Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 48
Vertical Partial Laryngectomy
David E. Eibling
The technique of vertical partial laryngectomy (VPL)
was popularized in the United States by Ogura’s group
in the 1970s.1,2 VPL is performed for early glottic carci-
noma and entails the removal of a portion of one or
both vocal cords with or without the anterior commis-
sure, together with the thyroid cartilage as the deep
margin. The resection may be as simple as excision of
one vocal cord or may involve resection of up to three
fourths or fi ve eighths of the glottic larynx. The term
hemilaryngectomy or VPL is generically used to include
removal of one half of the larynx, as well as any one of
the aforementioned variations. The introduction of
transoral endoscopic laser surgery, supracricoid laryn-
gectomy, and improved techniques of radiation therapy,
especially when combined with concomitant chemo-
therapy, has decreased the use of VPL for the treatment
of glottic cancer.
PATIENT SELECTION
VPL is ideally suited for primary treatment of glottic
cancers that are not likely to be satisfactorily managed
with endoscopic laser excision or radiotherapy.3 These
lesions typically include bulky T1 cancer of the true
vocal cord (TVC) involving the anterior commissure or
the vocal process of the arytenoids, cancer of the TVC
with invasion of the vocalis muscle but not the thyroid
cartilage, or T2 cancers that extend above or below the
level of the TVC.4 It should be noted that large tumor
volume correlates with the likelihood of radiation
failure in early-stage vocal cord cancer.5 The procedure
is also appropriate for surgical salvage of selected
patients with persistent carcinoma of the vocal cord
after initial treatment with radiotherapy, for early glottic
cancer in patients who wish to avoid radiotherapy, and
for patients with verrucous carcinoma.
The most commonly performed procedure is a ver-
tical frontolateral partial laryngectomy (Fig. 48-1). Many
surgeons now perform supracricoid partial laryngec-
tomy (SPL) with cricohyoidoepiglottopexy to manage
more extensive cancer involving both vocal cords, the
anterior commissure, and the paraglottic space.6 These
procedures rely on very different paradigms of recon-
struction, so decisions to use one or the other tech-
nique must be made before surgery.
Cancer involving the cricoid cartilage is a contrain-
dication to hemilaryngectomy and a relative contrain-
dication to SPL. Recently, Laccourreye and colleagues7
reported excision of the superior aspect of the cricoid
cartilage in patients with extensive subglottic extension.
Therefore, the cancer should ideally not extend more
than 1 cm subglottically at the anterior commissure and
no more than 5 mm subglottically posteriorly. Cancer
extending onto the arytenoid cartilage is theoretically
resectable by SPL as long as there is a suffi cient margin
of resection in the posterior commissure and the con-
tralateral arytenoid can be left intact. Cancers with
vocal cord fi xation or those that extend through the
ventricle up onto the false vocal cord (transglottic) are
not suitable for VPL. These cancers may be pathologi-
cally T4 because of proximity of the laryngeal ventricle
to thyroid cartilage with resultant cartilage invasion and
may spread by way of the rich lymphatic drainage into
the cervical lymph nodes.8,9 Because thyroid cartilage is
resected by SPL, some of these cancers may be candi-
dates for supracricoid resection if the cricoarytenoid
joint is free of involvement (see Chapter 47).7
Extended frontolateral partial laryngectomy with
epiglottopexy is feasible and in the past was considered
a standard procedure for larger tumors involving both
vocal cords. However, this procedure results in glottic
dysfunction and has largely been supplanted by SPL.
Decisions regarding resection of thyroid cartilage
and methods of reconstruction after VPL remain con-
troversial. If the thyroid ala is left in situ, a soft tissue
fl ap, typically strap muscle, may be used to fi ll the void.9
Brasnu and coauthors reported the use of a false vocal
cord (if uninvolved) fl ap for reconstruction.10 We
411

412
Section 3
Larynx
routinely resect the ipsilateral thyroid ala to permit the
adjacent soft tissue to fall into the void created by tumor
resection, which results in acceptable voice postopera-
tively. Patients with cancer involving the anterior com-
missure are good candidates for VPL because the results
of treatment with radiation therapy and laser surgery
are poor.11
PREOPERATIVE PLANNING
The most critical part of planning is preoperative
performance of suspension microlaryngoscopy to ade-
quately evaluate and stage the tumor. Esophagoscopy
should be carried out simultaneously to rule out second
primary cancers. Subglottic extension up to 1 cm below
the margin of the false vocal cord is staged T1, so most
cancers suitable for VPL are, in actuality, T1.12,13 Exami-
nation of the subglottic airway with 30-degree telescopes
is invaluable in assessing the extent of subglottic involve-
ment and should be routine. In the past, as many as
one third of T2 cancers were actually T4 on pathologic
examination13; however, with modern imaging tech-
niques such as the use of thin-cut computed tomogra-
phy scans, understaging should be encountered only
rarely. Accurate preoperative assessment of these tumors
is feasible because of the overall small size of tumors
amenable to resection by VPL. With accurate preopera-
tive tumor assessment, the likelihood that an unex-
pected intraoperative fi nding would require conversion
to total laryngectomy is low (Fig. 48-2). However, sur-
geons should routinely obtain consent for total
laryngectomy.
TECHNIQUE
The steps in the procedure are presented in Table 48-1.
The technique illustrated is that of thyroid cartilage
resection, which is our preferred technique.
A
B
Figure 48-1. A, Maximal size of a cancer that can be removed by
frontolateral hemilaryngectomy. B, Bulky lesion involving the vocal cord
and anterior commissure. (A, Redrawn from Pearson BW, Donald PJ:
Larynx. In Donald PJ [ed]: Head and Neck Cancer: Management of the Diffi cult
Case. Philadelphia, WB Saunders, 1984, pp 93-148.)
Figure 48-2. Sagittal incision through the larynx demonstrating
the limit of resectability for subglottic extension. A cancer that
extends more than 1 cm subglottically at the anterior commissure
may be a contraindication to partial laryngectomy.
Perioperative antibiotics are routinely administered
to reduce the incidence of postoperative wound infec-
tions, as in all other procedures that enter the aerodi-
gestive tract. The side of the tumor should be marked
on the skin of the neck before induction of anesthesia
and confi rmed again at endoscopy.

Chapter 48
Vertical Partial Laryngectomy
413
Table 48-1
STEPS IN HEMILARYNGECTOMY
Indications and Contraindications
Ideal for bulky lesions of the membranous true vocal cord
Normal or slightly impaired vocal cord mobility
No involvement of the supraglottis
Tumor may extend as far as the apex of the ventricle
Subglottic extension of no more than 5 mm posteriorly (10 mm anteriorly)
The body of the arytenoid is a contraindication, although the vocal process is not
No more than one third of the contralateral vocal cord involved (consider supracricoid partial laryngectomy)
Technical Points
Administer perioperative antibiotics
Re-endoscope the patient
Perform a preliminary tracheostomy
Make a horizontal skin incision over the thyroid ala
Raise the fl aps superiorly and inferiorly while avoiding the tracheostomy incision
Incise the perichondrium from the thyroid notch down the midline over the cricothyroid membrane
Elevate the perichondrium with the attached overlying strap muscles
Mark the cartilage incisions while retaining a 3-mm-wide posterior strip
Cut with a sagittal saw
Use a headlight
Incise the perichondrium along the superior border of the thyroid ala. Incise across the petiole of the epiglottis. This will
provide a panoramic view of the larynx
Incise the cricothyroid membrane along the superior aspect of the cricoid cartilage
Using a no. 15 blade, cut down to the true vocal cord and examine and cut through the true vocal cord either in the
midline or, in lesions that cross the anterior commissure, 2 to 3 mm behind the visible tumor. Be careful
Using hooks, open the thyroid alae like a book
STOP. Carefully evaluate the lesion and determine the area to be excised
Excise the tumor by incising along the apex of the aryepiglottic fold down around the arytenoid or through the vocal
process of the arytenoid, depending on the posterior extent of the tumor
Orient and examine the surgical specimen and select sites for frozen section examination of the margins
Obtain hemostasis
Suture the contralateral cord to the anterior end of the remaining cartilage or to the external perichondrium
An epiglottopexy must be performed in cases of extended vertical partial laryngectomy
Insert a nasogastric tube for feeding
Close the perichondrium with absorbable suture
Inferiorly based or bipedicle muscle fl aps may be used to reconstruct the glottis but are probably not necessary
A cricopharyngeal myotomy is not required
Close the wound in layers over a drain
Apply a neck dressing
Postoperative Care
Antibiotics are continued for 24 hours postoperatively
Nasogastric feedings can begin as soon as the patient has bowel sounds
The tracheotomy tube can be defl ated more rapidly than after supraglottic laryngectomy
Swallowing is characteristically delayed until the tracheostoma has closed
The larynx will appear abnormal for an extended period, so it is wise to delay biopsies until re-epithelialization has
occurred, usually in 6 to 8 weeks
The patient should undergo endoscopy again
before starting the procedure, especially if the initial
examination was performed elsewhere. Preliminary
endoscopy permits reconfi rmation of the side with the
tumor, the limits of tumor extension, and the margins
of the intended resection. We routinely use a micro-
scope to visualize the vocal cords and make an incision
in the vocal cord at the point where we will excise the
tumor when the larynx is open. This technique makes
the surgery very precise.
A tracheotomy is performed at the beginning of the
procedure in all patients. It should be noted that Lac-
courreye’s group has not routinely used a tracheostomy
and has reported no untoward consequences in a 25-
year experience, although their surgical technique
differs.7 Brumund and associates reported their experi-
ence with frontolateral partial laryngectomy without
tracheotomy for invasive squamous cell carcinoma of
the TVC and found that this technique has a very favor-
able outcome.11 The tracheotomy should be placed
suffi ciently low to avoid contamination of the surgical
wound with tracheal secretions during the postopera-
tive period. If the tracheostomy wound communicates
with the surgical wound, it must be separated with

414
Section 3
Larynx
several absorbable sutures between the strap muscles
and the subcutaneous tissue at the completion of the
procedure to avoid contamination of the cervical
wound.
A horizontal skin incision is made through the skin
crease over the thyroid ala (Fig. 48-3). An apron inci-
sion is not generally used in VPL because the likelihood
of extending the procedure to a total laryngectomy is
exceedingly low. Subplatysmal fl aps are elevated supe-
riorly and inferiorly while avoiding entry into the tra-
cheotomy incision. The fascia is incised in the midline
between the strap muscles and carried down to the level
of the thyroid cartilage and inferiorly over the cricoid
cartilage. The perichondrium is incised along the supe-
rior margin of the thyroid cartilage (Fig. 48-4). The
perichondrium is elevated with the attached overlying
strap muscles to the posterior margin of the thyroid ala
on the side of the tumor (Fig. 48-5). The perichon-
drium will need to be incised along its attachment to
the inferior portion of the thyroid ala to permit eleva-
tion laterally. Every attempt should be made to preserve
the perichondrium because it will become an important
component of the reconstruction.
The cancer usually extends to the midline, so the
cartilage incision must be made just lateral to the
midline to ensure adequate resection of the anterior
commissure with the specimen.14 A posterior vertical
cartilage cut is made as well, and a 3- to 5-mm-wide strip
of cartilage is retained to connect the inferior and
superior cornua of the thyroid cartilage (Fig. 48-6).
The incision should be made through cartilage only
and not through the underlying mucosa at this time.
An oscillating saw with a small right-angled blade
is ideal for this procedure, particularly because the
larynx is usually ossifi ed in patients in the older age
group.
The larynx is entered by cutting across the petiole
of the epiglottis, which facilitates visualization of the
entire glottis and the incisions in the vocal cords made
at endoscopy to mark the limits of resection (Fig. 48-7).
The cricothyroid membrane is then incised just above
the cricoid cartilage (Fig. 48-8). The TVC is transected
with care to ensure that the cord is cut at right angles
(Fig. 48-9A) and not at a different angle (Fig. 48-9B).
Once the contralateral vocal cord or the anterior com-
missure has been divided, the cartilage halves are spread
open like a book, and the incision is extended across
the false vocal cord on the involved side with scissors.
This is done by placing one blade of the scissors within
the lumen and above the ipsilateral thyroid ala; several
incisions are made to open the larynx for visualization
of the posterior extent of the cancer (Fig. 48-10). The
incisions are continued along the superior margin of
the cricoid cartilage on the side of the cancer while
taking care to ensure that an adequate margin below
the carcinoma is obtained.
Figure 48-3. Incision for vertical partial laryngectomy. Care should
be taken to ensure separation of the tracheostomy incision from that
required for the partial laryngectomy.
Figure 48-4. Incision of the perichondrium to expose the thyroid
ala.

Chapter 48
Vertical Partial Laryngectomy
415
The incisions are extended posteriorly, and the
specimen is reviewed. The entire arytenoid may need
to be included with the resection (Fig. 48-11). There
will be some bleeding in this part of the procedure, and
it is important to achieve hemostasis for complete visu-
alization of the lesion to avoid leaving cancer.
At the completion of the resection, hemostasis is
obtained and the specimen is carefully oriented and
examined (Fig. 48-12). Frozen section analysis of the
margins is performed. It is necessary to obtain a new
margin for frozen section evaluation if any doubt about
margins exists.
Piriform mucosa can be advanced over the poste-
rior portion of the cricoid to resurface the posterior
larynx, particularly if the arytenoid has been resected.
The contralateral TVC must be reattached to the ante-
rior surface of the cartilage with nonabsorbable suture,
except in the unlikely situation in which the ligamen-
tous attachment of the contralateral anterior commis-
sure has been left intact (Fig. 48-13).
If it is apparent that much of the least involved
vocal cord was resected, the surgeon has a number of
options. One is to convert the procedure to an SPL (see
Chapter 47). Another option is to use the epiglottis to
reconstruct the larynx (epiglottopexy) (Fig. 48-14). The
mucosa of the laryngeal surface of the epiglottis pro-
vides immediate epithelialization of the interior of
Figure 48-5. Elevation of the perichondrium with the overlying
strap muscles.
A
B
Figure 48-6. A and B, Incision of cartilage for a left frontolateral hemilaryngectomy and the planned incision in the vocal cord. To remove
the entire anterior commissure, note the incision in the cartilage just to the right of the midline. A 3- to 5-cm-wide strip of cartilage is main-
tained posteriorly. (Redrawn from Pearson BW, Donald PJ: Larynx. In Donald PJ [ed]: Head and Neck Cancer: Management of the Diffi cult Case. Philadel-
phia, WB Saunders, 1984, pp 93-148.)

416
Section 3
Larynx
Figure 48-7. Scissors are used to extend the incision across the
preepiglottic space and the false vocal cord to expose the cancer.
Figure 48-8. The cricothyroid membrane is opened just superior
to the cricoid cartilage to verify that the cricoid is not involved.
A
B
Figure 48-9. Proper (A) and improper (B) angles of the cut through
the vocal cord. Note the excess sacrifi ce of tissue caused by improper
angulation of the incision through the vocal cord.
Figure 48-10. View of the posterior aspect of the cancer after the
superior incision is completed.

Chapter 48
Vertical Partial Laryngectomy
417
the larynx. The epiglottic cartilage provides structural
support to prevent glottic stenosis. This preserves an
adequate glottic airway but leads to an open anterior
glottis with a resultant breathy voice.
A nasogastric tube is inserted and secured for post-
operative feeding. The anterior perichondrium and
the strap muscles are closed with absorbable suture. A
Hemovac drain is placed subcutaneously. The neck
incision is closed, with care taken to ensure that the
wound does not communicate with the tracheostomy
incision.
POSTOPERATIVE CARE
Antibiotics are continued for 24 hours postoperatively.
Nasogastric feeding is usually begun when bowel sounds
are audible. After approximately 10 days, decannula-
tion can commence because aspiration is not generally
a problem in this patient population. Decannulation is
begun by defl ating the cuff of the tracheostomy tube
and, if tolerated, downsizing to a smaller (usually a no.
4 Shiley) uncuffed tube. The patient is decannulated
when able to tolerate plugging of the uncuffed tube for
24 hours. Once decannulation has occurred, the naso-
gastric tube can be removed and oral feeding resumed.
Patients who have failed previous radiation therapy may
have more edema, and decannulation may require
several weeks.
Visualization of the larynx will be quite abnormal
for several weeks postoperatively. Remarkably, once
healing has occurred, the excised vocal cord is replaced
by a scar band that often resembles a TVC.
Figure 48-11. Resection of the cancer by continuing the incision
superiorly through the vocal process and vocal cord posterior to the
cancer. The arytenoid may be taken at this step.
Figure 48-12. Hemilaryngectomy specimen. Anterior is toward the
left. The tumor is indicated with arrows. Note the close margins feasi-
ble with this procedure.
Figure 48-13. Reattachment of the vocal cord remnant to the
thyroid ala.

418
Section 3
Larynx
A
B
C
D
Figure 48-14. Epiglottopexy. A, The remaining larynx after the specimen has been removed. B, The lingual surface of the epiglottic cartilage
is undermined in the subperichondrial plane. C, The epiglottis is pulled inferiorly. D, The epiglottis is sutured to the cricoid cartilage to
reconstruct the lumen of the larynx.

