I. PREOPERATIVE CONSIDERATIONS

A. Preoperative Evaluation

1. CT of larynx and neck

2. Panendoscopy and biopsies

3. Assess pulmonary functions as per supraglottic laryngectomy

B. Indications

1. Supraglottic lesions with ventricle extension with epiglottic base involvement and anterior one-third of false vocal cord (T₁ to T₃)

2. Supraglottic lesions extending to glottis, anterior commissure with or without true cord mobility

3. T₃ transglottic carcinoma with limited true cord mobility

4. Selected cases of T₄ supraglottic and transglottic carcinoma invasive the thyroid cartilage

C. Contraindications

1. Subglottic extension

2. Bilateral arytenoid involvement

3. Cricoid invasion

4. Unilateral arytenoid involvement will compromise postoperative voice and swallow results

D. Consent

1. Describe procedure: “Through incision in your neck, remove upper and front part of voice box, leaving only back part of one or both vocal cords.” Caution about the possibility of the need for total laryngectomy.

2. Repeat laryngoscopy immediately prior to surgery if more than 2 weeks has passed since diagnostic procedure.

3. Bleeding, infection, reaction to anesthesia, damage to remaining arytenoid(s)

4. Tracheostomy

5. Hoarse voice

6. Aspiration, feeding difficulties, inability to swallow (average 2 months, up to 6 months, occasionally long-term failure requiring total laryngectomy)

7. Do not proceed unless patient is prepared for total laryngectomy.

II. 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

2. Special

a. Tracheotomy tray

b. Sterile anesthetic breathing circuit and tubing

c. Rousch Laryngoflex 7 mm endotracheal tube

d. Corpak feeding tube

C. Medications (specific to nursing)

Antibiotic ointment

D. Prep and Drape

1. Standard prep, 10% providone iodine (neck and chest)

2. Drape

a. Head drape

b. Towels from nose to upper chest

c. Split sheet

E. Drains and Dressings

Penrose drains

F. Special Considerations

1. If Tracheotomy is done as a separate procedure, a separate setup will be necessary.

2. Panendoscopy and/or neck dissection may be done in conjunction with procedure.

III. ANESTHESIA CONSIDERATIONS

A. General Anesthesia

1. Tube position: If tracheotomy is required, consider the tracheal position change that will occur during closure.

2. Paralysis is useful and necessary during closure

B. Systemic Medication

1. Antibiotics (see Antibiotic protocol)

2. Steroids; may aid in postoperative swelling, 10 mg Decadron IV

C. Positioning

Supine

IV. OPERATION

A. Elevate U-shaped skin flap extending from mastoid tips across cricoid or shorter if not doing neck dissection; raise the flap at subplatysmal layer to a level of 1 to 2 cm above the hyoid bone.

B. Perform neck dissection if indicated.

C. Cut thyrohyoid and sternohyoid muscles along inferior border of the hyoid and detach the sternothyroid from the inferior border of the thyroid cartilage; maintain inferior pedicle of the strap muscles.

D. Preserve the superior laryngeal neurovascular bundle for laryngeal innervation.

E. Cut pharyngeal constrictors and external perichondrium along the posterior border of the thyroid cartilage and release the piriform sinus mucosa.

F. Very carefully (preserve the recurrent laryngeal nerve) disarticulate the cricothyroid joints with a parallel movement of a scalpel or narrow Freer elevator.

G. Perform thyroid isthmusectomy and mobilize upper trach with blunt finger dissection.

H. Perform Tracheotomy either via the same flap incision or preferably through a lower separate incision; withdraw the endotracheal tube.

I. Incise the hyoid periosteal layer and dissect pre-epiglottic space from hyoid.

J. Enter the larynx through uninvolved vallecula by horizontal incision and inferiorly transversely cut the cricothyroid membrane at the superior border of the cricoid cartilage; transect the cricothyroid muscle attached to the thyroid cartilage.

K. Visualize and assess the tumor.

L. Grasp the epiglottis with sharp hook and pull inferiorly.

M. Cut vertically from the aryepiglottic fold to the cricoid level while preserving as much pyriform sinus mucosa as feasible.

N. Cut uninvolved cords at the level of the vocal process.

O. Pull larynx anteriorly for exposure and cut one ipsilateral vocal cord at the vocal process or remove one arytenoid if involved; paraglottic and pre-epiglottic contents are removed with the specimen

P. Closure

1. Suture only the mucosa of the upper part of the arytenoid.

2. Leave the inferior portion open.

3. Suture the arytenoid cartilage with 3-0 vicryl anteriorly to the cricoid cartilage to prevent posterior sliding.

4. No other mucosal sutures are placed; the cricoid and hyoid are brought together with at least 3 submucosal 0 prolene sutures placed in the midline and 1 cm to each side; incorporate 1 to 2 cm of tongue base sutures; place NG tube before closure.

5. Suture the strap muscles to the base of tongue.

6. Place 2 narrow Penrose drains.

7. “Grillo” stitch (extending from chin to sternum) may be placed if tension existing in closure; this suture ensures that the head is flexed forward on the chest.

VI. CRICOEPIGLOTTOPEXY

A. Open the lateral pharynx to visualize the tumor.

B. Section the epiglottis at or below the hyoepiglottic ligament.

C. Remove the inferior third of the epiglottis along with the pre-epiglottic space.

D. Release the hyoepiglottic ligament.

E. During closure suture the epiglottic remnant to the anterior cricoid.

F. Complete closure as with cricohyoidopexy.

VII. POSTOPERATIVE CONSIDERATIONS

A. Change Tracheotomy tube on postoperative day 5.

B. Remove drains as per drainage.

C. Involve speech pathologist; begin gelatinous foods after patient can swallow own saliva and increase amount of ingested fluid as tolerated; if no effective swallowing achieved, place gastrostomy tube.

VIII. CPT CODING

A. 31599, Unlisted procedure, larynx; or, most closely approximated by

B. 31367, Laryngectomy, subtotal supraglottic, without radical neck dissection

IX. SUGGESTED READING

A. de Vincentiis M, Minni A, Gallo A. Supracricoid laryngectomy with cricohyoidopexy (CHP) in the treatment of laryngeal cancer: a functional and oncologic experience. Laryngoscope. 1996;106:1108-1114.

B. Chevalier D, Piquet JJ. Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma; review of 61 cases. Am J Surg. 1994;168:472-473.

C. Laccourreye O, Brasnu D, Merite Drancy A, et al. Cricohyoidopexy in selected infrahyoid carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg. 1993;119:881-886.

D. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope. 1990;100:735-741.

E. Piquet J. Functional laryngectomy (cricohyoidopexy). Clin Otolaryngol; 1976;1:7-16.