Surgery in the Upper Airway: Trends in Technique and Technology

Educational Objectives

The goal of this program is to improve the application of surgical procedures targeting pathologies of the tonsils and larynx. After hearing and assimilating this program, the clinician will be better able to:

1.   Inform patients about risks associated with traditional tonsillectomies.

2.   Avoid common complications encountered during traditional tonsillectomy procedures.

3.   Discuss the benefits of intracapsular partial tonsillectomy.

4.   Identify cases of laryngeal and epiglottal cancer for which supracricoid partial laryngectomy is an appropriate treatment option.

5.   Compare outcomes associated with chemotherapy and radiation therapy to those achieved with surgical treat­ment of laryngeal cancers.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Wein­stein is a principal investigator and consultant for Intuitive Surgical. Drs. Rosenfeld and Ward and the planning committee reported nothing to disclose. In his lecture, Dr. Weinstein presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Drs. Rosenfeld and Ward were recorded at Annual Clinic Day, held December 3, 2008, in Uniondale, NY, and sponsored by The Nassau Surgical Society, and the Brooklyn and Long Island Chapter of the American College of Surgeons. Dr. Weinstein was recorded at Miami CME Winter Series, held January 15-17, 2009, in Miami Beach, FL, and sponsored by the University of Miami Health System and the Miller School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Tonsillectomy  —  Traditional Surgery

Richard M. Rosenfeld, MD, Professor of Otolarnygology, SUNY Downstate Medical Center, Chair, Depart­ment of Otolaryngology, Long Island College Hospital, Brooklyn, NY

Background on tonsillectomy: significant rate of complications (eg, dysgeusia, phantogeusia, sagittal sinus throm­bosis); adenoid removal alone often sufficient for treating sleep disordered breathing in children ³4 yr of age; Mc­Gyver mouth gag  —  dangerous instrument (potential for accidental dislodging of teeth); speaker recommends keeping water-filled syringes within arm’s reach as preparation for tube ignition (rare); spandex cheek retractors  —  prevent burns during tonsillectomy; increase visibility

Anatomy: tonsillar capsule  —  preserving capsule critical; examination after procedure recommended; capsule should be free of muscle and other attached tissues; speaker recommends large incision (»2 cm) for greater visibil­ity; capsule-patient interface  —  white area; speaker recommends preserving this; superior retraction required for access; palatopharyngeal complications  —  palatopharyngeus muscle and fibrous tissue insert into “equator” or “belt” of tonsils (junction of lower lobe and middle); bleeding complications often arise from mistreatment of pala­topharyngeal connection; capsule pushes into tonsil two-thirds down; only fascia (white fossa) should remain visi­ble by end of procedure

Procedure: current density  —  ground pad disperses current over large area; tip of electrosurgical instrument contains dense current; most effective with minimal contact between tip and tissue (excessive contact may create burns); ig­nitions and fires typically occur at ³30 watts (speaker recommends 12 watts for Bovie tonsillectomy); cold proce­dures required for patients with cochlear implants; pacemakers may be disabled during procedure; incision  —  absolute perpendicular orientation with mucosa critical (creates narrow area of injury and burn); Bovie instrument  —  speaker recommends aligning toward middle (prevents complication of carotid artery); combination of cauterization with tissue stretching (mechanical counterforce) produces ideal results; Deutsch study  —  in young children, internal carotid artery only »1 cm from fossa; suction Bovie  —dangerous instrument (burns through mus­cle common); speaker recommends fully retracting tonsillar pillars and making minimal contact with superficial layer; necessary only with significant bleeding; majority of blood vessels found in equator; exact dissections should not produce hemorrhage; extra care when freeing muscular attachments in groove prevents complications with larger vessels entering tonsil; contingency plan  —  use blunt instruments when blood obscures field of view; speaker recommends pushing until capsule emerges, or making lower incision to locate capsule before applying Hurd dis­sector; Metzenbaum procedures  —  entirely cold; utilize sickle blade and Metzenbaum forceps (for spreading); finger    —can use to remove tonsil; snares  —  useful in emergencies; tonsil pushed downward before ensnaring stalk and squeezing to remove; packing then used to stop bleeding; audit data   —evaluated >40,000 tonsillectomies; va­riety of techniques (hot and cold methods); 6-fold increase in complications found with monopolar cautery, com­pared to cold techniques (possibly due to collateral damage); thermal energy applied should be minimized; continuous bleeding  —  continued application of instrument exacerbates problem; speaker recommends figure-of-eight suturing (with 2-0 chromic or plain gut sutures); carotid artery tying  —  occasionally necessary with persistent bleeding; rare occurrence; communication  —  speaker recommends having patients sign forms documenting all proper instructions have been communicated (critical from legal standpoint); dietary restrictions  —  studies failed to find significant benefit; speaker instructs patients to ingest as much liquid as possible

