الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Supracricoid laryngectomy, which is a form of subtotal laryngectomy (SCPL), was initially described by Majer and Rieder and thereafter by Labayle and Bismuth. This procedure was developed to avoid total laryngectomy in patients with tumor in which traditional partial procedures would not be indicated, thus avoiding definitive tracheostomy and the irreversible loss of laryngeal voice.
SCPL can be used for wide range of supraglottic and glottic carcinoma (T2b - T4). This procedure avoids the creation of a tracheostoma via preservation of the hyoid bone, cricoid cartilage, and at least one functional arytenoid unit in order to preserve the airway and laryngeal sphincter function. The epiglottis may or may not be resected depending on the extent of the tumor. Reconstruction is then preformed using either cricohyoideoepiglottpxey (CHEP) or cricohyoidopexy (CHP). This neoglottis functions via close approximation of the remaining arytenoid mucosa against the epiglottis or base of tongue; this allows for voice generation via vibration of mucosa between these surfaces.
SCPL seems to be safe in the vast majority of clinical T2 lesions, as bilateral extensive glottic involvement, impairment of the vocal fold mobility, subglottic extension not reaching the cricoid cartilage are all considered as indications for this surgery. SCPL can be also used in T3-T4 lesions with some precautions. The functional aspects of these surgical procedures have not been widely described in medical literature (Swallowing and phonation). The aim of this study was to assess the oncological and functional outcomes of supracricoid laryngectomy in moderately advanced cancer larynx.
This study was a descriptive case series study conducted in two tertiary care centers (LeLe hospital for advanced head and neck cancer & laser in Nashik , Mumbai , India and Kasr El-Ainy school of medicine, Cairo university) from January 2017 to January 2018. Approval of the ethical committee of the hospital was taken with a written consent taken from every patient.
Inclusion criteria were: 1) glottic squamous cell carcinoma (T2b-T4) with impaired mobility or even fixity of vocal cord/cords but with mobile arytenoid, or supraglottic tumor reaching the anterior commissure; 2) no prior induction chemotherapy; 3) patients fit for surgery with adequate pulmonary function tests. Patients with subglottic extension more than 10 mm anteriorly and 5 mm posteriorly), glottic carcinoma with cord fixation or supraglottic carcinoma with invasion of base of tongue were excluded. As well, tumors reaching the pre-epiglottic space or post cricoid region were excluded.
All patients underwent: 1) Full history taking, detailed office examination including routine otolaryngology examination with rigid or fibro-optic laryngoscopy for a better evaluation of vocal cord movements along with that of arytenoids.; 2) Direct laryngoscopy with pandenoscopy using 0° and 30° rigid endoscopes to specify the exact extension at the anterior commissure, the subglottic region, and the ventricle; 3) Neck imaging using CT and MRI in specific cases to evaluate tumor extensions inside the larynx; 4) Metastatic work-up to exclude the distant metastases and pulmonary function tests to exclude respiratory insufficiency.
All patients were treated by SCPL-CHEP according to Majer (4) and Piquet (8) techniques. All patients underwent tracheostomy during surgery. Ten patients were operated: 6 cases with CHEP and 4 cases with CHP having one case with preservation of both arytenoids for each surgical approach.
Regarding patients’ characteristics, this study included 10 patients, 8 males and 2 females with a sex ratio of 8: 1. The patients’ age was ranging between 45 and 75 years, with the mean age of 50.9 ± 9.2 years and coefficient of variation = 1.5%. The glottis was the most common site of origin of the lesions 90% (9 patients), while 10% (1patient) of lesions were purely supraglottic carcinoma.
This study focused on (T2b-T4a) which is moderately advanced laryngeal carcinoma Majority of patients were T3NOMO (4 patients). Others were T2N0M0 (2 patients), T2N2A M0 (2 patients), T2N2b M0 (1 patients) and T4aN0M0 (1 patients).
SCPL-CHEP was the main surgery in the study patients (60%). One arytenoid was resected routinely in all patients except one patient who had both arytenoids preserved. Neck dissection was performed on the tumor side in 60%, and on the contralateral side in 40%of patients. The types of neck dissection are mentioned in. Post-operative radiotherapy was delivered in 2 of the primary surgeries (20%). The indications of post-operative radiotherapy were high T stage, extra nodal disease, and positive or close margins.
Regarding the outcomes, the adjusted primary local control and overall control results at the time of the analysis were 100%. There was a deficit in follow up due to short period of the study. The estimated mean duration of hospitalization was 30 ± 60 day. Tracheotomy was done during the surgery for all patients, and was kept in place for one week at least. Six cases were decanulated before one month, and 4 cases after one month with two of them decanulated after 3 months due to severe aspiration. All the patients had nasogastric feeding tube during the surgery and it was kept more than 30 days in 3 patients due to aspiration. The complications of SCP were aspiration pneumonia, salivary fistula, Pexy rupture and arytenoid paralysis
In Conclusion, SCPL with CHEP and CHP provides excellent functional and oncological control with low risk of aspiration. Careful selection of cases is the key of success in supracricoid laryngectomy.