OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

SUPRACRICOID LARYNGECTOMY Alejandro Castro, Javier Gavilán

Supracricoid laryngectomy consists of en and glottic regions. One arytenoid can also
bloc resection of both vocal cords, the be resected. However combined resection
paraglottic spaces and the thyroid cartilage of the epiglottis and one arytenoid usually
(Figure 1). It was first described by Majer results in poor functional outcomes and
in 1959 1 and Piquet in 1974 2. It is used increases the chance for aspiration and
for the treatment of selected early and delayed decannulation.
locally advanced glottic and transglottic
carcinoma in an oncologically safe Types of supracricoid operations
manner, while preserving laryngeal func-
tion i.e. swallowing (airway protection), With supracricoid laryngectomy the hyoid
breathing and phonation. bone is approximated directly to the
cricoid with three sutures (Figures 2a-c).
Types of supracricoid laryngectomy are
illustrated below i.e. cricohyoidoepiglotto-
pexy (CHEP), cricohyoidopexy (CHP),
and tracheocricohyoidoepiglottopexy (Fig-
ures 2a-c). With tracheocricohyoidoepi-
glottopexy the anterior cricoid is resected
for an additional tumour margin anteriorly.

Figure 1: Typical supracricoid laryngec-

tomy specimen
c
Indications and limitations

Supracricoid laryngectomy is used to treat

glottic carcinoma affecting one/both vocal
cords, including cancers with deep inva-
sion of the paraglottic space and altered
vocal cord mobility. The epiglottis and Figure 2: Cricohyoidoepiglottopexy (a),
pre-epiglottic space can be included in the cricohyoidopexy (b), and tracheocrico-
specimen, allowing for resection of trans- hyoidoepiglottopexy (c)
glottic tumours that invade the supraglottic
Function cricoarytenoid units; sacrificing one unit
increases the chance of disabling aspiration
Key functional outcomes are airway, pho- in the cases where the epiglottis is
nation and swallowing without aspiration. resected.
Phonation and swallowing depend on the
arytenoids being able to tilt forwards and
make contact with the base of the tongue;
to breathe the arytenoids tilt posteriorly to
open the airway (Figures 3, 4).

Base of
a tongue
a

Figure 5: Anatomy of the cricoarytenoid

Figure 3: Arytenoids tilt forwards and
unit and the course of the recurrent
backwards for phonation, swallowing and
laryngeal nerve (yellow arrow) directly
breathing
behind the articular facet of the inferior
cornu of the thyroid cartilage

Figure 4: Arytenoids tilt backwards and

forwards for breathing, phonation, swal-
lowing

Cricoarytenoid unit (Figures 5, 6)

An intact cricoarytenoid unit is critical for

function. It comprises the arytenoid moun-
ted on an intact posterior cricoid ring, with
a functioning recurrent laryngeal nerve and Figure 6: Right side illustrates the
lateral and posterior cricoarytenoid mus- situation after supracricoid laryngectomy
cles. Ideally one should preserve both with preserved cricoarytenoid unit