Microdebrider Intracapsular Tonsillectomy

Robert F. Ward, MD, Professor of Otolaryngology, Weill Cornell Medical College, New York, NY

Background on intracapsular tonsillectomy: reduced recovery time (compared to traditional tonsillectomy); first presented in 2000; obstruction often requires removal of tonsils and adenoids; original procedures performed pri­marily due to concerns about formerly common complications of streptococcal infection (eg, scarlet fever, rheu­matic fever, rheumatic heart disease, rheumatic kidney disease); majority of contemporary procedures performed due to obstruction

Partial intracapsular tonsillectomy: preserves small amount of tonsillar capsule (reduces pain associated with ex­posure of nerve endings and muscle); avoids exposing blood vessels (lower incidence of hemorrhage); potential for tonsil regrowth (evidence remains questionable); often performed in conjunction with adenoidectomy; speaker uti­lizes microdebrider, but finds instrument choice less important than maintaining partial approach; elevator may be used to protect uvula; »90% of tonsils shaved off; appears similar to full tonsillectomy once completed; initial data  —  based on »2000 procedures; low rate of regrowth and bleeding complications; few readmissions; safety of procedure well-established; thus far, none of speaker’s patients have required return to operating room for bleeding; small number of completion tonsillectomies performed; procedure does not cause scarring or changes to tonsillar pillars and functioning of soft palate (reduces risk for velopharyngeal insufficiency); no hospital readmissions re­ported; younger children  —recommendations state patients <3 yr of age should remain hospitalized overnight; however, no difference in pain levels, oral intake, or analgesic consumption found when compared to children >3 yr of age; benefits  —  outpatient procedure; less pain, so less narcotic necessary; significantly less postoperative bleed­ing; children rarely admitted unless complicating issues present (eg, neurologic problems, cerebral palsy, Down syndrome); no special criteria for length of stay in recovery room (standard surgical guidelines recommended)

Postoperative considerations: majority of children leave recovery room and hospital in »1 hr; patients typically per­mitted normal diet; few activity restrictions; speaker does not recommend delaying return to school (³2 wk typi­cally required with full tonsillectomy); speaker does not prescribe narcotics (acetaminophen [eg, Tylenol] recommended); partial procedures result in far fewer phone calls from and follow-up consultations with concerned parents; low incidence of hypernasality (compared to full tonsillectomy and adenoidectomy); speaker recommends using most comfortable or familiar debrider blade (manufacturer unimportant)

Supracricoid Partial Laryngectomy:
Current Indications

Gregory S. Weinstein, MD, Professor and Vice Chair, Department of Otorhinolaryngology – Head and Neck Surgery, Director, Head and Neck Surgery Division and Head and Neck Surgery Clinic, and Co-Director, Cen­ter for Head and Neck Cancer, University of Pennsylvania, School of Medicine, Philadelphia

