Supracricoid partial laryngectomy (SCPL) was first

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1 Original Research Head and Neck Surgery Supracricoid Partial Laryngectomy: Analyses of Oncologic and Functional Outcomes Otolaryngology Head and Neck Surgery 147(6) Ó American Academy of Otolaryngology Head and Neck Surgery Foundation 2012 Reprints and permission: sagepub.com/journalspermissions.nav DOI: / Ercan Pinar, MD 1, Abdulkadir Imre, MD 1, Caglar Calli, MD 1, Semih Oncel, MD 1, and Huseyin Katilmis, MD 1 No sponsorships or competing interests have been disclosed for this article. Abstract Objective. The aim of this study was to analyze the functional and oncologic results of supracricoid partial laryngectomy. Study Design. Case series with chart review. Setting. Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey. Subject and Methods. The medical records of 56 patients, who underwent supracricoid partial laryngectomy between March 2002 and December 2010, were reviewed in this study. Forty-three patients underwent supracricoid partial laryngectomy with cricohyoidopexy, and 13 patients underwent cricohyoidoepiglottopexy. The overall and diseasespecific survival, local control rates, and the mean time of decannulation and nasogastric tube removal were evaluated. Association of type of surgery with the functional and oncologic outcomes was evaluated and statistically compared. Results. The median follow-up period was 58 months. The 1-, 3-, and 5-year overall survival rates were 100%, 96.4%, and 82.1%, respectively. The 1-, 3-, and 5-year local control rates were 100%, 96.1%, and 92.5%, respectively. Type of surgery did not show any significant difference in survival and local control rates (P =.546, P =.455). The mean (SD) decannulation and nasogastric feeding tube removal time was (2.03) and (3.51) days, respectively. The mean time of decannulation and nasogastric tube removal was significantly longer in patients who underwent cricohyoidopexy when compared with those who underwent cricohyoidoepiglottopexy (P =.002, P =.000). Conclusion. Although delaying deglutition functions could be termed a disadvantage of supracricoid laryngectomy, especially with cricohyoidopexy, supracricoid laryngectomy has reliable oncologic and functional results for locally advanced laryngeal cancers while maintaining laryngeal functions. Keywords laryngeal carcinoma, supracricoid partial laryngectomy Received April 5, 2012; revised June 1, 2012; accepted July 17, Supracricoid partial laryngectomy (SCPL) was first described by Majer and Rieder in and modified by Piquet et al in The procedure was then popularized and developed by French and European surgeons. This technique is now being accepted and advocated by numerous authors. Supracricoid partial laryngectomy involves the removal of the whole thyroid cartilage, both true and false cords, the ventricles, the epiglottis, and the paraglottic and preepiglottic spaces, sparing only the cricoid cartilage, hyoid bone, and at least one functional and mobile arytenoid. It is classified according to the type of reconstruction: cricohyoidoepiglottopexy (CHEP) and cricohyoidopexy (CHP). 3,4 This can be applied according to tumor extension. Supracricoid partial laryngectomy with either CHEP or CHP has reliable oncologic and functional results for selected glottic and supraglottic carcinomas. 5 It reduces the necessity for total laryngectomy, and recently, Weinstein et al 6 also demonstrated that quality of life with SCPL is superior to that after total laryngectomy with tracheoesophageal puncture. Prior publications have reported good survival and local control rates for SCPL. 3,4,7 In particular, acceptable and reliable oncologic results have also been reported for salvage surgery for recurrent cancers following radiation therapy. 8,9 The aim of this study was to evaluate oncologic and functional results of SCPL and compare the functional results of CHP and CHEP. Patients and Methods We retrospectively reviewed 56 patients with laryngeal carcinoma who were treated with SCPL between January 2002 and December The Institutional Review Board of the Dokuz Eylul University (Izmir, Turkey) approved this study (February 15, 2012). 1 Otorhinolaryngology Department, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey Corresponding Author: Ercan Pinar, MD, Otorhinolaryngology Department, Katip Celebi University Ataturk Training and Research Hospital, Koruturk mh. Cagdas cad. No: 11/ Balcova-Izmir, Turkey epinar66@yahoo.com

