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Head and Neck > Hypopharynx, Larynx, Trachea > Flashcards

Hypopharynx, Larynx, Trachea Flashcards

1
Q

What are the 3 subsites of the hypopharynx?

A

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

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2
Q

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

A
  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
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3
Q

Outline the T-staging for Hypopharynx Carcinoma

A

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

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4
Q

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?

A
  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

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5
Q

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

A

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

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6
Q

Discuss the EORTC 24891 Trial (for Hypopharyngeal cancer) 1996

A

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

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7
Q

Discuss the overall management of hypopharyngeal carcinoma?

A
  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

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8
Q

What is long term sequelae of chemorads for the hypopharynx?

A

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

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9
Q

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

A
  1. Suprahyoid (transhyoid) pharyngotomy
  2. Lateral pharyngotomy
  3. Combined suprahyoid and lateral pharyngotomy
  4. Median Labiomandibular glossotomy
  5. TORS/TLM (case series)
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10
Q

What are surgical options for cancer of the pyriform sinus?

A
  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
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11
Q

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

A
  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
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12
Q

Indications for bilateral neck dissection in hypopharynx 3

A

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

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13
Q

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

A

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

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14
Q

List 12 risk factors for cervical esophageal carcinoma

A
  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)

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15
Q

Layers of the esophagus

A

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

MSCLA

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16
Q

Describe the TNM and Overall Staging for Esophageal squamous cell cancer

A

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

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17
Q

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

A

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

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18
Q

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

A

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)

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19
Q

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

A

3cm (to fit a KAO feed)

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20
Q

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?

A
  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

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21
Q

What are 5 indications for radiotherapy for laryngeal dysplasia/Cis

A

60-66Gy

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

Wide RSPP

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22
Q

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

A
  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)
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23
Q

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

A
  1. 25% of all HN cancers
  2. M:F 4:1
  3. 75% true vocal fold
  4. 90% OS for early stage
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24
Q

Outline a malignancy differential diagnosis for glottic lesions

A

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

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25
Q

Name 6 histologic barriers to laryngeal carcinoma spread.

Where does Cartilage invasion typically occur? List 4 places

A

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

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26
Q

List 5 causes for vocal fold fixation from laryngeal tumors

A
  1. Thyroarytenoid muscle involvement
  2. Cricothyroid muscle involvement
  3. RLN involvement
  4. Bulky tumor (too much weight to move)
  5. Cricoarytenoid joint
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27
Q

Describe the TNM staging for laryngeal carcinoma

A

See separate staging document

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28
Q

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

A
  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

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29
Q

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

A
  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?

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30
Q

Summarize the VA study for advanced laryngeal cancer (1991)

A

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

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31
Q

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

A

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

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32
Q

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

A

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

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33
Q

What are 7 contraindications for endoscopic laryngeal microexcision?

A

Posterior commisure (absolute)
Cartilage invasion
Anterior commissure
Bulky
T3 Glottic
T4 glottic
Subglottic extension

PCA BTS

Similar to contraindications for laser

34
Q

List the European Laryngological Society Classification of Endoscopic Cordectomies

A
  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
35
Q

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

A

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)

Vancouver Pg 130

36
Q

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

A

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

Vancouver Pg 131

37
Q

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

A

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

Vancouver Pg 131

38
Q

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

A

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

Vancouver Pg 131

39
Q

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

A

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

Vancouver Pg 131

40
Q

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

A

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

Vancouver Pg 132

41
Q

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

A

TYPE Vc = EXTENDED CORDECTOMY ENCOMPASSING THE VENTRICULAR FOLD

Resection: Type IV + ventricle + false fold

Indications:
1. T2 cancers infiltrating the false fold

42
Q

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

A

TYPE Vd = EXTENDED CORDECTOMY ENCOMPASSING THE SUBGLOTTIS

Resection: Type IV + up to 1cm under the glottis (controversial)

Indications:
1. T2 carcinoma

43
Q

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

A
  1. One cricoarytenoid unit
  2. One laryngeal valve:
    - Epiglottis
    - False vocal folds
    - True vocal folds
44
Q

What are 4 open approaches to the larynx?

A
  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

Vancouver Pg 132

45
Q

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

A
  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

Draw these out

46
Q

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

A
  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
47
Q

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

A
  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%)
48
Q

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

A
  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
49
Q

What is removed in the vertical partial laryngectomy?

A
  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

Vancouver Pg 133

50
Q

Most common reconstruction after Vertical partial laryngectomy

A
  1. Bipedicled strap muscle flap - omohyoid or sternothyroid
  2. Patients will all require post-op SLP to regain vocal function
51
Q

What are the 5 anatomical subsites of the supraglottis?

A
  1. Suprahyoid epiglottis (including tiip, lingual, and laryngeal surfaces)
  2. Infrahyoid epiglottis
  3. Aryepiglottic folds
  4. False vocal folds
  5. Arytenoids
52
Q

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

A
  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
53
Q

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

A

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)
54
Q

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

A
  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)

Vancouver Pg 132

55
Q

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

A
  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
56
Q

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

A
  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

57
Q

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

A

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)

Vancouver Pg 134

58
Q

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

A

(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
59
Q

What are the 5 components of the cricoarytenoid unit

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

“A CARS”

60
Q

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

A

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%

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225965/

61
Q

Discuss the use of radiotherapy for laryngeal carcinoma

A

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

62
Q

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

A
  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
63
Q

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

A
  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

Check Cummings

64
Q

Describe the Sisson classification of stomal recurrence

A
  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

Kevan HN #215

65
Q

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

A
  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)
66
Q

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

A

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)

67
Q

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

A
  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
68
Q

What are 8 alaryngeal communication methods?

A
  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
69
Q

What are 3 methods of voice production post-laryngectomy?

A
  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
70
Q

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

A
  1. Decreased LOC
  2. While sleeping
  3. True upper airway obstruction
  4. High aspiration risk
  5. Cuffed trach
  6. Severe COPD
  7. Poor dexterity
71
Q

What are 6 reasons for alaryngeal tracheoesophageal speech failure? 6

A
  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)
72
Q

Discuss the management of dysfluent speech post-laryngectomy?

A

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
73
Q

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

A
  1. Pharyngeal constrictor myotomy
  2. Pharyngeal plexus neurectomy
  3. Botox injection
74
Q

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

A
  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)

75
Q

What are 8 complications of a TEP? (Prostehsis)

A
  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

76
Q

What are 3 late complications of total laryngectomy?

A
  1. Stomal stenosis
  2. Hypothyroidism
  3. Pharyngoesophageal stenosis or stricture

Other complications:
1. Pharyngocutaneous fistula / salivary fistula
2. TEF
3. Infection
4. Bleeding

77
Q

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

A

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

78
Q

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?

A

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

79
Q

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

A
  1. Tracheostomy
  2. Laser debulking
  3. Endoscopically inserted stent
80
Q

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

A

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
81
Q

List 8 tracheal lengthening techniques

A
  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

Head and Neck (15 decks)

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