Hypopharynx, Larynx, Trachea

Question 1

What are the 3 subsites of the hypopharynx?

Answer 1

3 P’s:
1. Piriform sinus
2. Posterior pharyngeal wall
3. Post-cricoid region

Question 2

Rank the subsites of the hypopharynx with regard to incidence of cancer

Answer 2

1. Piriform (65-75%) - 75% regional metastasis
2. Posterior pharyngeal wall (20-25%) - 60% regional metastasis
3. Post-cricoid (< 5%) - associated with plummer vison syndrome - 40% regional metastasis

Question 3

Outline the T-staging for Hypopharynx Carcinoma

Answer 3

TX: Primary tumor cannot be assessed

Tis: Carcinoma in situ

T1: Tumor limited to one subsite of hypopharynx and/or ≤ 2cm greatest dimension

T2: Tumor invades more than one subsite of hypopharynx or an adjacent site, 2-4cm (≤4cm) without fixation of hemilarynx

T3: >4cm OR with fixation of hemilarynx OR extension to esophageal mucosa

T4 Moderately advanced or very advanced local disease

T4a: Moderately advanced local disease
- Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, or central compartment soft tissue (prelaryngeal strap muscles and subcutaneous fat)

T4b: Very advanced local disease
- Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures

Question 4

What is different about hypopharyngeal and cervical esophageal cancer spread as compared to other sites in head and neck?

What are the recommended surgical margins?

Answer 4

1. Propensity for submucosal extension (especially lower hypopharynx and esophagus)
2. Satellite lesions are common

Recommended margins:
1. 4-6cm inferiorly
2. 2cm laterally
3. 2-3cm superiorly

Question 5

What is the prognosis of hypopharyngeal carcinoma, with no treatment vs. treatment?

Answer 5

No treatment: 10% at 1 year
Treatment: 48% at 1 year, 30-40% at 5-year

Question 6

Discuss the EORTC 24891 Trial (for Hypopharyngeal cancer) 1996

Answer 6

European Organisation for Research and Treatment of Cancer = EORTC

Hypopharyngeal Carcinoma (T2-3, N0-N2b) comparing primary surgery vs. induction CRT

Results:
- No difference in Local regional control
- Fewer distant metastasis with CRT
- Better overall survival in CRT arm
- 42% laryngeal preservation at 3 years

Implications: CRT is the primary treatment modality for most hypopharyngeal cancers

Question 7

Discuss the overall management of hypopharyngeal carcinoma?

Answer 7

1. RT for all except small T1 (rare presentation)
2. Early stage (1/2): XRT, Surgery, or both
3. Late stage (3/4): Induction Chemo (T2-4a, N0-3), Surgery + post op ChemoXRT

Note: Ipsilateral hemithyroid with surgery

SUMMARY:

Stage I/II: T1N0, some T2N0 amendable to larynx-preserving surgery: Primary RT, or partial laryngectomy/hemithyroid ± adjuvant (C)RT

Stage III/IV, options:
1. Induction chemo, then reassess
- Complete response - then proceed with definitive RT or CRT
- Partial response - CRT or definitive surgery (partial/TL) ± adjuvant CRT
- Less than partial response - definitive surgery ± adjuvant CRT, or deemed unresectable
2. Surgical (partial or total laryngectomy) ± adjuvant CRT
3. CRT
4. Clinical trials

Question 8

What is long term sequelae of chemorads for the hypopharynx?

Answer 8

High risk of:
1. Hypopharyngeal stricture requiring G-tube (~30%)
2. Laryngeal dysfunction requiring a trach (~30%)

Question 9

What are the surgical approaches to the posterior pharyngeal wall? 5

Answer 9

1. Suprahyoid (transhyoid) pharyngotomy
2. Lateral pharyngotomy
3. Combined suprahyoid and lateral pharyngotomy
4. Median Labiomandibular glossotomy
5. TORS/TLM (case series)

Question 10

What are surgical options for cancer of the pyriform sinus?

Answer 10

1. T1 lesions in high medial area - partial laryngopharyngectomy (TORS/TLM use has also been reported)
2. T2+ lesions - usually require total laryngectomy, partial pharyngectomy if lateral extension present

Question 11

What are surgical options for cancer of the post-cricoid area?

Answer 11

1. Total Laryngectomy, partial pharyngectomy, and cervical esophagectomy
2. Conservative options of surgery are not possible, as cancers in this location present late and have early invasion of cartilage and esophagus

Question 12

Indications for bilateral neck dissection in hypopharynx 3

Answer 12

Bilateral neck dissection for :
1. Medial piriform
2. Beyond midline/posterior wall
3. Post-cricoid area

Question 13

What are 6 contraindications to larynx preserving surgery in hypopharyngeal cancer?