Chapter 48
Vertical Partial Laryngectomy
419
References
1. Biller HF, Ogura JH, Pratt LL: Hemilaryngectomy for T2 glottic
cancers. Arch Otolaryngol 93:238-243, 1971.
2. Pratt LW: Historical perspective. In Ferlito A (ed): Neoplasms of
the Larynx. New York, Churchill Livingstone, 1993, pp 2-4.
3. Rothfi eld RE, Johnson JT, Myers EN, Wagner RL: The role of
hemilaryngectomy in the management of T1 vocal cord cancer.
Arch Otolaryngol Head Neck Surg 115:677-680, 1989.
4. Rucci L, Gallo O, Fini-Storchi O: Glottic cancer involving anterior
commissure: Surgery vs. radiotherapy. Head Neck 12:403-410,
1991.
5. Gilbert RW, Birt D, Shulman H, et al: Correlation of tumor
volume with local control in laryngeal carcinoma treated by radio-
therapy. Ann Otol Rhinol Laryngol 96:514-518, 1987.
6. Holsinger FC, Laccourreye O, Weinstein GS, et al: Technical
refi nements in the supracricoid partial laryngectomy to optimize
functional outcomes. J Am Coll Surg 201:809-820, 2005.
7. Laccourreye O, Laccourreye L, Garcia D, et al: Vertical partial
laryngectomy versus supracricoid partial laryngectomy for
selected carcinomas of the true vocal cord classifi ed as T2N0. Ann
Otol Rhinol Laryngol 109:965-971, 2000.
8. Kirchner JA: Pathways and pitfalls of partial laryngectomy. Ann
Otol Rhinol Laryngol 93:301-305, 1984.
9. Olsen K, DeSanto L: Partial vertical laryngectomy—indications
and surgical technique. Am J Otolaryngol 11:153-160, 1990.
10. Brasnu D, Laccourreye O, Weinstein G, et al: False vocal cord
reconstruction of the glottis following vertical partial laryngec-
tomy: A preliminary analysis. Laryngoscope 102:717-719, 1992.
11. Brumund K, Gutierrez-Fonseca R, Garcia D, et al: Frontolateral
vertical partial laryngectomy without tracheotomy for invasive
squamous cell carcinoma of the true vocal cord: A 25-year experi-
ence. Ann Otol Rhinol Laryngol 114:314-322, 2005.
12. American Joint Committees on Cancer Staging Manual, 6th ed.
New York, Springer, 2002.
13. Pillsbury HRC, Kirchner JA: Clinical vs. histopathologic staging
in laryngeal cancer. Arch Otolaryngol 105:157-159, 1979.
14. Barbosa M, Araujo V, Boasquevisque E, et al: Anterior vocal com-
missure invasion in laryngeal carcinoma diagnosis. Laryngoscope
115:724-730, 2005.
E
Figure 48-14, cont’d. E, The reconstruction is completed.
PITFALLS
• Re-endoscopy in patients in whom the diagnosis has
been made elsewhere and who were referred for
surgery will help verify the diagnosis and avoid
understaging.
• Inaccurate staging may result in excessive vocal cord
excision that can lead to glottic stenosis, prolonged
tracheostomy dependence, unanticipated total
laryngectomy, or early recurrence of the cancer.
• Extensive excision of the contralateral vocal cord will
result in glottic stenosis unless an epiglottopexy is
performed.
• Failure to reconstruct the posterior glottis after
arytenoid resection will lead to aspiration.
• Resection of one arytenoid cartilage will cause
aspiration, which can usually be overcome by
intensive swallowing therapy.
PEARLS
• Vertical partial laryngectomy is a procedure ideally
suited for patients who have cancer of the vocal
cord that is too large for laser excision and not
extensive enough for total laryngectomy.
• Preoperative endoscopy is necessary to evaluate the
tumor before surgery.
• Imaging may help identify cartilage invasion and
subglottic extension.
• Meticulous surgical technique is critical in ensuring
complete excision of the tumor and a functional
larynx.
• Glottic stenosis after extended vertical partial
laryngectomy can be prevented with an
epiglottopexy.

Chapter 49
Total Laryngectomy
David E. Eibling
Of the approximately 12,000 new cases of carcinoma of
the larynx discovered each year in the United States,
slightly more than one half are initially seen in an
advanced stage and are not suitable for endoscopic
excision or conservation laryngeal surgery. The most
important factor leading to early diagnosis of laryngeal
cancer is recognition by the patient and primary care-
giver that a sore throat or abnormal voice may indicate
a risk for carcinoma of the larynx, particularly in patients
with the risk factors of tobacco and alcohol use. Further
improvement in the control rate of laryngeal carcinoma
will require earlier recognition of the need for laryn-
goscopy in symptomatic patients. The American
Academy of Otolaryngology–Head and Neck Surgery
Foundation has established a web-based educational
program for primary care providers to assist in these
educational efforts, of which hoarseness is one module
( accessed 15 April
2005).
PATIENT SELECTION
Total laryngectomy is required when alternative means
of controlling the cancer are not feasible. This includes
patients who have fi xation of the vocal cord or cancer
that has spread out of the endolarynx by invasion of
cartilage, base of the tongue, or hypopharynx.1 Radia-
tion or chemoradiation therapy is inadequate in the
management of locally advanced cancer, especially with
cartilage invasion, and surgical salvage is required in
a signifi cant number of patients treated with this
modality.2
Over the past several decades the paradigm has
shifted signifi cantly in that patients with cancer that
would have required total laryngectomy in the past can
now be offered laryngeal preservation—either surgi-
cally with conservation partial laryngectomy or trans-
oral endoscopic CO2 laser excision, as described in
previous chapters, or through protocols combining
chemotherapy and radiotherapy. Some patients with
cancer that would be amenable to conservation laryn-
geal surgery are not candidates as a result of underlying
medical conditions, usually pulmonary. Because total
laryngectomy separates the airway from the digestive
tract, aspiration is eliminated, which often leads to
improvement in preoperative pulmonary status for
patients unable to tolerate aspiration.
Organ Preservation with
Chemoradiation Therapy
Locally advanced cancer cannot usually be cured with
radiation alone, and most centers report rates of less
than 50%.2 The addition of chemotherapy, either neo-
adjuvant or concurrent, increases the probability of
cure to approximately that of surgical excision if surgi-
cal salvage is performed expeditiously for persistent
disease. Long-term disease-free survival rates for T3 and
T4 cancers are similar for either surgery or chemoradia-
tion protocols, with about two thirds of the latter group
succeeding in retaining their larynx.3-5 Functional organ
preservation remains elusive for many of these patients,
however, because of the swallowing dysfunction or aspi-
ration that accompanies successful treatment of these
larger tumors such that many of these patients will have
a permanent tracheotomy and percutaneous endo-
scopic gastrostomy despite cure of their cancer. Others
will require total laryngectomy as a result of radionecro-
sis of the larynx or recurrent cancer.6,7 Diffi culty recog-
nizing recurrent or persistent cancer because of edema
and submucosal location of recurrence may result in
delayed diagnosis of recurrence. Newer imaging
modalities with positron emission tomography (PET)-
computed tomography (CT) scanning may reduce this
risk somewhat,8 but the optimal utility of PET-CT in
monitoring this patient group is still unknown. Some
patients ultimately require laryngectomy for the man-
agement of pain and aspiration secondary to laryngeal
dysfunction after completion of therapy. Although
421

422
Section 3
Larynx
cost is often quoted as a factor, there is little signifi cant
difference in cost between surgery and organ preserva-
tion. A recent report analyzing cost indicated that organ
preservation protocols actually cost approximately 10%
more than surgical extirpation and postoperative
radiotherapy.9
The fi nal decision must be customized for each
patient. Organ preservation carries with it a degree of
uncertainty regarding the status of the retained larynx,
a higher risk for signifi cant dysphagia, and an increased
risk of aspiration but avoids the presence of a stoma and
facilitates nearly normal speech. Each patient must be
counseled regarding the options and educated suffi -
ciently to take an active role in decision making. Sur-
geons who undertake to direct the management of
patients with advanced laryngeal cancer must be cogni-
zant of the nuances of surgical as well as organ-sparing
paradigms of therapy to optimally counsel and manage
patients seeking their care.
Total laryngectomy is the standard against which all
other forms of therapy for laryngeal cancer must be
measured because total laryngectomy is highly effective
in managing glottic, subglottic, and supraglottic carci-
noma.10 Total laryngectomy is an integral part of laryn-
gopharyngectomy and is required for advanced
hypopharyngeal cancer. Cancer confi ned to the glottis
tends to remain localized; hence, total laryngectomy
alone will achieve cure in the vast majority of cases
staged T3 or less. Once cancer has extended outside
the glottis by extension through cartilage either
into the soft tissue of the neck, into the subglottis, or
into the supraglottic tissues (transglottic), extirpation
of all disease is more challenging.
Neck Dissection
The glottis, in direct contradistinction to the supraglot-
tis, is relatively devoid of lymphatics. Cervical metastases
are rare if the cancer is confi ned to the true vocal cord.
As a result, routine elective neck dissection is not
required for T1 or T2 glottic cancer. However, all supra-
glottic cancers, hypopharyngeal cancers, and T3 or T4
glottic cancers are more likely to have clinically appar-
ent or occult regional metastatic disease. Bilateral neck
dissection is required for all supraglottic cancers, all
hypopharyngeal cancers that involve the medial wall,
and cancer of the anterior commissure with cartilage
invasion. Cancer that originates in the subglottis or is
glottic with extension more than 2 cm subglottically has
a high propensity to involve the paratracheal nodes.
Tumor deposits in these nodes are thought to be
responsible for the high incidence of stomal recurrence
in patients with tumors that exhibit subglottic exten-
sion.11,12 As a result, removal of the ipsilateral thyroid
lobe and adjacent paratracheal nodes is routine for
tumors with subglottic extension.
Adjuvant radiotherapy is warranted in all patients
with hypopharyngeal cancer, those with more than two
positive nodes or extracapsular spread on pathologic
examination of the neck specimens, patients with
greater than 2 cm of subglottic extension, and those
with positive paratracheal lymph nodes. In patients with
primary cancer of the subglottis or subglottic extension
or with positive paratracheal lymph nodes, the radio-
therapist must be specifi cally directed to treat the area
of the stoma and the upper mediastinum to prevent
stomal recurrence. These regions are not routinely
included in postoperative adjuvant radiation therapy of
the neck because irradiation of the stoma and trachea
can result in severe tracheitis.
PREOPERATIVE PLANNING
All patients with cancer of the larynx require careful
preoperative evaluation, which must include a search
for a second cancer of the upper aerodigestive tract,
esophagus, or lung; assessment of the patient’s general
medical condition; and evaluation of the cancer by
direct laryngoscopy and biopsy for verifi cation of histol-
ogy. Imaging studies are helpful in the staging of larger
cancers by identifying involvement of the laryngeal
framework, the paraglottic space, and the neck.8,11
Minimal benefi t is derived from radiographic imaging
in early vocal cord carcinoma. Current wisdom suggests
that high-resolution CT scanning is more benefi cial
than magnetic resonance imaging (MRI) in the evalua-
tion of advanced malignancies; however, this may
change in coming years as the resolution of MRI and
other modalities improves. PET scanning is not helpful
in the evaluation of primary glottic cancer but is useful
in identifying metastatic disease in the neck or second
primary lung cancer and may become standard in
future years. Preoperative chest radiography is manda-
tory because almost all these patients have a signifi cant
smoking history and a certain percentage will demon-
strate the presence of a simultaneous cancer of the
lung. CT scanning of the chest is warranted to further
evaluate abnormalities noted on chest radiography and
may be benefi cial in the evaluation of all patients with
laryngeal cancer. Glottic cancer with vocal cord paraly-
sis may represent advanced-stage laryngeal cancer or
two primary cancers with recurrent laryngeal nerve
involvement by metastatic lung cancer. Assessment of
the patient’s general medical condition, particularly
pulmonary reserve, is necessary to select the optimal
treatment modality. Total laryngectomy is the treat-
ment of choice if the patient has impaired pulmonary
status, even if the tumor may be amenable to a surgical
organ preservation procedure.
Preoperative endoscopy under general anesthesia
should be carried out in all patients, not only to assess
the size and extent of the primary cancer and to obtain
tissue for biopsy but also to search for second primary
cancers. Careful examination of the oral cavity, base of
the tongue, piriform sinuses, and esophagus is war-
ranted. The routine use of bronchoscopy has been
somewhat controversial; however, some surgeons rou-
tinely perform fl exible fi beroptic bronchoscopy with
washings to assist in identifying patients with a second
primary cancer of the lung. Bronchoscopy should cer-
tainly be carried out when imaging studies suggest a
simultaneous bronchogenic carcinoma.

Chapter 49
Total Laryngectomy
423
Selection of the appropriate treatment modality is
the most diffi cult responsibility in the management of
these patients. Patients should be counseled regarding
surgical and nonsurgical options. It is inappropriate to
insist that patients undergo one specifi c form of therapy,
particularly when acceptable cure rates can be obtained
by other options. Surgeons must be aware of their own
biases and strive to present a balanced and informed
set of options to the patient and family. Usually, frank
discussion with the patient will result in a clear decision
regarding the treatment modality most benefi cial for
the individual patient.
Patients must be counseled regarding the risk of
continued smoking, which has been demonstrated to
result not only in an increased incidence of second
primary cancer and risk of recurrence but also in a
reduction in the probability of cure by radiotherapy.13
Enrollment in a smoking cessation program and the use
of transdermal nicotine replacement, as well as the
administration of bupropion, may be helpful. Frank
discussion with the patient and family may assist in
reducing or eliminating dependence on tobacco.
Unfortunately, smoking remains a problem in many
patients, even those who have undergone total laryn-
gectomy. Development of a second primary cancer in
the lung and esophagus, particularly in patients who
continue to smoke after radiotherapy or partial laryn-
gectomy, remains a serious problem and is a common
cause of death in patients treated successfully for their
initial primary cancer.
TECHNIQUE
The steps for total laryngectomy are listed in Table
49-1.
As in any surgical procedure in which the upper
aerodigestive tract is entered through the neck, antibi-
otics are administered perioperatively. Antibiotics must
be administered before initiation of the surgical proce-
dure and continued for 24 hours postoperatively. There
is probably no need to continue antibiotics past 24
hours, and the antibiotic must cover gram-positive
organisms, as well as anaerobes, essentially normal oral
fl ora.
The patient is anesthetized, a tracheotomy is per-
formed, and an endotracheal tube is placed in the
stoma. Care must be taken to perform the tracheotomy
at an adequate distance inferior to the cancer if there
is signifi cant subglottic extension. It may be necessary
to perform the tracheotomy under local anesthesia in
patients with large obstructing tumors in whom induc-
tion of general anesthesia and endotracheal intubation
cannot be accomplished safely.
An apron incision is outlined (Fig. 49-1) such that
the tracheostomy incision is incorporated. If neck dis-
section is to be performed in continuity with the laryn-
gectomy, the apron incision can be extended laterally
as a utility incision to gain access to the contents of the
neck. Subplatysmal skin fl aps are elevated to above the
level of the hyoid bone for exposure of both sterno-
cleidomastoid muscles (Fig. 49-2).
The cervical fascia is divided over the sternocleido-
mastoid muscles, and the incisions are connected infe-
riorly and superiorly. It will be necessary at this stage to
divide and ligate the anterior jugular veins. “Outer
tunnels” are bluntly dissected between the sternocleido-
mastoid muscle and the strap muscles on either side to
free the medial contents of the neck (Fig. 49-3). The
strap muscles are divided, usually at about the level of
the tracheotomy stoma (Fig. 49-4). They are elevated
superiorly and medially to gain access to the thyroid
gland. The thyroid isthmus is divided (if not done at
the time of the tracheotomy), and the contralateral
thyroid lobe is freed from its attachment to the trachea
(Fig. 49-5). The ipsilateral thyroid lobe is left attached
and removed with the specimen. Electrocautery is effec-
tive in reducing the bleeding commonly encountered
Table 49-1
STEPS IN TOTAL LARYNGECTOMY
Administer perioperative antibiotics
Perform a tracheostomy
Make an apron fl ap incision
Perform a subplatysmal dissection of the fl ap
Divide the fascia and anterior jugular veins
Expose the sternocleidomastoid muscle and dissect the
“outer tunnels”
Incise the strap muscles and elevate them off the thyroid
gland
Divide the thyroid isthmus and free the thyroid lobes
Dissect the inner tunnels
Divide the superior laryngeal artery, vein, and nerve
Expose and free the body and greater cornu of the hyoid
bone
Rotate the larynx and divide the constrictor muscles
Free the piriform mucosa and superior cornu of thyroid
cartilage
Divide the trachea and identify the party wall
Open the pharynx through the vallecula, piriform sinus,
or postcricoid mucosa
Excise the tumor under direct vision with adequate
margins (<1 cm) while preserving as much piriform
sinus mucosa as possible
Examine the specimen and select sites for frozen section
determination of margins
Insert and secure the nasogastric tube
Close the pharynx via a vertical, horizontal, or T closure
with an inverting suture
Do not close the constrictors. Irrigate the wound and
test the pharynx for leaks
Create a permanent tracheostoma with pie-crust sutures
while remembering to bevel the trachea and “walk the
skin” to prevent stomal stenosis
Close the skin over suction drains

424
Section 3
Larynx
Figure 49-1. Apron incision for total laryngectomy.
Figure 49-2. Elevated apron incision.
Figure 49-3. Incision of the fascia over the sternocleidomastoid
muscle and over the hyoid bone with the development of “outer
tunnels” deep to the sternocleidomastoid muscle (right side).
Figure 49-4. Division of the strap muscles.

