Clinical Research Of Reparation Of Laryngeal Defect And Reconstruction Of Laryngeal Function After Partial Laryngectomy

Part I Reparation of Laryngeal Defect and Reconstruction of Laryngeal FunctionObjective To analyze the recovery status of laryngeal function after partial laryngectomy and repairing laryngeal defects, and to discuss the selective application of the reconstruction of laryngeal function.Methods1 Material Retrospective review of complete collected data from 92 cases with malignant tunours of larynx diagnosed by pathology from September 1990 to September 2006, who were executed the partial laryngectomy for the first time and reconstructed functionally. The population included 89 male and 3 female patients whose ages ranged between 35 and 77 years with a mean age of 58.59±10.68 years. In this group, 90 cases were diagnosed for squamous cell carcinoma, 1 for mucoepidermoid carcinoma and 1 for leiomyosarcoma; 3 cases were sorted to Tis, 32 to T1, 39 to T2, 17 to T3 and 1 to T4; 86 cases were sorted to NO, 4 to N1 and 2 to N2; all cases were sorted to M0; 81 cases were classified for glottis carcinoma, 8 for supraglottic carcinoma and 3 for subglottic carcinoma. 2 Method2.1 Type of partial laryngectomyAll cases were executed partial laryngectomy by different methods: 12 cases by laryngofisssure-chordectomy, 33 cases by partial vertical hemilaryngectomy, 11 cases by anterial vertical partial laryngectony, 23 cases by extended vertical partial laryngectony and 13 cases by other methods.2.2 Reparation and reconstrunctionAccording to procedure, the excision of the lesion and systemic conditions, the main four kinds of repair methods have applied: 38 cases with residual mucosa (A), 13 cases with muscular fascial flap (B), 13 cases with strap muscle flap (C) and 17 cases with cervical skin flap (D).2.3 Data acquisitionThe data on postoperative function of respiration (time of extubation), deglutition (time of nasogastric feeding tube, aspiration), voice and complications, survival (recurrence and metastasis, death) and so on, have be collected by means of postoperative examination, telephone calls, and letters.2.4 Statistical AnalysisAll data was analyzed statistically by SPSS 13.0. The age and the recovery time of the function of respiration and deglutition among four main reparation methods compared with one-way analysis of variance (One-way ANOVA), the effect of phonation among them compared with non-parametric test (Kruskal-Wallis test). Testing standards a=0.05.Results In our series, 81 cases repaired with four main reparation methods were male. There was no statistically significant differences in age among four groups (F=0.603, P=0.615).The total postoperative decanulation rate was 97.8% (87/89). 92.1% of cases were extubated tracheal cannula after a month. There was statistically significant differences in time of extubation among four groups (F=5.465, P=0.002). The extubation rates within two weeks in group A, B and C were 86.8%, 76.9% and 69.2% respectly. The rate in group D was low obviously (47.1%).92.9% (79/85) of cases were removal of nasogastric feeding tube in 2 to 14 days, they could eat and drink without choking, of 60.0% recovered after one week. There was statistically significant differences in function of deglutition among four groups (F=3.227, P=0.027). Swallow function in group A was recovered well after two weeks, of 71.4% in in group A, 61.5% in group B recovered one weeks later, but slowly in group C and D, only 30.8% and 35.3%.The whole cases could give off sound postoperatively, 41 cases of which phonated well, 38 moderately and 13 poorly. There was no statistically significant differences in function of deglutition among four groups (x~2=1.025, P=0.795). But phonation effect of group A and C were better. The rate of the good and the moderate was 92.3% (12/13) in group A and 92.1% (35/38) in group C.The 3 and 5 years survival rates were 93.2% (69/74) and 81.8% (45/55) respectively. The overall local recurrent cases were 9,2 cases were recurrent in one year. Conclusion Choosing the appropriate type on partial laryngectomy should be based on the location of the tumor and the extent of the features. The normal tissue should be retained as far as possible to repair the laryngeal defects under guaranteeing the safety margin. The cases repaired with residual mucosa etc. can get better laryngeal function. The cases with large defects or not be repaired with residual mucosa may also get better breathing, swallowing and phonation by selecting the reasonable repair techniques. Part II Reconstruction of Glottis for the Glottic Carcinoma after Partial LaryngectomyObjective To discuss the effect of application of repair methods and reconstruction techniques for the glottic carcinoma after partial laryngectomy.Methods1 Material Retrospective review of complete collected data from 37 cases classified glottic carcinoma diagnosed by pathology from September 1990 to September 2006, who were executed the partial laryngectomy for the first time, and whose defects were repaired. All patients were men. Ages ranged between 43 and 76 years, with a mean age of 61.05±9.03 years. In this group, 11 cases were classified for first-stage, 18 for second-stage. 