Answer 13

Involvement of T3/T4 structures:
1. Thyroid cartilage
2. Apex of piriform sinus
3. Post-cricoid area
4. Esophagus
5. Vocal fold paralysis
6. Inter-arytenoid region/bilateral arytenoid

Question 14

List 12 risk factors for cervical esophageal carcinoma

Answer 14

1. Smoking (4.5x increased risk)
2. EtOH (11x increased risk, synergistic with smoking)
3. Nitrosamines
4. Prior H/N carcinoma
5. Barrett’s esophagus - distal increased 5-15% increased risk of adenocarcinoma
6. Caustic burn/scar/stricture
7. Achalasia
8. Plummer-Vinson syndrome
9. Oculopharyngeal muscular dystrophy (inheritence: AD, ptosis, dysphagia, proximal limb weakness)
10. Pernicious anemia
11. Tylosis (thickening palms and soles)
12. Scleroderma

“ESOPHAGUS”
E: EtOH
S: Smoking
O: Oculopharyngeal muscular dystrophy
P: Plummer Vision, Past H/N cancer
H: Heat/trauma (caustic burn, scar, stricture)
A: Achalasia
G: GERD (Barrett’s esophagus)
U: Unsure what category to put these under (Nitrosamines - high curated foods, Pernicious anemia)
S: Scleroderma, Soles (Tylosis - thickening palms and soles)

Question 15

Layers of the esophagus

Answer 15

Mucosa / lamina propria
Submucosa
Inner circular musclar fibers (muscularis propria)
Outer longitudinal musclar fibres (muscularis propria)
Adventitia

MSCLA

Question 16

Describe the TNM and Overall Staging for Esophageal squamous cell cancer

Answer 16

T-STAGING:

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: High grade dysplasia, defined as malignant cells confined to the epithelium by the basement membrane
T1: Tumor invades the lamina propria, muscularis mucosae, or submucosa
- T1a: Tumor invades the lamina propria or muscularis mucosae
- T1b: Tumor invades the submucosa

T2: Tumor invades the muscularis propria
T3: Tumor invades the adventitia
T4: Tumor invades adjacent structures
- T4a: Tumor invades the pleura, pericardium, azygos vein, diaphragm, or peritoneum
- T4b: Tumor invades other adjacent structures, such as the aorta, vertebral body, or airway

N-STAGING:
NX: Cannot be assessed
N0: No regional LN metastasis
N1: 1-2 regional LN
N2: 3-6 regional LN
N3: ≥7 regional lymph nodes

M-STAGING:
M0: No distant mets
M1: Distant mets

OVERALL STAGING cTNM:

Stage 0: TisN0M0
Stage 1: T1N0-1M0
Stage 2: T2N0-1M0, T3N0M0
Stage 3: T3N1M0, T1-3N2M0
Stage 4a: T4N0-2M0, AnyT-N3M0
Stage 4b: Any T, Any N, M1

Question 17

Regarding Esophageal cancer, discuss:
1. Clinical signs/symptoms - 8
2. Types - most common and second most common
3. Investigations and Diagnosis - 4 investigations
4. Complications - 5
5. Treatment

Answer 17

CLINICAL SIGNS/SYMPTOMS:
1. Nonpainful dysphagia and weight loss (common)
2. Odynophagia
3. Dysphagia
4. Anemia
5. Hemorrhage
6. Aspiration pneumonia
7. VF paralysis
8. Adenopathy (20%)

TYPES:
1. SCC most common
2. Adenocarcinoma less common

INVESTIGATIONS:
1. Esophagoscopy with brush cytology or biopsy
2. Endoscopic ultrasound
3. CT/MRI ± PET
4. Barium swallow

COMPLICATIONS:
1. Obstruction
2. Hemorrhage
3. Airway compromise
4. Perforation
5. Lack of serosal lining –> no limit to spread

TREATMENT:
1. CRT or Surgery

Prognosis: 15% 2 year OS

Question 18

What are four methods of reconstructing the cervical esophagus? Discuss them as well as their advantages and disadvantages?

Answer 18

A. FREE JEJNUM FLAP: Preferred for total pharyngoesophageal defects, not ideal if significant base of tongue is resected
1. Advantages: Mucosalized tubed structure that re-establishes conduit
2. Disadvantages: Requires laparotomy, requires microvascular anastomosis, often unable to achieve tracheoesophageal speech

B. COLONIC INTERPOSITION (Not a first-choice, reconstructive alternative)
1. Advantage: Mucosalized tube structure that re-establishes food conduit
2. Disadvantage: Requires laparotomy, high morbidity/mortality from postoperative infection

C. GASTRIC PULLUP/TRANSPOSITION (Preferred for resections that extend into the cervical esophagus)
1. Advantage: Single anastomotic line, can perform total esophagectomy for margins
2. Disadvantage: Morbidity with the pullup (pneumothorax), postoperative early satiety/dumping/emesis, mortality 5-15%

D. FREE MICROVASCULAR TRANSFER
1. Radial forearm, lateral thigh
2. Pec flap
3. Deltopectora (2 stage)

Question 19

During pharyngolaryngectomy, what is the minimal hypopharyngeal mucosa width that has to be preserved for primary closure (ie. no flap requirement)?

