Laryngeal Cancer

Management of Carcinoma LarynxBy :Dr. Trilok GuleriaJunior Resident, ENT - HNS

Epidemiology2.63% of all the body cancers in India

40- 70 years

M:F = 10:1

Female incidence increasing

Risk factors

Smoking tobacco- implicated as the prime factor - only 1% of laryngeal ca occur in non smokers Alcohol - synergistic with tobaccoHuman Papilloma Virus Genetic Susceptibility Gastroesophageal reflux

Risk factors Diets lacking green leafy vegetables, fruits & fibre Diets rich in salt preserved meats and dietary fatsOccupational Metal/plastic workers Exposure to paint Exposure to diesel and gasoline fumes Exposure to asbestos Exposure to radiation

AnatomySITESUBSITESupraglottisSuprahyoid epiglottisInfrahyoid epiglottisAryepiglottic folds( laryngeal surface )ArytenoidsVentricular bands (false vocal cords)GlottisTrue vocal cords+ ant and post. Commissure SubglottisNo subsites

EmbryologySupraglottic larynx derived from buccopharyngeal primordium which develop from 3rd & 4th archGlottis & subglottis are derived from tracheobronchial primordium from 6th archDifferent embryological derivations creates natural barriers & restrict laryngeal compartments in early stages cancerForm basis of laryngeal conservation surgery

Barriers to spreadHyoid boneLaryngeal cartilagesHyoepiglottic ligamentThyrohyoid membraneVentricleAnterior commisureCricothyroid membraneConus elasticusQuadrangular membrane

Subtypes

Supraglottic CancerGlottic CancerSubglottic Cancer

Transglottic tumors McGravan (1961)Tumors crossing ventricle in vertical axis Usually initiate as supraglottic or glottic cancers

Tumor can become transglottic in 4 ways :- Crossing ventricle directlyCrossing at anterior commissure Through paraglottic spaceSpreading along arytenoid cartilage posterior to ventricle

Pathology85 - 95% Squamous Cell CarcinomaVariations : Verrucous carcinomaSpindle cell carcinomaBasaloid SCCPapillary SCC

Other types of carcinoma:Neuroendocrine carcinomaLymphepitheliomatous carcinomaAdenocarcinomaChondrosarcomasLymphomasAdenoid cystic (trachea more than subglottis)

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Glottic cancerSpread -> tend to stay confined vocal folds Anteriorly- anterior commisure Posteriorly- vocal process of arytenoidUpward- ventricle and false cordDownward- Subglottic region

Glottic Cancer

Hoarseness of voice is an early sign Even Tis may produce significant voice changeProgressive dyspnoea & stridorHaemoptysisReferred otalgia( via vagal complex ) suggest deep invasionThere are no lymphatics in vocal cords and nodal metastasis are rarely seen unless the disease spreads beyond the region of membranous cords.Good Prognosis : Early presentation and late spread, it has good prognosis.

Supraglottic cancerMajority of lesion are seen on epiglottis, false cord followed by aryepiglottic fold, in that orderMay spread locally and invade the adjoining areas (vallecula, base of tongue and pyriform fossa)Preepiglottic space involvement through foramen in infrahyoid epiglottis.Paraglottic space involvement through mucosa of the ventricle.

Supraglottic CancerNodal metastases occur early(T1- 20%,T2-35%,T3-50%,T4-65%)Upper and middle jugular nodes are often involvedSymptoms: Often silent, Hoarseness is a late symptom Foreign body sensationLump in throat / throat pain Muffled voiceDysphagia Referred pain in ear StridorSwelling neckBad Prognosis : Due to early spread and late presentation.

Supraglottic Ca

Subglottic CancerRare( 1 - 2%)Spread: superficially/submucosally to the opposite side or downwards to the tracheaMay invade Anteriorly cricothyroid membrane, thyroid gland and muscles of neckLN involvement seen in 10-34%Symptoms: Stridor is the earliest presentation.Hoarseness is a late symptom as upward spread to the vocal cords is late.Hoarseness of voice indicates :Spread of disease to undersurface of vocal cords.Infiltration of thyroarytenoid muscle.Involvement of recurrent laryngeal nerve.