Chapter 49
Total Laryngectomy
425
at this step. The “deep tunnel” between the carotid
sheath and the larynx is dissected bluntly along the
prevertebral fascia. By dissecting superiorly to the level
of the greater cornu of the hyoid bone, the superior
laryngeal bundle is encountered and should be
ligated.
The hyoid bone is exposed in the midline and
grasped with a towel clip (Fig. 49-6). The suprahyoid
Figure 49-5. Separation of the thyroid lobe from the trachea. Elec-
trocautery is effective in reducing bleeding.
muscles are divided, and the hyoid bone is left attached
to the thyrohyoid membrane and the strap muscles.
When the central portion of the hyoid bone has been
released, it is grasped with a towel clip and retracted
anteriorly to gain exposure of the lateral cornua. The
lateral cornu is grasped with an Allis clamp and pulled
away from the hypoglossal nerve and lingual artery. The
ligament and its attachments are divided to free the
cornu. It is important at this stage to stay on bone to
avoid injury to the hypoglossal nerve and lingual artery
(Fig. 49-7).
The larynx is rotated by placing a hook under the
lateral aspect of the ala. The constrictor muscles are
then incised along the lateral border of the thyroid
cartilage (Fig. 49-8). Piriform mucosa is bluntly elevated
Figure 49-6. The hyoid bone is grasped with a towel clip and the
suprahyoid muscles dissected from bone via electrocautery.
C
A
B
Figure 49-7. Freeing the greater
cornu of the hyoid bone. Care must
be taken to keep the dissection on
the undersurface of the hyoid to
avoid injury to the lingual artery
and hypoglossal nerve. This is done
by retracting the lateral cornu with
an Allis clamp and exposing the tip
of the hyoid (A), incising immedi-
ately deep to the cornu with scissors
(B), and bluntly dissecting the
bone from the piriform sinus wall
with the handle of the scissors
(C).

426
Section 3
Larynx
Figure 49-8. Lateral rotation of the larynx to assist in incising the
inferior constrictor muscle along the lateral margin to the thyroid
ala.
Figure 49-9. Elevation of the piriform mucosa to assist in preserv-
ing the mucosa. This step is key to ensure that adequate mucosa is
preserved for closure of the pharynx.
from the undersurface of the thyroid ala (Fig. 49-9)
(unless there is ipsilateral involvement of the piriform
sinus mucosa by cancer). This maneuver will assist in
preserving mucosa needed for closure of the pharynx
and is particularly important if the contralateral piri-
form mucosa must be sacrifi ced.
The trachea is divided, and the posterior wall of the
trachea is separated from the cervical esophagus. Blunt
dissection superiorly will free the larynx up to the level
of the postcricoid mucosa (Fig. 49-10). The larynx is
now freed except for its attachments to the pharyngeal
mucosa.
The pharynx can be entered in one of several ways.
Ideally, the surgeon is familiar with several choices and
selects one distant to the site of the tumor to afford
maximal exposure and provide direct visualization of
the cancer. Unless involved by tumor, the most expedi-
tious approach is to enter through the vallecula. The
hyoepiglottic ligament is identifi ed by dissecting poste-
riorly from the hyoid (Fig. 49-11). By following this liga-
ment posteriorly under the tongue musculature, the
epiglottis can be identifi ed and grasped with an Allis
clamp and the mucosa incised to enter the vallecula. It
is useful for the surgeon to put on a headlight at this
time and move to the head of the table. With scissors
and careful visualization of the mucosal surfaces, the
larynx can be examined in detail and resected while
taking care to ensure preservation of uninvolved pha-
ryngeal mucosa to allow adequate mucosa for later
closure (Figs. 49-12 to 49-14). This technique conserves
maximal pharyngeal mucosa for closure (Figs. 49-13B
Figure 49-10. Division of the posterior wall of the trachea and dis-
section to the postcricoid region. The most diffi cult part of this dis-
section is identifi cation of the correct plane of dissection. Once the
correct plane is identifi ed, the dissection is easily performed with a
fi nger.

Chapter 49
Total Laryngectomy
427
Figure 49-11. Identifi cation of the epiglottis is eased by following
the hyoepiglottic ligament. With adequate retraction, the epiglottis is
exposed and the pharynx is opened into the vallecula. This is usually
farther from the hyoid bone than would be suspected.
Figure 49-12. Excision of the larynx is begun by incising the pha-
ryngoepiglottic fold while staying just lateral to the aryepiglottic fold.
The outside scissors blade will be medial to the hyoid and the thyroid
ala.
A
B
Figure 49-13. A and B, Mucosal
cuts for excision of the larynx, with
care taken to preserve as much of the
piriform mucosa as feasible. The
pyriform mucosa must be sacrifi ced
if the cancer extends over the aryepi-
glottic fold or is within the piriform
sinus (B).
and 49-14). It is critical that hypopharyngeal cancers be
accurately assessed preoperatively to ensure that ade-
quate mucosa will remain for pharyngeal closure. The
specimen is resected and submitted for pathologic eval-
uation (Fig. 49-15). It is unnecessary to obtain frozen
sections because adequate margins are the purpose of
this operation.
After hemostasis is obtained, a nasogastric tube is
inserted through the nose, brought out into the
pharynx, and passed into the esophagus and secured.
If a tracheoesophageal puncture is planned, it is per-
formed at this time, as described in Chapter 50. Care
must be taken during tracheoesophageal puncture to
ensure that the tract does not communicate with the
neck but passes directly through the posterior wall of
the trachea into the esophagus. Some surgeons rou-
tinely denervate the pharyngeal muscles or perform a
myotomy by dividing the constrictor muscles along the
posterior aspect of the pharynx to assist in postopera-
tive voicing.

428
Section 3
Larynx
The type of closure will often be dictated by the
amount of remaining piriform sinus mucosa. The pha-
ryngeal mucosa is closed with running inverting suture
(Fig. 49-16), usually in a T, vertical, or horizontal fashion
(Fig. 49-17). The suturing technique is critical, and
more than one individual should be observing each
suture to ensure that the mucosa is inverted. Reinforc-
ing sutures may be used; however, the constrictor
muscles should not be closed because this will contribute
to postoperative dysphagia and diffi culty with voicing if
speech rehabilitation with a tracheoesophageal punc-
ture is used.
The wound is irrigated, and the stoma is created by
half-mattress sutures (Fig. 49-18). Stoma stenosis can be
prevented by beveling the tracheal incision and advanc-
ing skin by taking larger bites on the skin side than on
the tracheal side during closure. Hemovac suction
drains are used. The neck incision should not be closed
until the stoma has been created, and then the neck
incision can be closed in the typical manner with absorb-
able deep sutures and skin staples. A dressing is applied
and secured to assist in coapting the skin fl aps. The
anode tube is removed and a cuffed tracheostomy tube
inserted. We generally use a no. 8 cuffed tracheostomy
tube that is changed to an uncuffed laryngectomy tube
after several days.
The patient is fed by nasogastric tube when bowel
sounds are heard. After the appropriate period, usually
about 7 days, the nasogastric tube is removed and the
Figure 49-14. Defect after removal of the larynx. Note the pres-
ervation of the piriform sinus mucosa.
Figure 49-15. Laryngeal specimen opened to show transglottic
cancer. The cancer is crossing the anterior commissure from superior
to inferior.
Figure 49-16. Closure of the pharynx with detail of the suturing
technique. Mucosal edges must be inverted or a fi stula will develop.

Chapter 49
Total Laryngectomy
429
A
B
C
A
B
C
Figure 49-17. Three types of pha-
ryngeal closure. A T closure (A) is
most common, although the T is tech-
nically diffi cult and prone to leakage.
Vertical (B) or horizontal (C) closure
can be performed if adequate mucosa
is preserved, and these closures may
be preferable.
Figure 49-18. Creation of the stoma with half-mattress sutures. A,
The skin fl aps are “walked” medially to ensure adequate stomal diam-
eter by taking wider “bites” of skin than of trachea with each suture.
B, Detail of a half-mattress suture. This technique pulls skin over the
tracheal edge to cover cartilage. C, Stomal closure. In actuality, the
half mattress sutures pull the skin over the exposed tracheal rings.
Figure 49-19. Barium swallow in a patient who has undergone total
laryngectomy with a small pharyngeal leak. If small, it may respond
to conservative treatment and not progress to a pharyngocutaneous
fi stula.

430
Section 3
Larynx
patient is maintained on a liquid diet. Patients who have
previously undergone radiotherapy or in whom the
pharyngeal closure is diffi cult or who demonstrate ery-
thema of the fl ap with or without fever are studied with
an esophagogram before initiating an oral diet. Identi-
fi cation of a sinus tract is an indication to delay the oral
diet and continue tube feeding until it is clear that a
fi stula or a sinus tract is not present (Fig. 49-19).
References
1. American Joint Committees on Cancer Staging Manual, 6th ed.
New York, Springer, 2002.
2. Croll GA, Gerritsen GJ, Tiwari RM, Snow GB: Primary radiother-
apy with surgery in reserve for advanced laryngeal carcinoma.
Results and complications. Eur J Surg Oncol 15:350-356, 1989.
3. The Department of Veterans Affairs Laryngeal Cancer Study
Group: Induction chemotherapy plus radiation compared with
surgery plus radiation in patients with advanced laryngeal cancer.
N Engl J Med 324:1685-1690, 1991.
4. Wolf G, Hong WK, Fisher S, et al: Larynx preservation with induc-
tion chemotherapy (CT) and radiation (XRT) in advanced laryn-
geal cancer: Final results of the VA Laryngeal Cancer Study
Group cooperative trial. Proc Am Soc Clin Oncol 12:277, 1993.
5. Forastiere A, Goepfert H, Maor M, et al: Concurrent chemother-
apy and radiotherapy for organ preservation in advanced laryn-
geal cancer. N Engl J Med 349:2091-2098, 2003.
6. Simental A, Carrau R: Assessment of swallowing function in
patients with head and neck cancer. Curr Oncol Rep 6:162-165,
2004.
7. Angelis E, Feher O, Barros A, et al: Voice and swallowing in
patients enrolled in a larynx preservation trial. Arch Otolaryngol
Head Neck Surg 129:733-738, 2003.
8. Barbosa M, Araujo V, Boasquevisque E, et al: Anterior vocal com-
missure invasion in laryngeal carcinoma diagnosis. Laryngoscope
115:724-730, 2005.
9. Davis G, Swaretz S, Veenstra D, Yueh B: Cost comparison of
surgery vs organ preservation for laryngeal cancer. Arch Otolar-
yngol Head Neck Surg 131:21-26, 2005.
10. Beckford NS: The role of total laryngectomy in the treatment of
carcinoma. In Myers EN (ed): New Dimensions in Otorhinolar-
yngology–Head and Neck Surgery, vol 1. New York, Elsevier,
1985.
11. Kacker A, Wolden S, Pfi ster D, Kraus D: Cancer of the larynx. In
Myers EN, Suen JY, Myers JN, Hanna EYN (eds): Cancer of the
Head and Neck, 4th ed. Philadelphia, WB Saunders, 2003.
12. Rubin J, Johnson JT, Myers EN: Stomal recurrence after laryngec-
tomy: Interrelated risk factor study. Otolaryngol Head Neck Surg
103:805-812, 1990.
13. Kacker A, Wolden S, Pfi ster DG, Kraus DH: Cancer of the larynx.
In Myers EN, Suen JY, Myers JN, Hanna EYN (eds): Cancer of the
Head and Neck, 4th ed. Philadelphia, WB Saunders, 2003, pp
333-377.
PEARLS
• Not every patient is best served by total
laryngectomy. Discussion with the patient will
usually lead to a clear understanding of the
patient’s preferences for therapy.
• Conservation laryngeal procedures require that the
tumor and the patient both be amenable to the
planned procedure. Do not perform conservation
horizontal procedures on patients in whom
aspiration will be a problem.
• Extension beyond the larynx to the subglottis, base
of the tongue, and hypopharynx increases the
chance of leaving persistent tumor behind. Frozen
section evaluation of surgical margins is necessary.
• A carefully performed pharyngeal closure is key to
avoiding a postoperative fi stula.
• A tracheotomy under local anesthesia may be
necessary in patients with a large obstructive
laryngeal cancer.
PITFALLS
• The most common pitfall in the surgical
management of laryngeal carcinoma is failure to
accurately stage the tumor and thereby make an
inappropriate choice of therapy. Repeat endoscopy
just before the procedure is helpful, particularly
when the patient has undergone diagnostic
endoscopy and biopsy elsewhere.
• Failure to administer perioperative antibiotics will
result in an unacceptable rate of wound infection in
patients in whom the upper aerodigestive tract is
opened. Each surgeon must establish a system—or
confi rm that a system exists—to ensure that
antibiotics are administered at the right time and in
the right dose.
• Continued soilage of the wound with oropharyngeal
secretions as a result of technical error during
pharyngeal closure is the most common cause of
postoperative wound infection and
pharyngocutaneous fi stula.
• Failure to accurately close the pharynx can result in
the development of a fi stula. This complication can
be prevented by meticulous attention to detail
during closure of the pharynx. The closure must be
performed without tension and with careful
inversion of the mucosa. Adequate wound drainage
is necessary to prevent accumulation of fl uid, which
acts as a culture medium for wound infections.

Chapter 50
Voice Restoration after
Total Laryngectomy
David E. Eibling
Loss of voice is the greatest disability for most patients
after total laryngectomy. Although the presence of a
tracheostoma and the associated anterior neck defor-
mity pose a cosmetic and functional deformity, it is loss
of a normal speaking voice that is most debilitating to
the patient, both functionally and emotionally. As a
result of the severity of this disability and its effect on
social interaction, efforts to rehabilitate the voice after
total laryngectomy have been made almost since the
fi rst laryngectomy was performed more than a century
ago.
Acoustic signals that are interpreted as voice are a
complex compilation of varying frequencies created by
a number of anatomic structures. The larynx is respon-
sible for the fundamental vibratory frequency of the
sound produced, as well as the associated interruptions
and alterations in airfl ow. Airfl ow is created by expira-
tory lung volume, and the complexities of articulated
speech and resonance are produced in the air passages
superior to the larynx. Therefore, any means that can
approximate normal vibratory airfl ow function proxi-
mal to the articulators has the possibility of resulting in
understandable speech. All forms of speech rehabilita-
tion after laryngectomy rely on this principle.
TYPES OF SPEECH REHABILITATION
Speech rehabilitation after total laryngectomy can be
subdivided into three major categories:
1. Esophageal speech
2. Prosthetic artifi cial oscillators
3. Tracheopharyngeal shunts or fi stulas
Esophageal Speech
Esophageal speech is a learned technique in which air
is swallowed (“injected”) into the esophagus and then
allowed to escape through the pharynx. Appropriate
tensing of the pharyngeal walls during expiratory airfl ow
results in vibration of the pharyngeal walls, which
creates sound. Esophageal speech is typically of lower
pitch than normal speech frequencies because of char-
acteristics of the pharyngeal wall. The advantages of this
technique are that it requires no surgical procedure,
prosthesis, or cumbersome hand motions. However,
few patients who have undergone laryngectomy are
able to achieve usable esophageal speech, and fewer
than one in fi ve achieve speech acceptable for social
interaction. Extensive training is required by most
people, and individuals vary widely in their ability to use
this training to rehabilitate their speech; nonetheless,
despite recent advances it remains useful for those who
are able to master it. A few patients are able to use
esophageal speech as their sole speech modality, but
most retain other forms of speech as a backup.
Prosthetic Oscillators
Electronic devices supplying vibration into the oral
cavity will permit speech, albeit monotone and machine-
like. This is clearly the easiest method to use and, for
many patients, remains their sole form of speech after
total laryngectomy. The devices can be divided into two
types: those that cause the pharyngeal wall to vibrate
and result in secondary vibration of the air column and
those that cause vibrations within the oral cavity via a
connecting tube (Fig. 50-1). One (and perhaps more)
of the instruments available commercially can be modi-
fi ed to permit either vibration of the oral cavity tissues
externally or entrance of vibrating air into the oral
cavity. As in many other skills, speech production by
these techniques is learned by experience, and patients
vary widely in their ability to develop useful communica-
tion. An externally applied device will not be satisfac-
tory in a patient whose pharynx has been reconstructed
with bulky fl aps or who has undergone radiotherapy
because of the increased rigidity of the tissues and resis-
tance to vibration.
431