Answer 19

3cm (to fit a KAO feed)

Question 20

What are 5 categories of early laryngeal squamous malignancy?
What is the % risk of laryngeal dysplasia to SCC for mild/moderate, severe, and Cis?
What are the treatment options? What is the follow up?

Answer 20

1. Hyperkeratosis
2. Atypia/dysplasia
3. Carcinoma in-situ - chance of developing SCC with CIS or severe dysplasia is ~16% if left untreated
4. Superficial invasive carcinoma/microinvasive - through BM but not vocalis
5. Invasive carcinoma

“SACHI”

Risk of laryngeal dysplasia transition to SCC:
1. Mild to moderate - 10% at 120 weeks
2. Severe - 18% at 80 weeks
3. Cis - 50%

Treatment:
1. Excision vs. stripping of mucosa for widespread disease
2. Follow q1-3 months for 5 years

Question 21

What are 5 indications for radiotherapy for laryngeal dysplasia/Cis

Answer 21

60-66Gy

1. Multiple recurrences
2. Persistent smoking
3. Poor surgical candidate
4. Patient preference
5. Multiple lesions/wide field disease

Wide RSPP

Question 22

What are the genetic/molecular markers for laryngeal cancer? List 5.

Answer 22

1. HSV: found in 75% of laryngeal cancers but only 25% of oral cancers
2. p53: Mutations correlate with the clinical outcome
3. pRb: Lack of expression associated with a higher likelihood of lymph node metastasis and a significantly lower 5-year survival rate
4. Cyclin D1: Low levels correlate with radio-resistant early-stage carcinoma
5. EGFR: Overexpression correlates with greater invasiveness, poorer local-regional control and DF progression in dependent of treatment modality (?disease progression)

Question 23

Discuss the epidemiology of laryngeal malignancies.
Most common sex?
What is the most common sub site?
Overall survival of early stage?

Answer 23

1. 25% of all HN cancers
2. M:F 4:1
3. 75% true vocal fold
4. 90% OS for early stage

Question 24

Outline a malignancy differential diagnosis for glottic lesions

Answer 24

A. EPITHELIAL
1. SCC
2. Melanoma

B. NON-EPITHELIAL
1. Sarcomas (histologic grade more important than stage)

C. NEUROENDOCRINE
1. Carcinoid
2. Small cell carcinoma

D. SALIVARY
1. Adenoid cystic
2. Adenocarcinoma
3. Mucoepidermoid

E. IMMUNE
1. B-cell lymphomas

F. METASTASIS

Question 25

Name 6 histologic barriers to laryngeal carcinoma spread. Where does Cartilage invasion typically occur? List 4 places

Answer 25

HISTOLOGIC BARRIERS TO LARYNGEAL CARCINOMA SPREAD: 1. Thyroid and cricoid cartilages with overlying perichondrium 2. Conus elasticus 3. Quandrangular membrane 4. Ventricle 5. Hyoepiglottic ligament 6. Thyrohyoid membrane Cartilage invasion occurs at: 1. Broyle's ligament 2. Cricothyroid membrane attachment 3. Thyroarytenoid muscle attachment 4. Cricothyroid joint attachment

Question 26

List 5 causes for vocal fold fixation from laryngeal tumors

Answer 26

1. Thyroarytenoid muscle involvement 2. Cricothyroid muscle involvement 3. RLN involvement 4. Bulky tumor (too much weight to move) 5. Cricoarytenoid joint

Question 27

Describe the TNM staging for laryngeal carcinoma

Answer 27

See separate staging document

Question 28

Name 5 different treatment options for early glottic cancer. Which one has the best voice function?

Answer 28

1. Radiation (preserves normal anatomic relationships) 2. Endoscopic cordectomy - cold steel or laser - Controversial as to better voice outcomes with RT vs. surgery for early stage lesions 3. Laryngofissure and cordectomy 4. Vertical partial laryngectomy 5. Hemilaryngectomy Radiation vs. Laryngeal Preservation Surgery A. RADIATION B. ENDOSCOPIC C. OPEN

Question 29

According to NCCN, what are the adverse pathologic features used to assess for suitability of adjuvant treatment in glottic cancer? 8

Answer 29

1. Positive margins or close margins 2. Lymphovascular invasion 3. Perineural invasion 4. Extranodal extension 5. pT4 primary 6. pN2 7. pN3 8. Subglottic extension N1? T3?