2
Preoperative Evaluation superior border of the cricoid cartilage.
Some authors describe partial or com-
Careful selection of candidates is the key plete resection of the anterior cricoid
to success of supracricoid laryngectomy. arch 3, 4. Although this might be oncolo-
Both tumour and patient factors must be gically safe, in our hands it compro-
taken into account to ensure satisfactory mises the functional results and should
oncologic and functional outcomes. be performed only in very carefully
selected cases (Figure 2c)
1. Tumour factors  Superiorly: Epiglottis or tongue base,
depending on the upper extent of the
TNM classifications were not developed tumour: The epiglottis and pre-epiglot-
to guide the indications for different surgi- tic space can be included in the resec-
cal techniques; other factors should be tion (Figure 2b). Although limited
taken into account when considering extension to the base of the tongue can
supracricoid laryngectomy. In general, be excised, resection should not extend
supracricoid laryngectomy is indicated for beyond the circumvallate papillae as the
T1 and selected T2-3 glottic as well as base of the tongue plays a critical role
selected T2-4a supraglottic cancers. Never- with laryngeal closure during swallow-
theless supracricoid laryngectomy is ing (Figures 3, 4)
usually appropriate, for example, for vir-  Laterally: Pyriform sinus: Limited
tually any T2 glottic cancer but it is con- resection of the medial wall of the
traindicated for those rare T2 glottic can- pyriform sinus can be accomplished.
cers with extensive subglottic extension. However, wide resection which inclu-
des the lateral wall may compromise
Two types of vocal cord immobility should swallowing
be taken into account when considering  Posteriorly (midline): The interaryte-
supracricoid laryngectomy noid space must be free of tumour: It is
 Tumours that invade the paraglottic strongly recommended to preserve both
space and “fix” the vocal cord, but arytenoids when the epiglottis is inclu-
with some preserved mobility of the ded in the resection. At least one mobile
arytenoid: These tumours can usually arytenoid must always be preserved
be resected by supracricoid laryngecto-  Thyroid cartilage: As the paraglottic
my as resection of the arytenoid is spaces and thyroid cartilage are resected
likely to produce a negative margin en bloc, involvement of only the inner
 Cricoarytenoid joint invasion: This perichondrium is not a contraindication.
must be suspected when the arytenoid However, more extensive invasion of
is “frozen”. Supracricoid laryngectomy thyroid cartilage is a contraindication to
is not recommended as even resecting supracricoid laryngectomy. Yet cancers
the arytenoid is unlikely to yield a of the anterior commissure invading
negative margin thyroid cartilage in the midline may still
be considered for supracricoid
The extent of the tumour relative to the laryngectomy.
resection limits of supracricoid laryngec-
tomy must be considered Careful preoperative evaluation should be
 Inferiorly: Superior border of cricoid undertaken to ensure that the primary
cartilage: Routine intraoperative frozen tumour falls within these abovementioned
section is strongly recommended to limits. As a rule, indirect (fiberoptic) and/
ensure negative mucosal margins at the or direct laryngoscopy are adequate for this

3
purpose. CT scan or other imaging techni- Age is an important consideration as the
ques may help in some cases, particularly brain’s plasticity decreases with age as
to determine extralaryngeal extension does a patient’s ability to learn new swal-
through thyroid cartilage. lowing techniques. Classically, 65-70yrs is
considered the cut-off for open partial
Extending the resection beyond the laryngectomy. However, a patient’s
abovementioned parameters reduces the general status is more important than age
chance of functional success (aspiration itself, and successful results have been
and/or inability to be decannulated), and reported in older patients 5, 6.
should be performed only in very carefully
selected patients. Employing supracricoid Careful evaluation of comorbidities is im-
laryngectomy with too advanced tumours, portant to ensure successful functional out-
or relying on postoperative radiotherapy to comes. The cough reflex is of critical
treat positive margins is unacceptable as it importance to deal with aspiration. In our
increases recurrence rates and reduces series, up to 15% of patients developed
survival. pneumonia 7. Pulmonary and cardiac
reserve is crucial to overcome this compli-
Frozen section should always be used with cation. Some authors recommend routine
any type of open partial laryngectomy. preoperative pulmonary function tests 8, 9.
With supracricoid laryngectomy, it should We believe that a detailed clinical history
be obtained to confirm oncologic safety of is adequate, focusing attention on symp-
every close margin, and routinely at the toms relating to chronic obstructive pul-
level of the cricoid. Patients should agree monary disease e.g. dyspnoea when walk-
preoperatively that total laryngectomy will ing up a flight of stairs and types of
be performed if negative margins cannot medication.
be obtained.
Supracricoid laryngectomy operation
Neck dissection can be performed simul-
taneously. T1-2 glottic cancer without The operation is done under general
evidence of neck metastases can be treated anaesthesia with the patient in a supine
with supracricoid laryngectomy without position. Antibiotics are administered peri-
neck dissection. Elective ipsilateral neck operatively.
dissection is advocated for locally advan-
ced, purely glottic tumours (vocal cord 1. Surgical approach
fixation). Bilateral neck dissection is
recommended in all patients with tumour  A U-shaped cervical incision is made.
invading the supraglottis regardless of T The vertical limbs of the incision start
and N stage. a few centimetres above the hyoid bone
and run along the anterior borders of
2. Patient factors the sternocleidomastoid muscles. The
horizontal limb passes 2-3cms above
Patients need to learn new ways to swal- the sternal notch
low after removal of part of the larynx.  If neck dissection is planned, the U-
Every patient undergoing supracricoid shaped incision runs from mastoid-to-
laryngectomy will experience aspiration of mastoid close to the posterior border of
varying degrees during the initial the sternocleidomastoid muscle to
postoperative days. create a broader flap. Neck dissections
are done before the laryngectomy

