Adult Chest Surgery

Chapter 55. Subglottic Resection of the Airway 

The use of cricotracheal resection in the treatment of cancer is rare owing to the rarity of cancers of the subglottis and their lack of confinement to the larynx. Of the three subsites of the larynx, the subglottis is the origin of squamous cell carcinoma, (by far the most common cause of laryngeal cancer), in only 1–2% of patients.Cricotracheal resection for the treatment of subglottic stenosis is much more common, and the surgical techniques used for treating subglottic stenosis can be applied to surgical resection of the rare neoplasm that remains confined to the subglottis.

The glottis is defined by the American Joint Committee on Cancer as the superior and inferior surfaces of the true vocal cords occupying a horizontal plane 1 cm in thickness extending inferiorly from the lateral margin of the ventricle. The subglottis is defined as that region which extends from the lower border of the glottis to the lower margin of the cricoid cartilage.On the basis of histologic sectioning of whole larynges, Kirschner was able to demonstrate that the conus elasticus represents the definitive anatomic boundary between the glottis and the subglottis.Tumors above the plane of the conus elasticus tend to behave as glottic tumors and remain within the confines of the larynx, whereas those below the conus spread more easily beyond the borders of the larynx and metastasize more commonly to the prelaryngeal, paratracheal, and mediastinal lymph nodes. The epithelial lining also can be used to differentiate the glottis (lined by keratinizing squamous cells) from the subglottis (lined by ciliated respiratory epithelium).

ONCOLOGIC PRINCIPLES

While squamous cell carcinoma arises in the subglottis in only 1–2% of all laryngeal cancers, the subglottis is involved by contiguous spread of tumors of glottic origin in 11–33% of patients. These more common tumors are not amenable to cricotracheal resection.4,5 Early primary subglottic carcinomas are asymptomatic. Patients generally present with stage T3 or T4 tumors (Table 55-1), and airway obstruction is relatively common. These tumors usually exhibit circumferential growth, early cartilage invasion, and tumor growth beyond the borders of the larynx. Since glottic tumors with subglottic extension are not amenable to cricotracheal resection, and primary tumors of the subglottis of grade T2 or above are not contained within the subglottis, cricotracheal resection for squamous cell carcinoma is only possible for the rare T1 tumor. Otherwise, subglottic squamous cell carcinoma is treated with either radiation therapy or wide-field surgery, such as laryngectomy or laryngopharyngectomy. Tracheal tumors rarely extend superiorly to involve the subglottis.

Table 55-1. AJCC Staging of Subglottic Carcinoma

T1

Tumor limited to the subglottis

T2

Tumor extends to vocal cord(s) with normal or impaired mobility

T3

Tumor limited to larynx with vocal cord fixation

T4a

Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)

T4b

Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

 

AJCC = American Joint Committee on Cancer.

See reference 2.

Unlike the glottis, the subglottis contains laryngeal mucous glands and can be the primary site of tumors that arise from these glands. Nonsquamous laryngeal carcinomas make up only 1–5% of laryngeal cancers. They consist of adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, neuroendocrine tumors, and cartilaginous tumors. In addition, plasmacytomas, non-Hodgkin's lymphoma, and metastatic lesions can arise in the subglottis. While different tumors require different margins of resection and may respond to radiation with different efficacy, the selected early nonsquamous cell carcinoma may be resected by cricotracheal resection if the correct conditions exist. Perhaps best suited for cricotracheal resection is the chondroma or chondrosarcoma, the most common laryngeal sarcoma. Because the low-grade form of chondrosarcoma is easily confused with the benign chondroma, the true incidence is difficult to know. Chondrosarcomas arise from the hyaline cartilages of the larynx, the most common arise from the cricoid, especially the posterior lamina (70%), followed by the thyroid cartilage (20%), and the arytenoids (10%).Endoscopically, chondrosarcomas of the posterior cricoid lamina tend to grow into the airway, causing obstruction, and rarely, they extend beyond the confines of the perichondrium. As a consequence of the unresponsiveness of low-grade chondrosarcomas to radiation therapy and their confined growth patterns, cricotracheal resection with voice preservation can be accomplished.7This often occurs after multiple endoscopic resections have failed to ameliorate the recurring airway obstruction. Paragangliomas and granular cell tumors of the subglottis are also amenable to cricotracheal resection.