Diagnosis Of Laryngeal CancerHistory : Symptomatology of glottic, subglottic, supraglottic is as explained earlierInformation regarding risk factors, medication & medical comorbidities such as cardiovascular, pulmonary, renal disease Examination Of Head & Neck : It is done to find the- a) Extralaryngeal spread of the disease. b) Nodal metastasis.

Indirect Laryngoscopy : It is done to see the- A) Appearance & site of lesion B) Vocal Cord Mobility Fixation of vocal cords indicate deeper infiltration. Direct Laryngoscopy : Gold standard It is done to see the- a) Hidden areas of larynx b) Extent of disease. c) Punch biopsy/ excision biopsy

Microlaryngoscopy: - Laryngoscopy is done under microscope for better visualisation. -For smaller lesions of vocal cord - Accurate biopsy specimen can be taken

Chest X Ray Essential for co-existent lung diseases, pulmonary metastasis and mediastinal nodes.

X-ray STN Extent of lesion of epiglottis ,aryepiglottic, ventricular & vocal fold . Laryngeal & tracheal airway , preepiglottic space involvement can be seen.

Barium swallow recommended in advanced laryngeal cancer to find involvement of pyriform fossa , pharyngeal wall & post cricoid area

Esophagoscopy : Performed to exclude synchronus primary tumor in esophagus.

Bronchoscopy : Usually not required if chest imaging is normal.

CT Scan To find the site & extent of the tumour, invasion of pre epiglottic and paraglottic space, destruction of cartilage, extralaryngeal tissue, prevertebral space, encasement of carotid and lymph node involvement. MRI Superior to CT in evaluation of cartilage erosion

PET/CT Residual Recurrent

Supravital staining and biopsy: Toluidine blue is applied to the laryngeal lesion and then washed and examined. CIS and superficial carcinomas take up dye while leukoplakia does not and thus helping in selecting the area for biopsy

Videostroboscopy useful in CIS lesion of vocal cord - deeper invasion into basement membrane produce distortion of mucosal wave - loss of synchrony between vocal cords

Optical coherence tomographyFibreoptically based Perform high resolution subepithelial imaging of tissue by measuring backreflected infrared light from internal tissue structureUseful for diagnosis of hyperplasia, early stage keratosis of vocal foldAllow visualization of epithelium, basement membrane, and lamina propria of vocal cordAbility to observe integrity of basement membrane help in detecting early stage carcinoma of vocal cord

TNM STAGINGStaging of disease is very important It influences the choice of therapy Helps in predicting the overall prognosisProvides confirmity amongst clinicians thereby helping in comparing the efficacy of various forms of therapy.

Staging Primary TumourTx - Primary tumor cannot be assessed.T0 - No evidence of primary tumor.Tis - Carcinomain situ.

SupraglottisT1 - Tumor limited to one subsite of supraglottis with normal vocal cord mobility.T2 - Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.T3 - Tumor limited to larynx with vocal cord fixation and/or invades postcricoid area, pre-epiglottic space, paraglottic space .T4a - Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b - Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Glottis T1 Tumor limited to the vocal cord(s)(may involve anterior or posterior commissure) with normal mobility.T1a Tumor limited to one vocal cord.T1b Tumor involves both vocal cords.T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility. T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space T4a Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

SubglottisT1: Limited to subglottisT2: Extends to vocal cord with normal or impaired mobility T3: Limited to larynx with vocal cord fixationT4a: Invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).T4b: Invades prevertebral space, encases carotid artery, or invades mediastinal structures

Regional Lymph Nodes (N)

Nx: regional LN cant be assessedN0: no regional node metastasisN1: single ipsilateral node, 3 cmN2a: single ipsilateral node, > 3 cm, 6 cmN2b: multiple ipsilateral nodes, 6 cmN2c: bilateral or contralateral nodes, 6 cmN3: node > 6 cm

Distant metastasis (M)

