safety margin, To leave a functioning i larynx i.e. respiration, phonation & swallowing.

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2 The aim of the horizontal supra-glottic laryngectomy is: To remove the tumour with good safety margin, To leave a functioning i larynx i.e. respiration, phonation & swallowing.

3 Disadvantages of classical surgery Tracheostomy may be permanent Long hospital stay Aspiration due to : Superior laryngeal nerve injury Injury of suprahyoid musculature Aspiration may necessitate total laryngectomy in up to 10% of cases ( Suaraz et al 1996 ). Dissected Tissues in classical surgery Epiglottis. Pre-epiglotticepiglottic space. Ary-epiglottic folds. False vocal cords. Superior half of the thyroid cartilage.

4 The same achievement could be done by LASER Epiglottis. Pre-epiglotticepiglottic space. Ary-epiglottic folds. False vocal cords.?? Superior half of the thyroid cartilage. When we do supraglottic laser surgery T staging of supraglottic carcinoma T1 - Tumor limited to one subsite T2 - Tumor extended from one site to other site or region with mobile cords T3 - Tumor extended d to - vocal cord with fixed mobility of the cords - mucosa of the post cricoid region - pre-epiglottic space T4 - Tumor extended out side the thyroid cartilage

5 Limitation of laser surgery Extension of the tumor: Out side the thyroid cartilage. To the hyoid bone or to the thyrohyoid y ligament. Incompatible larynx after surgery i.e. If both arytenoids are involved. If both vocal cords are involved. Exposure difficulties e.g. high larynx, short neck or large tongue. Technique of laser surgery

6 Technique of laser surgery Technique of laser surgery

7 75 years female, epiglottic ca. extended to Rt. ventricular band and Rt. aryepiglottic fold Operative technique Second postoperative p day One week later 6 years later

8 Pre-operative One year post op khattab fekery one year post op.wmv khattab fekery pre op.wmv

9 48year male, supraglottic malignancy destroying the epiglottis and extended to tongue base and both aryepiglottic folds Pre-operative 9 month Post op ramadan mohamed 5 years after op.mpg 5 years Post-op Advantages of laser surgery No bleeding and Minimal edema. No external wound Border between healthy and tumor tissue can be easily identified Tumor imbolization through lymphatic vessels is blocked by laser coagulation of the lymph vessels. Mostly no tracheotomy. Constant view of the two dimensional extension of the tumor mass. Sphincteric function is preserved Minimal post operative hospital stay, most of the patients can leave the hospital in the same day of the operation.

10 Thank you Radiotherapy after laser, why? There is no guarantee about the tumor margin due to: The wide field of tumor bed. Micro vascular emboli. To cover undetected neck lymph nodes. The local control rate T stage radiotherapy Laser Radiotherapy + Laser T % 82-90% 90-95% T % % 64-84% T % 74-80%

11 Lymph node problem The situation here is different from the open neck surgery. Strategy for lymph node management LN stage Tstage N0 N1/2 N T1/4 T1/4 T1/4 Management No interference Functional neck surgery Radical neck surgery

12 48 patients, 44 males and 4 females (age range 40-80) had been managed by : Supraglottic laryngectomy followed by curative dose of radiotherapy, Neck dissection was done for N+ve cases only. Conclusion The oncological results of combined LASER and Rdith Radiotherapy in the control of the supra-glottic carcinoma are satisfying and definitely improve the out come of the disease

13 Thank you Prof. Wageeze backgrounds series T stage No. patients t N0 N1 N2 T T T T

14 Number of cases Surgical procedure 36 Laser supraglottic laryngectomy Laser supraglottic laryngectomy 7 + unilateral F N D 5 Laser supraglottic laryngectomy + Bilateral F N D Local and regional control rate Locall control: For T1 lesions 100% while for laser alone 82-95% and for radiotherapy alone 71-80% For T2 lesions 94% while for laser only 64-84% and for radiotherapy 59-74% For T3 lesions 86% while for laser only 56-64% Lymph node control: N0 100% N1 85% N2 60%

15 T stage No of Local N No of cases recurrence stage cases L N recurrence T N T N1 7 1 T N2 5 2 T4 5 2 Anatomically Supraglottic larynx is different from the glottic & the subglottic region: Embryology Pressman(1956) dye injection Pathologically Supraglottic carcinoma tend to respect the genetic of their territory It often show exophytic feature and may fill the whole hl vestibule bt but stop at the level of the vocal cords

16 Understanding the anatomy & the tumor extension, form the bases of the horizontal supra-glottic laryngectomy.