Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol S Vol: 0 Issue: 1

A Novel Functional Reconstruction Method for Recurrent Laryngeal Cancer after Vertical Partial Laryngectomy

Shinichi Ohba, Junkichi Yokoyama*, Mitsuhisa Fujimaki, Shin Ito and Katsuhisa Ikeda
Department of Otolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
Corresponding author : Dr. Junkichi Yokoyama MD, PhD
Department of Otolaryngology-Head and Neck Surgery, Juntendo University School of Medicine, Hongo 3-1-3, Bunkyo-ku, Tokyo 113-8431, Japan
Tel: 81-3-3813-3111; Fax: 81-3-5840-7103
E-mail: [email protected]
Received: November 17, 2014 Accepted: January 30, 2015 Published: March 06, 2015
Citation: Ohba S, Yokoyama J, Fujimaki M, Ito S, Ikeda K (2015) A Novel Functional Reconstruction Method for Recurrent Laryngeal Cancer after Vertical Partial Laryngectomy. J Otol Rhinol S1:1. doi:10.4172/2324-8785.S1-011

Abstract

Background: To evaluate our novel approach to composite reconstruction through combining the myocutaneous flap and free cartilage grafts following resection of recurrent laryngeal cancer.

Methods: A vertical incision was made from the thyroid notch to the cricoid cartilage. The myocutaneous flaps below the strap muscle were elevated. The thyroid cartilage was removed sufficiently to secure the required surgical margin. After tumor resection, the composite reconstruction was carried out by combining the myocutaneous flap and free cartilage grafts. At first, small pieces of cartilage were grafted into the paraglottic space and covered with omohyoid muscle. Following this, cartilage approximately 15 mm in length and 3mm in width was inserted along the level of the vocal cord. This cartilage altered the vocal cord plastic protrusion and demonstrated good postoperative vocal function. The flap was fixed to the edge of the laryngeal mucosa.

Results: There was neither local infection nor partial wound dehiscence associated with this new procedure. Patients could receive nutrition orally the day after the procedure was performed. In this series, no aspiration was observed. The mean postoperative maximum phonation time (MPT) was 19.5 seconds with good phonation.

Conclusion: This novel approach to reconstruction was effective in terms of healing and functional outcomes.

Keywords: Vertical partial laryngectomy; Infrahyoid myocutaneous flap; Laryngeal cancer; Radiation failure; Reconstructive surgery

Keywords

Vertical partial laryngectomy; Infrahyoid myocutaneous flap; Laryngeal cancer; Radiation failure; Reconstructive surgery

Introduction

Vertical partial laryngectomy (VPL) has been accepted for earlystage glottic, subglottic cancer and residual or recurrent tumors following radiation failure [1-3]. An S-shaped skin flap has been used for vocal reconstruction in Japan. Although various other reconstruction methods have been developed, none of them has been accepted as ideal due to concerns about wound healing and laryngeal function [4-7].
In fact, delayed wound healing and infections in patients who had undergone partial laryngectomy after full course irradiation therapy have been reported [3].
We present herein a modification of the reconstruction following vertical partial laryngectomy that employs an infrahyoid myocutaneous flap harvested by midline longitudinal skin incision and free cartilage grafts.

Method

Recurrent glottic cancers treated by radiation were included in this study (Table 1). The surgical procedure is described as follows. We introduced a vertical straight skin incision from the thyroid notch to the cricoid cartilage and the myocutaneous flaps were elevated below the strap muscle. The thyroid cartilage was exposed and removed widely enough not only to secure the surgical margin but to reduce the tension after vocal cord reconstruction. The resected intact cartilages grafts were stored in saline for the following reconstruction. The larynx was incised by cutting the inner perichondrium of the thyroid cartilage and membrane just above the notch of the thyroid cartilage. The interior of the larynx was examined carefully.
Table 1: Patients’ characteristics.
Part of the larynx was resected and the specimen was carefully oriented. Frozen section analysis of the surgical margin was performed. After resection, a composite reconstruction was made by combining the myocutaneous flap and free cartilage grafts. At first, small pieces of cartilage were grafted into the paraglottic space and covered with omohyoid muscle. In addition, cartilage 15 mm long and 3mm in width was inserted along the level of the vocal cord (Figure 1).
Figure 1: Free cartilage grafts (A) Free cartilage grafts (about 15 mm × 3 mm) which provided the mound for the neo vocal cords; (B) Intraoperative findings; (a) Grafted cartilage; (b) False vocal cord; (c) Cricoid cartilage.
This cartilage altered the vocal cord plastic protrusion, which showed good post-operative vocal function. The flap was fixed to the edge of the laryngeal mucosa with absorbable sutures. First, muscle layers were sutured and then skin layers were sutured (Figure 2 and 3).
Figure 2: Schematic drawing of result after extended fronto-lateral vertical partial laryngectomy. Free cartilage grafts put in the paraglottic space are covered with myocutaneous flap. (A) Small pieces of cartilages grafted into the paraglottic space; (B) Muscle flap. * Indicates each long cartilage inserted at the level of vocal cord.
Figure 3: Intra-operative view of the reconstruction of the right vocal cord. Postoperative defect is filled with free cartilage graft. The myocutaneous flap was sutured to the cut end with absorbable sutures. The muscle and skin layers are sutured, respectively. (a) grafted cartilage; (b) false vocal cord; (c) cricoid cartilage.
This flap covered the subglottic tissue without tension in cases with partially resected cricoid cartilage (Figure 3). To avoid tension at the wounds, horizontal skin incisions were added and thyroid cartilage was adequately resected. It is important to make the anterior part of the vocal cord slightly bulky for good post-operative phonation (Figure 4). A temporary laryngocutaneous fistula was made. This procedure provides stability to the wound and prevents aspiration. The stoma was closed about three months after the initial surgery under local anesthesia using a Hinge flap. All patients gave their written informed consent and the study was approved by the ethics committee of the Juntendo University Faculty of Medicine.
Figure 4: The endoscopic laryngeal findings 6 months after the VPL. The MPT of this patient was 25 seconds. (A) Vocal cord; (B) False vocal cord.