432
Section 3
Larynx
Shunt Formation
The fi rst laryngectomy performed by Billroth in 1874 is
said to have included the formation of a shunt by main-
taining an intact communication between the airway
and pharynx. Details of the procedure are not known,
but apparently maintenance of communication required
a prosthesis.
The desire to create a functional shunt for voice
production has led to the development of various surgi-
cal procedures since about the mid-1960s. The list of
procedures is lengthy; however, the most popular surgi-
cal shunt was the Staffi eri procedure.1 In this procedure
a mucosal shunt is created at the end of the trachea,
and a tracheostomy tube is placed through a separate
opening into the trachea. Creating a shunt large enough
to permit air to escape but not so large that it results in
debilitating aspiration was technically diffi cult, and this
procedure has fallen into disuse.
In 1980 Blom and Singer fi rst reported the use of
a prosthetic one-way valve inserted through a simple
puncture in the posterior tracheal wall.2 The one-way
valve permitted expired air to pass from the trachea
into the esophagus but prevented retrograde passage of
pharyngeal contents into the trachea (Fig. 50-2). This
technique is now the standard technique of voicing in
postlaryngectomy patients in the United States. A wide
variety of prosthesis styles, pressures, and lengths are
readily available. In Europe, the Provox prosthesis
devised by Hilger and Schouwenburg is very similar to
the Singer-Blom valve and used widely in Europe.3
THE ROLE OF THE
SPEECH-LANGUAGE PATHOLOGIST
The role of the speech-language pathologist (SLP) in
speech rehabilitation after laryngectomy must be
emphasized. Although tracheoesophageal puncture
(TEP) is straightforward, use and care of the prosthesis
and various techniques to assist voice production require
signifi cant patient instruction for optimal voicing.
Training in postlaryngectomy speech is now an integral
part of SLP training programs. In most centers, the SLP
actually inserts the prosthesis, instructs the patient in
care and insertion of the prosthesis, and details the
potential problems. In our practice, patient appoint-
ments are scheduled in tandem with a visit to the SLP.
The SLP should be intimately involved in care of the
patient from the time that the decision is made to
perform a total laryngectomy, with or without TEP. The
patient is informed by the SLP about possible complica-
tions such as yeast infection, discharge around the valve
with aspiration, and loss of the TEP with closure of the
fi stula. A brochure is helpful in educating the patient
and caregiver regarding TEP management (Fig. 50-3).
PATIENT SELECTION
Preoperative evaluation of a patient who is scheduled
to undergo total laryngectomy or who has already
undergone total laryngectomy and desires speech reha-
bilitation should include early consultation with the
SLP. The patient should be counseled on the various
means of speech production, and assessment should be
made of the patient’s ability to manage the TEP valve.
Patients who have signifi cant diffi culty with coordina-
tion, severe arthritis of the fi ngers, advanced senility, or
cognitive dysfunction are not good candidates for TEP
placement. Patients who have previously undergone
total laryngectomy and are satisfi ed with their current
methods of speech production may not wish to proceed
with TEP once the requirements for care have been
explained to them. On the other hand, every patient
undergoing total laryngectomy should be considered
Figure 50-1. Various artifi cial oscillators useful for patients after
total laryngectomy.
Figure 50-2. A tracheoesophageal puncture in place demonstrat-
ing the valve placed through an artifi cial fi stula from the trachea into
the cervical esophagus. (Redrawn from Singer MI: Voice rehabilitation. In
Cummings CW, Fredrickson JM, Harker LA, et al [eds]: Otolaryngology; Head
and Neck Surgery. St Louis, Mosby–Year Book, 1986, p 2195.)

Chapter 50
Voice Restoration after Total Laryngectomy
433
A
B
C
D
Figure 50-3. A to D, Photographs from patient brochure demonstrating how to insert a catheter into a tracheoesophageal puncture to
maintain an intact fi stula.
for TEP placement unless there are contraindications
to its performance.
There are relatively few absolute contraindications
to TEP placement aside from patient cognition and
coordination. Patients with either pharyngeal or stomal
stenosis after laryngectomy are not good candidates.
Those with stomal stenosis should undergo stomoplasty
before or at the time of performance of TEP. Voice
rehabilitation with TEP is feasible in patients who have
undergone gastric pull-up or jejunal free fl ap interposi-
tion; however, the voice is usually suboptimal.
Secondary TEP performed after delivery of radia-
tion therapy to the stoma is contraindicated because
these patients heal poorly and widening of the fi stula
occurs, occasionally to the point that surgical interven-
tion for closure of the fi stula becomes necessary.
PREOPERATIVE EVALUATION
Patients undergoing TEP at the time of total laryngec-
tomy do not require any special testing. A major diffi -
culty in the production of speech after TEP in some
cases is inappropriate contraction of the pharyngeal
musculature during phonation. Various intraoperative
techniques have been described in an attempt to dimin-
ish this diffi culty, including myotomy and myectomy,
neurectomy of the pharyngeal plexus, and chemode-
nervation with botulinum toxin.4 Perhaps the most
important factor in preventing the problem is to ensure
that the pharyngeal muscles are not reapproximated
during pharyngeal closure.
The history and physical examination remain
important parts of the evaluation of a patient for TEP.
Additional caution is warranted if the patient has pre-
viously undergone high-dose radiation therapy to the
stoma, such as those with a history of subglottic or piri-
form sinus cancer. Patients who have a history of diffi -
culty swallowing should be evaluated by barium swallow.
If a stricture is noted, the patient is not a candidate for
TEP.
Performance of an insuffl ation test (insuffl ating air
into the pharynx through a catheter placed through the
nose of the patient into the pharynx) may be useful in
determining whether the patient will be able to gener-
ate speech, but it is not an absolute requirement before
secondary TEP.
Procedures performed secondarily can be carried
out under general anesthesia with a rigid endoscope or

434
Section 3
Larynx
under local anesthesia with a fl exible esophagoscope.
The latter technique is of particular benefi t when fi bro-
sis and scarring preclude placement of a rigid endo-
scope into the esophagus. If fi brosis precludes passage
of a rigid endoscope and a fl exible esophagoscope is
not available, it is occasionally possible to use an endo-
tracheal tube placed in the cervical esophagus and visu-
alize the puncture site with a fi beroptic laryngoscope
passed through the endotracheal tube.
TECHNIQUE
Primary Tracheoesophageal Puncture
After total laryngectomy has been performed, the infe-
rior aspect of the trachea stoma is sewn to the skin.
Several 4-0 chromic catgut sutures are placed superfi -
cially between the membranous posterior wall of the
trachea and the cervical esophagus to prevent any
leakage of saliva into the visceral space of the neck. A
right-angled clamp is then inserted into the cervical
esophagus and its point pressed anteriorly against the
membranous wall of the trachea approximately 1 cm
below the posterior verge (Fig. 50-4). It is very impor-
tant to avoid placing the TEP too inferior because
replacing the valve will be diffi cult to impossible. Placing
the TEP too close to the mucocutaneous junction may
interfere with diversion of air into the trachea because
the valve may be occluded by digital pressure while
phonating. Care is taken to avoid shearing the trachea
from the esophagus and creating a dissection plane in
the region through which the right-angled clamp and
catheter will pass. Indeed, should such dissection occur,
it is probably best to abort the performance of a primary
TEP and plan a secondary procedure at a later date
after healing.
A scalpel is used to incise the mucosa directly over
the tip of the right-angled clamp, and the clamp is used
to pull a 14-gauge red rubber catheter through the
opening into the pharynx. The end of the catheter is
brought out through the pharynx and then placed in
the distal esophagus with forceps through the esopha-
goscope. A suture is used to anchor the catheter to
prevent inadvertent removal during closure of the
pharynx and formation of the stoma.
A myotomy should be performed to reduce postop-
erative muscle spasm, especially in patients with abnor-
mal insuffl ation test results. In most instances a myotomy
is most easily performed posteriorly on the pharyngeal
wall.
The red rubber catheter is replaced with a valve
prosthesis in approximately 12 to 14 days, depending
on the surgeon’s impression of wound healing and
patient progress.
Secondary Tracheoesophageal Puncture
This procedure is best performed with the patient
under general anesthesia, although local anesthesia can
be used. Recently, the use of a transnasal fl exible esoph-
agoscope has been reported to facilitate performance
of the procedure under local anesthesia in the offi ce.5
The procedure can be performed under direct visual-
ization with a tracheal incision, dilatation of the tract,
and insertion of a catheter, or the TEP prosthesis can
be inserted immediately by using a gel cap over the end
of the prosthesis.5 An alternative is to fi rst pass a guide-
wire to pull the catheter into the puncture. We prefer
the guidewire technique performed under general
anesthesia, which is the technique described here.
Under general anesthesia, the short cervical esoph-
agoscope is passed into the esophagus. The tip of the
scope can be palpated through the stoma (Fig. 50-5). If
the cervical esophagoscope cannot be passed because
of fi brosis, an endotracheal tube can occasionally be
placed through the mouth into the cervical esophagus
and a fl exible fi beroptic laryngoscope passed through
it and used for endoscopic visualization. In addition,
this technique helps protect the posterior esophageal
wall. The position of the endoscope can also be identi-
fi ed by the light shining through the posterior tracheal
wall. The cervical esophagoscope is turned 180 degrees
so that the opening at the distal beveled end of the
laryngoscope is directed anteriorly.
A
B
Figure 50-4. Primary tracheo-
esophageal puncture. A right-
angled clamp is placed in the
esophagus, and an incision is made
in the posterior wall of the trachea
over the tip of the clamp. A, A 14-
gauge red rubber catheter is
grasped and brought into the
esophagus through this opening.
B, The end of the catheter is
inserted into the distal portion of
the esophagus, and the catheter is
secured with a suture.

Chapter 50
Voice Restoration after Total Laryngectomy
435
An 18-gauge spinal needle is then inserted through
the posterior wall of the trachea at a point approxi-
mately 1 cm inferior to the posterior verge of the trachea
stoma. Palpation of the open end of the esophagoscope
(or endotracheal tube) will assist in placement of the
needle so that its tip comes to lie within the end of the
esophagoscope. Placing the needle may be diffi cult in
patients with chronic obstructive pulmonary disease as
a result of the large anterior-to-posterior diameter of
the chest. Bending the needle slightly will ease insertion
(it is important to remove the stylet before bending the
needle because it frequently cannot be removed from
the needle if the needle is bent with the stylet in place)
(Fig. 50-6).
A segment of 24-gauge stainless steel wire is then
passed through the needle into the esophagoscope
(Fig. 50-7). In most cases the wire must be grasped with
forceps and pulled up into the esophagoscope. In other
cases it will thread itself spontaneously. Eye protection
must be worn to avoid inadvertent injury to the eye of
personnel observing through the endoscope.
The needle is then withdrawn from the puncture
site and used to puncture the end of a 14-gauge red
rubber catheter. The wire is passed through the needle
and thereby threaded through the end of the catheter.
Care must be taken when attaching the wire to the
catheter to avoid leaving a protruding end that will
preclude easy passage of the catheter into the esopha-
gus or lacerate the esophageal mucosa.
With the wire held tight, a scalpel blade is used to
enlarge the opening in the tracheal mucosa (Fig. 50-8).
A hemostat is attached to the wire and pulled through
the incision into the esophagus (Fig. 50-9). When it is
certain that the tip of the hemostat is within the lumen
of the esophagus, the tips are spread so that the passage
is bluntly enlarged. Failure to enlarge the fi stula at this
Figure 50-5. Performance of a secondary tracheoesophageal punc-
ture. The esophagoscope is placed into the cervical esophagus and
rotated so that the bevel is directed anteriorly and can be palpated
with a fi nger placed through the laryngectomy stoma.
Figure 50-6. An 18-gauge spinal needle is placed through the
mucosa of the posterior tracheal wall approximately 1 cm below the
posterior verge, and its tip is directed into the end of the esophago-
scope. It is often necessary to bend the needle slightly to ease passage
of the wire.
Figure 50-7. A 24-gauge wire is passed through the needle and
brought out the end of the esophagoscope. Care must be taken to
protect the eye of the assistant when the wire is threaded up the
esophagoscope. A fi beroptic esophagoscope can also be used to
retrieve the wire.
point is the most usual cause of diffi culty in perfor-
mance of the procedure. Once it has been ascertained
that the opening is of suffi cient diameter, the wire is
used to pull the tip of the red rubber catheter through
the party wall into the esophagus and out of the mouth
(Figs. 50-10 and 50-11). The wire is then cut from the
end of the red rubber catheter. The red rubber catheter
is subsequently directed into the distal end of the
esophagus by observing through the cervical esophago-
scope and using long-cup forceps to direct the scope
distally into the esophagus (Fig. 50-12). A knot is placed
in the proximal end of the red rubber catheter to pre-
clude regurgitation of gastric contents through the
catheter. A suture is used to secure the catheter near

436
Section 3
Larynx
Figure 50-8. The puncture site must be enlarged slightly to facili-
tate passage of the red rubber catheter. This is performed by making
a small incision with a knife.
Figure 50-9. The wire is grasped with a hemostat and used to guide
the hemostat into the puncture. Spreading the hemostat slightly will
enlarge the fi stula so that the red rubber catheter can be
introduced.
Figure 50-10. A 14-gauge red rubber catheter is attached to the
wire. Care must be taken to ensure there are no protruding ends of
the wire to catch on the soft tissues.
Figure 50-11. The red rubber catheter is pulled through the
esophagoscope, and the wire is cut off.
Figure 50-12. The esophagoscope is advanced into the esophageal
lumen to push the end of the catheter inferiorly.
Figure 50-13. After verifi cation of correct positioning of the cath-
eter, a suture is used to attach the catheter to the skin of the neck to
avoid inadvertent dislodgement. A knot is placed in the catheter to
prevent regurgitation of gastroesophageal contents onto the patient’s
clothing. The catheter is fi xed to the chest with a plastic dressing.

Chapter 50
Voice Restoration after Total Laryngectomy
437
the posterior verge of the tracheal stoma (Fig. 50-13).
A plastic dressing is placed over the catheter to prevent
accidental removal of it.
POSTOPERATIVE CARE
The red rubber catheter is removed on the 12th to 14th
day for primary TEP (or the 3rd to 5th day for second-
ary procedures) and replaced with a TEP prosthesis
(Fig. 50-14). In most instances this is performed by an
SLP skilled in the management of TEP. If the stoma is
too large for digital occlusion, a prosthesis can be
created. Some patients are able to use a “hands-free”
device that closes automatically so that digital occlusion
of the stoma is not required.6 If the contour of the neck
is good, a prosthesis can be placed over the Singer-Blom
valve (Fig. 50-15). This is a “fl utter valve” that collapses
on inspiration and closes on expiration to divert air
through the Singer-Blom valve into the pharynx and
oral cavity. An adhesive is applied to allow the valve to
adhere to the skin. A number of factors affect successful
use of these devices, such as pressure requirements,
minimal expiratory restriction of airfl ow, and adequate
dexterity and cognitive function of the patient to affi x
Figure 50-14. The tracheoesophageal valve in place within the
puncture site.
Figure 50-15. A hands-free device has a fl utter valve that is fi xed
to the peristomal skin with adhesive.
the device. The SLP will instruct the patient in the
technique of using the prosthesis and continued main-
tenance of the valve.
PEARLS
• TEP is the best of the available voice restoration
strategies and should be offered to nearly all
patients at the time that they undergo total
laryngectomy.
• A trained speech-language pathologist is required to
ensure optimal rehabilitation.
• Chemodenervation of the pharyngeal muscles with
botulinum toxin will assist in voicing in some
patients with excessive pharyngeal muscle tension.
• An external valve to facilitate “hands-free” use of the
valve can be suggested for highly selected patients.
PITFALLS
• Failure to enlarge the fi stula widely enough to permit
passage of the red rubber catheter leads to breakage
of the wire and the need to start again.
• Performance of the procedure on a patient who is
unlikely to heal, such as one who has recently
received full doses of radiotherapy to the stoma or
who is severely malnourished, may lead to a large
fi stula that requires surgical closure.
• Stomal stenosis is a contraindication to the
performance of TEP. A stomoplasty must be
performed fi rst (see Chapter 72) and allowed to heal
before performance of TEP.
• Stenosis of the pharynx is a relative contraindication
to TEP. Treatment of the stenosis should be carried
out before TEP.
• If the TEP becomes dislodged and cannot be
replaced, the patient must be instructed to return
quickly for replacement or the fi stula may close.
References
1. Staffi eri M, Serafi ni I: La riabilitazione chirirgica della voce er
della respirazione dopo larinjectomia totale. Twenty-ninth National
Congress of the Associazione Otologi Ospedaliere Italiana.
Bologna, Associazione Otologi Ospedaliae Italiana, 1976, p 57.
2. Singer MI, Blom ED: An endoscopic technique for voice restora-
tion after total laryngectomy. Ann Otol Rhinol Laryngol 89:529-
533, 1980.
3. Hilgers FJ, Schouwenburg PF: A new low-resistance, self-retaining
prosthesis (Provox) for voice rehabilitation after total laryngec-
tomy. Laryngoscope 100:1202-1207, 1990.
4. Lewin J, Bishop-Leone J, Forman A, Diaz E: Further experience
with Botox injection for tracheoesophageal speech failure. Head
Neck 23:456-460, 2001.
5. Bach K, Postma G, Koufman J: In-offi ce tracheoesophageal punc-
ture using transnasal esophagoscopy. Laryngoscope 113:173-176,
2003.
6. Roxburgh J, Perry A: Use of a “hands-free” tracheostoma valve in
patients with laryngectomy and tracheoesophageal puncture. Ann
Otol Rhinol Laryngol 113:565-570, 2004.