Mx: cant be assessedM0: no distant metastasisM1: distant metastasis

AJCC Stage GroupingsStage 0 Tis, N0, M0

Stage I T1, N0, M0

Stage II T2, N0, M0

Stage III T3, N0, M0 T1, N1, M0 T2, N1, M0 T3, N1, M0

Stage IVA T4a, N0, M0 T4a, N1, M0 T1, N2, M0 T2, N2, M0 T3, N2, M0 T4a, N2, M0

Stage IVB T4b, any N, M0 Any T, N3, M0

Stage IVC Any T, any N, M1

Treatment

Carcinoma in situIs replacement of the full depth of epithelium by malignant cells, without those transgressing the basement epitheliumTis should be regarded as part of the continuum of early laryngeal cancer and managed as T1 carcinomaHigh possibilities of recurrent disease suggests holding back use of radiotherapy for those lesions where resection would lead to significant functional defcit and use of surgical technique wherever possibleSuccessful management also requires implementation of tobacco & alcohol cessation strategies, treatment of LPR when present and vigilant follow up

Glottic Carcinoma

T1 Glottic ca

T1 Glottic CarcinomaMid cord Radiation therapy - Offer best quality of voice Treatment of choice in professional voice users Surgery :- Young patients Veruccous cancer Pt desire short treatment time Willing to have some voice compromise Transoral endoscopic CO2 laser cordectomy - TOC - > 90% cure ratesLaryngofissure & Cordectomy - Rarely used now - Only done when endoscopic exposure is poor

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(Anterior commissure lesion /Cord lesion extending to ant commissure )

Vertical Partial laryngectomy Frontal/ frontolateral - Std accepted surgical treatment - > 90% cure rates - Hospitalisation, temporary tracheostomy & NG tube feeding Transoral endoscopic CO2 laser resection - Day-care procedure - Higher recurrence due to unsatisfactory exposure of this regionRadiation therapy - Also have higher failure rate Difficulty in delivery of adequate dose to this region - Undetected cartilage erosion- lack of inner perichondriumT1 Glottic ca

T1 Glottic ca(Cord lesion extending posteriorly vocal process of arytenoid ) Transoral endoscopic CO2 laser resection - Surgical treatment of choice

Laryngofissure & Cordectomy Radiation therapy -Like ant comm. lesion post placed cord lesion also have higher failure rate

T2 Glottic carcinoma (freely mobile cords)

T2 Glottic carcinoma (freely mobile cords)Surgery is TOC Vertical Partial laryngectomy Frontal/ frontolateral /Extended hemilaryngectomy - better quality of voice than SCPL with CHEP - better tolerated by frail & COPD patients

Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy - offer superior cure rates with T2 glottic cancer - poor quality of voice than VPL - post operative aspiration problems - best to reserve this procedure for very fit pts

Transoral endoscopic CO2 laser resection - best only in experienced hands - satisfactory endoscopic exposure is most important - well tolerated by elderly & frail pts

Radiation therapy - preferred only in mid cord lesion with extention to supraglottis - good voice results

T2 Glottic carcinoma (impaired cord mobility)

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T2 Glottic carcinoma (impaired cord mobility) Open partial laryngectomy is treatment of choice VPL ( Hemilaryngectomy ) - lateralised lesion (Frontolateral ) lesion across ant comm. safer in elderly individualsSCPL-CHEP reserve for very fit ptsChemo radiation TOC - unfit/unwilling for surgery Neoadjuvant CT +RT in respondersRadiation alone reserve for - unfit/unwilling for surgery - unlikely to able tolerate chemoradiation

T3 glottic ca(cord fixed arytenoid mobile)

T3 glottic ca (Fixed hemilarynx)

T4 Glottic Carcinoma (T4a resectable lesion )Best treated by total laryngectomy combined with neck dissection if lymph nodes are palpable followed by post operative RT.Near total laryngectomy > in well lateralised lesion with uninvolved arytenoid region and2/3 of contralateral cord

Supraglottic Carcinoma

Supraglottic Carcinoma T1-T2 Supraglottic Carcinoma

Transoral endoscopic CO2 laser resection - treatment of choice

If endoscopic laser resection is not feasible Radiotherapy -lesion at marginal zone - T1 & small T2 lesions - smaller lesion < 6cm response rate 80% - minimal neck disease - poor pulmonary reserve