Results

All patients were without remarkable complications. The mean surgical time was 121 mins. There were neither local infections nor partial wound dehiscence resulting from the new procedure. Oral nutrition was started between the first and 7th post operative days. The laryngocutaneous fistula was closed three months after the initial surgery. In this series, no aspiration or granulation that might have caused airway stenosis was seen. The mean postoperative MPT was 19.5 seconds. The duration of post operative hospitalization ranged from 10 to 13 days (mean, 11.5 days).

Discussion

Salvage for patients with recurrence following radiotherapy for early glottic cancer can be a challenge for any surgeon attempting to preserve the laryngeal function [1-3]. Although trans-oral laser surgery could be applied, there might be a risk of epithelialization or web formation, and laryngeal stenosis might result from anterior commissure resection. When vertical partial laryngectomy (VPL) is selected, significant complications such as chondronecrosis, flap necrosis and loss, post operative infection and aspiration peumonia might occur, especially for radiation failure patients [3]. To avoid such fatal complications, various reconstruction techniques have been developed [4-7]. The S-shaped skin flap is one of the acceptable reconstructive methods that we have used for VPL. In such cases, the increased tension on the wound edges might contribute to wound dehiscence even if sufficient thyroid cartilage is removed. The poor vascularity of the tip of the flap might cause necrosis and infection in cases of radiation failure. In cases with partially resected cricoid cartilage in the subglottic invasion, the flaps were usually too short in length to suture the subglottic tissue without tension. Furthermore, when bilateral vocal cord processes are resected near the arytenoid, a large amount of tissue with a reliable blood supply is required to stabilize the wound.
In order to address such complications, we have devised a novel and feasible technique that employs a simple vertical skin incision, which provides long and wide flaps with adequate tissue bulk for the vocal cords created from free cartilage grafts and strap muscle. This technique allows for safe reconstruction after wide resection according to the extent of tumor invasion even if the bilateral vocal cords are resected at the level of the posterior commissure. We made a temporary laryngocutaneous fistula, which was closed three months after the initial surgery.
The postoperative swallowing function has been good. The resumption of oral feeding ranged from 2 to 7 days (mean 4.1 days). None of the patients required nasogastric tube feeding. Aspiration was initially observed in widely resected patients and they practiced effective cough, which was facilitated by good glottis closure. As a result, all patients were capable of oral intake in a few days and all patients could be discharged without complications.
The maximum phonation time (MPT) after VPL ranged from 14 to 25 seconds (mean 19.5 sec). These values were better than those previously described (8.1 to 11 seconds) [1]. The neo-vocal cord process created with a free cartilage graft appeared to enable an acceptable quality of speech after surgery. All patients were satisfied with their acoustic outcomes and they had no trouble in talking by phone.
In none of our cases did wound dehiscence with consequent fistula formation occur. In contrast, Stegnjajic et al. [8] reported postoperative fistula formation in 8.8%.
We also had no cases with postoperative laryngeal stenosis, also differing from the results of Stegnjajic et al. [8]. Regardless of the thickness of the supraplatysmal skin flap, we observed no cases of skin necrosis.
Our modified reconstructive method after VPL is effective in terms of preserving the laryngeal function and preventing complications, even in cases of glottic cancer for which radiation treatment has failed.

Conclusion

This novel reconstructive method of vertical partial laryngectomy is effective in terms of healing and functional outcome.

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