Traditional transcutaneous approaches in head and neck surgery

Abstract

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Table 1. Influencing factors in choice of treatment modality (modified according to [98])

Table 2. Contraindications to open supracricoid laryngectomy [155]

Table 3. Contraindications to open supraglottic laryngectomy [37]

Table 4. Retrospective studies with initial local control rates for T1/T2 glottic carcinomas (modified according to [38])

Table 5. Results of retrospective studies for therapy of T1/T2 glottic carcinomas (modified according to [38])

Table 6. Results for the treatment of supraglottic laryngeal carcinomas with open partial laryngectomy

Table 7. Tabelle 7: Local control rates and survival rates with laryngeal preservation in hypopharyngeal carcinomas

Figure 1. Figure 1(a. and b.): Indications and surgical margins of frontolateral partial laryngectomy (from [154], with permission)

Figure 2. Transcervical approach to vertical partial laryngectomy

Figure 3. Transcervical dissection of thyroid cartilage

Figure 4. Oscillating saw for cutting the thyroid cartilage

Figure 5. Resection of the anterior commissure

Figure 6. Dissection of an apron flap

Figure 7. Dissection of an apron flap from hyoid to clavicle, needles mark the hyoid bone

Figure 8. Mobilization of piriform sinus

Figure 9. a. Indications and surgical margins of supraglottic laryngectomy; b. Note potential danger zone: preepiglottic space (both from [154], with permission)

Figure 10. Dissection of superior laryngeal nerve

Figure 11. Resection of the supraglottis (from [154], with permission)

Figure 12. Partial pharyngolaryngectomy with pectoralis major-flap for reconstruction

Figure 13. Reconstruction of partial laryngopharyngeal defects (modified from [103], with permission)

Figure 14. Reconstruction of circumferential laryngopharyngeal defects (modified from [103], with permission)