Cricohyoepiglottopexy: long-term results in 55 patients

Near total laryngectomy with cricohyoepiglottopexy (CHEP) allows cure of glottic carcinomas with voice preservation. The subject of this study was to evaluate CHEP in terms of tumour control and functional result in T1 and T2 glottic carcinomas. This study reviewed retrospectively 55 consecutive cases of CHEP performed between January 1, 1981 and September 1, 1992 with the exclusion of post-radiotherapy salvage surgery. CHEP was indicated for a T1a limit to the anterior commissure and/or with dysplasia of the other vocal fold (10 cases), T1b (11 cases) and T2 (34 cases) glottic carcinomas. All our patients have a follow-up of more than five years. The post-operative course after this surgery was generally uneventful. The median time to decannulation was 18 days, to removal of the nasogastric tube was 15 days and to discharge from hospital was 23 days. No significant difference was observed according to the preservation of one or both arytenoid cartilages. The long-term functional result can be considered to be good in three-quarters of cases, with normal oral swallowing and an easily understood voice. The remaining one quarter had a whispery voice and sometimes episodes of aspiration when swallowing liquids. In terms of oncological results, the five-year recurrence-free survival rate was 94 per cent for T1 and 84 per cent for T2. The ultimate tumour control (taking into account four cases of total laryngectomy) was 94 per cent for T1 and 93 per cent for T2. Primary surgery by CHEP therefore appears to be a good option for early glottic carcinomas. The main problem remains that voice recovery is mediocre in one quarter of patients.

[Results of the surgical treatment of severe caustic pharyngo-esophageal stenosis. The value of complete reconstruction of the pharynx by transposition of the ileum and colon]

STUDY AIM

The aim of this study was to report the results of pharyngoesophageal reconstruction in extensive corrosive strictures and to describe an original conception concerning extensive chemical burns of the pharynx with involvement of the epiglottis, oro-hypopharyngeal junction and cricopharyngeal pinchcock.

PATIENTS AND METHODS

A personal series of 253 esophageal reconstructions using the colon and ileum is reported. In 124 patients, the cervical anastomosis of the graft was performed at the level of the pharynx, and these cases with extensive pharyngeal lesions were the basis of this study. The anastomosis was performed with the hypopharynx in 27 patients, with the oropharynx in nine and a total reconstruction of the pharynx or "pharyngoplasty" was carried out in 69 patients. The pharyngoplasty was classified according to the approach, in anterior, posterior, lateral, superior (transmandibular) and inferior. In high strictures with epiglottic injury, epiglottectomy was necessary in order to prevent recurrence. A visceral pharyngoplasty was performed in 61 patients, using the colon in 42 and the ileum in 19, a skin reconstruction in six patients and a myocutaneous flap in two.

RESULTS

The global postoperative mortality rate was 4.7%. Stenosis of the cervical anastomosis occurred in 4.9% of the whole series. With a follow-up from 6 months to 10 years, 70% of the patients resumed a normal oral diet, 21% had mild symptoms and 7% had poor results (patients with tracheostomy and gastrostomy).

CONCLUSION

Extensive chemical burns of the pharynx are very severe and their treatment very difficult. For the author, total visceral pharyngeal reconstruction is considered to be the procedure of choice, using ileopharyngoplasty with realization of an ileal pouch. Good results were obtained in 70% of the patients with extensive corrosive strictures.

[Tongue base reduction with hyoid-epiglottoplasty. A surgical alternative in severe sleep apnea syndromes]

We present preliminary results and indications of tongue base reduction with hyo-epiglottoplasty for the treatment of severe obstructive sleep apnea syndrome (OSAS) due to isolated hyolingual abnormalities. The procedure consists in a subtotal resection of the tongue base after identification and derouting of the lingual neurovascular bundle. Hypopharyngeal enlargement, epiglottis verticalization, floor of the mouth tension and hyoid bone repositioning are also performed during the procedure. 14 severe OSAS male patients (mean apnea-hypopnea index of 71) were treated in our institution from November 1992 to February 1996. Indications were determined after a cephalometric analysis and a magnetic resonance imaging evaluation. Results were evaluated on clinical and polysomnographic criteria. No neurovascular complications occurred. Clinical results were excellent but success rate based on polysomnography was 50%. These preliminary results led us to change some of the steps in the technique. We also identified a predictive factor of success on the cephalometrics: an oropharyngeal area greater than 25 cm2.