2 1094 Otolaryngology Head and Neck Surgery 147(6) Table 1. Pathological TNM Classification for CHEP and CHP CHP (n = 43) Pathological TNM Classification Glottic (n = 29) Supraglottic (n = 14) CHEP Glottic (n = 13) Total (N = 56) T1N T2N T2N T2N T3N T3N T3N T4N T4N T4N Abbreviations: CHEP, cricohyoidoepiglottopexy; CHP, cricohyoidopexy. The patients included 51 men (91.1%) and 5 women (8.9%) with a mean (SD) age of (7.91) years (range, years). All patients had biopsy histologically proven squamous cell carcinoma. Of the 56 patients, 42 had glottic cancer and 14 had supraglottic cancer. We performed 43 SCPLs with CHP (76.8%) and 13 with CHEP (23.2%). None of the patients had received previous radiation therapy, and no induction chemotherapy was administered to the patients. The type of SCPL chosen was based on tumor localization and extension. The patients were staged according to the 2002 American Joint Committee on Cancer staging system. Indications for CHEP were as follows: (1) glottic tumors classified as T2 due to tumor extension to the ventricle, false vocal cord, petiole of epiglottis, and/or impaired true vocal cord and (2) glottic tumors classified as T3 due to fixation of the true vocal cord without fixation of the arytenoid cartilage. Indications for CHP were as follows: (1) T2 glottic tumors with bilateral invasion or T2 supraglottic tumors extending to the vocal cord and anterior commissure, with or without impaired mobility of the true vocal cords; (2) transglottic and supraglottic tumors classified as T3 due to true vocal cord fixation and/or preepiglottic space invasion but without fixation of the arytenoid cartilage; and (3) glottic tumors originating from the anterior commissure with preepiglottic space invasion classified as T3. The type of SCPL and the pathological TNM classification are illustrated in Table 1. The mobility of the true vocal cord on the tumor-bearing side was fixed in 28 patients and impaired in 18 patients. All patients underwent chest radiography and computed tomography of the head and neck. This operation was not performed on patients with restrictive pulmonary functioning or poor general conditions. Unilateral arytenoid cartilage was completely resected in 7 patients and partially resected in 14 patients. In the remaining 35 patients, both arytenoids were spared. Fifty (89.2%) patients had a neck dissection at the time of surgery. A bilateral neck dissection was performed in 41 patients (34 patients had bilateral functional neck dissection, 7 patients had unilateral radical neck dissection on one side and functional neck dissection on the other). Nine patients had an associated unilateral selective neck dissection of level II to IV nodes (sparing the internal jugular vein, cranial nerve XI, and the sternocleidomastoid muscle). No neck dissection was performed in the remaining 6 patients. Postoperative radiotherapy was used in 14 patients. The surgical procedure performed was CHP in 12 of 14 patients and CHEP in 2 patients. The decision to use adjuvant radiotherapy was based on the presence of a positive surgical margin in 1 patient, thyroid cartilage invasion in 6 patients, and multiple nodal metastasis and nodal metastasis with extracapsular spread in 7 patients. For the oncologic results of SCL, we calculated the 3- and 5-year overall disease-specific survival rates and 1-, 3-, and 5-year local control rates and examined the type of SCPL. For the functional outcomes, the mean time of decannulation and nasogastric feeding tube (NGT) removal was analyzed in all patients, and we also compared the mean time of decannulation and NGT removal between the patients who underwent SCPL with CHP and CHEP. The tracheal cannula was removed if the neolaryngeal airway returned through natural airways. The NGT was removed after the patient started to swallow liquids without aspiration. We also investigated the complications that occurred after SCPL. Statistical analysis. Statistical analysis was performed using SPSS for Windows version 15.0 (SPSS, Inc, an IBM Company, Chicago, Illinois). Comparison of survival was performed using the log-rank test, and comparison of the time to decannulation and NGT removal was performed using the paired t test. P values of \.05 were considered statistically significant. Results Follow-up of our patients after surgery varied from 14 months to 10 years, with a mean of 58 months. Oncologic Results of SCPL Survival. All patients were followed for at least 1 year. Forty-nine patients were followed 3 years, and 39 patients

3 Pinar et al 1095 Figure 1. Kaplan-Meier analysis of overall survival in patients treated with cricohyoidopexy (CHP) and cricohyoidoepiglottopexy (CHEP). Figure 2. Kaplan-Meier analysis of disease-specific survival in patients treated with cricohyoidopexy (CHP) and cricohyoidoepiglottopexy (CHEP). were followed 5 years. Five patients died of laryngeal carcinoma, 3 due to pulmonary metastases and 2 due to local recurrence. Two patients died of causes that were not related to laryngeal cancer. The 1-, 3-, and 5-year overall survival rates were 100%, 96.4%, and 82.1%, respectively. The 1-, 3-, and 5-year disease-specific survival rates were 100%, 95.9%, and 86.5%, respectively. There were no statistically significant differences in 1-, 3-, and 5-year overall survival (P =.546) and 1-, 3-, and 5-year disease-specific survival (P =.868) between patients with CHP and CHEP. The analyzed data curves are shown in