Hypopharyngectomy

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The piriform sinuses play a critically important role in a successful swallow. Their main function is to transmit the food bolus safely into the esophagus without laryn-geal penetration or aspiration during the final phase of swallowing. During a normal c swallow, the larynx elevates and the piriform sinuses open widely to accept the food bolus passing it through a relaxed cricopharyngeal conduit. This sequence of events is critical to propel the bolus into the cervical esophagus, since residual or regurgitated food or liquid will spill over the aryepiglottic folds (penetration) and be sucked into the trachea (aspiration) after the swallow is complete and the larynx returns to its normal unprotected position. Anything that disrupts this intricate process will often result in disabling dysphagia and aspiration. Even an adynamic upper esophageal segment (within about 3 cm from the cricopharyngeus) will disrupt this process. Therefore, circumferential reconstruction of the esophagus within 3 cm of the crico-pharyngeus places the patient at significant risk for aspiration. Even relatively minor resection and primary closure of the lateral piriform sinus often result in aspiration difficulties, but these problems can usually be overcome with intensive swallow therapy. Through this, the patient is taught to turn the head toward the affected side to close off (functionally obliterate) the piriform sinus. This directs the bolus to transit the normal side. The success of this maneuver provides insight into how to prevent aspiration in patients with larger piriform defects. It must be stated, however, that the majority of patients undergoing significant partial resection of their piriform sinus will require a coincidental total laryngectomy since disabling (and life-threatening) aspiration will result if the larynx is left intact. Attempting to reconstruct the piriform sinus, even with a thin sensate flap (e.g., radial forearm), is often ineffective in restoring a normal swallow and preventing intractable aspiration. Like soft palate reconstruction, simply recreating the form is inadequate. Obliteration of the affected piriform holds promise by redirecting the food bolus. Still, the patient will be at significant risk for aspiration and must be warned that total laryngectomy may be required if postoperative rehabilitation to prevent aspiration is unsuccessful. Obliteration of the piriform is accomplished by limited recruiting of adjacent pharyngeal

mucosal to allow closure. The piriform is essentially closed as the surrounding mucosa is recruited. A soft tissue flap may be placed over the suture line to further aid in collapsing the sinus. Nevertheless, the success of this operation with regard to the preservation of laryngeal and swallow function is poor. The surgical treatment of defects that extend beyond a single piriform is total laryngopharyngectomy with partial or total pharyngectomy. Coincidental laryngectomy is usually necessary after surgical resection of a piriform sinus neoplasm, especially in older patients, those with pre-existing sensory or pharyngeal motor disturbance, and patients with a history of prior radiation therapy.

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