Laryngotracheal invasion by thyroid carcinoma has an incidence of 7%.Invasion of the thyroid and cricoid cartilages occurs through direct extension and represents an important cause of death from well-differentiated thyroid carcinoma. Controversy exists over the treatment of locally invasive thyroid carcinoma. "Shaving" the tumor from the larynx and trachea, followed by treatment with 131I, produces good long-term control of the disease, but this technique is only effective if no gross residual tumor is left behind.It is our practice to resect all tumors and reconstruct the airway.

PRINCIPLES OF STENOSIS TREATMENT

Subglottic and superior tracheal stenoses remain the most common indications for cricotracheal resection, and the principles of this technique are easily applied to surgical resection of the rare amenable neoplasm. Mechanical ventilation from endotracheal intubation remains the most common etiology of laryngeal stenosis.10 Mucosal injury by either the tube or the balloon cuff results in either ischemia from pressure or mucosal tears from movement or placement of the tube. These iatrogenic events can lead to mucosal ulceration, perichondritis, chondritis, and finally, cartilage necrosis.11 The injury can occur at the glottic, subglottic, or tracheal levels and is largely preventable by early tracheotomy and aggressive adjunctive management, such as antibiotics and proton pump inhibitors. Laryngotracheal stenosis is also caused by autoimmune diseases, infection, and posttracheotomy and idiopathic causes. The incidence of subglottic stenosis in patients with Wegener's granulomatosis 16–20% of patients.12 We have treated more than 60 patients with subglottic stenosis caused by Wegener's granulomatosis. In our own practice, we find that endoscopic treatment of the stenosis, including direct injection of steroid and balloon dilation has prevented the necessity of tracheotomy or open airway reconstruction in all patients with Wegener's granulomatosis.13 In previously treated patients, especially in those who have undergone multiple endoscopic laser excisions, we have had to resort to open laryngotracheal reconstruction.

Tracheal and subglottic damage is often due to tracheotomy tube injuries. Inappropriately high tracheotomies, migration of the tube superiorly, and suprastomal granulation tissue are common causes of failure to decannulate patients after tracheotomy.14 The cause of the superior migration is unknown but may be due to movement from swallowing or external neckties that pull the tube superiorly. These patients often are amenable to cricotracheal resection but are challenged by extensive damage of the trachea and cricoid from chronic infection caused by microbial colonization of the tracheotomy tube, in addition to the concurrent disease that necessitated the tracheotomy in the first place. Contraindications in our own practice for cricotracheal resection for tracheotomy removal include poorly controlled diabetes, systemic steroid therapy, likely need for intubation in the near future, obstructive sleep apnea, and concomitant pulmonary disease. Similarly, poorly controlled diabetes, systemic steroid therapy, and severe pulmonary disease are contraindications to cricotracheal resection for neoplasms of the subglottis, and nonsurgical treatments such as radiation therapy, chemotherapy, and palliative therapy are best suited to patients with significant comorbidities.

PREOPERATIVE ASSESSMENT

Office assessment of the patient includes flexible nasal fiberoptic endoscopy to exclude glottic involvement, vocal fold fixation and posterior commissural interarytenoid stenosis, and impending airway compromise. Fine-cut CT scan determines cartilage invasion and extralaryngeal spread, as well as cervical lymphadenopathy. Three-dimensional reconstruction and "fly through" radiologic endoscopy can further define the pathologic process. It is our practice to use full-body CT/PET to exclude distant disease. Combined endoscopy under general anesthesia including direct laryngoscopy with biopsy, bronchoscopy, and esophagoscopy permit tissue diagnosis, debulking, determination of the inferior extent of the tumor, and exclusion of esophageal spread posteriorly. Patients should be warned that their voice will be hoarse for some period postoperatively and that the quality of their voice may differ permanently with a decrease of fundamental frequency of approximately 10 Hz.