Supraglottic laryngectomy/SCPL-CHEP - infrahyoid supraglottic cancer - T2 lesion - bulky nodal disease - young patients - fit patients; no COPD

T3 Supraglottic Carcinoma Treatment options in order of preference Chemo radiotherapy Endoscopic CO2 laser resection if the pre epiglottic space invasion is limited Supraglottic partial laryngectomy (for small volume disease) and SCPLCHEP(if the growth is bulky or encroaching the glottis) -in patients who are fit and have no significant chest problems. Near-total laryngectomy - lateralised lesion.Total Laryngectomy as a last resort - if none of the above is feasible

T4 Supraglottic Carcinoma

Total laryngectomy + post op RT Near-total laryngectomy + post op RT ( for lateralised disease )

Subglottic Carcinoma

Subglottic carcinomaT1 & T2 Subglottic carcinomaRadiotherapy alone -treatment of choice with preservation of voiceSurgery is reserved for failure of radiation therapy or for patients who cannot be easily assessed for radiation therapy.

T3 & T4 Subglottic carcinomaTotal laryngectomy and post-op. RT (radiation should also include superior mediastinum)Radiotherapy alone ( who are unfit for surgery )

Management of neck

Main predictor of survival in squamous cell carcinoma is the presence, number and extracapsular spread of lymph node metastases

Management of neck Depends on site of primaryT stage of primary Clinical N stageChoice of treatment modality for the primary

N0

Elective neck dissection is commonly performed for management of node negative T2-4 supraglottic, T3-4 glottic cancer

Elective neck irradiation

N+

Comprehensive neck dissection is procedure of choice followed by postoperative radiotherapy or chemotherapyRT- Neck dissection prior to radiation or post radiation salvage surgery for residual neck nodes

Radiotherapy

Radiation therapy :Cure rates with radiation therapy ranges from 80% -95%.

Conventional radiotherapy consists of :Once daily treatment delivering 2 Gray/day. 5 doses/week to total dose of 70 Gy over period of 7 weeks.

Attempts to improve outcome of RT schedules focus upon modification of radiotherapy fractionation schedules. Two altered fractionation schedule:Hyper fractionation Accelerated fractionation

Hyper fractionationDelivers a higher total dose over the same 7 weeks treatment period using multiple smaller fractions of radiotherapy per day. The lower dose per fraction results in preferential sparing of late responding tissues thus reducing the incidence of late normal tissue effects.

Accelerated fractionation Delivers the same total dose over a shorter overall treatment time Aimed at overcoming treatment failures caused by tumour cell repopulation during longer courses of treatment.

Concurrent chemo-radiotherapy

- 66-70 Grays of radiationConcurrently Cisplatin 100mg/m2 is given on day 1,22, & 43- Claims highest cure ratesCarries high toxicity

Neoadjuvant chemotherapy

- 2 cycles of Cisplatin(80-120mg/m2) + 5- FU(10-15mg/m2) given within 3 weeks interval- Only those with > 50% tumour regression will receive radiation therapy

Operative Procedures

Transoral Laser Surgery

Inclusion Criteria

Complete endoscopic visualization of the carcinoma

Tumor extension to the contralateral VC < 3mm

Absence of arytenoid involvement (except vocal process)

Subglottic extension < 5mm

Supraglottic extension no further than lateral extension of ventricle

Mobile vocal folds

No cartilage involvement

Strict correlation between recurrent lesion and 1 lesion before radiation.

Advantages

Good voice qualityGood swallowingLower complications ratesLower costShorter hospitalizationTracheostomy and NG tubes not routinely required

Complications Complication rates are 3 weeks)

LateAspirationChondritis Laryngeal stenosis (Must rule out local recurrence) Severe hoarseness Granulation tissue (CO2 laser and keel) Tumor recurrence

Supracricoid Laryngectomy with CricohyoidoepiglottopexyRemoval of:Entire thyroid cartilageBilateral true and false vocal cordsVentricleParaglottic spacesEpiglottis ( lower portion )One arytenoid (may spare both if not involved)

At least one arytenoid must be spared to preserve phonation and sphincter functions

Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Reconstruction using Hyoid bone Cricoid TongueCricohyoidopexy is done 3 suture of 1-0 vicrylTemporary tracheostomy tube and feeding tube is required.