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 A superiorly based subplatysmal apron
flap is elevated. This exposes the
supra- and infrahyoid muscles of the
neck (Figures 7, 8)

Figure 9: Divide sternohyoid muscle

Figure 7: Infra- and suprahyoid muscles

Figure 10: Retract omohyoid and divide

thyrohyoid muscle

Figure 8: Infra- and suprahyoid muscles

 Detach the sternohyoid muscles from

the hyoid bone and reflect them infe-
riorly to the level of the 1st tracheal
ring (Figure, 9)
 Retract the omohyoid muscles laterally
(Figure 10)
 Detach the thyrohyoid muscles from
the hyoid and reflected them inferiorly
to their insertions on the thyroid carti- Figure 11: Divide sternothyroid muscle
lage (Figure 10)
 Section the sternothyroid muscles at  Expose, ligate and divide the isthmus
the inferior border of the thyroid of the thyroid gland
cartilage (Figure 11)

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 Dissect both thyroid lobes off the
larynx and trachea to expose the
thyroid and cricoid cartilages, as well
as the first tracheal rings (Figure 12)

Figure 13: Divide superior laryngeal

vessels

 Rotate the larynx with a hook placed at

the posterior border of the thyroid
cartilage (Figure 14)
 Identify and divide the lateral thyro-
hyoid ligament (Figure 14)

Figure 12: Surgical view of exposed larynx

with strap muscles reflected. Thyroid lobes
have been dissected and retracted laterally
exposing the larynx and the first tracheal
rings. Note that the anterior wall of the
trachea has been dissected to facilitate
cricohyoidopexy at the end of the surgery

 Stop the dissection posteriorly at the

level of the inferior cornu of the
thyroid cartilage to avoid injuring the
recurrent laryngeal nerves (Figure 5)
 Identify, ligate and divide the superior Figure 14: (Right side) Rotate the larynx
laryngeal artery and vein over the with a hook placed at the posterior border
thyrohyoid membrane (Figure 13) of the thyroid cartilage and divide the
 One may preserve the internal branch lateral thyrohyoid ligament at its insertion
of the superior laryngeal nerve when on the superior cornu of the thyroid
the epiglottis and pre-epiglottic space cartilage
are preserved (Some authors report
better swallowing when supraglottic  Divide the inferior constrictor muscle
sensation is preserved, but in our along the posterior border of the
opinion preservation of the internal thyroid cartilage (Figures 15a, b)
branch of the superior laryngeal nerve  When reaching the inferior cornu,
does not improve swallowing) direct this cut obliquely in an
anteroinferior direction to follow the
anterior border of the cornu in order to
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 protect the recurrent laryngeal nerve border of the right thyroid ala exposing the
which lies close to the posterior aspect submucosa of the pyriform sinus
of the inferior cornu (Figure 15a)
 Expose the pyriform sinus submucosa  Place a submucosal stitch in the
after cutting the inferior constrictor pyriform sinus without violating the
muscle and dissect it from the inner mucosa, and leave it in place; this
perichondrium of the thyroid lamina stitch is used later during reconstruc-
(Figure 15b) tion (Figures 16, 31)
 Separate the thyroid and cricoid carti-
lages. The recurrent laryngeal nerve is
close to the cricothyroid joint and may
be injured at this point. We recom-
mend transecting the inferior cornu of
the thyroid cartilage at its base with
scissors while the assistant steadies the
thyroid and cricoid cartilages to avoid
the blades slipping (Figure 17)