TECHNIQUE

Figure 55-1 demonstrates the common technique of cricotracheal resection for circumferential subglottic stenosis. This technique is described not only for use by surgeons wishing to resect stenoses but also for those wishing to excise tumors of the subglottis, as demonstrated in Fig. 55-2. In most cases of subglottic tumor resection, the mucosa and submucosa overlying the posterior plate of the cricoid need to be resected. In some amenable tumors, partial vertical height of the cricoid must be resected to obtain suitable margins, preserving enough posterior cricoid cartilage inferiorly and between the arytenoids to preserve arytenoid stability. If the mucosa is resected up to the interarytenoid area, or if a limited margin exists inferior to the true vocal fold, laterally hindering normal vocal fold movement, a laryngofissure is created not only to permit adequate exposure but also to incorporate the use of a stenting T-tube around which healing occurs, preventing postoperative glottic stenosis (Fig. 55-3).

Figure 55-1.

 

A. Circumferential stenosis of the subglottis and superior trachea. Dashed lines represent the external extent of resection. A lateral transection through the cricoid lamina allows removal of the anterior cricoid arch while preserving the posterior cricoid lamina, thereby protecting the recurrent laryngeal nerves. A posterior membranous tracheal wall flap is formed distally. B. The superior line of resection is through the cricothyroid membrane, curving inferiorly through the lateral cricoid laminae. The first preserved tracheal ring is shaped into an inverted U for anastomosis directly to the thyroid cartilage. If a longer posterior flap is required for reconstruction, the level of tracheal resection may be dropped by an additional ring. C. The internal line of resection (dotted line) removes the stenosis involving the posterior cricoid lamina. With neoplasms that involve the cricoid, the posterior lamina may be resected, but the posterior perichondrium and a superior horizontal strut of cartilage should be preserved to maintain arytenoid stability and posterior muscular attachments. D. The denuded posterior lamina of the cricoid is covered with the membranous flap from the posterior trachea. The first tracheal ring is shaped to fit the inferior thyroid cartilage resection line. E. 4-0 Vicryl is used internally to close the mucosal defect over the posterior cricoid lamina. 3-0 Vicryl suture is used to anastomose the tracheal ring to the thyroid and cricoid cartilages and to anchor the base of the membranous flap to the posterior cricoid cartilage, taking care not to injure the recurrent laryngeal nerves. All knots are tied outside the lumen. F. The superior trachea is anastomosed to the thyroid cartilage with 3-0 Vicryl sutures. The most superior tracheal ring has been formed into an inverted U for best fit into the laryngeal defect. Laterally, the cricoid is approximated to the second tracheal ring to minimize the tension on the first preserved tracheal ring.

 

Figure 55-2.

 

A. An endolaryngeal tumor occupies the posterior subglottis. The anterior cricoid is separated from the thyroid cartilage in a similar manner as in cricotracheal resection for stenosis. The inferior tracheal resection is performed at a level that obtains a negative margin on the tumor. Lastly, the superior tracheal rings and cricoid arch are divided in the midline for optimal tumor visualization. B. Superior and inferior margins are obtained on the tumor. If the posterior cricoid lamina is involved, the cartilage may be resected, but the posterior perichondrium and a strut of cartilage superiorly upon which the arytenoids articulate must be preserved for stability. Additional tracheal rings may be resected to elongate the posterior tracheal flap. C. Reconstruction occurs in an identical manner as in stenosis treatment. The denuded posterior cricoid cartilage is covered by the posterior tracheal flap and approximated to the remaining superior mucosa. The first tracheal ring fits like a prow of a ship into the defect of the anterior cricoid arch.

 

Figure 55-3.

 

A. Negative mucosal margins are obtained, with optimal visualization achieved via the laryngofissure. Despite the tumor being superficial, partial thickness of the cricoid cartilage is drilled for an additional deep margin. As much of the interarytenoid mucosa is preserved as possible to maintain arytenoid mobility. B. The trachea is advanced into the defect, with the posterior membranous flap approximated directly inferior to the true vocal folds with interrupted 4-0 Vicryl. Less violation of the interarytenoid mucosa is desirable, although postoperative stenting assists in decreasing posterior glottic stenosis. C. The temporary T-tube has been placed through a separate tracheotomy two rings inferior to the anastomosis. The superior limb ends superior to the true vocal folds, whereas the inferior limb is short. Other than closure of the laryngofissure, the remainder of the anastomosis is performed in the same manner as in previously described procedures.