Supracricoid Laryngectomy: ContraindicationsInfiltration of both aryntenoid cartilagesInfiltration of cricoarytenoid joint or inter-arytenoid regionSubglottic extension >1cm below the vocal foldExtension to the valleculaMajor preepiglottic space invasionHyoid bone invasionInvasion of outer perchondrium of thyroid cartilageExtra-laryngeal spread

Supracricoid Laryngectomy: Complications Swallowing disorders are the most common in the short termVoice quality is hoarse, rough, breathy but with acceptable intelligibility.Aspiration Pneumonia is the most frequent complication (17.5%)Neo-laryngeal edema

Supraglottic Partial LaryngectomyParts removedEpiglottis and Pre-epiglottic spaceHyoid boneThyrohyoid membraneUpper half of thyroid cartilage preserving external perichondrium Supraglottic mucosa

Supraglottic Partial LaryngectomyReconstruction is done by approximating base tongue to lower half of thyoid cartilageTemporary tracheostomy is required.Bilateral selective lymph node dissection is carried out at the same timeIt is important to identify and preserve internal and external branches of superior laryngeal nerve

Three- quarter laryngectomyOperation popularised by Biller & LawsonThree- quarter laryngectomy combining supraglottic laryngectomy with vertical hemilaryngectomy on the side of the tumour

IndicationsSupraglottic cancer which involve an arytenoid &/or vocal cord on one side onlyTumour should be no longer than 2cm in maximum diameterShould not extend in subglottis

Near total laryngectomyDescribed by PearsonTechnically complex procedure to create a physiological voice shunt based on mobile arytenoidNo significant gains over total larygectomy

INDICATIONS:T3/T4 laterlised transglottic lesions with no extension to arytenoidsT3/T4 laterlised lesions of Pyriform Sinus with involvement of apex and causing fixity of hemilarynxInterarytenoid , retroarytenoid & postcricoid region must be free.

Removal of Strap ms I/L thyroid crtilage Thyroid lobe I/L cricoid cartilage ring Upper tracheal ring Preepiglottic space Epiglottis Hyoid I/L VC with involved C/L VC

Total Laryngectomy

Mainstay of treatment for advanced laryngeal cancer

Fistly performed by Billroth in 1870

Curative as well as palliative.

Indications

Advanced laryngeal malignancies with extensive cartilage destruction and extra laryneal spreadInvolvement of posterior commissure / both arytenoidsCircumferential submucosal disease with / without vocal fold paralysisSubglottic extension to involve cricoid cartilageCompletion procedure after failed partial laryngectomy / irradiationHypopharyngeal tumors originating / spreading to post cricoid areaRadiation necrosis of larynx unresponsive to antibiotics / hyperbaric oxygen therapySevere aspiration following partial / near total laryngectomyMassive nodal metastasis

Selection criteriaPt should be fit for general anaesthesiaPt should be motivated for post surgical lifePositive biopsyScreening for metastasis

Gluck Sorenson incisionU shapedStoma is incorporated into the incisionVertical Limb situated just medial to medial border of sternomastoid muscleHighest limit is the mastoid process on both sidesHorizontal limb encircles tracheostome

Flap elevation Flap is elevated in the subplatysmal plane and stitched out of the wayMedial border of sternomastoid identified on each sideGeneral investing layer of cervical fascia is incised vertically from the hyoid bone above, to the clavicle belowOmohyoid muscle is divided at this stageThis enables entry into the loose areolar compartment of neck

Division of strap musclesMuscles are divided close to their sternal marginsDivision of strap muscles exposes thyroid gland

ThyroidTotal / hemithyroidectomyMassive midline / bilateral tumors Total thyroidectomy preferredUnilateral laryngeal tumors Hemithyroidectomy is preferred

Suprahyoid dissectionHyoid bone is skeletonizedMylohoid, geniohyoid, digastric sling and hyoglossus separated from hyoid from medial to lateralPharynx is entered and epiglottis is delivered into the neck

