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39 Horizontal Partial Supracricoid Laryngectomy with Crico-Hyoidopexy or Crico-Hyoido-Epiglottopexy
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Fig. 39.8 Supracricoid partial laryngectomy with crico-hyoidopexy (SCPL–CHP): upper access to the resection with subperiosteal dissection of
the hyoid bone (a) and dissection of the pre-epiglottic space (b)
between the fourth and fth ring and then suturing the trachea
39.4.6 Reconstruction
circumferentially to the skin with ve stitches on the lower
edge and three on the upper edge (Fig.39.11). The endotracheal tube can now be exchanged for a tracheostomy tube.
There is also the possibility of not suturing the trachea to
the skin; some surgeons prefer this option, which does not
interfere with movement of the laryngotracheal axis and
avoids subsequent interventions for tracheostomy closure. In
our opinion, however, tracheostomy presents many
advantages:
Reconstruction differs depending on the type of resection
(SCPL + CHEP or SCPL + CHP with resection of one arytenoid or less). Reconstruction begins with anterior repositioning of the arytenoids using a Vicryl or monolament 3-4/0
stitch placed above the vocal process of the arytenoid, which
is then tied to the cricoid cartilage. If both arytenoids are
spared, this tie can be placed laterally on the cricoid. If one
arytenoid is resected, the suture for the remaining cartilage
should be placed in the anterior cricoid to move the arytenoid
• Safe post-operative management
• Possibility of early decannulation
• Swallowing exercises without cannula
more medially. Two 3-0 Vicryl stitches are placed in the fascia of the released inferior constrictor muscles in order to
reposition the piriform sinuses after the impaction.
• Stabilisation of the pexy
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Fig. 39.9 SCPL with crico-hyoido-epiglottopexy (CHEP): upper
access to the resection via transepiglottic laryngotomy
In the case of SCPL-CHP without arytenoid resection, the
pexy between the cricoid and the hyoid bone is made using
three stitches of resorbable but very resistant suture material
(Vicryl II, Dexon II), which is passed between the cricoid and
the rst tracheal ring and includes the base of the tongue surrounding the hyoid bone (Fig.39.12). The rst double median
G. Succo et al.
point passes through the base of the tongue, taking approximately 2cm. The lateral stitches pass close to the hyoid bone
in order not to damage the lingual artery and the branches of
the hypoglossal nerve. After removing the support under the
patient’s shoulders and slightly exing the head, the stitches
are tightened symmetrically using a double knot held in place
with a mosquito supported by the third operator.
In the case of SCPL-CHEP without arytenoid resection,
the pexy differs because it is passed between the cricoid and
the rst tracheal ring; the median double stitch takes about
1cm of the outer perichondrium of the epiglottis, crosses the
pre-epiglottic space and nally includes the base of the
tongue surrounding the hyoid bone, while the lateral stitches
pass through the epiglottis and then run close to the hyoid
bone in order not to damage the lingual artery and the
branches of the hypoglossal nerve.
In the case of resection extending to an arytenoid, a
meticulous reconstruction of the piriform sinus is necessary
on the side of the resected arytenoid before xing the cricoid
to the hyoid bone. The mucosa of the corniculate cartilage, if
spared, or the aryepiglottic fold is anchored by a resorbable
3/0–4/0 suture to the subglottic mucosa (Fig. 39.13). The
pexy is substantially the same as that with conservation of
both arytenoids; from the side of the resected arytenoid, the
most lateral point seals the reconstruction by anchoring the
hypopharyngeal mucosa.
After the pexy is completed, the constrictor muscles are
reattached anterolaterally to the neolarynx in order to
improve the recovery of swallowing function. If preserved,
the strap muscles can be used to close over the impaction
side. In our practice, considering the quite systematic strap
muscle resection, the pexy is instead stabilised by thyroid
gland suspension to the suprahyoid muscles using 0 Vicryl
stitches (Fig.39.14).
Two or three suction drains are inserted, providing negative pressure. Finally, the superior edge of the tracheostomy
is tied, and the incision is closed in layers.
39 Horizontal Partial Supracricoid Laryngectomy with Crico-Hyoidopexy or Crico-Hyoido-Epiglottopexy
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Fig. 39.10 Resection. (a) Section of the paraglottic spaces from above
downward, through the aryepiglottic fold, the false vocal cord just anterior to the body of the arytenoid cartilage, the thyroarytenoid muscle
anterior to the vocal process of the arytenoid, and the conus elasticus,
including the lateral cricoarytenoid muscle. (b) Resection with direct
visualization of the tumour extent
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G. Succo et al.