Stenosis Resection

Figure 55-1 demonstrates the common appearance of circumferential subglottic stenosis with involvement of the upper tracheal rings. Not only is the anterior subglottis narrowed, but also the posterior thickening impedes airway patency. Resection of such lesions is begun with induction of anesthesia by transoral intubation with a small-caliber endotracheal tube, often of an extended length to permit later entrance into the trachea without violating the balloon cuff. If the stenosis is of such caliber that dilation must take place before intubation, jet ventilation is used temporarily during the dilation, which is minimal, to avoid causing too much edema. A previously existing tracheotomy tube can be used for induction but is changed immediately to translaryngeal intubation such that the tracheostomy tube does not crowd the operative field. After intubation, the head is extended, and a transverse incision is made from sternocleidomastoid to sternocleidomastoid superior to the manubrium. The skin flaps are raised subplatysmally superiorly to the hyoid bone and inferiorly to the clavicles. The strap muscles are separated, and the thyroid gland is divided at the isthmus. Neither suprahyoid nor thyrohyoid release maneuvers are routinely used. The trachea is dissected in a pretracheal plane, very close to the cartilaginous rings to avoid damaging the recurrent laryngeal nerves, which we do not identify routinely. The trachea is dissected down to the carina to produce the mobility for future anastomosis, and care is taken to avoid dividing its lateral blood supply.

The cricothyroid muscle is elevated laterally to permit lateral division of the cricoid laminae. The proximal line of resection transects the cricothyroid membrane just inferior to thyroid cartilage and bevels laterally through the lateral laminae of the cricoid cartilage, usually more than halfway to a midlateral line. We then make a posterior cut at the inferior level of the cricoid cartilage, which may not resect the full extent of the posterior stenosis within the cricoid lamina. The stenosis within the cricoid then is resected off the posterior lamina once it is fully visualized with direct vision through the transected airway. A transverse cut against the posterior plate of the cricoid cartilage inferior to the vocal cords and arytenoid cartilages is made, leaving the denuded posterior plate of the cartilage intact. Removal of a portion of the posterior cartilaginous plate is sometimes necessary but risks injury to the recurrent laryngeal nerves. Preservation of at least the posterior perichondrium is required, and care must be used to avoid disrupting the cricothyroid joints.

The distal level of resection was determined earlier by endoscopic visualization. If the inferior border of the stenosis or tumor is in question, the initial transection always should be made slightly more superiorly because repeat resection more inferiorly is always possible. The first preserved ring is beveled backward from a high point in the anterior midline to the lower margin of that ring, creating an inverted U, and care is taken not to fracture this ring. At this point, a posterior membranous wall flap is formed to fit over the exposed posterior plate of the cricoid cartilage. The length of flap is determined by the amount of exposed posterior lamina. If needed, an additional anterior tracheal ring may be sacrificed to lengthen this posterior flap.

The shoulder roll then is removed and the field made orderly to prepare for closure. Endotracheal intubation is temporarily switched to cross-table ventilation to permit optimal access to the posterior wall closure. Four 3-0 Vicryl sutures are placed between the inferior margin of the posterior plate of cricoid cartilage to the base of the distal posterior tracheal flap. These sutures are clamped to the drapes such that they can be tied later in the order of the most anteromedial suture first, lateral suture second, and posteromedial suture last. Next, 4-0 Vicryl sutures approximate the tip of the posterior membranous wall flap of the trachea to the distal laryngeal mucosal line of resection within the cricoid cartilage. These sutures are placed from within the larynx, but the knots are arranged to lie outside the lumen and are clamped over the patient's head temporarily so as to avoid confusion with the external anastomotic sutures. Lastly, 3-0 Vicryl is used to complete the anastomotic closure, starting through the remnant of lateral cricoid cartilage to the second and third tracheal rings, followed by the thyroid cartilage to the first tracheal inverted-U ring. Tying of sutures begins after the patient is reintubated transorally and starts with the endolaryngeal 4-0 sutures, continues with the anteromedial sutures, and progresses laterally and posteriorly to the posterior midline. Strap muscles can be approximated over the anastomotic suture line, adding an additional layer of closure. Nonsuction drains are placed, the head is kept in a flexed position, and the patient is extubated immediately.

Tumor Resection

With tumors that occupy the laryngeal-tracheal junction, a resection similar to the type used to remove airway stenoses is employed. Benign tumors are removed with a minimal margin of normal tissue, whereas the rare malignancy confined to the endolaryngeal or endotracheal surface is removed with a margin depending on the aggressiveness of the tumor. Preoperative imaging and initial endoscopy are used to determine the superior and inferior extents of the tumor and to rule out extralaryngeal and extratracheal extension.

