-positive disease.

3. General indications for horizontal partial laryngectomy

a. T₁ or T₂ supraglottic cancers

b. T₃ supraglottic cancers with pre-epiglottic space involvement

c. T₂ or T₃ supraglottic cancers with extension limited to the upper medial wall of the pyriform sinus or mucosa of the base of tongue

C. Contraindications

1. Transglottic extension to involve the true vocal cord (see Supracricoid laryngectomy protocol)

2. Extensive involvement of the base of tongue past the circumvallate papillae or sufficient involvement to require bilateral resection of the hypoglossal nerves or lingual arteries (see Total laryngectomy protocol)

3. Involvement of the pyriform sinus other than the upper medial wall

4. T₄ cancers based on thyroid cartilage invasion

5. Postcricoid or interarytenoid extension

6. Although it is commonly expressed that one arytenoid can be safely resected when performing a supraglottic laryngectomy, swallowing is usually markedly impaired by extension of a supraglottic cancer to remove this structure through the conventional open approach. If resection of the arytenoid is necessary, alternative approaches more likely to preserve swallowing function (such as endoscopic laser supraglottic laryngectomy or irradiation) may be considered.

7. It has also been commonly supported that a supraglottic laryngectomy should not be done if a margin less than 5 mm is present between the tumor and the anterior commissure. Current practice permits much closer (ie, 1 mm) margins at the anterior commissure.

8. Poor health is a contraindication to supraglottic laryngectomy that must be individually evaluated. Inadequate pulmonary reserve to tolerate the expected aspiration is a contraindication.

II. PREOPERATIVE PREPARATION

A. Evaluation

1. CT of larynx and neck for all supraglottic cancers

2. Panendoscopy (see Panendoscopy protocol) with biopsies to potentially include microscopic direct laryngoscopy and tumor mapping

3. Radiation oncology consult to discuss alternatives to surgery

4. Videoendoscopy to record voice and dynamic appearance of larynx (see Videostroboscopy protocol)

5. Chest x-ray

6. Consider swallowing evaluation (see Oropharyngeal motility study protocol)

7. Assess lung function: Consider internal medicine consultation, pulmonary function tests; best test of general fitness to tolerate procedure is to physically walk with them up 2 flights of stairs

8. Tumor board discussion

B. Consent

1. Describe procedure: “Through incision in your neck, we plan to remove part of the voice box (above the vocal cords). If tumor extends farther than we have assessed, may require removal of entire voice box.” “A tracheotomy, incision into your windpipe will be made to permit you to breathe as the healing progresses.”

2. Describe potential complications: bleeding, infection, reaction to the anesthetic, damage to structures

a. Loss of voice

b. Aspiration with inability to swallow

c. Long-term dependence on tracheotomy

d. Potential need for subsequent total laryngectomy to address persistent dysphagia

3. General principle: Do not offer a partial laryngectomy to a patient unless (s)he is prepared for Total laryngectomy if the tumor extent at the time of surgery is found to be greater than initially anticipated.

C. Counseling

1. Include services of a speech pathologist to identify what to expect regarding potential “life without the larynx”

2. Counsel regarding swallowing strategies should be given if a supraglottic laryngectomy is performed

III. NURSING CONSIDERATIONS

A. Room Setup

See Basic Soft Tissue Room Setup

B. Instrumentation and Equipment

1. Standard

a. Major instrument tray #1, Otolaryngology

b. Major instrument tray #2, Otolaryngology

c. Bipolar forceps tray

d. Tracheotomy tray

2. Special

a. Sterile anesthesia breathing circuit, adult

b. Nerve stimulator control unit and instrument

c. Varidyne vacuum suction controller

d. Rousch laryngoflex 7 mm endotracheal tube

e. Corpak feeding tube

C. Medications (specific to nursing)

1. Antibiotic ointment

2. 1% lidocaine with 1:100,000 epinephrine

D. Prep and Drape

1. Standard prep, 10% providone iodine

2. Drape

a. Head drape

b. Square off with towels the neck, from chin to clavicle

c. Split sheet

E. Drains and Dressings

1. Varidyne vacuum suction: 7 mm or 10 mm and/or Penrose drain

2. Antibiotic ointment

F. Special Considerations

Confirm if the Tracheotomy will be done first, as a separate procedure, or as part of the procedure.

IV. ANESTHETIC CONSIDERATIONS

A. Induction

1. Systemic medications

a. Antibiotics (see Antibiotic protocol)

b. Consider Decadron 8 to 10 mg to diminish postoperative edema

2. Oral endotracheal intubation may require critical attention to management of an uncertain airway. Discussion between the surgeon and anesthesiologist improves safety. The difficult airway may best be managed by

a. Management of the airway if treating supraglottitis

b. Flexible fiber optic awake intubation

c. Tracheotomy under local anesthesia

B. Positioning

1. A tracheotomy under local anesthesia is done with the patient’s head toward anesthesia (turned 0°).

2. Panendoscopy, if it is to precede the supraglottic laryngectomy may be done at 0°, but more commonly with the table turned 90°, head facing the door.

3. The supraglottic laryngectomy is performed with the table turned 180° to permit access to both sides of the neck.

4. A shoulder roll is placed for the tracheotomy (if it is tolerated), the panendoscopy, and the laryngectomy.

5. The head of bed is elevated to diminish bleeding.

V. OPERATIVE PROCEDURE

A. Tracheotomy

Use horizontal skin incision (may require local tracheotomy if the tumor is sufficiently large to make intubation difficult).