Fig. 39.11 Tracheostomy
Fig. 39.12 Pexy after resection preserving both arytenoids
a
39 Horizontal Partial Supracricoid Laryngectomy with Crico-Hyoidopexy or Crico-Hyoido-Epiglottopexy
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399
Fig. 39.14 Thyroid gland suspension
b
39.5 Post-operative Care
All patients should be monitored for early complications
(local and general) and late sequelae. Overall, acute complications during hospitalisation are expected in about 10% of
cases; the more frequent are cervical bleeding, aspiration
pneumonia and wound infection. Fortunately, perioperative
deaths are extremely rare. The mean hospitalisation time for
patients with acute complications is signicantly longer than
that for patients without acute complications. Late sequelae
following discharge are expected in about 15% of cases; the
most frequent are stenosis of the neoglottis due to soft tissue,
aspiration pneumonia and permanent dyspnoea. As a rule,
complications are often treated successfully by transoral CO2
laser surgery, revision of the pexy, injection laryngoplasty
using Vox implants or by total laryngectomy.
In our institutions, all patients without serious early complications undergo the same postoperative rehabilitation
protocol:
Fig. 39.13 Pexy after resection preserving one arytenoid: piriform
sinus reconstruction (a); pexy after piriform sinus reconstruction (b)
• Days 1–4: Immediate insertion of an uncuffed tracheal
cannula at the end of the operation; the beginning of pho-
nation in the rst postoperative hours; attempts at inter-
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G. Succo et al.
mittent occlusion of breathing through the tracheal
cannula from the rst postoperative day, using natural
methods
• Days 4–6: Decannulation and, during the daytime, continuous or intermittent occlusion of the tracheostomy
with saline-soaked gauze; starting of feeding using sterile
gelied water, followed by semi-solid foods without the
tracheal cannula in place
• Day 6 onwards: The nasogastric tube (NGT) is removed
as soon as a good level of swallowing of both solids and
liquids is achieved; removal is also controlled by functional endoscopic evaluation of swallowing (FEES), conducted with different types of food. Grading of
post-operative aspiration is checked in accordance with
Pearson’s scale. Rarely, intense dysphagia and repeated
episodes of aspiration pneumonia require a temporary
gastrostomy.
In our protocol, progressive closure of the tracheostomy
is preferred and occurs spontaneously in the majority of
patients following occlusion. For patients, especially in the
rst weeks after discharge, this leads to a sensation of greater
safety with regard to minor episodes of food inhalation,
which are relatively frequent. When the tracheostomy has
almost closed, minor plastic surgery can then be performed.
The expected average time of NGT placement is
15.5 days, and the expected average time to tracheostomy
closure is 80.4days. The expected mean hospitalisation time
for patients without acute complications is currently
20±5days.
References
1. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu
D. Supracricoid laryngectomy with cricohyoidopexy: a partial
laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope. 1990;100:735–41.
2. Succo G, Peretti G, Piazza C, Remacle M, Eckel HE, Chevalier
D, et al. Open partial horizontal laryngectomies: a proposal for
classication by the working committee on nomenclature of the
European Laryngological Society. Eur Arch Otorhinolaryngol.
2014;271:2489–96.
3. Thomas L, Drinnan M, Natesh B, Mehanna H, Jones T, Paleri
V.Open conservation partial laryngectomy for laryngeal cancer: a
systematic review of English language literature. Cancer Treat Rev.
2012;38:203–11.
4. Chevalier D, Laccourreye O, Brasnu D, Laccourreye H, Piquet
JJ.Cricohyoidoepiglottopexy for glottic carcinoma with xation or
impaired motion of the true vocal cord: 5-year oncologic results
with 112 patients. Ann Otol Rhinol Laryngol. 1997;106:364–9.
5. Piquet J, Desaulty A, Decroix G.La crico-hyoido-épiglotto-pexie.
Technique opératoire et résultats fonctionnels. Ann Otolaryngol
Chir Cervicofac. 1974;91:681–90.
6. Labayle S, Bismuth R.La laryngectomie totale avec reconstruction.
Ann Otolaryngol Chir Cervicofac. 1971;88:219–28.
7. Succo G, Crosetti E, Bertolin A, Lucioni M, Caracciolo A, Panetta
V, etal. Benets and drawbacks of open partial horizontal laryngectomies, Part A: early- to intermediate-stage glottic carcinoma. Head
Neck. 2016;38(Suppl 1):E333–40.