Question 30

Summarize the VA study for advanced laryngeal cancer (1991)

Answer 30

Advanced laryngeal cancer (Stage III/IV), randomized into two arms: 1. Surgery (TL) + post-op XRT 2. Induction chemo (Cisplatin + 5FU) + XRT - if no (even partial) response after 2 cycles or recurrent/residual disease after XRT --> salvage laryngectomy Results: - Overall Survival rate at 2 years identical (68%) - Laryngeal preservation rate in Group 2 = 64% but only 39% had fully functioning larynx Conclusion: New role for Chemo and CRT is an options, compared to the standard of care (TL) with equivalent OS and organ preservation Clinical implications: - CRT is now given instead of surgery for organ preservation in patients with T3 laryngeal carcinoma

Question 31

Summarize RTOG 91-11 (2003) - Radiation Therapy Oncology Group (RTOG)

Answer 31

Advanced laryngeal cancer, randomized into 3 arms, looking at laryngeal preservation (LP), locoregional control (LC) and OS rates. Group 1: Concurrent cisplatin + XRT - LP: 88% - LC: 78% Group 2: Neoadjuvant Cisplatin + 5FU, then XRT - LP: 75% - LC: 61% Group 3: XRT alone - LP: 70% - LC: 56% Results: 1. OS rate was similar for all groups: 54-56% at 5 years Implications: 1. VA study showed that induction CRT was equivalent to survival rates with surgery 2. This study added to this by showing that induction CRT was not significantly better than XRT alone (except for distant control) - but rather Concurrently together it was better 3. This is why concurrent cisplatin-RT became the standard of care for patients with advanced laryngeal cancer

Question 32

What are 7 contraindications for laser microlaryngeal excision of glottic carcinoma?

Answer 32

ABSOLUTE: 1. T4 2. Inability to expose adequately 3. Distant metastasis OTHER: 1. Select T3 glottic tumors - VC fixation and paraglottic extension, or posterior commissure involvement 2. Subglottic extension 3. Extensive reconstruction required 4. N3 disease

Question 33

What are 7 contraindications for endoscopic laryngeal microexcision?

Answer 33

Posterior commisure (absolute) Cartilage invasion Anterior commissure Bulky T3 Glottic T4 glottic Subglottic extension PCA BTS Similar to contraindications for laser

Question 34

List the European Laryngological Society Classification of Endoscopic Cordectomies

Answer 34

1. Type 1: Subepithelial cordectomy 2. Type 2: Subligamental cordectomy 3. Type 3: Transmucular cordectomy 4. Type 4: Total or complete cordectomy 5. Type 5a: Extended cordectomy encompassing the contralateral vocal fold 6. Type 5b: Extended cordectomy encompassing the arytenoid 7. Type 5c: Extended cordectomy encompassing the ventricular fold 8. Type 5d: Extended cordectomy encompassing the subglottis

Question 35

Describe the Type 1 ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 35

TYPE I = SUBEPITHELIAL CORDECTOMY Resection: Through the SLP, but not deeper Indication: - Lesions suspected of to be premalignant or have malignant transformation (diagnostic procedure, not therapeutic) ## Footnote Vancouver Pg 130

Question 36

Describe the Type 2 ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 36

TYPE II: SUBLIGAMENTAL CORDECTOMY Resection: Reinke's space, vocal ligament (intermediate and deep lamina propria) - Preserve vocalis INDICATIONS: 1. Severe leukoplakia with stroboscopy indicating deeper infiltration - loss of mucosal wave 2. Carcinoma in situ 3. Microinvasive carcinoma ## Footnote Vancouver Pg 131

Question 37

Describe the Type 3 ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 37

TYPE III: TRANSMUSCULAR CORDECTOMY Resection: Epithelium, lamina propria, part of vocalis muscle - Can extend from vocal process to the anterior commissure ± false fold (for exposure) but not taking the commissure INDICATIONS: 1. Carcinoma of mobile vocal fold (T1a) without deep infiltration of the vocalis ## Footnote Vancouver Pg 131

Question 38

Describe the Type 4 ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 38

TYPE IV: TOTAL OR COMPLETE CORDECTOMY Resection: Cover, ligament and muscle resected + internal perichondrium of thyroid ala - The vocal ligament attachment at the anterior commissure is cut - ± False fold for access INDICATIONS: 1. T1a cancer: not involving anterior commissure of arytenoid ## Footnote Vancouver Pg 131

Question 39

Describe the Type Va ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 39

TYPE VA: EXTENDED CORDECTOMY ENCOMPASSING THE CONTRALATERAL VOCAL FOLD Resection: Type IV + anterior commissure, segment, or the entire contralateral vocal fold - ± petiole of epiglottis, subglottis mucosa and cricothyroid membrane (for lesion involving the anterior commissure) INDICATIONS: 1. T1b: Controversial procedure for cancers deeply infiltrating the anterior commissure (relative contraindication for endoscopic management), but could be attempted if anterior commissure infiltration is superficial and not spreading to the base of the epiglottis ## Footnote Vancouver Pg 131

Question 40

Describe the Type Vb ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 40

TYPE VB: EXTENDED CORDECTOMY ENCOMPASSING THE ARYTENOID Resection: Type IV + partial or total resection of the arytenoid with preservation of posterior arytenoid mucosa INDICATIONS: 1. T1a with involvement of vocal process but sparing the rest of the arytenoid (arytenoid mobile) 2. Some will do thiis for T2 (impaired mobility) or T3 (fixed folds) tumors, but this is controversial ## Footnote Vancouver Pg 132