Chapter 51
Closure of Tracheoesophageal Fistula
Eugene N. Myers
Speech restoration is of great signifi cance for the social
and economic welfare of patients who undergo total
laryngectomy.1 More than 80% of patients with a tra-
cheoesophageal voice prosthesis develop intelligible
speech.2-4 Voice restoration with tracheoesophageal
puncture (TEP) is superior in quality to esophageal
speech or electrolarynx.
Discussion of the management of speech produc-
tion has been focused on the methods of rehabilita-
tion.5 Although most patients do well with their
tracheoesophageal speech, there are certain problems
associated with the valve:
• Yeast infection of the valve
• The valve dropping out or being coughed out
• Spontaneous closure of the fi stula following loss of
the valve
• Aspiration of the valve into the tracheobronchial
tree
• Leakage of saliva and food into the tracheobronchial
tree
• Aspiration pneumonia from severe leakage, which
could be life-threatening in patients with preexisting
chronic lung disease1
• Lack of patient acceptance of the valve
PATIENT SELECTION
The absolute indication for closure of the TEP is severe
leakage with aspiration. Most salivary leakage responds
to conservative measures such as reduction in the size
of the valve to allow shrinkage of the fi stulous tract.
Cauterization of the fi stula has also been used to
promote shrinkage of the tract.6 Another indication for
surgical closure of a TEP is poor voicing. This problem
may be caused by spasm of the cricopharyngeus muscle
or pharyngeal stenosis. Treatment for this condition
includes the following:
• Botox injection
• Cricopharyngeal myotomy
• Cervical neurectomy
• Pharyngoplasty for pharyngeal stenosis
I have also encountered a few patients who have
none of the above problems but simply wanted the
fi stula closed because they either did not like the idea
of a fi stula and the valve or just did not like their
voice.
I have been doing primary TEPs at the time of total
laryngectomy since shortly after the introduction of the
Singer Blom valve.7 I try to carefully select out the
patients who I feel would not succeed with a Singer
Blom valve, such as those who have poor manual dexter-
ity (e.g., rheumatoid arthritis), low level of motivation,
chronic brain syndrome, and inability to maintain the
prosthesis.
Patients who are candidates for closure of the TEP
should be counseled by the speech language patholo-
gist about the use of alternative methods of communi-
cation, such as the electrolarynx or esophageal speech.
The stoma should be carefully examined. Several issues
should be resolved, including the size of the stoma and
the location of the TEP. Also, the stoma must be exam-
ined to determine whether it has been heavily
radiated.
If the stoma is quite small, then stomaplasty should
be included at the time of the closure of the TEP. I have
described the techniques of stomaplasty, which include
creation of a small local fl ap in the superior aspect of
the stoma.8 If the size of the fi stula is quite large or the
TEP is located superiorly near the cutaneous junction,
then stomaplasty with a fl ap is not feasible. Patients who
have a stoma that has been heavily radiated present a
unique problem. These patients do not tend to do well
when stomaplasty is performed and have marked diffi -
culty in healing.
439

440
Section 3
Larynx
PREOPERATIVE PLANNING
Patients whose only problem is leakage do not require
any special testing. Patients who have requested closure
of the TEP due to diffi culty in voicing or swallowing
should have an esophagram to evaluate the pharynx
and esophagus, but not with barium to avoid aspiration
of the barium into their lungs.
SURGICAL TECHNIQUE
The procedure9 may be performed under local or
general anesthesia. The patient is prepared and draped
in the usual manner. The area that surrounds the supe-
rior aspect of the tracheostoma is infi ltrated with 1%
lidocaine with epinephrine 1:100,000. An incision is
made in the mucocutaneous junction of the tracheal
stoma from the 9-o’clock to the 3-o’clock position (Fig.
51-1). The posterior wall of the trachea is undermined
inferiorly and separated from the esophagus down to
and beyond the tracheoesophageal fi stula (Fig. 51-2).
The tracheoesophageal tract is divided and the mucosa
of the esophagus is closed with inverted interrupted
sutures using 4-0 absorbable Vicryl on a P-2 (small
circle) lacrimal needle (Figs. 51-3 and 51-4). A multiple-
layer closure of the esophageal fi stula is carried out to
prevent leakage. Subsequently, the mucosa of the tra-
cheal lumen is freshened and closed with everted
sutures in a single layer with the same suture material.
After the complete closure, the stomal incision is closed
without a drain. The patient begins a puréed diet on
the same day.
Rosen and colleagues1 describe a technique for
closure of TEP, which is performed under general anes-
thesia with a small fl exible endotracheal tube. A 34F
dilator is introduced into the esophagus to elevate the
tracheoesophageal party wall. A circumferential circu-
lar incision is made in the tracheal mucosa 2 to 3 mm
lateral to the fi stula. The tracheal mucosa is under-
Skin incision
TE fistula
Stoma
Figure 51-1. Incision from the 9-o’clock to the 3-o’clock position
at the mucocutaneous junction. (Reprinted with permission from Hosal
SA, Myers EN: Closure of tracheoesophageal puncture site. Head Neck 23:215,
2001.)
Stoma
Membraneous wall
of the trachea
TE fistula
Esophagus
Skin incision
Figure 51-2. Exposure of the fi stula. (Reprinted with permission from
Hosal SA, Myers EN: Closure of tracheoesophageal puncture site. Head Neck
23:215, 2001.)
Stoma
Membraneous wall
of the trachea
TE fistula
Esophagus
Skin incision
Figure 51-3 Division of the fi stula. (Reprinted with permission from
Hosal SA, Myers EN: Closure of tracheoesophageal puncture site. Head Neck
23:215, 2001.)
Stoma
Membraneous
wall of the
trachea
Mucosal closure
Esophagus
Skin incision
Figure 51-4. Closure of the tracheal and esophageal mucosa.
(Reprinted with permission from Hosal SA, Myers EN: Closure of tracheo-
esophageal puncture site. Head Neck 23:215, 2001.)

Chapter 51
Closure of Tracheoesophageal Fistula
441
mined toward the center of the fi stula and then inverted
into the esophageal lumen and sutured closed. A tra-
cheal mucosal fl ap is created. A 3- × 3-cm thin dermis
graft from the thigh is trimmed to size and sutured in
to resurface the trachea.
Issing and associates10 followed up on 103 patients
with total laryngectomy and voice rehabilitation, 3 of
whom eventually required closure of the TEP because
of severe leakage. The authors state that the TEP was
closed with muscle skin fl aps but details of the surgical
technique were not described. Annyas and colleagues11
described a technique in which an interposition dermal
graft was placed between the trachea and the esophagus
with separate skin incisions just superior to the stoma.
POSTOPERATIVE MANAGEMENT
The patients are usually discharged the day of the
surgery. The patient is encouraged to keep the area of
the stoma clean and apply antibiotic ointment to the
incision. The patient is encouraged to eat a puréed diet
for 1 week and then progress to a normal diet over the
next few weeks.
References
1. Rosen A, Scher N, Panje WR: Surgical closure of persisting failed
tracheoesophageal voice fi stula. Ann Otol Rhinol Laryngol
106:775-778, 1997.
2. Blom ED, Singer MI, Hamaker RC: A prospective study of tra-
cheoesophageal speech. Arch Otolaryngol Head Neck Surg
112:440-447, 1986.
3. Singer MI, Blom ED, Hamaker RC: Further experience with voice
restoration after total laryngectomy. Ann Otol Rhinol Laryngol
90:498-502, 1981.
4. Wetmore SJ, Johns ME, Baker SR: The Singer-Blom voice restora-
tion procedure. Arch Otolaryngol 107:674-676, 1981.
5. Eibling DE: Voice restoration following total laryngectomy. In
Myers EN (ed): Operative Otolaryngology—Head and Neck
Surgery, 1st ed. Philadelphia, WB Saunders, 1997, pp 444-455.
6. Ward PH, Andrews BC, Mickel RA, et al: Complications of medical
and surgical approaches to voice restoration after total laryngec-
tomy. Head Neck Surg 10(suppl II):124-128, 1988.
7. Singer MI, Blom ED, Hamaker RC: Voice rehabilitation following
laryngectomy. In Myers EN, Suen JY (eds): Cancer of the Head
& Neck, 2nd ed. New York, Churchill Livingstone, 1989, pp
593-620.
8. Myers EN, Gallia L: Tracheostomal stenosis after total laryngec-
tomy. Ann Otol Rhinol Laryngol 91(4 pt 1):450-453, 1982.
9. Hosal SA, Myers EN: Closure of tracheoesophageal puncture site.
Head Neck 23:214-216, 2001.
10. Issing WJ, Fuchshuber S, Wehner M: Incidence of tracheo-
oesophageal fi stulas after primary voice rehabilitation with the
Provox or the Eska-Herrmann voice prosthesis. Eur Arch Otorhi-
nolaryngol 258:240-242, 2001.
11. Annyas AA, Escajadillo JR: Closure of tracheoesophageal fi stulas
after removal of the voice prosthesis. Laryngoscope 94:1244-1245,
1984.
PEARLS
• Patients who have been heavily radiated should have
the procedure described above, but muscle should
be interposed between the trachea and esophagus
because the radiation interferes with healing and an
even larger fi stula may be produced.
• Patients should maintain a puréed diet in the near
term to help with healing.
• Patients need to be counseled about alternative
methods of communication such as the
electrolarynx and esophageal speech.
• Conservative measures of closure for salivary leakage
should be tried before surgical closure.
• Efforts to improve voicing by Botox should be
exhausted before closing the TEP in patients who
are dissatisfi ed with their voice.
PITFALLS
• Patients with a mild degree of diffi culty in voicing
may also be dissatisfi ed with closure because then
they will have no voice at all.
• Patients who have had heavy radiation to the stoma
have a major risk of not healing and may require
major reconstructive surgery if this is carried out.
• Patients should not return to a regular diet
immediately because this may disrupt the wound.
• Every effort should be made to ensure proper
patient selection so that the degree of satisfaction
with the valve is as high as possible.

section 4
Hypopharynx and
Cervical Esophagus
Chapter 52
Esophagoscopy
Ryan J. Soose and Ricardo L. Carrau
HISTORICAL BACKGROUND
The fi rst reported attempt to examine the esophagus is
attributed to Bozzini, who in 1809 attempted to examine
the upper esophagus by placing a mirror in the throat.1
Recognizing the need for an instrument that could
keep the esophageal lumen widely open, other sur-
geons used different hollow tubes. Most devices used
mirrors to compensate for the angulation necessary to
pass the instrument through the mouth into the esoph-
agus. The fi rst straight esophagoscope was a urethro-
scope, used in 1868 by Kussmaul, who also described
the correct head position to pass the endoscope after
learning it from observing a sword swallower.2 Never-
theless, it was not until the early 1900s that Chevalier
Jackson invented an instrument similar to what is known
today as a rigid esophagoscope. Even more importantly,
Jackson standardized the technique and safe use of the
instrument by emphasizing training in the laboratory
before the operator was permitted to use the technique
on human subjects.3
During the late 1930s, bronchoesophagologists
adopted the use of fi beroptic illumination systems,
which made the instruments more effective.4 Flexible
endoscopes were introduced during the 1960s and,
along with further advances in fi beroptic systems, micro-
instrumentation, and lasers, expanded the role of
esophagoscopy in the diagnosis and treatment of dis-
eases of the esophagus. The transnasal esophagoscope,
which does not require intravenous sedation, was
designed in the 1990s. This instrument allows a quick
offi ce examination that is generally well tolerated and
has diagnostic accuracy comparable to that of conven-
tional esophagogastroduodenoscopy.5,6
ANATOMY
The endoscopist should be familiar with the “superfi -
cial” anatomy of the esophagus. The cervical esophagus
is curved to the left, whereas the thoracic esophagus is
convex toward the right, where it comes in contact with
the aorta and left main stem bronchus.7,8 In adults, the
esophagus starts at the level of the cricopharyngeus
(upper esophageal sphincter), ends at the cardia (lower
esophageal sphincter), and measures approximately
22 cm in length. The endoscopist, therefore, usually
advances the instrument 38 cm from the incisors before
the cardia is reached. As the instrument is advanced,
several constricting points are encountered: the crico-
pharyngeal sphincter (16 cm from the incisors), the left
main stem bronchus (27 cm from the incisors), and the
gastroesophageal junction (38 cm from the incisors).
The cricopharyngeal sphincter is the narrowest point
and is the area at highest risk for injury or perforation
(Fig. 52-1).
443

444
Section 4
Hypopharynx and Cervical Esophagus
INDICATIONS
Rigid or fl exible esophagoscopy is most commonly used
as a diagnostic tool for the evaluation of suspected
tumors, trauma, strictures, or benign infl ammatory con-
ditions (e.g., gastroesophageal refl ux).
Esophagoscopy may also be used as a surgical
approach for dilatation of webs or strictures under
direct visualization with or without placement of endo-
luminal stents, as well as for biopsy, removal of foreign
bodies, myotomy of the cricopharyngeal muscle for
Zenker’s diverticulum (i.e., Dohlman’s procedure or
endoscopic stapling), tracheoesophageal puncture, and
palliative laser excision of obstructing tumors.
PATIENT EVALUATION
Recommendations for esophagoscopy are usually based
on a thorough history and physical examination with
emphasis on the affected area (e.g., upper aerodigestive
tract and chest). Fundamental factors in formulating
a differential diagnosis include the age of the patient;
the onset, duration, and progression of the dysphagia
or pain; and associated symptoms such as postnasal
drip, hoarseness, neck masses, cough, hemoptysis,
refl ux, and heartburn. Risk factors such as alcohol or
tobacco use should be noted. A past history regarding
neck surgery (e.g., cervical spine fusion), chest or
abdominal surgery (e.g., mediastinal surgery or surgery
to correct gastroesophageal refl ux), or the presence of
diverticula is important for surgical planning.
The physical examination should include evalua-
tion of factors that infl uence passage of the instrument,
such as the status of the dentition and the range of
motion of the neck and mandible. Flexible pharyngo-
laryngoscopy is recommended as part of the offi ce
examination for all patients with swallowing problems
related to the pharynx or cervical esophagus (Fig. 52-2).
Besides providing direct visualization of the anatomy,
the fl exible laryngoscope allows dynamic evaluation of
the pharyngeal phase of swallowing.
In addition to the clinical examination and
fl exible pharyngolaryngoscopy, a preoperative contrast-
enhanced esophagogram is helpful in patients whose
symptoms suggest esophageal dismotility, a stricture, or
a pulsion diverticulum. Contrast-enhanced esophagog-
raphy complements esophagoscopy for the diagnosis of
these conditions and other anatomic abnormalities
(Fig. 52-3). A contrast-enhanced esophagogram is also
recommended for patients with high-risk factors for
cancer (i.e., alcohol and tobacco use) and those whose
symptoms suggest neoplasia. A chest radiograph should
likewise be part of the diagnostic evaluation of patients
in this category.
Incisors
Hyoid bone
Cricoid upper
esophageal sphincter
Thoracic inlet
Aorta
Diaphragm
Gastroesophageal
junction
16 cm
19 cm
23 cm
38 cm
40 cm
Figure 52-1. Surgical landmarks
during esophagoscopy. (Redrawn
from Lee KJ: Essential Otolaryngology:
Head and Neck Surgery, 8th ed. New
York, McGraw-Hill, 2003.)
E
O
Figure 52-2. A cervical osteophyte (O) displacing the epiglottis
anteriorly (E).