8. Succo G, Crosetti E, Bertolin A, Lucioni M, Arrigoni G, Panetta V,
etal. Benets and drawbacks of open partial horizontal laryngectomies, part B: intermediate and selected advanced stage laryngeal
carcinoma. Head Neck. 2016;38(Suppl 1):E649–57.
9. Marioni G, Marchese-Ragona R, Kleinsasser NH, Lionello M,
Lawson G, Hagen R, Staferi A.Partial laryngeal surgery in recurrent carcinoma. Acta Otolaryngol. 2015;135:119–24.
10. Lucioni M, Bertolin A, Lionello M, Giacomelli L, Rizzotto G,
Marioni G.Open partial horizontal laryngectomy for salvage after
failure of CO2 laser-assisted surgery for glottic carcinoma. Eur
Arch Otorhinolaryngol. 2016;273:169–75.
11. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA,
Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. A report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1996 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg.
2002;94:1052–64.
12. Schindler A, Favero E, Capaccio P, Albera R, Cavalot AL, Ottaviani
F. Supracricoid laryngectomy: age inuence on long-term functional results. Laryngoscope. 2009;119:1218–25.
13. Benito J, Holsinger FC, Pérez-Martín A, Garcia D, Weinstein GS,
Laccourreye O.Aspiration after supracricoid partial laryngectomy:
incidence, risk factors, management, and outcomes. Head Neck.
2011;33:679–85.
14. Lima RA, Freitas EQ, Dias FL, Barbosa MM, Kligerman J, Soares
JR, et al. Supracricoid laryngectomy with cricohyoidoepiglottopexy for advanced glottic cancer. Head Neck. 2006;28:481–6.
15. Dufour X, Hans S, De Mones E, Brasnu D, Ménard M, Laccourreye
O. Local control after supracricoid partial laryngectomy for
“advanced” endolaryngeal squamous cell carcinoma classied as
T3. Arch Otolaryngol Head Neck Surg. 2004;130:1092–9.
16. Laccourreye O, Brasnu D, Jouffre V, Couloigner V, Naudo P,
Laccourreye H. [Supra-cricoid partial laryngectomy extended
to the anterior arch of the cricoid with tracheo-crico-hyoidoepiglottopexy. Oncologic and functional results]. (Article in
French). Ann Otolaryngol Chir Cervicofac. 1996;113:15–9.
17. Succo G, Crosetti E, Bertolin A, Piazza C, Molteni G, Cirillo S,
etal. Treatment for T3 to T4a laryngeal cancer by open partial horizontal laryngectomies: prognostic impact of different pathologic
tumor subcategories. Head Neck. 2018;40:1897–908.
Part XVI
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Laryngeal Surgery: Voice Restoration
Voice Restoration Following
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Laryngectomy
AkshatMalik andPeterClarke
40
Total laryngectomy is a surgical procedure that is often
undertaken for treatment of advanced laryngeal or hypopharyngeal cancers. One of the major sequelae of this procedure
is the loss of voice [1].In this chapter, we will discuss various
options of voice rehabilitation after total laryngectomy, with
greater emphasis on the use of tracheo-oesophageal
prostheses.
40.1 Rationale
A few options exist for voice restoration after laryngectomy.
These include tracheo-oesophageal puncture (TEP) with
valve insertion, oesophageal speech and use of an electrolarynx. Valved speech is considered to be the gold standard for
voice restoration. Oesophageal speech is produced by swal-
lowing air into the oesophagus and allowing it to return into
the mouth via the pharynx, which vibrates in response to the
airow but is difcult to learn; it is further limited by the low
reservoir of air in the oesophagus. Speech is often in short
phrases interrupted by the swallow of more air [2]. The electrolarynx is a battery powered device that produces a
mechanical/robotic quality to speech and is therefore not
liked by patients [3]. Both these options are considered only
if valved speech is not possible.
Valved speech is simple to learn and utilises the vibration
of the pharyngeal mucosa as air passes over it but uses the
lungs as the driver of air. The valve that sits in a surgically
created tracheo-oesophageal stula is a one-way valve,
which allows air from the lungs into the neopharynx. The
sound is produced by the vibration of the neo-pharyngeal
mucosa (pharyngo-oesophageal (PE) segment) (Fig.40.1).