Figures 1 and 2. Local control and recurrence. Recurrence occurred in 2 patients. These 2 patients had local recurrence, resulting in a local control rate of 96%. The 1-, 3-, and 5-year local control rates were 100%, 96.1%, and 92.5%, respectively. Salvage treatment was total laryngectomy in these 2 patients. There was no regional recurrence in the neck. Type of surgery (SCPL 1 CHEP or SCPL 1 CHP) did not show any significant difference in the local control rate (P =.455). Comparison of survival according to adjuvant radiotherapy. The overall survival rate of the patients who received postoperative radiotherapy was significantly lower that of the patients without adjuvant radiotherapy (P =.008). Functional Results of SCPL Decannulation. Decannulation was possible (54/56 patients, 96.4%) for all but 2 patients. Only 2 patients did not tolerate decannulation. Unilateral arytenoid cartilage was partially removed in 1 of these 2 patients. These 2 patients still had tracheostomies because of arytenoid Table 2. Analysis of the Functional Parameters of Supracricoid Partial Laryngectomy CHP CHEP P Value Decannulation, d a NGT removal, d b Abbreviations: CHEP, cricohyoidoepiglottopexy; CHP, cricohyoidopexy; NGT, nasogastric feeding tube. a Statistical value of comparison of decannulation time between CHEP and CHP. b Statistical value of comparison of NGT removal time between CHEP and CHP. cartilage edema. The mean (SD) decannulation time was (2.03) days in all patients. Deglutition. The mean (SD) time of nasogastric tube removal was (3.51) days. The NGT was successfully removed in 54 (96.4%) patients. Temporary grade 1 to 2 aspiration, according to the scale used by Pearson and Leipzig, 10 occurred in 11 (80.4%) patients. Only 3 patients did not tolerate NGT removal. Supracricoid partial laryngectomy with CHP was the operation type in these patients. Of the 2 patients, 1 had unilateral total arytenoid resection, and the other had partial arytenoid resection. These 2 patients underwent total laryngectomy due to intractable aspiration and repeated aspiration pneumonia. Type of surgery. The mean (SD) time of decannulation and NGT removal was (1.84) and (3.01) days in patients who underwent SCPL 1 CHP, whereas it was 9.92

4 1096 Otolaryngology Head and Neck Surgery 147(6) Table 3. Analysis of the Functional Results of Arytenoid Cartilage Resection No Resection (n = 35) Partial (n = 14) Unilateral Total (n = 7) P Value Decannulation, d NGT removal, d Abbreviation: NGT, nasogastric feeding tube. Table 4. Complications after Supracricoid Partial Laryngectomy Complications Number Surgical Wound infection 2 Wound hematoma 1 Pharyngocutaneous fistula 2 Medical Aspiration pneumonia 2 Myocardial infarction 1 (1.97) and (2.29) days in patients with SCPL 1 CHEP, respectively (Table 2). The mean time of decannulation and nasogastric tube removal was significantly longer in patients who underwent SCPL 1 CHP when compared with those who underwent SCPL 1 CHEP (P =.002, P =.000). Furthermore, unilateral partial or total arytenoidectomy had no negative effect on swallowing recovery. The mean decannulation and NGT removal time was not statistically different in patients with partial or unilateral total arytenoidectomy (Table 3). Complications after surgery. Postoperative complications were observed in 8 (14.2%) patients (Table 4). All complications were treated successfully with medical or surgical treatments. None of the patients died due to complications. Discussion Optimal primary treatment for laryngeal cancer is still controversial. Since the reports by Majer and Rieder 1 and Piquet et al 2 describing SCPL with CHEP or CHP for selected glottic and supraglottic carcinomas, numerous reports in the literature have demonstrated reliable oncologic and acceptable functional results with this procedure. 3-5 SCPL has reliable oncologic results for locally advanced tumors and also reduces the indications for total laryngectomy. In the literature, 3-year overall survival rate ranged from 71.4% to 95.7%, and the 5-year rate ranged from 69% to 86%. 3,11-14 In our series, 1-, 3-, and 5-year overall survival rates were 100%, 96.4%, and 82.1%, respectively. The reported results in the current series are in agreement with previous reports. Local and regional recurrence rates have also been discussed in the literature. Chevalier and Piquet 15 reported a 97% local control rate in supraglottic tumors after SCPL. Similarly, Laccourreye et al 16 reported a 98.2% local control rate at 5 years in glottic tumors. Furthermore, 1-, 3-, and 5- year local control rates were 97.3%, 93.5%, and 91.4%, respectively, in the study by Dufour et al. 17 In the current retrospective series, 2 patients had a local recurrence. Local recurrence was encountered at the 20th and 37th months postoperatively. The 1-, 3-, and 5-year local control rates were 100%, 96.1%, and 92.5%, respectively. There was no regional recurrence in the neck in our patients. As expected, and unfortunately, local recurrence had a negative impact on distant metastasis and survival. The mean time of decannulation and nasogastric tube removal is a commonly used parameter for the evaluation of the functional outcome of SCPL. The rate of decannulation and the duration of tracheotomy are the major parameters defined for the functional success of SCPL in terms of respiration. Laryngeal stenosis can appear after SCPL. The cause of stenosis included arytenoid edema, posterior prolapse of the epiglottis, mucosal webs, and cicatricial narrowing of the pexy. 18 Decannulation times are reported between 7 and 38 days in the literature. 