Chapter 52
Esophagoscopy
445
An esophagogram may also help identify radiolu-
cent foreign bodies not visualized on plain fi lms. Barium
is usually recommended as a contrast material except
when injury to the esophagus with possible leakage is
suspected. In these circumstances we prefer a water-
soluble contrast agent because it will not induce the
foreign body reaction associated with extravasation of
barium into soft tissue. Conversely, water-soluble agents,
especially meglumine diatrizoate (Gastrografi n), can
induce a severe infl ammatory reaction when aspirated
into the lower respiratory tract; consequently, water-
soluble agents are contraindicated when aspiration or
tracheoesophageal fi stula is suspected.
Preoperative preparation requires minimal effort.
The patient is given H2-blockers or a proton pump
inhibitor to increase gastric pH (decrease the acidity)
and diminish the possibility of gastroesophageal refl ux
and may be given an anticholinergic agent to curtail
oropharyngeal secretions. Patients with cardiac valve
disease are treated with systemic prophylactic antibiot-
ics to protect them against bacterial endocarditis.
SURGICAL TECHNIQUE
Flexible Versus Rigid Esophagoscopy
Whether to use a fl exible or rigid esophagoscope
depends mainly on the surgeon’s preference, the
purpose of the esophagoscopy, and the general condi-
tion of the patient. As a general rule, a rigid esophago-
scope is more useful in evaluating the cervical esophagus
because this area has multiple folds that can hide
pathology and may not be easy to insuffl ate to allow
inspection with a fl exible instrument; therefore, fl exi-
ble esophagoscopy, transoral or transnasal, can miss
tumors at the distal pharyngeal, postcricoid, and crico-
pharyngeal areas. Rigid esophagoscopy is better for
evaluation of these areas.9 In addition, a rigid scope
allows the use of larger suction cannulas and surgical
instruments, thereby facilitating manipulation and
removal of large foreign bodies under direct
visualization.
Flexible esophagoscopy improves visualization of
the gastroesophageal junction and allows instrumenta-
tion in patients with severe limitation of range of motion
of the neck (e.g., cervical spine fusion, rheumatoid
arthritis) or other anatomic problems (e.g., osteo-
phytes).4 Transoral fl exible esophagoscopy is performed
with the patient under topical anesthesia and sedation,
whereas transnasal esophagoscopy (TNE) is performed
with topical anesthesia only. TNE is more suitable as an
“offi ce” procedure because it does not require an obser-
vation area.10,11 Flexible esophagoscopy, transoral or
transnasal, is preferred for patients who cannot tolerate
general anesthesia. Because TNE avoids general anes-
A
C
B
Figure 52-3. A, Barium esopha-
gogram demonstrating a Zenker
diverticulum. B, Barium esophago-
gram of a patient with dysphagia
and a large anterior cervical
osteophyte
(arrow).
C, Barium
esophagogram demonstrating an
esophageal web (arrow).

446
Section 4
Hypopharynx and Cervical Esophagus
thesia or conscious sedation, it may improve patient
safety, enhance practice effi ciency, and reduce overall
health care costs.12
Anesthesia
The choice of anesthesia is infl uenced by the patient’s
general condition, psychological profi le, potential for
aspiration, and need for instrumentation. For example,
diagnostic rigid esophagoscopy to rule out a second
primary tumor can be performed under either apnea
or monitored anesthesia care (MAC) with a superior
laryngeal nerve block (“direct laryngoscopy”). Con-
versely, general anesthesia with endotracheal intuba-
tion is needed for retrieval of a foreign body from the
thoracic esophagus, which may require complex instru-
mentation and protection of the airway from aspiration.
Severe trismus or limitation of range of extension of the
neck (e.g., in patients with cervical spine fusion) restricts
passage of a rigid esophagoscope. Communication
with the anesthesiologist is fundamental to prevent
complications.
Instrumentation
Rigid esophagoscopes are available in a variety of
lengths, diameters, and shapes to suit different pur-
poses. The design of surgical instruments and suction
tips has also followed this principle, and a special instru-
ment (e.g., to retrieve a foreign body) can even be fab-
ricated to one’s own specifi cations within a reasonable
time (Fig. 52-4). Likewise, transnasal esophagoscopes
are available in a variety of lengths and diameters, and
they may offer channels for insuffl ation, suction, and
instrumentation. Their degrees of fl exibility and there-
fore the ability to retrofl ex and examine the cardia
also vary.
Technique of Rigid Esophagoscopy
After induction of anesthesia or after sedation (MAC)
and topical anesthesia, the patient is placed supine with
the neck in a neutral position. Extension of the neck
increases the natural lordosis of the cervical spine and
thus increases the diffi culty of passing a rigid esopha-
goscope. The teeth are protected with a tooth guard or
wet surgical sponges (Fig. 52-5). The endoscope is held
between the thumb and index fi nger of the nondexter-
ous hand (e.g., left hand for a right-handed surgeon),
and the third fi nger is used to open the mouth and
support the endoscope over the incisors (Fig. 52-6).
The tip of the endoscope is introduced into the oral
cavity and advanced over the tongue to the posterior
pharyngeal wall. The instrument then passes along the
posterior pharyngeal wall into the hypopharynx, with
the angle of entry changed from 90 degrees to an angle
parallel to the pharyngoesophageal tract (Fig. 52-7).
The instrument is advanced under direct visualization
with the thumb of the nondexterous hand. The other
hand is used only to change the angle of entry, thus
preventing undue pressure over the walls of the esopha-
gus (see Fig. 52-6). A blunt-tipped suction catheter is
used as necessary to remove secretions that impair iden-
A
B
Figure 52-4. A, Esophagoscopes and suction cannulas. These
instruments are available in a wide range of widths and lengths. B,
Esophagoscopy forceps. From top to bottom are forceps with serrated
edges, cup forceps, and alligator forceps. A cup forceps is most suit-
able for biopsies, whereas the other two are most useful for the
retrieval of foreign bodies.
tifi cation of the lumen and inspection of the walls of
the pharynx and esophagus. Occasionally, the operator
will encounter diffi culty passing the esophagoscope
through the cricopharyngeal sphincter. Administration
of muscle relaxants, defl ation of the endotracheal cuff,
and the use of an esophagoscope with a smaller diame-
ter generally resolve this problem. Alternatively, the
upper esophageal sphincter may be dilated with a
balloon dilator to facilitate passage of the scope. As a
general rule, the instrument is passed down to the gas-
troesophageal junction and then retrieved slowly while
the walls of the esophagus are inspected.
It is best to biopsy suspicious lesions at the end of
the procedure to prevent blood from obscuring the
fi eld. Obtaining an adequate specimen requires multi-
ple biopsies, including the interface between the sus-
pected lesion and normal mucosa (biopsy of the center
of a tumor often yields necrotic tissue).
Technique of Transnasal Esophagoscopy
The patient is kept in a sitting or reclined position
(head of the bed raised 45 degrees), and the nose is
sprayed with 4% lidocaine and 0.05% oxymetazoline.
After the nose is decongested, cotton pledgets with
0.5% tetracaine (Pontocaine) are placed bilaterally for
5 to 10 minutes. Ten milliliters of 2% gel lidocaine is
administered by mouth for gargling and swallowing to

Chapter 52
Esophagoscopy
447
anesthetize the pharynx. The fl exible esophagoscope is
then passed transnasally through the widest nasal cavity
and advanced into the pharynx to assess the laryngo-
pharyngeal segment. Passage from the pharynx into the
esophagus is facilitated by having the patient burp,
which opens the upper esophageal sphincter. Alterna-
tively, the patient can be asked to sustain an “ee” sound,
which contracts the larynx and exposes the apex of the
piriform sinuses. The scope is advanced into the apex
of the left piriform sinus and the patient is asked to
swallow. The scope is then passed into the esophagus
as the patient swallows. After evaluating the lower
esophageal sphincter and gastroesophageal junction, it
is advanced into the stomach and then retrofl exed to
examine the gastric cardia. Insuffl ation should be kept
to a minimum. The esophageal walls are again exam-
ined as the scope is retrieved.
POSTOPERATIVE CARE
Rigid or transoral esophagoscopy is generally performed
in an outpatient or same-day surgery setting. Patients
are observed for several hours, during which clear
liquids are administered. Dysphagia, odynophagia,
chest pain, or tachycardia may indicate perforation of
the pharynx or esophagus, which must be addressed
urgently (see “Complications”). If recovery is unevent-
ful, the patient is discharged home with instructions to
return to the hospital if any of the aforementioned
problems are noted.
Figure 52-5. The patient is placed in the supine position with the
head in a neutral position. A common mistake is to try to perform
esophagoscopy with the head in an extended position (as for direct
laryngoscopy). The extended neck exaggerates the normal lordosis
of the cervical spine and makes passage of the esophagoscope more
diffi cult. In fact, the esophagoscope is sometimes easier to advance if
the neck is fl exed when the instrument passes the upper esophageal
sphincter.
Figure 52-6. The thumb of the left hand is used as a fulcrum for
the instrument to prevent pressure over the incisors and is used to
advance the instrument. The right hand is never used to force passage
of the instrument; rather, it is used only to guide the esophagoscope
by changing the angle of entry.
Figure 52-7. Insertion of the esophagoscope. The tip of the instru-
ment is advanced over the posterior pharyngeal wall. The base of the
tongue and the larynx are displaced anteriorly until the axis of the
endoscope is parallel to the longitudinal axis of the lumen.

448
Section 4
Hypopharynx and Cervical Esophagus
COMPLICATIONS
The most common complications of esophagoscopy
include injury to the upper aerodigestive tract and
aspiration of esophagogastric fl uid, oral secretions, or
blood. Faulty technique can lead to a wide variety of
dental trauma ranging from a chipped tooth to fracture
or even complete avulsion of a tooth. A chipped tooth
may require elective repair by a cosmetic odontologist.
Fracture of a tooth may threaten the viability of the
tooth and warrants urgent evaluation by a dentist. Avul-
sion of a healthy tooth should be rare. An avulsed tooth
should not be replaced into the socket until the endos-
copy has been completed, because a loose tooth can
dislodge and be aspirated into the airway. After esopha-
goscopy, the tooth can be replaced in the socket and
secured in place with interdental wire or wire-acrylic
fi xation. The patient is referred for assessment of the
viability of the tooth and possible endodontic treat-
ment. Poor dentition as a result of severe periodontal
disease or advanced caries is a contraindication to this
technique, because the viability of the teeth is already
compromised and the prognosis for reimplantation is
poor.
Perforation of the esophagus during esophagos-
copy is most common during therapeutic procedures
such as dilatation or during evaluation, biopsy, or de -
bulking of malignant tumors. To avoid this complica-
tion, the surgeon should never force passage of the
esophagoscope through a signifi cant stricture or
through tumor that involves the circumference of the
esophagus. Judicious use of lumen fi nders, guidewires,
and fi liform dilators helps identify the lumen and dilate
strictures. The surgeon should maintain a high index
of suspicion during these procedures or if unusual
diffi culty is encountered during the case (e.g., cervical
osteophytes). Bleeding from the esophageal mucosa is
a defi nite sign of injury (or friable neovascularization
associated with neoplasia) and should increase the
operator’s awareness.
If a perforation is suspected, intravenous antibiotics
with broad-spectrum coverage of the fl ora of the upper
aerodigestive tract should be administered immediately
(e.g., clindamycin). The esophageal procedure should
be terminated, but a nasogastric tube can be passed
under direct visualization, and if necessary, direct laryn-
goscopy can be completed. The surgeon and the anes-
thesiologist should evaluate the patient for signs of
pleural injury, such as subcutaneous emphysema, dimin-
ished breath sounds, high ventilatory peak pressure, or
increased CO2 in exhaled air. If any of these signs is
detected, a chest radiograph should be obtained in the
operating room to rule out pneumothorax. If fi ndings
on clinical examination are negative, the patient may
be transferred to the recovery room, where a chest
radiograph is taken. When the patient is fully awake, an
esophagogram enhanced with Gastrografi n is per-
formed to rule out a leak (Fig. 52-8).
Small leaks from the pharynx or cervical esophagus
may be managed conservatively by leaving a nasogastric
tube in place, restricting oral intake, and continuing
the intravenous antibiotics and H2-blockers or proton
pump inhibitors. Large leaks, such as those produced
when the esophagoscope is passed transmurally into a
false lumen, should be explored and repaired as soon
as possible (see Chapter 53). Leaks at the thoracic level
are better managed in consultation with an experienced
thoracic surgeon because they usually require explora-
tion and repair and often necessitate diversion proce-
dures (e.g., cervical esophagostomy).
Aspiration of gastroesophageal contents is more
common in patients with complete obstruction of the
esophagus secondary to foreign bodies, strictures, or
neoplasms and in patients with impaired consciousness
(e.g., alcohol intoxication, stroke). The airway of these
patients should be protected by endotracheal intuba-
tion, but before intubation is attempted, the pharynx
should be thoroughly suctioned and digital pressure
maintained over the cricoid cartilage to prevent
regurgitation
of
esophageal
contents
into
the
laryngopharynx.
Other intraoperative complications, such as arrhyth-
mia or changes in blood pressure, are generally second-
Figure 52-8. Gastrografi n esophagogram, lateral view, demonstrat-
ing an esophageal perforation (arrow) with extravasation of contrast
material into the mediastinum.

Chapter 52
Esophagoscopy
449
ary to vasovagal refl exes and may be self limited.
Removal of the instrument is usually helpful in stopping
the arrhythmia. If the arrhythmia is repetitive or if
the patient experiences hemodynamic compromise,
intravenous atropine or glycopyrrolate should be
administered.
References
1. Kelly HDB: President’s address: Origins of oesophagology. Proc
R Soc Med 62:781-786, 1968.
2. Staffel JG, Pillsbury HC: The rigid esophagoscope: A new handle
on an old problem. Otolaryngol Head Neck Surg 105:483-486,
1991.
3. Boyd AD: Chevalier Jackson: The father of American broncho-
esophagoscopy. Ann Thorac Surg 57:502-505, 1994.
4. Bacon CK, Hendrix RA: Open tube versus fl exible esophagoscopy
in adult head and neck endoscopy. Ann Otol Rhinol Laryngol
101:147-155, 1992.
5. Shaker R: Unsedated trans-nasal pharyngoesophagogastroduode-
noscopy (T-EGD): Technique. Gastrointest Endosc 40:346-348,
1994.
6. Dean R, Dua K, Massey B, et al: A comparative study of unsedated
transnasal esophagogastroduodenoscopy and conventional EGD.
Gastrointest Endosc 44:422-424, 1996.
7. Hollinshead WH: Anatomy for Surgeons, vol 1: The Head and
Neck, 3rd ed. Philadelphia, Harper & Row, 1982.
8. Lee KJ (ed): Essential Otolaryngology: Head and Neck Surgery,
4th ed. New York, Medical Examination, 1987.
9. Ritchie AJ, McManus K, McGuigan J, et al: The role of rigid
oesophagoscopy in oesophageal carcinoma. Postgrad Med J
68:892-895, 1992.
10. Postma GN, Bach KK, Belafsky PC, et al: The role of transnasal
esophagoscopy in head and neck oncology. Laryngoscope
112:2242-2243, 2002.
11. Postma GN, Cohen JT, Belafsky PC, et al: Transnasal esophagos-
copy: Revisited (over 700 consecutive cases). Laryngoscope
115:321-323, 2005.
12. Aviv JE: Transnasal esophagoscopy: State of the art. Otolaryngol
Head Neck Surg 135:616-619, 2006.
PEARLS
• Esophagoscopy continues to be a reliable diagnostic
and therapeutic tool with a wide variety of
applications, including biopsy, dilatation of
strictures, repair of Zenker’s diverticulum, placement
of stents, and retrieval of foreign bodies.
• Both rigid and fl exible esophagoscopic techniques
are available, each with their respective indications,
advantages, and disadvantages.
• Transnasal esophagoscopy is rapidly becoming
common practice in the outpatient otolaryngology
offi ce and offers the primary advantage of avoiding
general anesthesia or conscious sedation.
• Administration of muscle relaxants, defl ation of the
endotracheal tube cuff, and the use of a smaller-
diameter esophagoscope can facilitate passage of
the esophagoscope through the cricopharyngeus.
• Anatomic limitations, such as cervical spine fusion,
rheumatoid arthritis, and osteophytes, may prohibit
safe rigid esophagoscopic examination and are
often an indication for fl exible esophagoscopy.
PITFALLS
• The risk of esophageal perforation is generally higher
with therapeutic interventions such as dilatation of a
stricture or removal of a tumor or complex foreign
body.
• During rigid esophagoscopy, the upper/dexterous
hand is used only to change the angle of the scope
and never to push or force the instrument through
an area of resistance.
• Extension of the neck increases the natural lordosis
of the cervical spine and may therefore increase the
diffi culty of passing the rigid esophagoscope.
• The postcricoid or cricopharyngeal area is often not
well visualized by fl exible esophagoscopy, and thus
small tumors in this area may be missed by
transnasal esophagoscopy.
• Performing the biopsy before the end of the
procedure may obscure the surgeon’s vision with
blood for the remainder of the esophagoscopy.