Figure 15a: Divide the inferior constrictor

muscle. Traction on the muscle is
generated by rotating the larynx with a
hook placed at the posterior border of the
thyroid cartilage. The dotted red line
marks the course of the cut. Note that the
cut turns anteriorly as it approaches the
inferior cornu to protect the recurrent
laryngeal nerve

Figure 16: A suture is passed through the

pyriform sinus submucosa

Figure 15b: The inferior constrictor mus- Figure 17: The larynx is rotated with a
cle has been divided over the lateral hook. The inferior cornu of the thyroid
7
cartilage is divided with scissors taking the
course of the recurrent laryngeal nerve
(yellow line) into consideration

 Repeat the same surgical steps on

opposite side either simultaneously or
sequentially
 Free the thyroid cartilage from its
attachments so that it can be easily
displaced in any direction

2. Resecting the larynx

The supracricoid laryngectomy specimen

is resected by means of two horizontal and
two vertical cuts (Figure 18)
Figure 19a: Surgical view of the inferior
horizontal cut. Note that the endotracheal
tube is still in place

 Retract the cricothyroid membrane and

directly inspect the inner surface of the
cricoid cartilage
 Obtain frozen sections of this margin
 Remove the orotracheal tube and insert
a new tube through the cricothyrotomy;
this facilitates the subsequent steps of
the operation (Figures 19b).

Figure 18: Horizontal and vertical cuts

Inferior horizontal cut

 Make a wide cricothyrotomy at the

level of the superior border of the
anterior cricoid arch, extending from Figure 19b: Inferior horizontal cut (crico-
one inferior thyroid cartilage cornu to thyrotomy); the orotracheal tube is remov-
the other (Figures 19a) ed and a new tube is inserted through the
cricothyrotomy

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Superior horizontal cut

This can be made at two different levels,

depending on the superior extension of the
tumour

 Tumours not invading epiglottis

(cricohyoidoepiglottopexy) (Fig 20a-e)

o Make the cut at the level of the

superior border of the thyroid
lamina through the thyrohyoid
membrane and epiglottis Figure 20b: A cut is been made to one side
o Place a #11 scalpel in the midline,
perpendicular to the larynx
o Stab the scalpel through the epi-
glottic cartilage into the pharyngeal
lumen taking care not to injure the
posterior pharyngeal wall
o Cut laterally first to one side, then
the other to create a clean hori-
zontal cut above the ventricular
bands and the epiglottic petiole,
which are included in the speci-
men (Figures 20a-e)
o Obtain frozen section at this mar- Figure 20c: The cut is completed on the
gin if needed contralateral side

Figure 20a: Superior horizontal cut for

epiglottis-preserving approach. Scalpel is
inserted in the midline immediately above Figure 20d: Surgical view of the superior
the superior border of the thyroid cartilage horizontal cut. The mucosa is opened in
the midline before the cut is completed