The epiglottis and obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is caused by obstruction or narrowing of the airway at various levels. The repair of one site only will not alleviate the syndrome if there are obstructions in other sites. Epiglottis prolapse during inspiration is an unusual cause of airway obstruction and a rare cause of OSA. Twelve cases of OSAS due to an abnormal epiglottis are presented. We present our approach to the diagnosis using fibre-optic examination of the hypopharynx, and our treatment using endoscopic carbon dioxide laser partial epiglottidectomy. We found in our series that in 11.5 per cent of patients who failed the uvulopalatopharyngoplasty procedure, the reason was a narrow airway at the hypopharyngeal level caused by an abnormal epiglottis. It is our suggestion that in these cases a laser partial epiglottidectomy should be performed. The results of this study show that partial epiglottidectomy can increase the cure rate of patients with obstructive sleep apnoea syndrome by 10-15 per cent.

[The surgical treatment for the epiglottic cancer extended to the base of tongue]

26 cases of the epiglottic cancer extended to the base of the tongue were studied retrospectively. Among them, 14 were male and 12 female. The age varied from 43 to 62. Besides two cases who underwent total laryngectomy, the other twenty-four were treated with supraglottic horizontal partial laryngectomy or horizontovertical subtotal laryngectomy and resection of part of base of the tongue. 11 cases received bilateral radical neck dissection (RND) and 10 cases unilateral RND simultenously. The results showed twenty-four cases had resumed speaking ability, twenty had been decannulated and restored the laryngeal functions. The 5-year survival rate was 57.9% (12/19). It was concluded that transpharyngeal approach was reasonable for supraglottic horizontal partial laryngectomy associated with the resection of the base of the tongue.

[Supraglottic laryngectomy with or without one arytenoid in epiglottic carcinoma. A report of 40 cases]

OBJECTIVE

Supraglottic laryngectomy with or without one arytenoid is a functional laryngectomy suitable for treatment of epiglottic squamous carcinoma. This procedure consists of resection of the thyroid cartilage, epiglottis and the entire preepiglottic space.

METHODS

Between 1990 and 1996, supraglottic laryngectomy was used to treat 40 patients with epiglottic carcinoma. The data were collected by a review of patient records and follow-up. The cancers were in stages T1(17), T2(17) and T4(6) according to the 1987 UICC cancer staging criteria.

RESULTS

Twelve ipsilateral and one bilateral functional neck dissection were performed simultaneously of which 7 patients had metastasis in lymph nodes. No patient died postoperatively. Only 8(20%) had slight aspiration before the 20th day. All patients had decannulated. Twenty-nine cases received radiotherapy and chemotherapy. A follow-up analysis showed survival rate of 74% at 3 years.

CONCLUSION

We propose supraglottic laryngectomy for the surgical treatment of early supraglottic carcinomas, which could acquire almost normal laryngeal function.

A new epiglottoplasty procedure for the treatment of intractable aspiration

Intractable aspiration may require diversion of the airway from the pharynx. The epiglottoplasty procedure involves suturing the epiglottis onto the perimeter of the larynx without creating resistance to the natural lines of force of the epiglottic cartilage. The procedure starts by an anterior subhyoid pharyngotomy. The epiglottis is released from the pre-epiglottic space and the thyroepiglottic ligament is sectioned. The disinsertion is completed in the laryngeal lumen by sectioning the epiglottis on each side by following its edges. The pharyngoepiglottic folds are preserved so as to serve as the rotational axis for the freed epiglottis. The petiole of the epiglottis is anchored to the posterior commissure and the free edge of the epiglottis above the ala and the angle of the thyroid cartilage, while the lateral sides of the suprahyoid epiglottis are sutured to the superior part of the arytenoids. This procedure was performed successfully in three patients with intractable aspiration.

