A group of panelists discussed the intricacies of laryngeal reconstruction after prior radiation and surgery during a session held at the Triological Society Sections Meeting. The speakers covered when to attempt surgery, when to avoid it, and special techniques to use, offering up a slate of expert guidance for these tough cases.
Explore this issue:March 2016
Panel moderator Peak Woo, MD, clinical professor of otolaryngology at Mount Sinai Hospital in New York City, said the challenge of laryngeal reconstruction lies in restoring both form and function to a complex structure. “If one restores only one, then one is lacking,” he said. “If one only restores the form, as in [a] good airway, then you have aphonia. If you only restore the function, as in vibration, then you have laryngeal stenosis.”
He harkened back to a 1985 description, which held that the “ideal method” would involve using tissue that is native to the area, highly viable, convenient for the surgeon, and expendable to the patient (Ann Otol Rhinol Laryngol. 1985;94:437-441).
A Light Touch
Edward Damrose, MD, associate professor of otolaryngology-head and neck surgery at Stanford University in Stanford, California, said that when it comes to late surgical rehabilitation after radiation and surgery, his philosophy is to understand and modulate factors that are unfavorable, to minimize long-term morbidity and preserve function, to be expedient when needed, as in the case of an airway compromise, and to preempt and prevent complications in the first place through the education of his colleagues. And, he added, it’s good to know “when to use a light touch versus an iron fist.”
For instance, in the case of Wegener’s vasculitis with subglottic stenosis, patience and a light touch work well. “Suppressing and resolving inflammation through autoimmune drugs and steroids is key. Our surgical goal at this time should be to maintain luminal patency while the inflammation is resolving,” said Dr. Damrose.
He emphasized that attempts to limit toxicity from radiation, whether with antibiotics, keratinocyte growth factors, the cytoprotective agent amifostine, or intensity-modulated radiation therapy, have not been very effective to date. Reduction in radiation dose is likely key, but until then surgery will probably be a necessity in the management of post-treatment complications. “All of these are generally applied to try to minimize these types of sequelae where we see this horrendous scarring process that results from mucositis,” he said. “And trying to prevent this from happening is a chief goal and a chief focus.” At his center, they are transitioning from cisplatin therapy to cetuximab, reducing radiation doses when possible, and switching to surgical procedures to lower radiation use. Ongoing Eastern Cooperative Oncology Group studies,
Dr. Damrose noted, have identified 55 Gy as an important target dose.
It’s also important to minimize iatrogenic endotracheal and tracheostomy tube injuries, he said. Here, education of colleagues will be crucial. “The bottom line is, base tube size selection on height, not weight, and ensure tubes are adequately advanced, especially in taller patients,” Dr. Damrose said.
Voice and Swallow Rehabilitation
Michael Johns III, MD, director of the University of Southern California Voice Center in Los Angeles, said that when physicians are pondering the course of treatment for voice difficulties, “we’re listening and we’re looking.” Visually, the keys are the size of the gap between the vocal folds and the stiffness of the folds. When listening to a patient, he listens for breathiness. “The breathier the patient is, the more likely we’re going to be able to help them,” he said. Vocal stiffness is hard to manage, he said, but surgeons are able to close glottal gaps, which can improve vocal function significantly.
“Roughness is hard to manage,” he added. “Vocal fold stiffness—we don’t really have a lot of tools for improving that.” So, when a patient’s voice is rough and not very breathy, he is more likely to avoid surgery.
When it comes to trouble swallowing, including loss of sensation, loss of tongue base volume and strength, or reduced pharyngeal squeeze, there are not many good surgical options. Surgery can be more helpful with glottal insufficiency and cricopharyngeal or esophageal stenosis, he added. In cases of dysphagia, Dr. Johns usually will emphasize behavior modification. If things are not very severe, he advised strongly considering the risks and benefits of surgery. If, on a modified barium swallow, you don’t see hyolaryngeal excursion, he said, then dilation probably won’t help.
When assessing an airway patient for surgery, Dr. Johns recommended getting a sense of how easy it would be to obtain operative direct laryngeal exposure in the office, and whether a tracheotomy would be needed. “If those two features are unfavorable, then try to avoid surgery,” he said.
Stenosis Following Radiation
Tools for treating stenosis that occurs after radiation of the larynx include the CO2 laser, bougies and balloons, steroid injections, and the chemotherapy drug mitomycin, said Lucian Sulica, MD, director of the Sean Parker Institute for the Voice at Weill Cornell Medical College in New York City. “I’m sorry to say that none of these things is a game-changer,” he said.
Chronic infection is a common problem, he said, because crusting compromises the mucosa’s resistance to infection. “You can clear this temporarily, but it is constantly there and constantly complicating things,” he added.
A recent study has confirmed that injection augmentation and medialization laryngoplasty are generally safe in the radiated larynx (Otolaryngol Head Neck Surg. 2015;153:582-585); however, there might be more risk when it comes to arytenoid adduction.
Dr. Sulica drew particular attention to the minithyrotomy procedure for scarring, described by Stephen D. Gray, MD, in 1999. It’s a combination of an external neck and laryngoscopic technique in which a submucosal implant is placed through a thyroid cartilage window. For the implant, Dr. Sulica typically uses a generous amount of fat, “more than you think you’ll need,” which is usually readily available. “I think the minithyrotomy is an interesting approach to access the lamina propria, or where the lamina propria would have been in the scarred vocal fold, without an epithelial incision.”
Thomas Collins is a freelance medical writer based in Florida.Multi-Page