open access atlas of otolaryngology, head & neck operative surgery

anterior borders of sternocleidomastoidmuscles. For a laryngectomy with neckdissection(s), either a wider flap overlyingthe sternocleidomastoid muscles is made(Figure 3a), or a narrow flap withinferolateral extensions is made (Figure3b). The latter has the disadvantage of atrifurcation which is more prone to woundbreakdown and exposure of the majorcervical vessels.midline. Take care not to injure theexternal and anterior jugular veins.Elevate the apron flap in asubplatysmal plane, remainingsuperficial to the external and anteriorjugular veins.Dissect the flap superiorly up toapproximately 2cms above the body ofthe hyoid bone.Figure 3a: Wide apron flap toaccommodate neck dissectionsFigure 4: Elevated apron flap andincisions through investing layer ofcervical along anterior borders ofsternocleidomastoid musclesFreeing up the larynxFigure 3b: Narrow apron flap forlaryngectomy, with lateral extensions forneck dissectionsFlap elevation (Figure 4)Cut through the superficial layer ofinvesting fascia and platysma muscles.The platysma is often absent inFree up one side of the larynx at a time.Stand on the side of neck that is beingdissected.Ligate and transect the anterior jugularveins suprasternally and above thehyoid.Incise the investing layer of cervicalfascia along the anterior border of thesternocleidomastoid muscle (Figure 4).Retract the sternocleidomastoid musclelaterallyIdentify the sternohyoid and omohyoidmusclesTransect the omohyoid muscle medialto where it crosses the internal jugularvein (Figure 5)3

Carefully elevate and reflect thesuperior cut end of the sternothyroidmuscle from the thyroid gland usingelectrocautery dissection (Figure 7)Figure 5: Transect omohyoid along yellowlineIdentify the dissection plane betweencarotid sheath and larynx and thyroidgland and open this plane with sharpand blunt dissection with a finger toexpose prevertebral fascia (Figure 6)Figure 7: Transect & elevate sternothyroidto expose thyroid glandFigure 6: Transect sternohyoid muscle toexpose sternothyroid muscleTransect the sternohyoid muscle withelectrocautery wherever convenient(Figure 6)Identify the sternothyroid muscle, andcarefully divide it below larynx(Figure 6). It is a broad, thin muscle,so take special care not to injure thethyroid gland and its rich vasculaturewhich is immediately deep to muscleFigure 8: Divided sternothyroid retractedto expose thyroid. Line indicates course ofdissection of thyroid gland and alongmidline of tracheaDivide the thyroid isthmus withelectrocauteryDivide and strip the tissues overlyingthe cervical trachea anteriorly in the4

midline to avoid injuring the inferiorthyroid veinsCarefully reflect the thyroid lobe offthe trachea, cricoid and inferiorconstrictor with electrocautery (Figure9) while inspecting for and excludingdirect laryngeal tumour extension tothe thyroid glandartery, and reflect and preserve thesuperior thyroid pedicle from thelarynx (Figure 11)Identify and divide the superiorlaryngeal nerveFigure 9: Thyroid gland has beenmobilised from larynx and tracheaIdentify and transect the recurrentlaryngeal nerve (Figure 10)Identify the tracheo-oesophagealgroove and oesophagus (Figure 10)Figure 11: Identify and divide superiorlaryngeal branch of superior thyroidarteryRotate the larynx to the contralateralside, and identify the posterior borderof the thyroid ala (Figure 12)Figure 10: Identify oesophagus, and dividerecurrent laryngeal nerveIdentify and divide the superiorlaryngeal branch of superior thyroidFigure 12: Rotate the larynx with a fingerplaced behind the thyroid alaDivide the inferior pharyngealconstrictor muscle and thyroidperichondrium with electrocautery at,5

or just anterior to the posterior borderof the thyroid ala (Figure 13)The surgeon then crosses to the oppositeside of the patient, and repeats the aboveoperative steps.Suprahyoid dissectionThe following description applies tolaryngeal cancer not involving thepreepiglottic space, vallecula or the base oftongue. When tumour does involvevallecula, pre-epiglottic space and/or baseof tongue, then the pharynx is entered viathe opposite pyriform fossa or a retrogradelaryngectomy is done, commencing thedissection inferiorly at tracheostomy.Figure 13: Divided inferior pharyngealconstrictor and thyroid perichondriumStrip the lateral wall of the pyriformfossa off the medial aspect of thethyroid ala in a subperichondrial planewith a swab/sponge held over afingertip, or with a Freer’s elevator,only on the side of the larynx oppositeto the cancer (Figure 14). On the sideof the cancer, this step is omitted toensure adequate resection margins.Identify the body of the hyoid bone.Remember that the hypoglossal nervesand lingual arteries lie deep to thegreater cornua/horns of the hyoid boneDivide the suprahyoid muscles withelectrocautery along the superiorborder of the body of the hyoid bone(Figure 15)Figure 14: Pyriform fossa mucosa strippedfrom thyroid laminaFigure 15: Transection of suprahyoidmuscles from hyoid body6