Chapter 53
Penetrating Trauma to the Hypopharynx
and Cervical Esophagus
Ryan J. Soose and Ricardo L. Carrau
The most common mechanisms of penetrating trauma
to the hypopharynx and cervical esophagus are civilian
violence and iatrogenic injuries, which include peroral
instrumentation (i.e., esophagoscopy, dilatation, biopsy,
transesophageal echocardiography), as well as anterior
cervical spine surgery.
Iatrogenic trauma is the most common cause of
perforation of the hypopharynx and cervical esopha-
gus. Transcervical penetrating injuries to the hypophar-
ynx and esophagus are less frequent. However, escalating
civilian violence has led to an increased incidence of
penetrating injuries to the neck.
EVALUATION AND DIAGNOSIS
Iatrogenic Trauma
Iatrogenic pharyngoesophageal trauma is a rare, but
potentially life-threatening complication of multiple
surgical procedures. Such injuries to the hypopharynx
or cervical esophagus can be broadly categorized into
those resulting from either endoscopic procedures or
open surgical approaches to the neck. The latter pri-
marily consists of anterior cervical spine surgery, and
perforation can occur immediately during the cervical
spine surgery or may be delayed months to years after
the initial operation.
The incidence of perforation of the cervical
pharyngoesophageal segment during diagnostic rigid
endoscopy varies from 0.1% to 1%.1 The incidence is
higher when these procedures are associated with other
instrumentation, such as that used for dilatation, biopsy,
or retrieval of foreign bodies. Underlying esophageal
disease, such as a Zenker diverticulum, malignancy,
malnutrition, stricture, and previous radiation therapy,
may also increase the risk for endoscopic injury.2 The
injury is usually identifi ed—or at least suspected—
during the procedure or immediately after. The diag-
nosis is corroborated and treatment is initiated sooner
than in patients with transcutaneous injuries, thereby
leading to a better outcome.
Patients with subcutaneous emphysema, pneu-
momediastinum, neck pain, dysphagia, odynophagia,
unexplained fever, or tachycardia after endoscopy
should be evaluated to rule out perforation. A chest
radiograph is essential to confi rm free air in the subcu-
taneous area, mediastinum, or thorax. Imaging of the
esophagus with water-soluble contrast material is the
preferred method to evaluate a suspected perforation
of the hypopharynx or esophagus. Extravasation of a
water-soluble contrast agent is quickly cleared by tissues,
and thus less infl ammation is produced than when
barium is used. The sensitivity of these studies varies
considerably; for a meglumine diatrizoate (Gastrogra-
fi n) swallow, it ranges from 75% to 100%.3
Perforation of the esophagus has been well
described as a complication of the anterior cervical
spinal approach, with a reported incidence ranging
between 0.02% and 1.49%.4-6 Such perforations can be
noted during surgery, in the immediate postoperative
period, or years after the original spine surgery.7,8 Trans-
mural perforations are the most serious type because
they allow esophageal bacteria to invade an otherwise
sterile fi eld. Injuries to the serosa are fairly common
and are generally of little consequence, other than con-
tributing to postoperative dysphagia.
During surgery the spine surgeon may be con-
cerned that a direct, transmural esophageal injury has
occurred. If the surgeon is confi dent that a signifi cant
injury has taken place, an otolaryngologist should be
consulted immediately for assistance and confi rmation.
If a tear is suspected intraoperatively, a diluted solution
451

452
Section 4
Hypopharynx and Cervical Esophagus
of methylene blue may be irrigated into a nasogastric
tube with a distally placed Foley catheter.9 Should
the methylene blue leak into the surgical wound, a
transmural injury has been identifi ed and appropriate
therapy should be instituted. Alternatively, the surgeon
may use other colored fl uid such as povidone-iodine. If
an esophageal perforation is suspected postoperatively,
a Gastrografi n swallow should be performed immedi-
ately to confi rm the diagnosis and avoid a delay in
treatment.
Other types of iatrogenic trauma, such as perfora-
tion of the hypopharynx during endotracheal intuba-
tion, placement of a nasogastric tube, or transesophageal
echocardiography, are extremely rare.10 Perforation of
the pharynx during intubation is associated with the use
of a stylet during emergency intubations, especially
when performed by inexperienced personnel.11
Penetrating Trauma to the Neck
The ABC (airway, breathing, circulation) principles of
trauma life support are fundamental to the evaluation
and management of any penetrating wound to the
neck. Establishing or securing the airway, ventilating,
restoring blood volume, and stabilizing the cardiovas-
cular system should be accomplished promptly as an
overlapping series of events. Protection and evaluation
of the cervical spine are critical components that cannot
be overemphasized, because both low-velocity and high-
velocity missiles can transfer a signifi cant amount of
energy to the cervical spine. Clinical and radiologic
evaluation is necessary to rule out damage to the spine.
The cervical spine should be evaluated with lateral,
anteroposterior, and open-mouth anteroposterior
(odontoid) radiographs to demonstrate the entire spine
from C1 to the junction of C7 and T1. Computed
tomography (CT) may be the preferred study in most
institutions but is mandatory if radiographs are not sat-
isfactory or suggest an injury (Fig. 53-1).
The history and physical examination are also initi-
ated during the resuscitation phase. Knowledge of the
circumstances and mechanism of the injury is essential
to make an adequate diagnosis. Information regarding
the injury, such as a high-velocity versus a low-velocity
missile, type of weapon, distance, and trajectory, is
important in determining the degree of trauma and
injury to surrounding structures.
The hypopharynx and cervical esophagus are
located deep in the neck, posterior to the airway, ante-
rior to the spine, and medial to the great vessels. The
intimate association of these different structures makes
an isolated injury to the hypopharynx or cervical esoph-
agus a rare event. These injuries are commonly associ-
ated with vascular and airway trauma.1,11-15 Conversely,
a penetrating injury to the pharyngoesophagus should
be suspected in the presence of vascular or airway
trauma.
A history of hoarseness, dysphagia, odynophagia, or
hemoptysis suggests a penetrating injury to the upper
aerodigestive tract. The physical examination should be
thorough and address the possibility of other associated
injuries requiring intervention. Findings such as subcu-
taneous emphysema or saliva or bubbling fl uids arising
from the wound on swallowing also suggest injury to the
upper aerodigestive tract and are indications for surgi-
cal exploration. Fiberoptic examination may reveal a
hematoma, lacerations, blood, associated laryngotra-
cheal injuries, or vocal cord palsy. The presence of a
hematoma, cranial nerve or brachial plexus defi cits, or
injury to the contralateral pleura (e.g., contralateral
pneumothorax) suggests a signifi cant injury and is also
an indication for exploration. Chest CT corroborates
the presence or absence of free air, pleural fl uid, a
widened mediastinum, pneumothorax, and skeletal
injury.
Patients with symptoms suggestive of injury to the
hypopharynx or cervical esophagus but with no abso-
lute indication for exploration should be evaluated with
an esophagogram. Esophagography enhanced with a
water-soluble contrast agent is the preferred imaging
study to evaluate a possible transcervical penetrating
injury to the hypopharynx or esophagus. Alternatively,
if the patient has an isolated neck wound, a solution of
methylene blue may be given by mouth to observe any
extravasation into the neck wound. A negative esopha-
gogram does not completely rule out an injury. The
incidence of false-negative studies is as high as 20%.3,12
Rigid endoscopic examination complements the
imaging studies and upgrades the sensitivity of the eval-
uation. Fiberoptic fl exible esophagoscopy is not reli-
able in assessing injury to the proximal esophagus and
hypopharynx.3
MANAGEMENT
The critical prognostic factor in the management of
pharyngoesophageal perforations is the time elapsed
Figure 53-1. Axial computed tomography scan demonstrating free
air in the deep planes of the neck suggestive of an injury to the
aerodigestive tract.

Chapter 53
Penetrating Trauma to the Hypopharynx and Cervical Esophagus
453
between injury and initiation of therapy.2,16,17 Thus, a
high index of suspicion and rapid evaluation and diag-
nosis are paramount. A delay in management of more
than 24 hours has been shown to signifi cantly increase
morbidity and mortality.2 Historically, surgical explora-
tion with primary closure or resection was advocated for
all suspected cases of pharyngoesophageal injury. More
recently, there has been a trend toward more conserva-
tive management that focuses on broad-spectrum anti-
biotics, no oral intake, and abscess drainage.2,18,19
Medical Treatment
Iatrogenic perforation or stab wounds without any
other associated injuries may be managed conserva-
tively by inserting a nasogastric tube and permitting no
food by mouth for 3 to 5 days.1,20,21 Broad-spectrum
antibiotics (e.g., clindamycin, ampicillin-sulbactam)
that provide coverage against fl ora of the upper aerodi-
gestive tract are administered throughout this period.
An antibiotic mouthwash (e.g., clindamycin phosphate
[Cleocin], 900 mg per 1000 mL of a 0.9% saline solu-
tion) can be used to diminish the bacterial count of the
oral cavity and thus that of saliva. Antibiotic mouth-
washes should not be used for longer than 3 days to
prevent the selective growth of bacterial pathogens.
Controlling or preventing infection with antibiotics
and, if necessary, drainage essentially converts a con-
taminated neck or chest wound to a salivary fi stula.18
Adequate nutrition is fundamental to promote rapid
and adequate healing of the injury. In the rare instance
in which a nasogastric tube cannot be placed, the
patient may be nourished with a gastrostomy tube. After
closure of the salivary fi stula, a follow-up esophago -
gram will corroborate complete healing of the
pharyngoesophagus.
Surgical Treatment
Surgical management includes esophagoscopy, cervical
exploration, repair, and drainage. This surgical
approach is advocated for injuries not amenable to
medical treatment. The indications and timing for sur-
gical repair are controversial and depend on many
factors, including the time from injury to initial evalua-
tion, the mechanism and extent of injury, the experi-
ence of the surgeon, and the presence of grafts or
hardware.
Preoperative Planning
The patient should have blood typed and cross-matched
in preparation for any unsuspected vascular injuries. If
exploration or endoscopy is necessary, it is performed
under general anesthesia. Flexible direct laryngoscopy
is required to evaluate the airway before induction of
anesthesia and intubation. If possible, the patient is
allowed to ventilate spontaneously, because positive
pressure ventilation by mask may precipitate or exacer-
bate subcutaneous emphysema and pneumothorax. If
the airway is compromised by hematoma, edema, or
secretions, a tracheotomy is performed under local
anesthesia. The use of nitrous oxide is detrimental
because it can lead to expansion of the air trapped
within tissue planes. Signifi cant changes in blood pres-
sure should be avoided.
Surgical Technique
Esophagoscopy is helpful to assess the site of entry and
extent of injury, even in patients with clear indications
for exploration.3
A horizontal incision following a neck crease is
preferable to a diagonal incision for cosmetic reasons
and because it provides bilateral exposure if needed
(Fig. 53-2). Placement of the incision varies with the
level of the injury. High hypopharyngeal injuries are
approached through an incision placed at the level of
the midthyroid ala. Injury to the lower hypopharynx
(i.e., apex of the piriform sinus) or cervical esophagus
may be approached through an incision at the lower
edge of the cricoid cartilage. The incision should extend
from the anterior edge of the sternocleidomastoid
muscle to the midline. It can be extended to the ante-
rior edge of the contralateral sternocleidomastoid
muscle, if necessary, for bilateral exposure.
Figure 53-2. Transverse cervical incision at the level of the inferior
edge of the cricoid cartilage. This incision provides bilateral access
to the pharyngoesophageal area. However, it can be adapted to a
particular need according to the level of injury and laterality.

454
Section 4
Hypopharynx and Cervical Esophagus
Subplatysmal fl aps are elevated superiorly to the
level of the hyoid bone and inferiorly to the level of the
clavicle. The sternocleidomastoid muscle is dissected
from the strap muscles. The carotid sheath and its con-
tents are retracted laterally (Fig. 53-3), and the great
vessels can be exposed to confi rm the presence or
absence of any injuries. With a combination of blunt
and sharp dissection the prevertebral space is exposed.
A double-pronged retractor is placed at the posterior
edge of the thyroid ala, and the laryngotracheal complex
is rotated anteromedially (Fig. 53-3). This maneuver
provides access to the retropharyngeal space to avoid
inadvertent injury. The position of the superior laryn-
geal nerve, which courses medial to the carotid artery
and pierces the lateral margin of the thyrohyoid mem-
brane, as well as the entry point of the recurrent laryn-
geal nerve lateral to the cricothyroid joint, should be
kept in mind to avoid inadvertent injury.
The perforation is commonly identifi ed by follow-
ing the track of the penetrating weapon (Fig. 53-4).
When the perforation is not visible, air or water may be
insuffl ated into the pharynx and the wound observed
for a leak. The perforation is then repaired with a
double-layer technique, and an inverting stitch with
absorbable suture is used to repair the mucosa. The
inferior constrictor or esophageal muscles are approxi-
mated with interrupted stitches. A suction drain is left
in the prevertebral space. If the pleural space has
been contaminated, chest tube drainage may also be
required.18 Mediastinitis mandates aggressive therapy,
probably with a thoracotomy for débridement and
drainage.
Perforations older than 24 hours are usually associ-
ated with edematous and friable tissue that is not ame-
nable to primary repair. In these cases, a strap muscle
myofascial transposition fl ap may be used to buttress
the wound. Similarly, an inferiorly based sternocleido-
mastoid muscle fl ap, popularized by Conley and Gullane
in 1980, provides a safe and effective method of repair
with low morbidity.4,22 A pedicled pectoralis major fl ap
and a free omental fl ap have also been advocated.23,24
Special Circumstances
When a vascular injury requires primary repair or graft-
ing, drainage should be brought to the contralateral
side, away from the injured vessel (Fig. 53-5).13
Figure 53-3. Axial view of the surgical route to the pharyngoesoph-
agus (retropharyngeal space). The retractor at the left is displacing
the sternocleidomastoid muscle and the contents of the carotid
sheath. The retractor at the right is rotating the larynx in an antero-
medial direction.
Figure 53-4. Penetrating injury to the hypopharynx.
Figure 53-5. Tracheoesophageal injury associated with a carotid
injury after repair. The drain should not be in contact with the vas-
cular or esophageal repair. A suction drain is preferred unless there
is leakage of air from the airway.

Chapter 53
Penetrating Trauma to the Hypopharynx and Cervical Esophagus
455
Associated tracheal injuries may be repaired pri-
marily or left to close by secondary intention. A thyro-
hyoid muscle fl ap interposition between the tracheal
and esophageal injury is advisable to prevent a tracheo-
esophageal fi stula when both structures are injured at
adjacent sites.13,14,25 To mobilize this fl ap, the insertion
of the thyrohyoid muscle is transected with the cautery.
The muscle is dissected from the ipsilateral sternohyoid
and cricothyroid muscles. Dissection at the lateral
boundary of the muscle is avoided to preserve the blood
supply, which arises from the superior thyroid artery.
The motor nerve from the descending ansa cervicalis
can be transected or crushed with a hemostat to para-
lyze the muscle during the healing period (Fig. 53-6).
A second esophageal injury involving the thoracic
segment requires cervical esophageal diversion.13 The
cervical esophagus is mobilized, and the injured area is
externalized as a loop esophagostomy for a controlled
salivary fi stula (Figs. 53-7 and 53-8).
POSTOPERATIVE MANAGEMENT
Antibiotics are continued for a minimum of 24 hours
after exploration and repair. Nothing is allowed by
mouth, and enteral nutrition is continued by nasogas-
tric or gastrostomy tube unless abdominal injuries
mandate parenteral hyperalimentation. Antirefl ux
medications are mandatory because gastroesophageal
refl ux will produce a severe infl ammatory reaction and
Figure 53-6. Tracheoesophageal injury repaired primarily and
reinforced with a strap muscle pedicle fl ap.
Figure 53-7. The thyroid gland has been mobilized medially (i.e.,
the middle thyroid veins have been ligated and transected), and the
esophagus has been mobilized from the trachea. An esophagostomy
is opened, and the esophageal mucosa will be sutured to the skin.
Figure 53-8. Esophagostomy after completion.