Acute apnea caused by an epiglottic cyst

A life threatening complication in the course of routine sedation in a 5 year old child is reported in a case study. A retention cyst of the epiglottis was found to be responsible for obstruction of the larynx leading to acute apnea. The patient history revealed recurrent episodes of stridor previously diagnosed and treated as acute laryngotracheobronchitis as well as border line psychomotoric retardation. Cerebral magnetic resonance imaging was performed for neuroradiological evaluation. After administration of sedation the child presented with stridor and acute apnea. Emergency orotracheal intubation could prevent tracheotomy but was complicated by the unexpected presence of a tumor at the base of the tongue. Further evaluation revealed a large epiglottic cyst. After endoscopic removal of the cyst no further episodes of apnea or stridor were noted.

Aplasia of the epiglottis: a rare congenital anomaly

Aplasia of the epiglottis is a rare laryngeal anomaly. We present a case of absence of the epiglottis in a child whose clinical course has been followed for nine years. She required a tracheostomy at two years of age for obstructive sleep apnea which resulted in heart failure; she was eventually decannulated at age seven. This case report highlights the clinical challenges faced in the identification and treatment of the sequelae of this defect. Both endoscopic and computed tomography (CT) documentation are provided. Embryological development and a review of the literature are also discussed.

[Indications, technic and results following Sedlacek-Kambic-Tucker reconstructive partial resection of the larynx]

Management of laryngeal carcinoma located at the anterior commissure remains controversial. Local control rates with radiotherapy or surgery are not as good as those seen after treatment of midcord lesions. The vertical partial laryngectomy with epiglottic reconstruction (VPLER) may be a more successful approach to such lesions. The charts of all patients treated for larynx carcinoma between 1991 and 1996 at the authors' institutions were reviewed to identify those patients treated with VPLER as described by Sedlacek in 1965, Kambic in 1976 and Tucker in 1979. Indications for performing surgery and outcome data of patients were collected and analyzed according to the indications for surgery, surgical technique, perioperative complications, oncological outcomes and functional results. Twelve patients were identified that had been treated with VPLER. Indications for surgery included five patients with local recurrences following endoscopic laser partial laryngectomies, four cases with previously untreated primary tumors at the anterior commissure (T2 N0-2 M0), two with local recurrences following radiotherapy, and one with recurrence following frontolateral partial laryngectomy. There were no postoperative complications except for one laryngocutaneous fistula that required secondary repair. All patients were able to swallow at the tenth postoperative day. All had their tracheostomies closed after completion of wound healing, (a mean of 17 days after surgery). Phonatory results were usually poor. Two local recurrences occurred during the follow-up period. However, both patients were salvaged with total laryngectomies and have since been free from disease. All other patients are alive and well. Our findings show that VPLER is an effective surgical approach for carcinoma at the anterior commissure of the larynx that cannot be adequately managed with transoral laser surgery or simple frontolateral partial laryngectomy. This study demonstrates that the procedure can be successfully applied to the treatment of local recurrences following initial radiotherapy or surgery. No major complications occurred in our study.

Epiglottic augmentation for treatment of dorsal displacement of the soft palate in racehorses: 59 cases (1985-1994)

OBJECTIVE

To determine whether epiglottic augmentation, in conjunction with more traditional surgical methods, would be useful in the treatment of dorsal displacement of the soft palate in racehorses.

DESIGN

Retrospective study.

ANIMALS

40 Thoroughbred and 19 Standardbred racehorses.

PROCEDURE

Polytetrafluoroethylene paste was injected submucosally on the lingual epiglottic surface of each horse. In addition, sternothyrohyoideus myectomy or sternothyroideus tenectomy and staphylectomy were performed in most horses.

RESULTS

Racing performance was improved after surgery in 29 of 40 (73%) Thoroughbreds and 10 of 19 (53%) Standardbreds. Twenty-nine (49%) horses won > or = 1 race after surgery.

CLINICAL IMPLICATIONS

Results suggest that epiglottic augmentation, in conjunction with other surgical methods, may be an effective method of treating horses with poor racing performance attributable to dorsal displacement of the soft palate.