Skeletonization of larynxPosterior border of thyroid cartilage is rotated anteriorlyConstrictor muscles released from superior and inferior cornu by sharp dissection

Larynx removalFrom above downwardsEpiglottis is held with a forceps and pulled forwardsPharyngeal mucosa cut laterally with scissors on both sides of epiglottis aiming towards the superior cornua of thyroid cartilageConstrictor muscles are divided along the posterior edge of thyroid cartilageLarynx separated by incising the tracheal rings (between 1st and 2nd )

Pharyngeal closureInsert & secure nasogastric tube3-0 vicryl is usedContinous, interlocking extramucosal connel suturePharyngeal closure can be reinforced using cervical fascia and muscle layers

A - Closure of pharynx with detail of suturing techniqueB - T-closure C - Vertical closure D - Horizontal closure.

TracheostomaPermanent tracheostoma created with pie crust sutures after bevelling the tracheaSkin flap are walked medially to ensure adequate stomal diameter by taking wider bites of skin than of trachea with each sutureThis technique pulls skin over the tracheal edge to cover cartilage.

Skin flap closureSkin flap is repositionedFlap is sutured after anchoring the tracheostomeSuction drain is placed in the neck to prevent hematoma formation that could compromise the flap

ComplicationsHematomaSkin flap infectionPharyngocutaneous fistula Flap necrosisTracheal stenosisOesophageal stenosisHypothyroidism / Hypoparathyroidism

Pharyngocutaneous fistula

IntroductionA fistula is an abnormal communication between two epithelised surfaces. Pharyngocutaneous fistula is the most common non-fatal complication following total laryngectomy. It creates a communication between the pharynx and cervical skin around the surgical incision or, less frequently, the stoma of the tracheostomy.The 1st total laryngectomy was carried out by Billroth and Gussenbauer on 1870 with development a large PCF.PCF significantly increase morbidity and hospital stay.

Etiology

Local tissue ischemia followed by infection.Breakdown of the mucosal closure, resulting in salivary and secretion leakage into surrounding soft tissue.Ultimately cause communication of the salivary tract with the skin PCF

Predisposing factors

The cause of PCF is multifactorial.The local factors seem to play a major role.NutritionMalnutrition is reported to be present in 35 to 50% of all head and neck caner patients.BW loss more than 10% within 6 months is at a greater riskA postoperative Hb lower than 10 g/dL has been reported to increase the risk of PCF.Preoperative radiationPCF higher in pre-op RT group.

The PCF in peroperative RT patients:Appear earlier and close laterThe fistulas were significant larger than non-RT group.Longer healing duration More frequent progression to advanced muscle necrosis, soft tissue necrosis, vascular exposure and fistula expansionOften need surgical intervention earlier than nonirradiated patientsThe extent of surgical defect (pharyngolaryngectomy), comorbidity (CHF), and nonglottic tumor site carried an increased risk. Histological infiltration of tumors surgical margins

Signs and symptoms

The PCF will usually appear 7 to 11 days after surgery. First clinical sign: wound erythema with neck and facial edema/swelling.Fever (38.5oC) during the first 48 post-operative hours Tenderness of the skin incision.

Wound amylase levels: elevated amylase levels on the post-op days 3, 4 and 5 can be a significant predicator of PCF.

Prevention Perioperative nutritional supplementationPre-op enteral or parenteral alimentation.Restore serum protein levels.Blood transfusion if needed.Perioperative antibiotics :Coverage of aerobic and anaerobicImprove surgical techniqueClosure type: T or Y vs linear.Watertight two-layer to three-layer of mucosal closure.Catgut showed a higher rate of PCF than Vicryl.

Nonclosure of the pharyngeal constrictor muscle : reduce the pharyngoesophageal pressure lower PCF rate.Cricopharyngeal myotomy during total laryngectomy for lower intraluminal pressure.Reconstruction with flapsPatient with significant radiation effect or extensive mucosal defect may be considered for flap reconstruction rather than primary closure.Gastroesophageal reflux prophylaxis

Early oral feeding:Traditional standards for initiation of oral feeding: 7 days for nonirradiated patient and delayed for irradiated patient.Early oral feeding without NG insertion (even started as early as 24 hours after surgery) dose not increase the incidence of PCF.Early oral feeding can shorten the hospital stay.The NG tube has also been demonstrated as an ascending pathway for intestinal flora and to cause local trauma on the fresh suture with local tissue damage.