B. Supraglottic Laryngectomy

1. Incise through skin crease at level of laryngeal prominence, extend further laterally if neck dissection is to be done.

2. Do neck dissections (for the N₀ neck, perform bilateral selective, Levels II, III, IV neck dissection) pedicle the neck dissection to larynx is only the omohyoid muscle and its fascia; little point in obstructing access to larynx by preserving these attachments.

3. Strap muscles are dissected from the hyoid and pedicle inferiorly with care to detect and avoid any carcinoma that presses forward in the pre-epiglottic space under the thyrohyoid membrane.

4. Incise thyroid perichondrium at its upper border and reflect inferiorly; subperichondrial injection with 1% lidocaine with 1:100,000 epinephrine permits “hydrodissection” and increased ease of elevation of perichondrium intact.

5. Division of thyroid cartilage

a. Preserve at least the lower three-quarters of the cartilage in the midline

b. Horizontally to end of cartilage on involved side

c. Uninvolved side: horizontally to middle of ala then slants obliquely to the superior border to help preserve superior laryngeal nerve

6. Enter vallecula on uninvolved side

7. Patient’s head is extended, and surgeon puts on headlight; grasp epiglottic with tenaculum skin hooks retract the false cords and confirm the limitation of the tumor to the supraglottic larynx.

a. Mucosal resection begins on apex of the aryepiglottic folds immediately anterior to the arytenoid and angles across the false cords obliquely; as in nasal surgery, injection with vasoconstricting agent decreases bleeding and increases accuracy of mucosal cuts through improved exposure.

b. Make cuts above involved side first with visualization of the anterior commissure and the better side aided by unfolding the specimen.

c. Best to remove entire hyoid to avoid problem of this structure being mistaken later as a neck mass indicating recurrence.

d. It is best to remove entire false cord tissue to decrease postoperative supraglottic edema.

e. Maintain contralateral superior laryngeal nerve when possible.

8. The need for cricopharyngeal myotomy is assessed by placing a finger into the upper esophagus; unless the upper esophagus is tight and there is no history of reflux, a cricopharyngeal myotomy is not performed.

9. Place feeding NG tube.

10. Careful closure

a. Mucosal approximation is not the object; rather, elevate the remaining larynx as high as possible and position the tongue base to overhang the laryngeal introitus

b. With patient’s head still in the extended position, the closure is begun internally by suturing (as much as is possible) the medial pyriform mucosa to the residual lateral arytenoid mucosa with an unclosed area anteriorly left to re-epithelialize secondarily

c. Pharyngeal closure is begun by inserting sutures in the lateral pharyngeal wall, approximating pyriform fossa mucosa to itself up the thyroid perichondrium

d. Flex the head forward for subsequent closure

e. 2-0 tevdek from thyroid cartilage to periosteum of mandible

f. Perichondrium to base of tongue, leaving overlap of tongue with 3-0 tevdek, silk, or best 2-0 chromic

g. Third layer: strap muscles to suprahyoid muscles

11. Just as the nose is a vascular organ, so is the larynx. As a result, injection with 1% lidocaine with 1:100,000 epinephrine before making scalpel cuts permits better exposure due to less bleeding.

VI. POSTOPERATIVE CARE

A. Keep head flexed forward.

B. Begin swallowing about 12 to 14 days postoperatively. Consult speech pathology for swallowing rehabilitation

C. Perform full decannulation when patient can tolerate corking and demonstrate (s)he can sleep in recumbent position with it corked.

D. Swallowing is more likely to be successful if instituted after decannulation.

VII. CPT CODING

A. 31367, Laryngectomy; subtotal supraglottic, without radical neck dissection

B. 31368, Laryngectomy; subtotal supraglottic with radical neck dissection

C. 31370, Partial laryngectomy (hemilaryngectomy); horizontal

VIII. SUGGESTED READING

A. Hoffman HT, Eschwege F, Krause C. Combined surgery and radiotherapy. In: Clark JR, Snow GB, eds. Multimodality Therapy for Head and Neck Cancer. New York, NY: Thieme Medical Publishers; 1992:76-94.

B. Hoffman HT, Karnell LH. Laryngeal cancer. In: Steele GD, Jessup JM, Winchester DP, Menck HR, Murphy GP, eds. National Cancer Data Base Annual Review of Patient Care 1995. Atlanta, Ga: American Cancer Society;1995: 84-99.

C. Hoffman HT, McCulloch TM, Gustin D. Organ preservation therapy for advanced stage laryngeal carcinoma. Otolaryngol Clin N Am Curr Concepts Laryngeal Cancer. 1997;30:113-130.

D. Hoffman HT, Review of endoscopic treatment of supraglottic and hypopharyngeal cancer. Otolaryngol Club J. 1994;1:200-202.

E. Hoffman HT, Robbins KT. Tumors of the upper aerodigestive tract-supraglottic larynx. In: Medina, JE, ed. Clinical Practice Guidelines of the Diagnosis and Management of Cancer of the Head and Neck 1996. The American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons. Stuttgart/New York: Verlag; 1992:29-34.

F. McCulloch TM, Hoffman HT. Changing trends in the treatment of laryngeal cancer. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. 2^nd ed. Update 1.St. Louis, Mo: Mosby; 1995:11-34

G. Shah JP, Karnell LH, Hoffman HT, et al. Patterns of care for cancer of the larynx in the United States. Arch Otolaryngol. 1997;123:475-483.