Benign pleomorphic adenoma of the larynx: report of a case and review and analysis of 20 additional cases in the literature

Among the benign pleomorphic adenomas of the minor salivary glands, those that develop in the larynx are very rare. One such case of benign pleomorphic adenoma of the larynx in an adult female is described. The patient was treated with epiglottectomy with a lateral pharyngotomy approach. Review of the literature showed an additional 20 well-described cases of benign pleomorphic adenoma of the larynx. These patients usually present with hoarseness, dyspnea or dysphagia, or any combination of these depending on the site of origin and the size of the tumor. Occasionally the tumor may be discovered incidentally. The tumor can occur in any part of the larynx with the epiglottis being the most common site. Clinically they are indistinguishable from other benign laryngeal neoplasms, as surface mucosal lining remains intact. Histopathological examination is used to make the definitive diagnosis, but rarely, misinterpretation may occur. Conservative surgery provides a lasting cure.

A case of pleomorphic adenoma of the epiglottis. Bilateral vocal-cord paralysis after YAG laser surgery

Pleomorphic adenoma of the larynx is a rare disorder, and until recently has been treated mainly by approaches involving pharyngotomy. We encountered a case of pleomorphic adenoma originating from the laryngeal surface of the epiglottis and removed it using a YAG laser through a suspension laryngoscope. This case was complicated by delayed-onset bilateral vocal-cord paralysis, the causes of which are also discussed.

Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration

A new procedure has been developed to surgically separate the pharynx from the trachea that employs the best features of the Montgomery technique, but restricts the closure to only the epiglottis and the aryepiglottic folds. The petiole of the epiglottis is plicated to the false vocal folds and the interarytenoid mucosa. It is performed entirely through a midline thyrotomy approach and avoids injury to any of the structures within the rima glottidis. It has been successfully performed on seven very ill patients to date. The surgical decision-making process involved, a complete description of the surgical procedure, and a summary of the patients' preoperative condition, workup, and outcomes are presented and discussed.

Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome is caused by narrowing of the pharyngeal airway and loss of dilator tone during sleep. In patients with severe apnea surgical correction often requires attention to both the oropharynx and hypopharynx. Tongue reduction surgery has been described for persistent apnea after failure of palatal surgery. We describe our experience with midline glossectomy with epiglottidectomy in 12 patients with a mean age of 48.8 +/- 14.2 years and body mass index of 36.0 +/- 8.8 kg/m2. Response to treatment was defined as a postoperative respiratory disturbance index (RDI) below 20. Three patients (25%) responded to treatment. The mean apnea index decreased from 48.9 to 35.7, RDI decreased from 73.3 to 46.6, and lowest oxygen saturation increased from 65.9 to 77.9%. RDI in responders decreased from 69.7 to 10. Midline glossectomy with epiglottidectomy has variable results, yet is effective in selected patients with hypopharyngeal narrowing related to macroglossia.

Cricohyoidoepiglottopexy for glottic carcinoma with fixation or impaired motion of the true vocal cord: 5-year oncologic results with 112 patients

The medical charts and operative files of 112 patients (combined inception cohort) with well to moderately differentiated invasive glottic squamous cell carcinoma presenting fixation (22) or impaired motion (90) of the true vocal cord (TVC) consecutively treated with cricohyoidoepiglottopexy (CHEP) at our institutions from 1972 to 1989 were retrospectively reviewed. A minimum 5-year follow-up was always achieved. The Kaplan-Meier 5-year actuarial survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate for the entire group of patients were 84.7%, 5.4%, 6.4%, 1.2%, and 10.8%, respectively. The 5-year absolute and cause-specific survival rates were 85.5% and 94.1% for patients with fixation of the TVC and 81.3% and 96% for patients with impaired motion of the TVC. The 5-year actuarial local control rates for patients with fixation or impaired motion of the TVC were 95.4% and 94.4%, respectively. Local recurrence was statistically more likely in patients with positive margins (p = .007). Nodal recurrence was statistically more likely in patients with local recurrence (p = .005). Permanent tracheostomy related to postoperative laryngeal stenosis was requested in 2 patients. Aspiration-related completion total laryngectomy and/or permanent gastrostomy were never requested. Overall, local control and laryngeal preservation were achieved in 97.3%, and 95.5% of patients, respectively. At our institutions, the change from the conservative treatment modalities of radiotherapy and vertical partial laryngectomy to CHEP has brought about an increase in long-term survival, local control, and laryngeal preservation rates when compared to historical controls using vertical partial laryngectomy or radiotherapy.