Management of PCF

Classification of PCF:Small fistula, less than 0.5 cm in diameter.Medium fistula, 0.5 to 2.0 cm in diameter.Large fistula, more than 2.0 cm in diameter.

Small or medium size fistulas usually close spontaneously with conservative treatment.

Conservative treatment Residual tumor should be excluded first.

Principles:Salivary diversionSilicone salivary bypass tube.Complete debridementNutritional supportAntibioticsPressure dressing for flap downPlacement of a cuffed tracheostomy tube to prevent aspirationTube feeding with adequate nutritionSuccessful rate: 50% to 80%

Surgical repairSurgical intervention is reserved after failed by conservative treatment.Timing: Do not operate before 40th postopeartive day. Control infectionImprovement of local flapsMethod of surgical repair (depending on size of PCF and local condition).Primary closure.Rarely possible.Small fistula with minimal sounding tissue loss.Fibrin glue-reinforced closure.

Flap reconstruction: Adjacent flaps, distant pedicle flaps, free flaps, and combination of the above.

Flap reconstruction should not be undertaken until secondary healing healthy granulation tissue has occurred.Adjacent flaps: SCM & trapzius flaps within RT field prone to failure.Deltopectoral flap: multiple stage.Distant pedicle flaps: PMMCF: effective for all types of fistula.Latissimus dorsi myocutaneous flaps: extensive resection and additional bulk and skin were needed

Free flaps: Radial forearm and jejunal flaps (circumferential pharyngoesophageal defect).Radial forearm flap in combination with PMMFDouble paddle myocutaneous flap.Due to the reliability and highly successful rate for all types of fistulaPMMF/PMMCF remains the workhorse flap for PCF reconstruction.

Voice Rehabilitation following Laryngectomy

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Methods of speech following Laryngectomy

Esophageal speechElectro larynxTEP (Tracheo-oesophageal puncture)

Oesophageal speech Air is swallowed into cervical esophagusThis swallowed air is expelled out causing vibrations of pharyngeal mucosaThese vibrations along with articulations of tongue cause speech to occurThe exact vibrating portion of pharynx is the pharyngo-oesophageal segmentThe vibrating muscles and mucosa of cervical oesophagus cause speech

Pharango-oesophageal segmentThis segment is made up of musculature and mucosa of lower cervical area (C5-C7 segments).Vibration of this segment causes speech in patients without larynxCricopharyngeal spasm in these pts. Can lead to failure in developing Oesophageal speechCricopharyngeal myotomy may help these pts. in developing Oesophageal speech

Esophageal speech - AdvantagesPatients hands are freeNo additional surgery / prosthesis needed. Hence no extra cost for the pt.Pts. get easily adapted to esophageal voice

Esophageal speech - DisadvantagesNearly 40% of pts fail to develop esophageal speechQuality of voice generated is rather poorPatients will be able to speak only in short burstsSignificant training is necessaryLoudness / pitch control is difficult

Esophageal speech development causes for failurePresence of cricopharyngeal spasmPresence of reflux esophagitisThinning of muscle wall in that areaDenervation of muscle in the PE segmentPoorly motivated patient

ElectrolarynxThese are battery operated vibrating devices It is held in the submandibular regionMuscle contraction and changes in facial muscle tension causes rudiments of speechInitial training to use this equipment should begin even before surgery

Electrolarynx - TypesExternal /Neck

Intraoral type

Electrolarynx - External / Neck

Neck type is commonly usedHypoesthesia of neck during early phases of post op period can cause difficultiesIf neck type cannot be used intraoral type is the next preferred one

Intraoral artificial larynxIntraoral cup should form a tight seal over the stoma. There should not be any air leakOral tip should be placed in the oral cavityPts exhaled air rattles the cup placed over the stomaChanges in exhaled pressure can vary the quality of sound generated