Question 41

Describe the Type Vc ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 41

TYPE Vc = EXTENDED CORDECTOMY ENCOMPASSING THE VENTRICULAR FOLD Resection: Type IV + ventricle + false fold Indications: 1. T2 cancers infiltrating the false fold

Question 42

Describe the Type Vd ELS classification of Endoscopic cordectomies, including resection margins and indications

Answer 42

TYPE Vd = EXTENDED CORDECTOMY ENCOMPASSING THE SUBGLOTTIS Resection: Type IV + up to 1cm under the glottis (controversial) Indications: 1. T2 carcinoma

Question 43

What are two functional structures that MUST be preserved in any type of open partial laryngectomy

Answer 43

1. One cricoarytenoid unit 2. One laryngeal valve: - Epiglottis - False vocal folds - True vocal folds

Question 44

What are 4 open approaches to the larynx?

Answer 44

1. Laryngofissure 2. Trans-thyrohyoid membrane 3. MInithyrotomy - a term used any time a window is taken out of the cartilage, or a partiial incision into the cartilage is made 4. Woodman procedure - approaching the larynx around the thyroid ala cartilage - initiallly designed to assist with arytenoidectomy for bilateral VF paralysis ## Footnote Vancouver Pg 132

Question 45

What are 4 most common types of partial laryngectomies? When are they best used for?

Answer 45

1. Vertical Hemilaryngectomy - T1-2 Glottic tumor 2. Supraglottic laryngectomy (Horizontal Hemilaryngectomy) - T1-2 Supraglottic tumor 3. Supracricoid partial laryngectomy - T2-4 Glottic and Supraglottic tumor, reconstructed with either one of the following - CHP = Cricohyoidopexy (For supraglottic tumors, where epiglottis is removed) - CHEP = Cricohyoidoepiglottopexy (for glottic tumors, where epiglottis is preserved) 4. Near Total Laryngectomy ## Footnote Draw these out

Question 46

What are 8 indications for vertical partial laryngectomy/laryngoplasty in early glottic carcinoma?

Answer 46

1. T1-2 Glottic cancer 2. Anterior commisure involvement 3. Extension to the vocal process of the arytenoid 4. Select superficial transglottic lesions - < 1/3 of the contralateral VF 5. < 10mm of subglottic extension anteriorly and < 5mm posteriorly 6. The lesion must extend no higher than the lateral wall of the ventricle 7. No cartilage invasion 8. If recurrence after RT, the entire area of pre-RT tumor involvement must be encompassed in the resection

Question 47

What are 9 contraindications for vertical partial laryngectomy/laryngoplasty in early glottic carcinoma?

Answer 47

1. Lesion extending above the free edge of the false vocal folds superiorly 2. Posterior commissure involvement 3. Involvement of both arytenoids 4. Fixed vocal fold 5. More than 5mm (1/3) of contralateral true vocal fold involvement 6. Bulky transglottic lesions 7. Cartilage invasion - Thyroid or cricoid 8. More tham 10mm of subglottic extension anteriorly and 5mm posteriorly 9. Poor pulmonary reserve (FEV1/FVC < 50%)

Question 48

List 7 factors for treatment of glottic cancer with Vertical partial laryngectomy instead of XRT?

Answer 48

1. Radioresistant tumors (verrucous carcinoma) 2. Salivary gland malignancies 3. Benign laryngeal tumors 4. Patients deemed unreliable for 6 weeks of XRT 5. Young patients (Due to theoretical increase risk of late radiation-induced sarcoma) 6. Obese 7. T1 extending to anterior commissure

Question 49

What is removed in the vertical partial laryngectomy?

Answer 49

1. One vocal fold from anterior commissure to vocal process 2. 1/2 opposite fold can be removed 3. Ipsilateral false vocal fold 4. Ventricle 5. Paraglottic space 6. Overlying thyroid cartilage - 3mm posterior strip of cartilage preserved ## Footnote Vancouver Pg 133

Question 50

Most common reconstruction after Vertical partial laryngectomy

Answer 50

1. Bipedicled strap muscle flap - omohyoid or sternothyroid 2. Patients will all require post-op SLP to regain vocal function

Question 51

What are the 5 anatomical subsites of the supraglottis?

Answer 51

1. Suprahyoid epiglottis (including tiip, lingual, and laryngeal surfaces) 2. Infrahyoid epiglottis 3. Aryepiglottic folds 4. False vocal folds 5. Arytenoids

Question 52

What are 5 criteria that should be met for a supraglottic laryngectomy?

Answer 52

1. T1-2 (limited T3) supraglottic lesions (pre-epiglottic space involvement, or minimal medial piriform sinus (T2) involvement) 2. Mobile vocal folds 3. Anterior commissure uninvolved by cancer (>5mm) 4. Thyroid cartilage uninvolved by cancer 5. Minimal nodal disease

Question 53

What are 9 contraindications to a supraglottic laryngectomy? If a patient has these contraindications, what could they potentially be a candidate for?