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Figure 20e: Arytenoids visible through
Figure 21a: Superior horizontal cut for a
superior horizontal cut
supracricoid laryngectomy with removal of
epiglottis. The hyoid is retracted superiorly
 When the entire epiglottis and pre- (red arrow) and traction with forceps
epiglottic space need to be resected (black arrow) is applied to the pre-
(cricohyoidopexy) (Figures 21a-c) epiglottic fat. The preepiglottic space is
dissected by cutting with scissors against
o Make a superior infrahyoid hori- the inner aspect of the hyoid bone
zontal cut (not into the pharynx)
o Using sharp dissection with scis-
sors, remove tissue from the pre-
epiglottic space until the submuco-
sa of the valleculae is reached
o Make an opening in the mucosa of
the vallecula on one side, as far
from tumour as possible
o Introduced a blade of the scissors
inside the pharynx through the
opening, with the other blade
remaining outside
o Cut across both valleculae from
side-to-side
o Introduce a finger into the pharynx Figure 21b: The submucosa of the vallecu-
through the mucosal opening to la (arrow) is exposed. The fat of the pre-
palpate the tumour, or directly epiglottic space is included in the resection
inspect the tumour to assure a (asterisk)
macroscopically free margin
o Obtain frozen sections whenever
the tumour approaches the resection
margins

10
Figure 21c: The cut runs across both Figure 22a: (View from head of table). The
valleculae to expose the lingual surface of surgeon moves to the head of the patient to
the epiglottis. Note the fat of the pre- perform the 1st vertical cut through the
epiglottic space (asterisk), the lingual superior horizontal cut. One blade of the
surface of the epiglottis (+), and the scissors is inside the larynx and the other
posterior pharyngeal wall and free margin over the lateral laryngeal soft tissues
of the epiglottis (red arrow).

1st Vertical cut (Figures 22a, b)

 The 1st vertical cut is made on the side

opposite to the tumour; it connects the
lateral ends of the superior and inferior
horizontal cuts
 The surgeon moves to the head of the A
patient to look inside the larynx
through the superior horizontal cut
 Identify all structures by direct vision
and/or palpation before cutting
 Introduce one blade of the scissors
Figure 22b: Surgical view of the larynx
through the opening of the superior
from the head of the table. The first verti-
horizontal cut, while the other blade
cal cut has been made along the anterior
crosses over the lateral soft tissues of
surface of the left arytenoid (A). The left
the larynx (Figure 22a)
vocal cord is still in place. The right side
 Cut through the aryepiglottic fold (if remains untouched
epiglottis is included in the specimen)
 Cut along the anterior surface of the 2nd Vertical cut
arytenoid (Figure 22b)
 Cut the vocal ligament where it  The surgeon then moves back to the
attaches to the vocal process patient’s side
 Cut vertically through the subglottis  Grip the thyroid laminae with the
and along the superior aspect of the fingers of both hands, fracture the
cricoid up to the lateral edge of the thyroid cartilage down the midline and
cricothyrotomy open the larynx like a book to expose

11
 the endolarynx and the tumour (Figure
23a)
 Make the 2nd vertical cut as on the 1st A A
(non-tumour) side using a #15 scalpel VC
under direct vision, ensuring free VC
margins (Figures 23b, c, d)
Cr Cr
 If needed, the arytenoid is resected,
providing that the epiglottis has been
preserved
 Frozen section of the margins is
encouraged Figure 23c: Final stage of vertical cut

A A A A

VC

Cr

VC

Figure 23a: Thyroid cartilage has been Figure 23d: Surgical view of the larynx
fractured in midline to expose arytenoids before completing the resection. The
(A), cricoid (Cr) and vocal cords (VC) vertical cut on the left side has been
completed. The right vocal cord is the only
structure still retaining the larynx in place
(A=arytenoid)

A A  This completes the resection, leaving in

place the cricoid cartilage, hyoid bone,
VC arytenoid cartilages and epiglottis
VC depending on the extent of the
Cr resection (Figure 24)
 The resected specimen includes the
“voice box”: thyroid cartilage, both
vocal cords, and both ventricular bands
(Figures 1, 25). One arytenoid or the
Figure 23b: The endotracheal tube is epiglottis may also be included
inserted through the cricothyrotomy. The depending on tumour extension.
2nd vertical cut is being made with a
scalpel; Arytenoids (A), cricoid (Cr) and
vocal cords (VC)