Management of advanced-stage laryngeal cancer

Although the total laryngectomy is still the most reliable and simplest method for treating advanced laryngeal carcinoma, the shortcomings of the sequelae of the procedure have provided a constant challenge for improvement and change. Two alternatives that have shown some success are the Pearson near-total laryngectomy and the supracricoid partial laryngectomy with cricohyoidopexy and with cricohyoidoepiglottopexy. This article covers the procedural differences between these alternatives to the total laryngectomy.

[Ten-year experiences of epiglottic laryngoplasty after partial laryngectomy]

In order to objectively evaluate the long-term result of epiglottic laryngoplasty (ELP), ten-year experience of ELP after partial laryngectomy in 100 patients with glottic cancer was analysed. Our program included 1. complete excision of laryngeal carcinoma; 2. correct selection of material for laryngoplasty (LP); 3. technical modification of LP. The 3, 5 and 10 year survival rates were 87%, 79.5% and 66.7% respectively. It is believed that modified ELP is better than original K-S-T technique in the aspect of preserving all laryngeal functions.

Epiglottic plication for intractable aspiration

We describe a procedure to plicate the epiglottis into a vertical tube to prevent soiling of the airway due to intractable aspiration. The procedure is combined with an extensive cricopharyngeal myotomy. This technique allows laryngeal speech, even with a tracheostomy, and in some patients may allow the reversal of the tracheostomy. It is only suitable for a small proportion of patients with marked aspiration, as most will respond to conservative treatment. Nine patients underwent this operation and six gained a satisfactory result, with two patients achieving tracheostomy reversal. There were two late post-operative deaths from infective causes which reflects the general debilitation of these patients and the risk of exacerbating concomitant broncho-pulmonary infection.

[Large epiglottic lipoma. Intubation method for large tumors in the pharynx and larynx]

Large benign tumours in the aperture of the larynx are uncommon, and they are especially rare on the epiglottis. They are, however, important as they may cause fatal airway obstruction particularly at induction of general anaesthesia. We present a patient with a large lipoma originating in the vallecula epiglottica and the lingual surface of the epiglottis. The difficulties involved in tracheal intubation and possible solutions are discussed. In this case intubation was performed under local anaesthesia with the patient fully awake. A commissure laryngoscope was used for visualisation of the laryngeal inlet and a flexible bougie was inserted into the trachea. After removal of the laryngoscope a 7 mm ID endotracheal tube was advanced over the bougie into the trachea. After securing the airway in this way general anaesthesia was induced and the table tennis ball sized lipoma was uneventfully removed.

Laryngomalacia. The search for the second lesion

OBJECTIVES

To determine the necessity of rigid endoscopy in the diagnosis and management of laryngomalacia and its associated synchronous airway lesions (SALs), to analyze the incidence of SALs associated with laryngomalacia and their significance, and to determine the need for epiglottoplasty in management of laryngomalacia.

DESIGN

Retrospective medical chart review.

SETTING

Tertiary care children's hospital.

PATIENTS

Two hundred thirty-three patients with a primary diagnosis of laryngomalacia on flexible fiberoptic laryngoscopy treated at the Children's National Medical Center, Washington, DC, from January 1, 1984, to June 30, 1994.

INTERVENTION

Evaluation and treatment of laryngomalacia and associated SAL by flexible fiberoptic laryngoscopy, radiographic studies, rigid endoscopy, and other surgical procedures.

MAIN OUTCOME MEASURES

Resolution of airway symptoms from laryngomalacia and associated SAL.

RESULTS

Ninety patients (38.6%) underwent rigid endoscopy, and 12 patients (5.2%) required epiglottoplasty. Synchronous airway lesions were discovered in 44 patients (18.9%). Eleven patients (4.7%) had SALs that wre considered clinically significant; nine (3.9%) of these required surgical intervention.

CONCLUSIONS

Rigid endoscopy in evaluation of an infant with laryngomalacia is rarely necessary. Clinically significant SALs requiring surgical intervention are uncommon. Surgical intervention for laryngomalacia also is rarely necessary.