The extent of the skin incision depends on the necessity of concurrent lymphadenectomy, which is performed before addressing the primary tumor. The larynx and trachea are exposed in an identical manner to the stenosis resection. Again, the superoanterior resection is made through the cricotracheal membrane to remove the anterior cricoid arch, curving laterally through the lateral cricoid laminae. An inferior incision then is made at the tracheal ring, which permits the tumor to be resected with a negative margin. At this point, a midline vertical incision is made to open the cricoid ring, and the upper tracheal rings are marked for resection. This allows optimal visualization before the posterior cuts are made. While anterior tumors may be violated by this anterior midline incision, this does not preclude excellent tumor excision, albeit not adhering to the "no touch" tumor technique. In posteriorly placed tumors, the posterosuperior cut is made above the tumor site, with removal of underlying cricoid cartilage if the tumor requires. Again, the most common technique is drilling down the partial thickness of the posterior cricoid plate, although cricoarytenoid stability only depends on preservation of the posterior perichondrium and a superior strut of cartilage on which the arytenoid articulates. The location of the inferior cut depends on two factors: It must be sufficiently inferior to allow for a negative tumor margin, and it should be made superiorly enough to form an inferiorly based posterior tracheal wall flap. If there is insufficient posterior tracheal wall to permit both these requirements, an additional anterior tracheal ring should be resected to generate more available posterior wall. Minimal posterior tracheal flap is needed for the repair of anterior tumor resections. The rest of the anastomosis and closure is identical to the stenosis repair detailed previously.

Superior Cricotracheal Tumor Resection

In patients with high subglottic tumor spread bordering on the undersurface of the true vocal fold or the interarytenoid area, the surgeon must be realistic in determining whether a laryngeal preservation operation is possible. Preoperative vocal fold fixation implies thyroarytenoid muscle involvement, cricoarytenoid joint fixation, or recurrent laryngeal nerve involvement, all contraindications to cricotracheal resection with laryngeal preservation. Nonetheless, cricoid tumors often will encroach either on the undersurface of the true vocal fold or the interarytenoid space, and surgical judgment must be used in determining the suitability of candidates for laryngeal preservation surgery. If the tumor is indeed judged to be favorable for resection, three modifications are made to the standard cricotracheal tumor resection technique. The first is a midline laryngofissure. This permits maximal tumor visualization, which is critical in such a location in which adequate margins are needed on the tumor, but postoperative laryngeal function depends on preservation of every millimeter of normal laryngeal structure. The second modification is the formation of a longer distal posterior tracheal wall flap to permit total resurfacing of the denuded posterior cricoid, even between the two arytenoid cartilages if required. This may necessitate resection of additional normal tracheal rings to generate sufficient length to reline the cricoid posterior wall. The last modification is placement of a temporary T-tube through the glottis for the initial 4- to 6-week postoperative period. The tube is placed with the proximal limb lying approximately 0.5–1.0 cm superior to the glottic level. The inferior limb can be quite short (2 cm). The horizontal limb is placed through a tracheotomy two rings inferior to the anastomotic line. Strap muscles are approximated to the area around the T-tube during closure to reinforce the airtight seal to prevent postoperative air leaks into the neck.

POSTOPERATIVE CARE

Nonsuction drains and a neck wrap are used to prevent postoperative fluid collections. In cases of cricotracheal resection without T-tube placement, patients are extubated immediately postoperatively. For patients with edema, one to two doses of steroid have been used to decrease swelling without significantly impairing anastomotic healing. Vocal cord function is assessed, and the neck is kept in a flexed position (pillows and strict nursing precautions usually suffice) for 2 weeks postoperatively. Patients are fed via nasogastric tube for 1–2 weeks, after which a swallow study is performed before starting an oral diet. Humidified air is used to decrease the risk of mucus plugs forming at the anastomotic suture line. If a laryngofissure and T-tube are used, the T-tube is removed under general anesthesia, during which time the airway is assessed endoscopically for patency and vocal cord motion, and any granulation tissue is removed. Although other authors are more aggressive with oral feeding, we do not start an oral diet until the T-tube has been removed.