12
 Figure 26: Dissecting bluntly with a finger
along the anterior tracheal wall
Figure 24: Surgical view of the remaining  While maintaining the cricoid in this
larynx: Preserved epiglottis (red arrow); position, create a tracheostomy at the
vocal processes of arytenoids (asterisks); level of the suprasternal skin incision
and cricoid arch (black arrow) (usually 4th/5th tracheal rings) (Figure
27)

Figure 25: The surgical specimen includes

the thyroid cartilage with both vocal cords
and ventricular bands
Figure 27: With cricoid abutting hyoid,
create a tracheostomy at the level of the
3. Tracheostomy and feeding tube
suprasternal skin incision
 To allow one to pull the cricoid up to
 Resite the endotracheal tube into the
the level of the hyoid bone, mobilise
new tracheostoma (Figure 28)
the trachea by dissecting bluntly with a
finger along the anterior tracheal wall  Insert a nasogastric feeding tube under
taking care not to disturb the tracheal direct vision of the hypopharynx to
vasculature that enters through its ensure its proper positioning
lateral walls (Figure 26)

13
 rior position, closure of the laryngeal
entry during deglutition is improved 10

Closing the airway

 Cricohyodopexy/CHP (epiglottis resec-

ted) or cricohyoidoepiglottopexy/
CHEP (epiglottis preserved) is used to
close the airway
 Pass three #1 vicryl sutures around the
cricoid arch and the body of the hyoid
 One suture is placed in the midline and
Figure 28: Resiting the endotracheal tube
the other two are placed 0.5 cm to each
into the new tracheostoma
side (Figures 2, 30a-e)
4. Reconstruction

Arytenoids

 Place two 3-0 vicryl sutures between

the superior aspects of the arytenoids
and the cricoid arch (Figures 2, 29)

A A

Figure 30a: Cricohyoidoepiglottopexy

Cr
 The needle is passed from outside
Cr
through the cricotracheal membrane
and is directed submucosally through
the posterior surface of the cricoid arch
(Figure 30b)
Figure 29: Sutures (red arrows) are placed  It re-enters again through the inferior
between each vocal process and the border of the sectioned epiglottis, runs
cricoid (Cr) to pull the arytenoids (A) 1-2 cm between the epiglottic cartilage
forwards. Do not tie them too tightly as and the pre-epiglottic fat and exits
their role is simply to prevent posterior through the pre-epiglottic fat (Figure
rotation of the arytenoids during healing 30c)
 Finally, it surrounds the posterior and
 Do not tie the sutures too tightly superior aspect of the body of the
 The sutures avoid posterior rotation of hyoid bone and exits above the bone
the arytenoid and allow healing to through the suprahyoid musculature
occur in the correct position; by main- (Figure 30d)
taining the arytenoids in a more ante-

14
 Hyoid
Hyoid

A A

Cricoid

CTL

Figure 30b: The needle is passed through Figure 30d: Finally, the needle re-enters
the cricotracheal ligament (CTL), runs and passes behind the hyoid body, and
submucosally on the posterior surface of exits through the suprahyoid muscles
the cricoid arch, and exits at its superior
border; note sutures pulling arytenoids (A)  The 1st throw of the knots of the two
forwards lateral sutures are tightened simulta-
neously by the surgeon and the assis-
tant
Hyoid
 Tighten the midline suture; while
maintaining tension on the two other
sutures, throw at least 3 knots on every
suture to avoid dehiscence of the pexy
(Figure 30e)
 Align the anterior borders of the
cricoid and the hyoid; if this is not
done then the size of the neoglottis is
reduced and the functional outcome
may be compromised

Figure 30c: The same needle re-enters

between the epiglottic cartilage and pre-
epiglottic fat, runs a few cm parallel to the
anterior surface of the epiglottis, and exits
through the epiglottic fat below the hyoid