Electrolarynx - advantagesCan be easily learntImmediate communication is possibleAdditional surgery is avoidedCan be used as a interim measure till the patient masters the technique of esophageal speech or gets a TEP inserted

Electrolarynx - DisadvantagesExpensive to maintainSpeech generated is mechanical in qualityDifficult while speaking over telephone

Types of voice restoration surgeriesNeoglottic reconstructionShunt technique

Neoglottic procedureTracheo hyoidopexyThis can restore voice function in alaryngeal patientsAbandoned due to increased incidence of complications like aspiration

Shunt techniqueDeveloped by Guttmann in 1930Involves creation of shunt between trachea and esophagusLots of modifications of this procedure is available, Basic aim is to divert air from trachea into the esophagus

Types of shuntsHigh trachea-esophageal shunt (Barton)Low trachea-esophageal shunt (Stafferi)TEP shunts (Guttmann)

Causes of failure of shunt procedureAspiration through the fistulaClosure of the fistulaTo avoid these problems prosthesis was introduced

Types of Prosthesis

Tracheo-esophaseal punctureWas first introduced by Blom and Singer in 1979One way silicone valve is introduced via the fistulaThis valve served as one way conduit for air into esophagus while preventing aspirationThis prosthesis has two flanges, one enters the esophagus while the other rests in the trachea. It fits into the tracheo-esophageal wound

Prosthesis used in TEPBlom-Singer prosthesisPanje buttonGronningen buttonProvox prosthesis

Blom-Singer prosthesisAn initiative of drtbalu's otolaryngology onlineIntroduced by Blom and Singer in 1979Commonly used prosthesisThis prosthesis acts as one way valve allowing air to pass into the esophagus and prevents aspirationThis prosthesis is shaped like a duck bill hence known as Duck bill prosthesisThe duck bill end should reach up to oesophagusIt is an indwelling prosthesis can be left in place for 3 monthsThis prosthesis is available in varying lengths

Panje voice buttonBiflanged tube with one way valveCan be inserted through the fistula created for this purposeIt is supplied with an introducer which makes insertion simpleShould be removed and cleaned every two daysCan be removed, cleaned and reinserted by the patient

Gronningen buttonAn initiative of drtbalu's otolaryngology onlineIntroduced by Gronningen in Netherlands in 1980It causes high airflow resistance delayed speech in some patientsNow low air flow resistance tubes have been introduced

Provox prosthesisIndwelling low air flow pressure prosthesisIt has extended life time. Can last a couple of yeas if used properlyInsertion is easy

Types of TEPPrimary TEP Performed during total laryngectomySecondary TEP Performed 6 weeks after surgery

Primary - TEPHamaker first performed in 1985Primary TEP should be attempted where ever possibleIn this procedure puncture is performed immediately after laryngectomy and prosthesis is insertedPrimary tracheo-oesophageal puncture is now accepted as the optimal method for voice rehabilitation.Prosthesis of sufficient length should be usedAn initiative of drtbalu's otolaryngology online

Secondary TEPUsually performed 6 weeks following laryngectomyThis allows pt time to develop esophageal speechArea of fistula is identified using rigid esophagoscopeProsthesis can be inserted immediatlyAn initiative of drtbalu's otolaryngology online

Advantages of TEPCan be performed after laryngectomy / irradiation / chemotherapy / neck dissectionFistula can be used for esophago-gastric feeding during immediate PO periodEasily reversibleSpeech develops faster than esophageal speechHigh success rateClosely resembles laryngeal speech

Disadvantages of TEPPt should manually cover the stoma during voicingGood pulmonary reserve is a mustAdditional surgical procedure is needed to introduce itPosterior esophageal wall can be breached

TRACHEOSTOMAL PROBLEMS

Patients who have undergone total laryngectomy will have a permanent tracheostomy with the usual potential problems of increased chest infections, crusting and stenosis.

Surgical attention to detail when fashioning the stoma with access to nebulization and humidification devices can reduce these. The current trend is to use hands free occlusion for speech and moisture conservation devices applied directly to the stoma.

Figure - Heat moisture exchange devices. Stomvent Trachenaze Plus with shower protector Trachenaze Provox

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