Total Glossectomy with Preservation of the Larynx

A 52 year old patient had extensive squamous cell carcinoma involving the base of the tongue. The total glossectomy defect was devastating to both speech and swallow. Traditional treatment would include removal of the larynx to avoid problems with aspiration, but in selected cases this is unnecessary and laryngeal preservation should be considered. The basic reconstructive challenge was to replace the bulk of the diseased tongue with flap tissue to ensure contact with the hard palate. Duplicat-

Figure 18 Pectoralis flap used for tongue replacement in a patient who had undergone a total glossectomy and laryngectomy. Note how the neotongue lacks sufficient bulk and height to contact the hard palate. This is due to significant inferior migration and atrophy of the flap.

ing the intricate movement of the native tongue and restoring the patient to near-normal function was unrealistic. The best that can be hoped for is restoration of some degree of intelligible speech and minimal aspiration during a conditioned swallow. Some patients are able to rid themselves of their gastric tubes but advancement to a fully normal diet is seldom attained.

The solution was to reconstruct the total glossectomy defect with a myocuta-neous free flap (Fig. 17). Articulation and mastication would be severely compromised independent of the reconstruction technique. With intensive swallow and speech therapy, motivated patients can learn an effective method to initiate deglutition.

This is obviously a devastating defect and the primary goal is to prevent the wholesale delivery of the food bolus to the larynx or pharynx. To achieve this, bulk must be present, and the rule is to ensure contact between the neotongue and the hard palate. This may also improve articulation with the gross movements of the neoton-gue through its connections to the functioning mandible. The requirement for a sen-sate flap is not well accepted. However, in cases of laryngeal preservation it may be beneficial to assist in gross localization of the food bolus within the oral cavity. Using a sensate flap in the hope of triggering a normal swallow reflex is too optimistic at this point. Laryngeal preservation should be considered on an individual basis. All of these patients will aspirate to a degree; therefore several factors must be involved in the decision including the patient's physiological age, pulmonary reserve, and motivation. As mentioned previously, adjunctive procedures should be considered such as a tubed laryngoplasty, laryngeal suspension, or near-total laryngectomy. |

Regional flaps tend to displace inferiorly and atrophy over time, pulling away from the hard palate (Fig. 18). Despite these problems, however, in patients with coin- -g1

cident total laryngectomies a regional flap will be used because contact with the hard palate is not critical. Free musculocutaneous flaps such as the rectus abdominis and the latissimus dorsi may be sutured directly to the mandible to support the position of the overlying fat and skin. The rectus abdominis also has tendinous inscriptions that may be used with supporting sutures to counteract the weight of the overlying muscle |

and fat. The fat in these flaps will not atrophy like muscle. It is possible to reinnervate the latissimus dorsi muscle with the hypoglossal nerve stump and attain movement at the base of tongue. This may improve speech and swallow function (17).

Revascularized subcutaneous fat remains essentially unchanged after transfer; therefore, in addition to the free musculocutaneous flaps, sensate flaps with abundant subcutaneous fat would be appropriate. The lateral thigh and lateral arm free flaps fulfill these requirements. The lateral arm flap (introduced by Song in 1982), based on the posterior radial collateral branch of the profunda brachii artery, can be made sensate via its posterior cutaneous nerve. The lateral thigh flap (introduced by Baek in 1983), based on the third perforator of the profunda femoris artery, can be made sensate via its lateral femoral cutaneous nerve. Suspension and maintenance of the position of these flaps in the oral cavity are somewhat more difficult compared to the myocutaneous flaps.

PHARYNGEAL RECONSTRUCTION

When discussing pharyngeal defects it is helpful to define the problem more precisely. The great majority of these defects are created after extirpative cancer surgery. The tissues have commonly been exposed to radical radiation therapy and salivary contamination. It is an oversimplification to consider all pharyngectomy defects together. The main variables to consider with regard to the defect are the anatomical location of the defect within the pharynx, the amount of pharynx that has been resected, and the presence or absence of an intact larynx.

The pharynx is organized anatomically into the nasopharynx, oropharynx, and hypopharynx. Nasopharyngeal extirpation and reconstruction fall more appropriately within the purview of cranial base reconstruction and will not be considered here. The oropharynx includes the soft palate, posterior oropharyngeal mucosa to the level of the hyoid bone, the tonsillar fossae, and the base of the tongue. The hypopharynx includes the piriforms, postcricoid region including the cricopharynx, and the posterior and lateral pharyngeal walls from the hyoid bone to cricopharyn-geus. The cervical esophagus begins below the cricopharyngeus and ends at the sternal notch.

Modern reconstruction of the pharynx and cervical esophagus is usually limited simply to providing coverage that can be made sensate. Flaps cannot match the missing tissue exactly but are often successful in duplicating the form of what is missing. The oropharynx and hypopharynx are highly developed and complex anatomical areas that function to prevent aspiration and to allow the food bolus to pass unobstructed to the esophagus. Reconstruction of these areas with inanimate and insensate flap tissue can be inadequate to prevent disabling aspiration. Although form can be provided, function does not necessarily follow. This is illustrated in patients with multiple cranial nerve deficits after skull base surgery who experience crippling aspiration and dysphagia. The sensorimotor deficits caused by dysfunction of cranial nerves 9 and 10 predispose the patient to dysphagia and aspiration despite possessing a perfectly formed pharynx and larynx. For a patient with a significant surgical defect involving the pharynx, even dynamic or sensate flap tissue will lack the coordinated movement required for a normal swallow. In fact, attempts to reform vital areas of the pharynx by simple replacement with various flaps may be futile, and partial or complete obliteration of the affected portion may be more effec- @

tive in restoring a successful swallow. This is often the case in defects involving the soft palate and piriform sinuses. Intractable aspiration may be inevitable after large or critical areas of the pharynx are resected. In these cases, a total laryngectomy should be planned coincidentally with the pharyngeal resection even if the larynx is uninvolved with tumor.

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