 If the epiglottis has been preserved, it

is important that the suture runs 1-2cm
parallel to the epiglottic cartilage in
order to prevent inversion of the
epiglottis that may compromise the
outcome 11. If the epiglottis has been Figure 30e: Surgical view of the 3 pexy
resected, the sutures are passed around stitches after being tied
the cricoid cartilage and hyoid bone
submucosally in a similar manner
15
Pyriform sinuses  Suture the strap muscles to the hyoid
bone with vicryl to cover the pexy
 With loss of support of the thyroid (Figure 32)
laminae, the pyriform sinuses lose their  Insert a single suction drain that
shape and collapse crosses the midline; bilateral drains are
 Sutures were earlier inserted into the inserted if neck dissections have been
submucosa of the pyriform sinuses done
during the approach stage of the  Suture the skin, leaving a gap in the
operation (Figure 16) lower midline to introduce a cuffed
 To restore the shape of the sinuses, use tracheostomy tube
these sutures to hitch the outer surfaces
of the pyriform sinuses to each side of Postoperative Care
the pexy (Figure 31)
 A slightly compressive dressing is
placed around the neck and changed
every day for 5-7 days
 Drains are maintained for 2-3 days
 Some surgeons use prophylactic
antibiotics during the 1st postoperative
days, but we do not think it necessary
unless there are factors that may favour
infection
 Tracheostomy tube
o The cuff is deflated 24hrs after
surgery
o Significant coughing is guaranteed
Figure 31: After performing the crico- for 5-10min
hyoido(epiglotto)pexy the pyriform sinuses o If the cough persists after a few
are pulled forwards by suturing the minutes, the cuff is reinflated and
stitches (red arrows) to the anterior the manoeuvre is repeated 24hrs
tracheal wall later
o The sooner that the cuff can be left
deflated, the quicker the recovery
will be
o An uncuffed fenestrated tracheos-
tomy tube is inserted as soon as the
patient tolerates the cuff deflated
for 24-48 hours
o The tube is plugged as soon as it is
comfortably tolerated
o The tracheostomy tube is removed
when the patient tolerates a plug-
ged tube for 24-48hrs continuously
(including at night). This usually
Figure 32: The strap muscles are sutured happens 7-14days after surgery
over the cricohyoidoepiglottopexy. The o The tracheostomy wound is occlu-
tracheostomy is secured in its final ded with a dressing while it heals
position by second intention

16
 Swallowing retarded by radiotherapy, and some
o Provide nutrition by nasogastric patients need a new feeding tube during
feeding tube this period.
o If no complications have occurred,
attempt oral nutrition on Day 10 Outcomes
o Use “supraglottic swallow” and the
“chin tuck” techniques, starting Several large series 12-16 have demonstrated
with yogurt or custard consis- that the oncologic results of supracricoid
tencies. The patient takes a deep laryngectomy are equivalent to those of
breath and holds it, lowers the head total laryngectomy, providing that candida-
until the chin touches the chest, tes are properly selected and negative mar-
introduces a small volume of food gins are obtained on frozen section. The
and swallows twice while maintain- authors previously reported a 5-year
ing this position, elevates the head actuarial local control rate of >90% for T1-
and coughs immediately after the T2 tumours, and ca. 70% for T3 tumours 17.
2nd swallow, and subsequently
breathes normally After 2-3 Laryngeal function is maintained in a large
attempts a significant cough will be proportion of patients. Decannulation and
noted. The patient then rests for 1-2 adequate oral intake are achieved in >90%
hours and tries again of patients 7, 12, 13, 18.
o As swallowing is progressively
better tolerated, the supraglottic Quality of life has been shown to be better
swallow and chin tuck techniques than that of patients submitted to total
are abandoned laryngectomy with tracheoesophageal
o A noticeable improvement in swal- puncture 16. In a previous study, the
lowing occurs when the tracheos- authors reported excellent voice and
tomy tube is removed swallowing in a group of patients as
o Thicker and more liquid consis- measured by the Voice Handicap Index
tencies are gradually introduced and the MD Anderson Dysphagia Inven-
o Once oral intake is adequate to tory 7.
ensure correct nutrition, the feeding
tube is removed (usually 10-20 Comparison with other treatments
days after surgery)
o This process is prolonged following The indications for supracricoid laryngec-
resection of the epiglottis or one tomy overlap with those of vertical partial
arytenoid laryngectomy and its permutations. How-
ever, while voice after vertical laryngec-
Radiotherapy tomy is very breathy, patients undergoing
supracricoid laryngectomy preserve a
If required, postoperative radiotherapy is rough but powerful voice with excellent
commenced when the healing process is phonation times. For this reason supra-
complete i.e. 3-4 weeks after surgery. The cricoid laryngectomy has displaced vertical
authors used to leave the tracheostomy laryngectomy techniques in the authors’
tube in situ until the end of radiotherapy as standard surgical armamentarium. Supra-
many patients develop oedema that glottic carcinoma without glottic invasion
requires endoscopic resection (e.g. with is more properly treated with horizontal
CO2 laser) prior to definitive decannu- supraglottic laryngectomy, as voice quality
lation. Swallowing rehabilitation is also is much better than after supracricoid