PROCEDURE-SPECIFIC COMPLICATIONS

Complications generally involve issues of either stenosis, failure of the anastomosis to heal, and vocal fold dysfunction. When stenosis at the anastomosis occurs, conservative treatment with dilation often can correct the obstruction. Repeat resection and anastomosis may be required if one suspects that a technical error occurred during the initial operation. Posterior glottic stenosis either from scarring, from high resection, or from vocal fold immobility is a difficult problem to overcome. Often a laser cordotomy of the less mobile vocal fold will augment the airway sufficiently to permit unlabored breathing, albeit at the cost of good glottic competence, resulting in decreased voice quality. The most emergent and concerning complication is that of a nonhealing anastomosis. Patients with diabetes and those on steroids are the most susceptible to this complication, which, owing to the proximity of the great vessels, can be life-threatening. Often the most prudent course of action is to retreat, placing a T-tube and giving antibiotics while the wound progresses, after which the airway is reassessed to determine if a tracheotomy-free airway is possible once the healing process is finished.

FUTURE CONSIDERATIONS

In 1998, the senior author (Marshall Strome) led a team in performing the first successful total laryngeal transplantation.15 This operation was done for complete laryngeal stenosis resulting from trauma and included not only the larynx and pharynx but also the thyroid gland, parathyroid glands, and upper five rings of the trachea. Eleven years later, the patient's voice and swallowing remain excellent with minimal immunosuppression.16Although transplantation in the setting of cancer remains a barrier as a consequence of malignant potentiation from immunosuppression, more recent generations of immunosuppressives, such as everolimus, not only have demonstrated a lack of potentiation but also in our own animal studies have demonstrated tumor regression.17 Reconstruction with like-autologous tissue in the setting of malignancy is the latest frontier for maximizing function after tumor ablation.

SUMMARY

Cricotracheal resection for the treatment of airway stenosis is a highly effective and successful technique that can be used in the excision of neoplasms. While squamous cell carcinoma is by far the most common malignancy of the upper aerodigestive tract, it is rarely suitable for resection with the cricotracheal resection method. Other malignancies and several benign tumors of the subglottis and upper trachea are especially amenable to resection via this method, and excellent voice, airway, and swallowing results can be achieved. Allogenic transplantation is on the horizon of new technologies allowing complete upper aerodigestive tract reconstruction in the face of radical tumor ablation.

CASE HISTORY

B.J. is a 62-year-old woman who presented with a 1-year history of progressive dyspnea. A CT scan revealed a right-sided thyroid goiter, and she was referred for removal of the mass. On office examination, the patient was not notably hoarse but did demonstrate moderate biphasic stridor. Further review of the CT scan demonstrated a fullness to the right subglottis without destruction of the underlying cricoid cartilage (Fig. 55-4A ). Flexible fiberoptic nasal laryngoscopy demonstrated both deviation of the laryngotracheal complex to the left and a narrowed subglottic airway with a lesion on the posterior right subglottis (Fig. 55-4B ). Operative management began with direct laryngoscopy and biopsy of the subglottic mass, revealing adenoid cystic carcinoma. A transcervical right thyroid goiter biopsy then was performed, demonstrating a benign thyroid goiter on frozen section.

Figure 55-4.

 
 

A. A 62-year-old woman was referred for stridor. Initial presentation suggested a large right-sided substernal goiter with tracheal deviation. Further examination of the CT scan demonstrates a mucosal lesion of the right subglottis. The underlying cricoid cartilage is intact. B. Office endoscopy reveals a mucosal fullness to the right posterior cricoid region. Biopsy under general anesthesia demonstrates adenoid cystic carcinoma.

Since the lesion was present high on the undersurface of the right true vocal fold and posterior cricoid lamina, a cricotracheal resection was accomplished with an accompanying laryngofissure. Partial thickness of the inferior cricoid cartilage was drilled down for additional deep margin. Division of the thyroid cartilage was performed not only for optimal visualization of the tumor to obtain negative margins but also to allow reconstruction with a posteriorly based tracheal flap and placement of a temporary T-tube (see Fig. 55-3). One tracheal ring was resected to obtain total tumor removal and to form a posterior tracheal flap. Level VI (mediastinal) lymph nodes were resected and demonstrated no regional metastases. The patient was allowed to take an oral diet 2 weeks postoperatively without significant dysphagia despite the end of the superior limb of the T-tube lying above the glottic aperture. She received 7200 cGy of radiation to the area starting 4 weeks postoperatively. The T-tube was removed at the end of radiation, and the patient demonstrated a good voice and excellent airway. She remains tumor-free locally 4 years later with regular imaging and fiberoptic examination to check for local recurrence but she has developed asymptomatic lung metastases in the interim.