8 for third-stage.2 Method2.1 Type of partial laryngectomy and reparation methodIn this group, 3 cases were executed laryngofisssure-chordectomy, 12 cases partial vertical hemilaryngectomy, 4 cases anterial vertical partial laryngectony and 18 cases extended vertical partial laryngectony. The laryngeal defects postoperative were repaired with muscular fascial flap (10), cases with strap muscle flap (12) and cervical skin flap (15), and new glottises were reconstructed.2.2 Surgical techniqueFirstly, different type of partial laryngectomy was executed according to the extent of disease. Thyroid cartilage and the normal residual mucosa of the larynx should be retained as much as possible. After resection of lesions, on the cutting edge of morbid thyroid cartilage side, equivalent position of virgin glottis, made a "U"-shaped cartilage window, whose size should be suitable for the transplanted tissue to pass through. According the scope of excision, the long strip pedicled muscular fasciae, muscle flap or cervical skin flap with suitable thickness and size was cut, and led into the larynx through the thyroid cartilage U-shaped window. The remote of transplanted tissue was sutured with the soft tissue on vocal process of cricoarytenoid joint, its superior and inferior margin sutured with residual mucosa and deep tissue on cutting margin. Which made surgical wound covered completely, the new vocal cord repaired and the new glottis reconstructed. Then reested both sides of the opened thyroid cartilage accurately, interrupted sutured the membrane of thyroid cartilage.2.3 Data acquisitionBy means of postoperative examination, telephone calls, and letters, the shape and the movement of transplanted tissues and new glottis after reconstruction have be observed and understood, the data on postoperative function of voice, respiration, deglutition and complications, survival and so on, have be collected.2.4 Statistical AnalysisAll data was analyzed statistically by SPSS13.0. The effect of different repair method, modus operandi and TNM-stage compared with non-parametric test (Kruskal-Wallis test). Testing standards a=0.05.Results In our series, the achievement ratio of phonation was 100%. 15 cases voiced well, 16 moderately and 6 poorly. There was no statistically significant differences in effect of phonation among different repair methods and types of partial laryngectomy (x~2=1.371/5.115, P=0.504/0.164), but there was among different preoperative TNM-stages (x~2=13.134, P=0.001). The higher the TNM-stage stage, the worse the effect of phonation. The new vocal cord was swelling, white and poor blood supply about 10 days postoperative. 2 to 3 months later, the new laryngeal cavity after reconstruction was triangular, and the transplanted tissue was rosy, a good blood supply and a certain tension, like a vocal cord paralysis in centric position through indirect laryngoscopy or fiberoptic laryngoscope inspection. The contralateral vocal cord moved to the front of the new and close to each other when phonation.Conclusion After resection of the tumor for glottic carcinoma, the eligible repair materials should be choosen to reconstruct the glottis according to different circumstances, as long as the methods are appropriate, voiced functions postoperative recover better. After recnstructing new glottis with suitable size transplanted tissue selected through thyroid cartilage fenestration, the new vocal cord have a certain tension and stability, which will be conducive to rebuilding a new triangle laryngeal cavity with a physical shape and improving the quality of voice. Part III Reservation and Reconstruction of Pyriform Sinus for T2,T3 Laryngeal Carcinoma in Partial LaryngectomyObjective To discuss the application of reservation and reconstruction techniques of pyriform sinus in partial laryngectomyMethods1 Material Retrospective review of complete collected data from 56 cases with T2,T3 laryngeal carcinoma diagnosed by pathology from September 1990 to September 2006 in Zhujiang Hospital, who were executed the partial laryngectomy for the first time. The population included 54 male and 2 female patients whose ages ranged between 35 and 77 years with a mean age of 59.61±9.26 years. In this group, 56 cases were sorted to T2, 17 to T3; 46 cases were classified for glottis carcinoma, 7 for supraglottic carcinoma and 3 for subglottic carcinoma.2 Method2.1 Type of partial laryngectomy and the surgical techniqueVariant types of partial laryngectomy were adopted according to the tumor's position, type and extent in all 56 cases. Which included 22 cases executed partial vertical hemilaryngectomy, 7 cases anterial vertical partial laryngectony, 19 cases extended vertical partial laryngectony and 8 cases other methods(2 cases glottic partial laryngectomy, 3 cases supraglottic partial laryngectomy, 2 cases subtotal laryngectomy and 1 case horizontal vertical partial laryngectomy).The structure of the priform sinus such as mucosa, aryepiglottic fold, arytenoid cartilage and thyroid cartilage should be retained or reconstructed as far as possible, to keep the shape and symmetry of the pyriform sinus.2.2 Data acquisitionBy means of postoperative examination, telephone calls, and letters, the data about postoperative function of deglutition, respiration, voice and complications, survival and so on, have be collected.2.4 Statistical AnalysisAll data was analyzed statistically by SPSS 13.0. The recovery time of the function of deglutition in different T-stages compared with two-sample t test, in different types of laryngeal carcinomy compared with one-way analysis of variance (One-way ANOVA). Testing standardsα=0.05.Results In this group, all cases recovered well in swallowing function. 91.1% (51/56) of cases were removal of nasogastric feeding tube in 2 to 14 days, they could eat and drink without choking. There was no statistically significant differences in function of deglutition among different T-stages (t=-1.620, P=0.111), but There was among different types of laryngeal carcinoma (F=5.356, P=0.008). The cases of T3 stage recovered slower, better for the cases with glottic and subglottic carcinoma.Conclusion Pyriform sinus plays an important role in maintaining swallowing function. When undergoing partial laryngectomy for the supraglottic, glottic carcinoma and T2, T3 carcinoma, we should fully take into account extent of disease, remove the tumor reasonably, and retain or reconstruct pyriform sinus as far as possible, including its structure such as scoop epiglottis plica, arytenoid cartilage, thyroid cartilage. We should maintain the mucosal integrity, shape and symmetry of pyriform sinus to make cases recover better in swallowing function, and to prevent the occurrence of aspiration.