Background on supracricoid partial laryngectomy: organ preservation surgery; involves resection of entire thyroid cartilage (both true and false cords) and ³1 arytenoid; spares musculature and innervation from recurrent and supe­rior laryngeal areas; preserves integrity of cricoid ring; supracricoid partial laryngectomy with cricohyoidopexy (CHP)  —  involves resection of entire thyroid cartilage, bottom portion of epiglottis, and preepiglottic space; spares cricoid and ³1 arytenoid (cricoarytenoid unit); after finger dissection of cervicomediastinal trachea, sutures attach cricoid to hyoid, epiglottis, and tongue base; variation with cricohyoidoepiglottopexy (CHEP) —  for selected supra­glottic and transglottic carcinomas  —  similar to supracricoid partial laryngectomy with CHP, but resects entire pre­epiglottic space and epiglottis; sutures attach cricoid to hyoid and tongue base; clinical acceptance  —  classic conservation surgery focused on vertical partial laryngectomy and supraglottic laryngectomy; supracricoid laryn­gectomy initially disregarded as excessively radical due to removal of both cords; now confirmed reliable proce­dure with worldwide application; widely available despite highly technical approach

Oncologic indications in laryngeal cancer: radiation therapy (RT) failure  —  useful in selected instances (eg, failure with early T1 lesion); partial laryngectomies often impossible in patients with irradiated T2 or T3 malignancies; su­pracricoid laryngectomy works well within indicated parameters and resection margins; selected advanced laryn­geal cancers  —studies involving advanced malignancies (ie, T3 and T4) found lower survival rates with chemoradiation, compared to surgery; alternative to chemoradiation or RT alone with selected T2, T3, and T4 la­ryngeal cancers; alternative to classic extended conservation surgeries

Oncologic indications in glottic cancer: for T2 glottic carcinoma, RT achieves local control in 70% of cases (rates decrease at higher T stages); »20% local failure rate reported with vertical partial laryngectomy or laser surgery; la­ser surgery typically requires multiple resection procedures; speaker recommends procedures offering superior lo­cal control during initial treatment

Reconstruction: vertical partial laryngectomy  —  large number of approaches utilized (15 documented), creating dif­ficult teaching situation; typically involves resection as needed, followed by improvisation of novel reconstruction to fix hole; procedure out of favor due to high level of variability; supracricoid partial laryngectomy with CHEP  —only 2 variations exist (arytenoid either resected or spared); low variability simplifies teaching of procedure; repro­ducible technique with predictable outcome (compared to vertical partial laryngectomy)

Cricohyoidoepiglottopexy: achieves oncologic control in >95% of cases (confirmed by multiple series); most often indicated in T2 disease; performed on selected patients staged at T3 (uncommon); primary indications  —  bilateral cord involvement (only in patients with T2 disease or T1 with RT failure); impaired cord mobility (associated with T2 glottic carcinoma); selected cases of cord fixation where arytenoids retain mobility (indicates no involvement of cricoarytenoid joint or cricoid); majority of patients with cord fixation not candidates; however, most glottic can­cers detected from clinical evidence (eg, hoarseness) before fixation occurs; invasion of preepiglottic space  —  CHP recommended; invasion of cricoid cartilage  —  studies found tumors 1 cm below cord level never involved cricoid cartilage; tumors >1.5 cm below cord level associated with significant incidence of diffuse invasion into cricoid cartilage marrow space; at 1 to 1.5 cm, tumors typically abutted cricoid and did not show significant invasion; speaker contends procedures may be performed at 1.5 cm level by cutting laterally and shaving off top of cricoid; arytenoid cartilage fixation  —  assessed in-office by having patient cough gently; multiple series link arytenoid fix­ation with involvement of cricoarytenoid joint (precludes sparing cricoid and surrounding musculature); posterior arytenoid mucosa must be spared (even on involved side); joint fixation contraindicates CHEP; respiratory impairment  —classic contraindication for laryngeal surgeries with potential to compromise valve function or swal­lowing; defined as inability to climb 2 flights of stairs; speaker does not recommend pulmonary function tests, and treats request for pulmonary function testing as contraindication for surgery; failure rate with supracricoid partial laryngectomy consistently <10%; unilateral cord lesions  —  removing both cords allows reconstruction via impac­tion of cricoid to hyoid; if left behind, remaining cord may prevent arytenoid from moving forward toward epiglot­tis and tongue base; after removal of thyroid cartilage and cords, posterior and lateral cricoarytenoid muscles drive larynx and cord movement; after reconstruction, vocal process moves downward and arytenoids touch epiglottis and tongue base (allows patients to regain speech); all procedures at cord level result in varying degrees of hoarse­ness; RT  —  local failure in 30% of cases; in patients failing RT with any stage of disease, 50% eventually died from index cancer; supracricoid partial laryngectomy for treatment of T2 disease may produce significant hoarseness, but yields extremely low failure rates