17
laryngectomy. However, the latter allows  More advanced glottic cancers are
one to treat supraglottic tumours with resected by supracricoid laryngectomy
glottic invasion with open partial  Supraglottic cancers without glottic in-
laryngectomy. In recent decades, transoral vasion are managed by horizontal
endoscopic laser resection of early and supraglottic laryngectomy (only small
advanced carcinoma has been described. supraglottic tumours are endoscopically
The main advantages of endoscopic resected)
procedures are the avoidance of tracheos-  Supracricoid laryngectomy is used for
tomy in some patients and quicker supraglottic cancer that invades the
swallowing rehabilitation. However, glottis
limited exposure may compromise a  Chemoradiotherapy is offered to pa-
surgeon’s ability to obtain negative tients that cannot be managed with any
margins in bulky tumours, whereas long- form of partial laryngectomy due to
term functional results do not differ from tumour or patient factors
those of open partial laryngectomy.  Total laryngectomy is currently consi-
Moreover, the cost of a laser or a robot dered a first line treatment for laryngeal
limits its application in many developing and hypopharyngeal cancer when a
countries. Chemoradiation is often consi- tumour exceeds the limits of partial
dered to be a more sophisticated treatment laryngectomy and presents with adverse
for laryngeal cancer. Although the overall factors for chemoradiation (bulky, carti-
survival is considered similar to total lage invasion), or when the patient’s age
laryngectomy, local recurrence generally or comorbidities contraindicate other
requires salvage surgery. The local control surgical or non-surgical treatments
reported by the largest series of supra-
cricoid laryngectomies for locally advan- Conclusions
ced carcinoma is superior to that reported
by the main studies of non-surgical treat- Supracricoid partial laryngectomy is a ver-
ment 19, 20. Moreover, chemoradiated pa- satile technique for the treatment of glottic
tients experience late toxicity that worsens and transglottic carcinoma. The oncologic
their quality of life. Finally, the cost of results are supported by several long-term
chemoradiation is far higher than that of series. Long-term functional results are
supracricoid laryngectomy. Total laryngec- comparable to transoral procedures in the
tomy has been the classic treatment for treatment of T1-T2 glottic tumours, and to
laryngeal carcinoma for many years. While chemoradiation protocols in T3-T4 glottic
total laryngectomy patients experience and transglottic tumours. However, careful
excellent swallowing and voice can be selection of candidates is mandatory to
successfully restored by different achieve these results.
21
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Authors

Alejandro Castro, MD
Department of Otolaryngology
La Paz University Hospital
Madrid, Spain
[email protected]

Javier Gavilán, MD
Professor and Chairman
Department of Otolaryngology
La Paz University Hospital
Madrid, Spain
[email protected]

Editor

Johan Fagan MBChB, FCORL, MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]

THE OPEN ACCESS ATLAS OF

OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head &

Neck Operative Surgery by Johan Fagan (Editor)
[email protected] is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License

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