Answer 53

IF PRESENT = Supracricoid laryngectomy candidate 1. Vocal fold fixation (absolute contraindication) 2. Bilateral arytenoid cartilage involvement (absolute contraindication) 3. Involvement at the glottic level 4. Tumor within 5mm of anterior commissure 5. Ventricle or pyriform apex involvement 6. Thyroid or cricoid cartilage involvement 7. Involvement of the tongue base to within 1cm of the circumvallate papillae 8. Poor medical condition - extreme age, poor pulmonary functiion 9. Prior irradiation (relative)

Question 54

What is removed in a supraglottic (horizontal) laryngectomy? 6

Answer 54

1. Epiglottis 2. Aryepiglottic folds 3. False vocal folds 4. Pre-epiglottic space 5. Portion of the hyoid 6. Thyroid cartilage (spares true vocal folds and arytenoids) ## Footnote Vancouver Pg 132

Question 55

What are the indications for a supracricoid partial laryngectomy with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP)?

Answer 55

1. T2-4 glottic and supraglottic carcinoma 2. Floor of ventricle involvement 3. Anterior commissure involvement 4. Impaired vocal fold or arytenoids mobility 5. Preepiglottic invasion 6. Paraglottic space invasion below the glottic level 7. Selected T4 supraglottic carcinoma 8. Transglottic glottic carcinoma (but not if into subglottis) 9. Radiation failure for glottic and supraglottic carcinoma

Question 56

What are the contraindications for supracricoid partial laryngectomy with CHP/CHEP in supraglottic carcinomas?

Answer 56

1. Hyoid invasion (cannot reconstruct) 2. Massive pre-epiglottic space invasion with vallecula involvement 3. Tongue base invasion 4. Arytenoid fixation 5. Subglottic extension to cricoid 6. Pharyngeal or interarytenoid involvement 7. Extensive thyroid cartilage invasion 8. Inadequate pulmonary reserve (FEV1 < 50%) 9. Resectable by supraglottic laryngectomy 4 local factors RC question Posterior commissure involvement Subglottic or cricoid Invasion through thyroid cartilage outer perichondrium Arytenoid fixation Paraglottic extension

Question 57

What is removed and what is spared in a supracricoid partial laryngectomy?

Answer 57

REMOVED: 1. Entire thyroid cartilage 2. Bilateral true vocal folds 3. Bilateral false folds 4. One arytenoid (may spare both if not involved) 5. Paraglottic space 6. ± Epiglottis SPARED: 1. One arytenoid (functional) 2. Cricoid cartilage (for recon) 3. Hyoid bone (for recon) ## Footnote Vancouver Pg 134

Question 58

What are the contraindications for any organ preserving laryngeal surgery? 8

Answer 58

(anything that prevents total resection/margins/preservation of 1 C-A unit) - Vocal cord fixation - Posterior commissure involvement - Involvement of both arytenoids/CA joints - Subglottic involvement - Cartilage invasion - Significant oropharyngeal involvement - T4 disease (most T3s as well) - M1

Question 59

What are the 5 components of the cricoarytenoid unit

Answer 59

1. Arytenoid cartilage 2. Cricoid cartilage 3. Associated musculature 4. Recurrent laryngeal nerve for that unit 5. Superior laryngeal nerve "A CARS"

Question 60

Describe the general management of the neck in laryngeal carcinoma. What are the risks of nodal disease with each stage?

Answer 60

In general: N0 = ?Likely not recommended for T1/T2. T3/T4 Unilateral neck dissection; if positive then bilateral ND N1 = Bilateral ND or RT More than N2 = Multimodality = ND + RT/CRT Risk of nodal disease: T1 = 20% T2 = 30% Bilateral disease = 25% T3/4 = 30-40% ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225965/

Question 61

Discuss the use of radiotherapy for laryngeal carcinoma

Answer 61

T1/2 = consider after discussion with the patient T3 = CRT T4 = Primary surgical management preferred (total laryngectomy + adjuvant RT/CRT)

Question 62

What are the indications for thyroidectomy or hemithyroidectomy in carcinoma of the larynx/hypopharynx? 7

Answer 62

1. Palpable disease present 2. Subglottic carcinoma or glottic with >1cm subglottic extension 3. T4 pyriform sinus carcinoma 4. T3/T4 supraglottic (total thyroid) 5. T4 glottic (total thyroid) 6. T3 glottic (hemithyroid) 7. Nodal positive disease

Question 63

What are 6 measures in the prevention of tracheal stomal stenosis?