EDITOR'S COMMENT

Tracheolaryngeal resection usually requires collaboration between otolaryngology and thoracic surgery. One major objective is to protect the recurrent laryngeal nerves from injury. The cricoid can be substantially calcified and power instruments may be required for precise resection.

–RB

REFERENCES

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2. Greene F, Page D, Fleming I: AJCC Cancer Staging Manual. New York, Springer-Verlag, 2002.

3. Kirschner J: Growth and spread of laryngeal cancer as related to partial laryngectomy. In Bryce DP, Albert PW (eds): Workshops from the Centennial Conference on Laryngeal Cancer. East Norwalk, CT, Appleton-Century-Crofts, 1976.

4. Stell B, Tobin K: The behavior of cancer affecting the subglottic space. In Bryce DP, Albert PW (eds): Workshops from the Centennial Conference on Laryngeal Cancer. East Norwalk, CT, Appleton-Century-Crofts, 1976.

5. Olofsson J: Specific features of laryngeal carcinoma involving the anterior commissure and the subglottic region. In Bryce DP, Albert PW (eds): Workshops from the Centennial Conference on Laryngeal Cancer. East Norwalk, CT, Appleton-Century-Crofts, 1976.

6. Moisa I, Mahadevia P, Silver C: Unusual tumors of the larynx. In Silver CE (ed): Laryngeal Cancer. New York, Thieme Medical, 1991.

7. Bogdan CJ, Maniglia AJ, Eliachar I, Katz RL: Chondrosarcoma of the larynx: Challenges in diagnosis and management. Head Neck 16:127–34, 1994. [PubMed: 8021131]

8. Batsakis JG: Laryngeal involvement by thyroid disease. Ann Otol Rhinol Laryngol 96:718–9, 1987. [PubMed: 3688766]

9. Cody HS 3d, Shah JP: Locally invasive, well-differentiated thyroid cancer: 22 years' experience at Memorial Sloan-Kettering Cancer Center. Am J Surg 142:480–3, 1981. [PubMed: 7283051]

10. Kastanos N, Estopa Miro R, Marin Perez A, et al: Laryngotracheal injury due to endotracheal intubation: Incidence, evolution, and predisposing factors. A prospective long-term study. Crit Care Med 11:362–7, 1983. [PubMed: 6839788]

11. Courey MS: Airway obstruction: The problem and its causes. Otolaryngol Clin North Am 28:673–84, 1995. [PubMed: 7478630]

12. Langford CA, Sneller MC, Hallahan CW, et al: Clinical features and therapeutic management of subglottic stenosis in patients with Wegener's granulomatosis. Arthritis Rheum 39:1754–60, 1996. [PubMed: 8843868]

13. Hoffman GS, Thomas-Golbanov CK, Chan J, et al: Treatment of subglottic stenosis, due to Wegener's granulomatosis, with intralesional corticosteroids and dilation. J Rheumatol 30:1017–21, 2003. [PubMed: 12734898]

14. Lorenz RR: Adult laryngotracheal stenosis: Etiology and surgical management. Curr Opin Otolaryngol Head Neck Surg 11:467–72, 2003. [PubMed: 14631181]

15. Strome M, Stein J, Esclamado R, et al: Laryngeal transplantation and 40-month follow-up. N Engl J Med 344:1676–9, 2001. [PubMed: 11386266]

16. Lorenz RR, Hicks DM, Shields RW Jr, et al: Laryngeal nerve function after total laryngeal transplantation. Otolaryngol Head Neck Surg 131:1016–8, 2004. [PubMed: 15577810]

17. Knott PD, Tamai H, Strome M, Van Lente F, Shu S. RAD inhibition of sarcoma growth: implications for laryngeal transplantation. Am J Otolaryngol 28:375–78, 2007. [PubMed: 17980767]



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