Cricohyoidopexy: supraglottic cancer  —  classic surgical approaches achieved local control of disease in 95% of pa­tients; however, >50% of patients required total laryngectomy; 20% to 54% of supraglottic cancers invade paraglot­tic space and reach glottic level; supraglottic laryngectomies require removal of larynx in »50% of patients; supracricoid laryngectomy serves as middle-grade procedure (more radical than supraglottic laryngectomy, but less radical than total laryngectomy); supracricoid laryngectomy with CHP produces outstanding local control rates; indications  —  supraglottic cancer with glottic extension (recurrence rate of 20%-50%); supraglottic cancers with invasion of preepiglottic space; transglottic cancers originating in undersurface of false cord or involving both cords; selected cases with cartilage invasion (early stage); contraindications  —  massive invasion of preepiglottic space problematic due to necessity of preserving hyoid bone; glottic or supraglottic disease with involvement of pharynx or interarytenoid area complicates larynx-sparing procedures (³1 arytenoids must be salvageable); suprac­ricoid laryngectomy  —  greater numbers of patients eligible (compared to supraglottic laryngectomy); studies re­ported superior cancer control with supracricoid procedures; swallowing function at outcome comparable to nonsurgical therapy; Radiation Therapy Oncology Group (RTOG) 91-11 trial  —  radiation therapy with concurrent cisplatinum recommended as standard of care for patients seeking laryngeal preservation; speaker coauthored re­sponse advocating patient participation and appropriate counseling about all treatment options; 15% of patients in trial reported significant problems swallowing (associated with long-term stomach tube and tracheotomy; speaker recommends advising patients of potential risk); functional outcomes  —  <5% of patients undergoing supracricoid laryngectomy with CHP later require functional laryngectomy; functional outcomes superior to chemoradiation; superior quality of life, compared to total laryngectomy; American Society of Clinical Oncology guidelines  —supracricoid laryngectomy recommended for T2 glottic carcinoma; advise patients of superior local control and greater incidence of hoarseness

Suggested Reading

Holsinger FC et al: Supracricoid partial laryngectomy: an organ-preservation surgery for laryngeal malignancy. Curr Probl Cancer 29:190, 2005; Holsinger FC et al: Technical refinements in the supracricoid partial laryngectomy to optimize functional outcomes. J Am Coll Surg 201:809, 2005; Lee KD et al: Diameter of vessels across the tonsillar capsule as an anatomical consideration for tonsil­lectomy. Clin Anat 21:33, 2008; Littlefield PD et al: Radiofrequency excision versus monopolar electrosurgical excision for tonsil­lectomy. Otolaryngol Head Neck Surg 133:41, 2005; Nguyen CV et al: Comparison of intraoperative bleeding between microdebrider intracapsular tonsillectomy and electrocautery tonsillectomy. Ann Otol Rhinol Laryngol 118:698, 2009; Park A et al: Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy. Int J Pediatr Otorhi­nolaryngol 71:1205, 2007; Pellini R et al: Supracricoid partial laryngectomies after radiation failure: a multi-institutional series. Head Neck 30:372, 2008; Pfister DG et al: American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. J Clin Oncol 24:3693, 2006; Scinska A et al: Post-tonsillectomy dysgeu­sia with weight loss: possible involvement of soft palate. J Laryngol Otol 122:E5, 2008; Solares CA et al: Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. Int J Pediatr Otorhinolaryngol 69:21, 2005; Sorin A et al: Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope 114:297, 2004; Tunkel DE et al: Efficacy of powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope 118:1295, 2008; Wilson YL et al: Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study. Laryngoscope 119:162, 2009.