Answer 63

1. Tensionless anastomosis 2. Cut the medial heads of the SCM (often the closure collapses because it's not as flat, and the stoma is deeper in the neck - can't get your finger deeper into the stoma to get a flat closure) 3. Bevelled tracheal cuts, yet leave entire tracheal ring intact at anastomosis 4. Use of a laryngectomy tracheostomal tube 5. Bilaterally suture outer tracheal wall to clavicular periosteum 6. Prevent infection and radiation which predispose to stenosis 7. Elongate the base - elongate the anterior edge of the stoma by placing sutures from the midline outward, proceeding farther along the skin than the trachea, and continuing this well onto the lateral portion of the trachea (more skin, less trachea) 8. Cover the cartilage - can use a trifurcating suture in which the superior flap comes into contact with the lateral aspect of the stoma bilaterally (in long-flap approach) "PC-BOAT" Prevent infection/radiation Cut the medial heads of SCM Bevelled cuts of the trachea Outer trachea sutured to clavicular periosteum Anastomosis is tensionless Tracheostomy tube/ lary tube ## Footnote Check Cummings

Question 64

Describe the Sisson classification of stomal recurrence

Answer 64

1. Type I: Tumor involves superior half of the stoma without esophageal involvement 2. Type II: Tumor involves superior half of the stoma with esophageal involvement, or the inferior half of the stoma 3. Type III: Tumor involves the inferior half of the stoma and extends to the mediastinum 4. Type IV: Lateral extension under the clavicles, carina, or great vessels Overall prognosis = BAD at any stage, unlikely to be curable "SIM-Loses" - Terence's friend loses cuz he's a SISSy ## Footnote Kevan HN #215

Question 65

What are the risk factors for stomal/peristomal recurrence? 6

Answer 65

1. T4 stage/advanced stage 2. Advanced N stage 3. Subglottic extension 4. Salvage surgery post XRT failure 5. Pre-op tracheostomy 6. Pharyngocutaneous fistula (managed with NPO/NG, packing, abx, and rule out residual/recurrent tumor; free or rotation flap if conservative measures fail)

Question 66

What are the techniques that can be used during a laryngectomy to optimize tracheoesophageal voice post-op? 7

Answer 66

DURING RESECTION: 1. Preserve as much pharyngeal mucosa as possible (ideally 6cm in transverse dimension, minimum 3cm) 2. Preserve as much inferior constrictor (cricopharyngeus and thyropharyngeus) muscle as possible 3. Address cricopharyngeus to prevent spasm post op: (a) Cricopharyngeal myotomy; or (b) Pharyngeal plexus neurectomy (not widely used) CLOSURE OF PHARYNX: 1. Horizontal closure of pharynx to create a wider pharyngo-esophageal segment --> improves resonance of speech (alternative is T-closure of the pharynx) 2. Close the inferior constrictor --> creates a tonic pharyngoesophageal segment for good reservoir of air below and wide resonating segment above STOMA CREATION: 1. Ensure stoma is flat by cutting the medial heads of the SCM 2. Prevent tracheal retraction (suture the stoma to clavicle periosteum or SCM)

Question 67

What are some intraoperative techniques for minimizing post-radiation pharyngocutaneous fistula during a salvage total laryngectomy? 6

Answer 67

1. Short flap technique - separate stoma from neck incision (2cm) 2. Inferior constrictor closure over primary closure 3. Divided SCM sternal heads and use as a muscle flap in between carotid sheath and pharynx 4. Salivary bypass tube 5. Pedicled flaps 6. Free flaps

Question 68

What are 8 alaryngeal communication methods?

Answer 68

1. Writing 2. Gesturing 3. Mouthing words 4. AAC computer-based program 5. Alphabet boards 6. Buccal-pharyngeal speech, artificial laryngeal devices 7. Esophageal speech 8. Tracheo-esophageal speech

Question 69

What are 3 methods of voice production post-laryngectomy?

Answer 69

1. Artificial Larynx - Pneumatic vs. electronic devices - Transcervical (electrolarynx) - Transoral (cooper-rand) - Intraoral (ultra voice) 2. Esophageal speech - Low fundamental frequency (65Hz), short duration (80cc air), effort to produce - Injectional technique - air pushed into esophagus - Inhalational technique - air inhaled (sucked) into the esophagus 3. Tracheo-esophageal puncture - Primary (at time of resection) - Secondary

Question 70

What are 7 contraindications for a Passie-Muir speech valve?

Answer 70

1. Decreased LOC 2. While sleeping 3. True upper airway obstruction 4. High aspiration risk 5. Cuffed trach 6. Severe COPD 7. Poor dexterity

Question 71

What are 6 reasons for alaryngeal tracheoesophageal speech failure? 6

Answer 71

1. Inadequate air supply (decreased respiratory support, improper stoma occlusion) 2. Puncture site closure 3. Prosthesis failure (position, patency, size, type, degradation, infection) 4. Reflex pharyngeal constrictor spasm - constrictors reflexively contract when dilated 5. Non-vibrating pharyngoesophageal segment (e.g. post-radiation, reconstructed segment) 6. Candida infection of prothesis (most common)

Question 72

Discuss the management of dysfluent speech post-laryngectomy?