4,7,11,19,20 In our patients, we used these 2 parameters for the functional success of SCPL in terms of respiration. The rate of decannulation was 96.4%, and the mean (SD) decannulation time was (2.03) days. In our practice, tracheotomy occlusion is performed initially. We advocate decannulation as early as possible when the neolaryngeal airway is sufficient to breathe. Early decannulation enables rapid mobilization of the arytenoid, thereby avoiding ankylosis of the cricoarytenoid joint. Furthermore, it helps to reduce the incidence of tracheitis and decreasing aspiration by increasing elevation of the larynx. Swallowing impairment and aspiration are the main functional problems of SCPL. Aspiration may cause a variety of pulmonary complications, varying from asymptomatic focal inflammatory reactions to severe pneumonia. It is generally agreed that SCPL initially results in severe swallowing dysfunction but allows eventual return to oral nutrition in most cases. 21 One of the most important parameters that indicate success of swallowing functions is NGT removal time. It is reported in the literature that the rate of NGT removal varies from 92% to 100%, and the mean time of NGT removal has been reported to be 15 to 70 days after SCPL. 7,11-13,18-22 Similarly, in our case series, the rate of NGT removal was 96.4%, and the mean (SD) time of NGT removal was (3.51) days.

5 Pinar et al 1097 Classically, SCPL provides 2 types of interventions: CHEP and CHP. Cricohyoidoepiglottopexy consists of sparing the epiglottis. Although similar in surgical concept, their effects on aspiration are different. For CHEP, aspiration occurs in patients whose epiglottic dynamics do not return to a satisfactory level. For CHP, aspiration occurs because of the absence of the epiglottis and inadequate neoglottic closure. Few studies have compared the functional results of CHP and CHEP. In the current study, we also compared the mean time of decannulation and nasogastric tube removal between the patients who underwent SCPL either with CHEP or CHP. Cho et al 7 and Gallo et al 23 reported that the mean time for NGT removal was significantly longer in patients who underwent SCPL with CHP. Furthermore, Yuce et al 24 showed that the mean NGT removal time for CHP was significantly longer in patients with unilateral arytenoid resection compared with sparing the 2 arytenoids. However, the authors did not compare the effect of the operation type on swallowing recovery. On the contrary, some authors reported that the type of SCPL and the presence or absence of arytenoids had no statistically significant effect on swallowing recovery. 5,25 In our case series, the mean decannulation and NGT removal time was significantly longer in SCPL with CHP compared with SCPL with CHEP. Our results show that the neoglottis sphincter function of the CHEP operation is better than that of the CHP operation, since the glottic sphincter had been totally removed in patients with CHP. These patients also need longer hospitalization time. Our results also showed that unilateral partial or total arytenoidectomy had no negative effect on swallowing recovery. Conclusion The main goals of SCPL are acceptable oncologic and functional results. The current study demonstrated reliable survival and local control rates in locally advanced laryngeal tumors. On the basis of functional results, the decannulation and NGT removal time was longer in patients with CHP. The final swallowing ability was successfully obtained in both types of surgery. Furthermore, unilateral arytenoidectomy had no negative effect on swallowing recovery. Author Contributions Ercan Pinar, study design, analysis of data, drafting the article and final approval; Abdulkadir Imre, acquisition of data, drafting the article; Caglar Calli, acquisition of data, drafting the article; Semih Oncel, analysis and interpretation of data, revising the article, final approval; Huseyin Katilmis, analysis and interpretation of data, revising the article, final approval. Disclosures Competing interests: None. Sponsorships: None. Funding source: None. References 1. Majer EH, Rieder W. Technique of laryngectomy permitting the conservation of respiratory permeability (cricohyoidopexy). Ann Otolaryngol Chir Cervicofac. 1959;76: Piquet JJ, Desaulty A, Decroix G. 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