Laryngeal resectionFigure 19: Entering valleculaTracheostomyA tracheostomy is done at this stage soas to mobilise the larynx and tofacilitate the laryngeal resectionAsk the anaesthetist to preoxygenatethe patientIncise the trachea transversely betweenthe 3 rd /4 th /5 th tracheal rings or below apreoperative tracheostomy. With asmall trachea, incise the lateral trachealwalls in a superolateral direction tobevel and enlarge the tracheostoma.Place a few 3-0 vicryl half-mattresssutures between the anterior wall of thetransected trachea and the skin toapproximate mucosa to skinPuncture and deflate the cuff of theendotracheal tube, and cut the tube inthe pharynx, and remove the distal endof the tube through the pharyngotomyInsert a flexible endotracheal tube e.g.armoured tube into the tracheostoma.Avoid inserting the tube too deeply asthe carina is quite close to thetracheostoma. Fix the tube to the chestwall or drapes with a temporary sutureso that it does not become displaced,attach the sterile anaesthesia tubing andresume ventilationInspect the subglottis through thetracheostoma to ensure that the trachealresection margin is adequateMove to the head of the operating tableRetract the epiglottis and the larynxanteriorly through the pharyngotomy,and inspect the larynx and the tumourCommence laryngeal resectioncontralateral to the tumour usingcurved scissors with points locatedanteriorly/upwards so as to avoidinadvertently resecting too muchpharyngeal mucosaCut along the lateral border of theepiglottis on the less involved side, toexpose the hypopharynxRepeat this on the side of tumour, withat least a 1cm mucosal margin aroundthe tumourOn the less involved side, cut throughthe lateral wall of the pyriform fossaand hug the arytenoids and cricoid topreserve pyriform sinus mucosa(Figure 20). The superior laryngealneurovascular pedicle will betransected if not previously addressedRepeat on the tumour sideFigure 20: Resect the larynx preservingmaximum amount of pharyngeal mucosaJoin the left and right pyriformincisions by tunnelling below andcutting the postcricoid mucosatransversely (Figure 21)8

Figure 21: Transverse postcricoid cutSeparate the posterior wall of thelarynx (cricoid, tracheal membrane)from the anterior wall of theoesophagus by dissecting with ascalpel along the avascular planebetween that exists betweenoesophagus and trachea/cricoid (Figure22). Take care to stop just short of thetracheostoma.Figure 23: Transect trachea and removelarynxPharyngo-oesophageal myotomyOptimising speech and swallowingrequires a capacious and floppypharynxAlways perform a pharyngooesophagealmyotomy to preventhypertonicity of the pharyngooesophagealsegmentInsert an index finger into theoesophagusWith a sharp scalpel, divide all themuscle fibres down to the submucosa,and distally to the level of thetracheostoma (Figure 24). Themyotomy may be done in the midlineor to the side.Figure 22: Dissecting in the avascularplane between oesophagus and tracheaTransect the posterior wall of thetrachea, and remove the larynx (Figure23)Inspect the laryngectomy specimen foradequacy of resection margins, andresect additional tissue if indicatedFigure 24: Cricopharyngeal myotomy9

o 3rd layer: Approximate inferiorconstrictors and suture constrictorsto suprahyoid muscles withinterrupted 3-0 vicrylFinal stepsFigure 27: Pharynx well suited to atransverse closureTake care not to injure the lingualarteries when suturing the pharynx, asinjury to the arteries may lead tonecrosis of the tongueA 3-layered pharyngeal closure issuggestedo 1 st layer: 3-0 vicryl runningmodified Connell or true Connelltechnique (Invert mucosa)Ask the anaesthetist to do a Valsalvamanouevre to exclude bleeding andchyle leaksIf there is excessive, lax suprastomalskin that may occlude the tracheostomywhen the patient flexes the neck, thentrim a crescent of skin from the inferioredge of the apron flap suprastomallySuture the skin to the edges of thetracheostomy with half-mattressinterrupted 3-0 vicryl suturesSeal the trifurcation at the lateral edgeof the stoma with a suture as indicatedbelow (Figure 29)Figure 29: Suture technique to sealtrifurcation between skin and side oftracheostomaFigure 28: Completed 1 st layer oftransverse closure of pharynxo 2nd layer: 3-0 vicryl running sutureof submucosa and muscleInsert a ¼” suction drainIrrigate neck with sterile waterReapproximate the platysma with 3-0vicryl running suturesClose the skin with a running nylonsuture or with skin staplesSuction blood from tracheaInsert a cuffed tracheostomy tube, andsuture it to skin11

Postoperative careAntibiotics x 24 hoursChest physiotherapyRemove suction drains when

Figure 34: Pectoralis major augmentationof pharynxFigure 32: Large carcinoma ofhypopharynx that will require pharyngealreconstructionFigure 35: Tubed pectoralis major flapFigure 33: Insufficient pharyngeal mucosafor primary closure of pharynxFigure 36: Tubed free anterolateral thighflap13

Author & EditorJohan Fagan MBChB, FCORL, MMedProfessor and ChairmanDivision of OtolaryngologyUniversity of Cape TownCape TownSouth Africajohannes.fagan@uct.ac.zaFigure 37: Free jejunal flapUseful referencesThe Open Access Atlas of Otolaryngology, Head &Neck Operative Surgery by Johan Fagan (Editor)johannes.fagan@uct.ac.za is licensed under a CreativeCommons Attribution - Non-Commercial 3.0 UnportedLicenseAswani J, Thandar MA, Otiti J, FaganJJ. Early oral feeding following totallaryngectomy. J Laryngol Otol. 2009;123:333-338A practical guide to post-laryngectomyvocal and pulmonary rehabilitation -Fourth Edition: Postlaryngectomyvocal and pulmonary rehabilitationFagan JJ, Lentin R, Oyarzabal MF, SIaacs, Sellars SL. Tracheo-oesophagealspeech in a Developing WorldCommunity. Arch Otolaryngol 2002,128(1): 50-53Fagan JJ, Kaye PV. Management of thethyroid gland with laryngectomy forcT3 glottic carcinomas. ClinOtolaryngol, 1997; 22: 7-12Harris T, Doolarkhan Z, Fagan JJ.Timing of removal of neck drains withhead and neck surgery. Ear NoseThroat J. 2011 Apr; 90(4):186-9.14