Answer 72

Dysfluent speech = disruption of the forward flow and timing of speech by repetition of sounds, syllables or words (most common example = stuttering) 1. Speech therapy 2. Dilate or re-puncture 3. Use correctly sized prosthesis with ideal airflow characteristics 4. Pharyngeal constrictor myotomy, pharyngeal plexus neurectomy, botox injection 5. Allow edema to subside, provide external pressure

Question 73

What are 3 methods to prevent or cure pharyngoesophageal spasm post laryngectomy?

Answer 73

1. Pharyngeal constrictor myotomy 2. Pharyngeal plexus neurectomy 3. Botox injection

Question 74

What are the most common causes of TEP failure after successfully establishing speech?

Answer 74

1. Candida infection of prosthesis 2. Premature failure of prosthesis due to valve degradation with aspiration of liquids through prosthesis TREATMENT: Nystatin oral suspension (For candida)

Question 75

What are 8 complications of a TEP? (Prostehsis)

Answer 75

1. TEP extrusion 2. Granulation tissue 3. Prolapse 4. Fungal infection 5. Leak 6. Puncture site migration 7. Prosthesis aspiration 8. Voice failure (most common) Options: Change TEP size, type, company

Question 76

What are 3 late complications of total laryngectomy?

Answer 76

1. Stomal stenosis 2. Hypothyroidism 3. Pharyngoesophageal stenosis or stricture Other complications: 1. Pharyngocutaneous fistula / salivary fistula 2. TEF 3. Infection 4. Bleeding

Question 77

Regarding the anatomy of the trachea, discuss: 1. Anatomy of the rings, how many? How long is the trachea? 2. Boundaries - 2 3. Blood supply - 9 4. Innervation

Answer 77

RINGS: 1. D changed tube, C-shaped ring 2. 11cm 3. 18-22 rings in an adult (16-20 child) BOUNDARIES: 1. Superior: 1cm below glottis (C6) 2. Inferior: Carina (T4-5) BLOOD SUPPLY: 1. Inferior thyroid artery 2. Subclavian artery 3. Supreme intercostal artery 4. Internal thoracic artery 5. Brachiocephalic trunk 6. Bronchial arteries at the tracheal bifurcation 7. Segmental branches 8. Thyroid Ima artery 9. Aortic perforators INNERVATION: RLN

Question 78

Regarding tracheal tumors, discuss: 1. What are the most common benign vs. malignant tumors? Epidemiology? 2. 5 year survival? 3. What are some surgical pearls? 5 4. Treatment pearls?

Answer 78

EPIDEMIOLOGY: - 75% malignant in adults - 90% benign in pediatrics DIFFERENTIAL: - Chondroma is the most common benign lesion in adults - Most common malignant tumors: SCC (60% males) and Adenoid cystic (60% females) - Others: adenocarcinoma, chondrosarcoma, rhabdomyosarcoma, small cell, melanoma 5-YEAR SURVIVAL: 1. Adenoid cystic 45% 2. SCC 55% SURGICAL PEARSL: 1. Gentle inhalational induction, no paralysis 2. Rigid bronchoscopy and endotracheal debridement 3. Do not free more than 2cm of trachea circumferentially if that part remaining (risk of devascularization) 4. Tension-free end-to-end anastomosis with coated polyglactin suture (Vicryl) 5. Strap muscle flap for innominate artery protection TREATMENT: 1. Post-op radiation for SCC and adenoid cystic cancer

Question 79

What are 3 methods for pallation for a high tracheal adenoid cystic carcinoma?

Answer 79

1. Tracheostomy 2. Laser debulking 3. Endoscopically inserted stent

Question 80

What is the length, number of rings, and maximum length that can be excised for trachea?

Answer 80

NORMAL LENGTH = 10-12cm NORMAL RINGS = 18-22 - Can excise 6.5cm or 5-6 rings without a tracheal release - Maximum length that can be removed is ~6.5cm, 13 tracheal rings, or 50-55% total tracheal length - Maximum tension to anastomosis is 1100-1700gm

Question 81

List 8 tracheal lengthening techniques

Answer 81

1. Blunt dissection of larynx and trachea ( anterior and posterior): 3-5cm 2. Intercartilaginous incisions of alternating annular ligaments: 2.5cm (kinda like a slinky) 3. Suprahyoid laryngeal release: 5cm 4. Infrahyoid laryngeal release (usually causes dysphagia, risk to SLNs) 5. Release of inferior pulminary ligament/hilum 6. Cervical flexion suture (Grillo/Guardian stitch) 7. Re-anastomosis of left mainstem bronchus onto bronchus intermedius: 2.7cm DINT SIPS Dissect/release pulmonary vasculature/blunt dissection of trachea Infrahyoid muscle release Neck flexion - Grillo stitch Transplanation of left mainstem bronchus to bronchus intermedius Suprahyoid muscle release Intrapericardial hilar release Paratracheal ligament release Slinky - alternating intercartilaginous incisions through the annular ligaments