A. Malik
Max Super Speciality Hospital, Saket (Max Saket),
New Delhi, Delhi, India
P. Clarke (*)
Faculty of Medicine, Faculty of Medicine Centre, Imperial College
NHS Trust, London, UK
e-mail: peter.clarke2@nhs.net
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_40
403
404
xhaled air to pass
into the neopharynx
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Fig. 40.1 Post laryngectomy
showing valve in situ.
Occlusion of the stoma while
exhaling diverts air through
the valve into the neopharynx.
Air passing over the mucosa
creates vibration and therefore
sound which is then
articulated into speech in the
oral cavity
A. Malik and P. Clarke
Sound is articulated
into speech
40.2 History
The rst TEP was introduced commercially in 1980 by Blom
and Singer [4]. The initial devices were non-indwelling,
which means they could be removed for cleaning and reinserted often by the patients. The currently popular prostheses have undergone several modications in terms of
prosthesis itself and the technique of insertion. They are predominantly indwelling, that is, are only removed for
replacement.
40.3 Planning
It is important to have a multidisciplinary team approach for
the rehabilitation of these patients. The patient should be
introduced to a speech and language therapist (SLT) early
Vibration caused by
airflow across the
pharynx (PE segment)
Occlusion of the stoma
allows e
through the valve and
on. Their expectations and concerns should be addressed. It
is often helpful to patients if they meet or see videos of other
patients using this form of voice rehabilitation.
40.4 Primary TEP Insertion
Primary TEP insertion refers to when the TEP is inserted at
the time of laryngectomy. Primary insertion is now considered in the vast majority of primary laryngectomies.
This is undertaken immediately after the laryngectomy
specimen is dissected out and before the pharyngeal closure
is begun. A pharyngeal protector is inserted through the pharyngeal defect into the upper oesophagus. The bevelled end
of the protector faces anteriorly. The tracheo-oesophageal
party wall is punctured 1–1.5cm below the cut end in the
midline. This ensures the valve sits, not too close to the
Trocar
Oesophagus
oesophagus
40 Voice Restoration Following Laryngectomy
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Protector in upper
Fig. 40.2 Tracheo-oesophageal puncture
405
Trachea
mucocutaneous junction of the stoma, yet not too deep into
the stoma to make changing and cleaning the valve difcult.
The puncture needle is inserted into the bevelled end of the
pharyngeal protector; thereafter, a guidewire is inserted
through the puncture needle. Manufacturers vary, but the
valve is then pulled through into the stula produced by the
trocar. It is important to check the valve is seated with the
anges fully open in both the upper oesophagus and posterior tracheal wall (Fig.40.2).
An alternative is to create the stula, and instead of inserting a valve, insert a feeding tube, which can be changed for
a valve once oral feeding is established.
40.5 Operative Steps toMaximise Voice
andSwallowing Outcomes
Cricopharyngeal Myotomy: It is important to do a proper cricopharyngeal myotomy, and this should extend from just
below the level of the valve/puncture to encompass the cricopharyngeus muscle and hence cuts through the musculature
of the upper oesophageal sphincter. It is important that all the
muscle bres are cut so that the vessels over the submucosa
are seen. The myotomy is usually done posteriorly. The
myotomy helps in preventing hypertonicity and spasm of the
PE (vibrating) segment and provides good swallowing as
well as voice outcomes.
Pharyngeal closure: It has been observed that horizontal closure gives better functional results with regard to
speech and swallowing, as compared to the vertical closure. A T-shaped closures or closures with three-point
Fig. 40.3 Repair of thyropharyngeaus to the suprahyoid muscles
allows better functioning of the middle constrictor, which is important
for maintaining normal swallow
junction probably give a higher chance of developing a
leak and hence brosis and stricture, thus hampering the
mobility of the PE segment and consequently speech and
swallowing.
The thyropharyngeus muscle remnants should then be
repaired to provide some muscle with tone that can provide
an area of pharynx that will produce good vibration and
hence sound, which can be articulated into speech.
Following repair of the thyropharyngeus, this muscle
should be sutured to the suprahyoid muscles, which were
divided when entering the vallecula. These muscles include
the middle constrictors, repair of which allows the initial part
of the pharyngeal phase of swallow to be more efcient
(Fig.40.3).
It is helpful also to divide the sternal head of the sternocleidomastoid. This provides a at area around the TEP,
allowing easy handling of the prosthesis and placing a baseplate for the attachment of a heat and moisture exchange.
This also potentially reduces the chances of developing stomal stenosis.
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