456
Section 4
Hypopharynx and Cervical Esophagus
References
1. Dolgin SR, Kumar NR, Wykoff TW, Maniglia AJ: Conservative
medical management of traumatic pharyngoesophageal perfora-
tions. Ann Otol Rhinol Laryngol 101:209-215, 1992.
2. Eroglu A, Can Kurkcuoglu I, Karaoglanoglu N, et al: Esophageal
perforation: The importance of early diagnosis and primary
repair. Dis Esophagus 17:91-94, 2004.
3. Weigelt JA, Thal ER, Snyder WH, et al: Diagnosis of penetrating
cervical esophageal injuries. Am J Surg 154:619-622, 1987.
4. Navarro R, Javahery R, Eismont F, et al: The role of the sterno-
cleidomastoid fl ap for esophageal fi stula repair in anterior cervi-
cal spine surgery. Spine 30:E617-E622, 2005.
5. Orlando ER, Caroli E, Ferrante L: Management of the cervical
esophagus and hypopharynx perforations complicating anterior
cervical spine surgery. Spine 28:290-295, 2003.
6. Gaudinez RF, English GM, Gebhard JS, et al: Esophageal perfora-
tions after anterior cervical surgery. J Spinal Disord 13:77-84,
2000.
7. Pompili A, Canitano S, Caroli F, et al: Asymptomatic esophageal
perforation caused by late screw migration after anterior cervical
plating: Report of a case and review of relevant literature. Spine
27:499-502, 2002.
8. Witwer BP, Resnick DK: Delayed esophageal injury without
instrumentation failure: Complication of anterior cervical instru-
mentation. J Spinal Disord Tech 16:519-523, 2003.
9. Taylor B, Patel AA, Okubadejo GO, et al: Detection of esophageal
perforation using intraesophageal dye injection. J Spinal Disord
Tech 19:191-193, 2006.
10. Min JK, Spencer KT, Furlong KT, et al: Clinical features of com-
plications from transesophageal echocardiography: A single-
center case series of 10,000 consecutive examinations. J Am Soc
Echocardiogr 18:925-929, 2005.
11. O’Neill JE, Giffi n JP, Cottrell JE: Pharyngeal and esophageal
perforation following endotracheal intubation. Anesthesiology
60:487-488, 1984.
12. Asenio JA, Valenziano CP, Falcone RE, Grosh JD: Management
of penetrating neck injuries: The controversy surrounding zone
II injuries. Surg Clin North Am 71:267-296, 1991.
13. Feliciano DV, Bitondo CG, Mattox KL, et al: Combined tracheo-
esophageal injuries. Am J Surg 150:710-715, 1985.
14. Kelly JP, Webb WR, Moulder PV, et al: Management of airway
trauma II: Combined injuries of the trachea and esophagus. Ann
Thorac Surg 43:160-163, 1987.
15. Shama DM, Odell J: Penetrating neck trauma with tracheal and
oesophageal injuries. Br J Surg 71:534-535, 1984.
16. Andrade-Alegre R: Surgical treatment of traumatic esophageal
perforations. Clinics 60:375-380, 2005.
17. Rossetti G, Maffettone V, Napolitano V, et al: Esophageal perfora-
tion: Which factors affect the prognosis? Chir Ital 58:577-581,
2006.
further tissue necrosis. We prefer to administer a proton
pump inhibitor. The suction drain is kept in place until
healing is verifi ed by a Gastrografi n swallow and the
patient has resumed oral intake. Early and adequate
drainage of the wound is probably the most important
factor affecting the incidence of complications.
COMPLICATIONS
The most common complications are associated with a
salivary leak. Patients in whom cellulitis or an abscess
develops while being managed conservatively require
incision and drainage. Whenever possible, the wound
should be drained with a closed-suction device. This
type of drainage is more effective in evacuating secre-
tions and promoting apposition of tissues than a Penrose
drain and is resistant to retrograde bacterial contamina-
tion. Broad-spectrum antibiotics are continued until
the cellulitis is resolved. Delayed diagnosis may allow
the infection to spread into the mediastinum. Medias-
tinitis mandates aggressive therapy with a probable tho-
racotomy for débridement and drainage.
A salivary fi stula without cellulitis in the presence
of a well-drained wound usually heals within 2 weeks.
Adequate nutrition should be maintained with tube
feedings or total parenteral nutrition to promote
healing.
PEARLS
• Iatrogenic injuries to the hypopharynx and cervical
esophagus from endoscopic procedures and
anterior neck surgery are uncommon but potentially
life-threatening.
• A swallow imaging study with a water-soluble
contrast agent plays a key role not only in making a
prompt diagnosis of perforation but also in
determining the success of treatment and
resumption of oral intake.
• During anterior neck surgery, suspicion of a
pharyngoesophageal injury can be confi rmed by
placing a distal Foley catheter balloon and irrigating
methylene blue or povidone-iodine solution through
a proximally placed nasogastric tube.
• Most injuries that are diagnosed early (within the
fi rst 24 hours) can be managed conservatively with
broad-spectrum antibiotics, nothing by mouth, and
close observation.
• More extensive or late-diagnosed injuries may
require surgical therapy, including abscess drainage,
primary closure, and/or local fl ap coverage.
• Delay in diagnosis of more than 24 hours from the
time of injury can signifi cantly increase morbidity
and mortality.
• The proximity of the hypopharynx and esophagus to
the airway, cranial nerves, and major vessels
mandates a high index of suspicion and thorough
evaluation to avoid missing associated airway
compromise or vascular injury.
• Positive pressure mask ventilation may precipitate or
exacerbate subcutaneous emphysema and
pneumothorax.
• A nonhealing fi stula and failure of treatment may
signify inadequate drainage of a contaminated neck
or chest collection.
PITFALLS
• Underlying esophageal disease signifi cantly increases
the risk for iatrogenic trauma to the hypopharynx
and esophagus.

Chapter 53
Penetrating Trauma to the Hypopharynx and Cervical Esophagus
457
18. Vogel SB, Rout WR, Martin TD, et al: Esophageal perforation in
adults: Aggressive, conservative treatment lowers morbidity and
mortality. Ann Surg 241:1016-1023, 2005.
19. Goudy SL, Miller FB, Bumpous JM: Neck crepitance: Evaluation
and management of suspected upper aerodigestive tract injury.
Laryngoscope 112:791-795, 2002.
20. Mandal AK, Bui HD, Oparah SS: Surgical and nonsurgical treat-
ment of penetrating injuries to the cervical esophagus. Laryngo-
scope 93:801-804, 1983.
21. Ramirez JI, Velmahos GC: Management of cervical aerodigestive
injuries. Minerva Chir 59:563-572, 2004.
22. Conley J, Gullane PJ: The sternocleidomastoid muscle fl ap. Head
Neck Surg 2:308-311, 1980.
23. Pichler W, Maier A, Rappl T, et al: Delayed hypopharyngeal and
esophageal perforation after anterior spinal fusion. Spine 31:
E268-E270, 2006.
24. Reid RR, Dutra J, Conley DB, et al: Improved repair of esophageal
fi stula complicating anterior spinal fusion: Free omental fl ap
compared with pectoralis major fl ap. J Neurosurg 100:66-70,
2004.
25. Miller RH, Duplechain JK: Penetrating wounds of the neck. Oto-
laryngol Clin North Am 24:15-19, 1991.

Chapter 54
Dysfunction of the Upper Esophageal
Sphincter
Bridget Hathaway and Ricardo L. Carrau
The cricopharyngeus muscle, fi rst described by Valsalva
in 1917, is the major component of the upper esopha-
geal sphincter (UES). Jackson and Shallow subsequently
distinguished the cricopharyngeus from other muscles
of the UES, including the distal inferior constrictor and
the proximal circular esophageal muscle.1 The crico-
pharyngeus muscle is innervated by the pharyngeal
plexus, which is composed of contributions from the
vagus and glossopharyngeal nerves. Increasing evidence
suggests that contributions from the recurrent laryn-
geal nerve also innervate the cricopharyngeus muscle.2
The origin of the parasympathetic innervation is vagal,
whereas sensory branches are derived from the glosso-
pharyngeal nerve. Sympathetic fi bers arise from the
superior cervical ganglion and also join the pharyngeal
plexus.
In its normal resting state, the cricopharyngeus
muscle is in tonic contraction. When a swallow occurs,
the cricopharyngeus relaxes during pharyngeal con-
traction (mediated by the vagus nerve), and anterior-
superior movement of the larynx opens the UES to
allow passage of the bolus into the esophagus. Dyspha-
gia related to dysfunction of the UES results from (1)
failure of cricopharyngeal relaxation, which can be due
to lack of vagal innervation or loss of the normal visco-
elastic properties of the muscle; (2) discoordination
between cricopharyngeal relaxation and pharyngeal
contraction; or (3) weakness of the suprahyoid muscu-
lature with poor elevation (anterosuperior movement)
of the laryngeal complex.
In 1951 Kaplan described division of the cricopha-
ryngeus muscle in treating dysphagia resulting from
bulbar poliomyelitis.3 Since then, cricopharyngeal
myotomy has been used for treating cricopharyngeal
dysfunction caused by lesions of the central and periph-
eral nervous systems, which affect laryngeal and pharyn-
geal muscle activity and coordination, as well as for the
treatment of postsurgical dysphagia. Although indica-
tions for cricopharyngeal myotomy are controversial, in
general, the procedure is most successful when treating
patients with normal or nearly normal pharyngeal
function, which is required for bolus propulsion,
and with adequate laryngeal elevation, which is required
for opening of the UES. For example, patients
with amyotrophic lateral sclerosis (ALS), Parkinson’s
disease, or cerebellar atrophy have been treated by cri-
copharyngeal myotomy with generally poor results
because these conditions are characterized by diffuse
pharyngeal motor abnormalities and poor anterosupe-
rior elevation.
One of the most widely recognized manifestations
of UES dysfunction is Zenker’s diverticulum. Although
the fi rst description of a pharyngoesophageal diverticu-
lum is attributed to Ludlow in 1769, this entity became
known as Zenker’s diverticulum after it was described
in Zenker and Ziemssen’s Krankheiten des Oesophagus, a
landmark compilation of esophageal pathology pub-
lished in 1877. Killian clarifi ed the anatomic site of
origin as the space between the inferior constrictor
muscle and the cricopharyngeus muscle, hence its
name Killian’s triangle (Fig. 54-1).4 Zenker’s diverticu-
lum is a pulsion diverticulum that forms in the muscu-
lar dehiscence of Killian’s triangle as the UES fails to
open with pharyngeal contraction, thus raising pressure
in the pharynx (Fig. 54-2). Other areas of weakness
have been identifi ed and can lead to variations of the
site of origin of the diverticulum (Killian-Jamieson and
Lamier triangles). Failure of UES opening may be the
result of failure of cricopharyngeal relaxation or weak-
ness of laryngeal elevation.
459

460
Section 4
Hypopharynx and Cervical Esophagus
Since 1994, botulinum toxin A (BTX A) has been
used as an alternative to surgical cricopharyngeal
myotomy in the treatment of selected cases of UES dys-
function. Preliminary studies show BTX A to be a safe
and effective treatment of UES dysfunction of multiple
causes, including cerebrovascular accident, neuropa-
thy, and laryngectomy.11 BTX A may be injected trans-
cutaneously in the offi ce under electromyographic
guidance or endoscopically in the operating room.12
Given the preliminary nature of the studies, BTX A
should generally be reserved for patients who refuse
surgery or are not surgical candidates or when the diag-
nosis, prognosis, and expected response to myotomy
are in question. In addition, BTX A improves only UES
relaxation; thus, patients with poor pharyngeal propul-
sion or weak elevation of the larynx, such as those with
Parkinson’s disease or ALS, are unlikely to benefi t from
BTX A injection.
PATIENT SELECTION
Obtaining a thorough history in patients complaining
of dysphagia is of great importance. The clinician
should inquire whether the patient has experienced
weight loss, has a history of pneumonia, or has dietary
limitations as a result of dysphagia. A history of cerebro-
vascular accident or associated neurologic or neuro-
muscular disease helps exclude other types of problems
such as malignancy. Previous major head and neck
surgery or radiation therapy for cancer of the head and
neck may be associated with UES dysfunction. Progres-
sive dysphagia with associated regurgitation of undi-
Figure 54-1. Killian’s triangle is bounded superiorly by fi bers of the
inferior constrictor muscle and inferiorly by the cricopharyngeus
muscle (arrow).
Figure 54-2. Zenker’s diverticulum posterior to the esophagus
(arrow).
Standard treatment of Zenker’s diverticulum
includes a myotomy of the UES combined with resec-
tion of the diverticulum through a left-sided cervical
incision, but other techniques are also in common use.
Dohlman and Mattson described an endoscopic tech-
nique for cricopharyngeal myotomy that has been
modifi ed with the introduction of lasers, staplers, and
bivalved endoscopes.5 Advances in endoscopic instru-
mentation enabled Collard and associates to perform
the fi rst esophagodiverticulostomy with an endoscopic
stapler in 1993.6 This procedure involves endoscopic
division of the cricopharyngeus muscle with marsupial-
ization of the diverticulum into the pharyngoesopha-
gus. Modifi cation of the stapler as described by Lang
and colleagues allows the division to extend as close as
possible to the inferior aspect of the diverticulum.7
Recent studies have shown that use of the endoscopic
stapler technique results in shorter operative time, hos-
pital stay, and time to resume oral feeding, as well as a
lower complication rate than occurs with the open
approach.8,9 An alternative endoscopic approach uses
the CO2 laser to divide the party wall between the
esophagus and diverticulum. A recent study, however,
demonstrated a higher recurrence rate with this tech-
nique than with the open approach.10 Furthermore, the
open approach is still preferable for diverticula that are
too small to accommodate the endoscopic stapler
(<3 cm) or when endoscopic visualization is precluded
by anatomic factors.

Chapter 54
Dysfunction of the Upper Esophageal Sphincter
461
gested food and halitosis suggests Zenker’s diverticulum.
Signs and symptoms of gastroesophageal refl ux disease
(GERD) should also be elicited. After considering all
these aspects in the history and completing the evalua-
tion, the clinician must also consider the diagnosis of
cricopharyngeal achalasia or “cricopharyngeal dyspha-
gia,” the cause of which is unknown.
Radiologic studies, including barium swallow
esophagography and modifi ed barium swallow, are
useful in evaluating UES function. The most common
radiographic fi ndings in cricopharyngeal achalasia,
regardless of the cause, are prominence of the crico-
pharyngeal sphincter muscle, which is best seen on the
lateral view at the level of the C5-C7 vertebral bodies,
and failure of relaxation of the cricopharyngeus muscle
during the pharyngeal phase of swallowing (Fig. 54-3).
Likewise, barium esophagography is essential in con-
fi rming the diagnosis of Zenker’s diverticulum (Fig.
54-4). Modifi ed barium swallow can also identify and
quantify associated laryngeal penetration of the bolus
and aspiration and evaluate coordination of swallow
and elevation of the larynx.
Functional endoscopic examination of swallowing
(FEES) is a complementary tool in assessing swallowing
function but does not provide the necessary informa-
tion to evaluate UES function. FEES may provide useful
information, such as postcricoid pooling of secretions
(Fig. 54-5) and ingested material, as well as regurgita-
tion consistent with UES dysfunction. Weakness of the
palate, pharynx, and base of the tongue or discoordi-
nated initiation of deglutition may suggest more global
oropharyngeal dysphagia as opposed to isolated UES
Figure 54-3. Barium esophagogram (lateral view) demonstrating
failure of relaxation of the cricopharyngeus muscle (arrow).
Figure 54-4. Barium esophagogram demonstrating Zenker’s diver-
ticulum (arrow).
Figure 54-5. Postcricoid pooling of secretions detected by func-
tional endoscopic examination of swallowing.
pathology. FEES also helps identify laryngeal penetra-
tion or aspiration of saliva or ingested material. Occa-
sionally, regurgitation into the left piriform sinus is
directly observed and is highly suggestive of Zenker’s
diverticulum.

462
Section 4
Hypopharynx and Cervical Esophagus
The role of manometry in assessing the UES is
more controversial. Though frequently used as a
research tool, manometry has not been widely applied
clinically for the evaluation and management of
patients.
PREOPERATIVE PLANNING
Patients with global neurologic or neuromuscular prob-
lems should be carefully evaluated by a neurologist and
anesthesiologist before surgery. A precise diagnosis is
important because patients with ALS or Parkinson’s
disease do not benefi t from cricopharyngeal myotomy
and should not undergo this procedure.
Patients with signifi cant pulmonary problems
should be prepared with extensive respiratory therapy
preoperatively. Patients with uncontrolled GERD should
be treated both preoperatively and postoperatively to
minimize this problem.
Intravenous perioperative antibiotics are adminis-
tered to minimize postoperative wound infection in the
event that the pharynx is entered.
SURGICAL TECHNIQUE
Cricopharyngeal Myotomy
This operation is usually carried out under general
anesthesia but local anesthesia may also be used if the
patient’s condition does not permit general anesthesia.
The neck is extended with a rolled blanket placed
under the shoulders. Rigid esophagoscopy is performed
to exclude neoplasm or infl ammatory esophageal
disease as a cause of the dysphagia. A transverse incision
is carried out in a skinfold close to the level of the
cricoid cartilage, which marks the cricopharyngeal
muscle (Fig. 54-6). After the incision is made and
carried down through the platysma muscle, the fl aps
are elevated inferiorly to the clavicle and superiorly
above the thyroid notch (Fig. 54-7). Sharp separation
of the sternocleidomastoid (SCM) muscle from the
strap muscles exposes the carotid sheath. The SCM and
carotid sheath are separated from the strap muscles,
thyroid gland, and laryngotracheal complex and re -
tracted laterally to allow entry into the retropharyngeal-
prevertebral space. The middle thyroid vein and the
omohyoid muscle may be divided to facilitate the expo-
sure and decrease the need for retraction. A large
double hook is placed in the posterior aspect of the
midthyroid lamina, and the larynx, trachea, and thyroid
gland are rolled medially (Fig. 54-8). The loose areolar
tissue is bluntly dissected down to the prevertebral
Figure 54-6. A transverse incision is made in a skin crease at the
level of the cricoid cartilage.
Figure 54-7. Subplatysmal fl aps are undermined to expose the
sternocleidomastoid and strap muscles.
Figure 54-8. The carotid sheath is retracted laterally to expose the
prevertebral fascia.

Chapter 54
Dysfunction of the Upper Esophageal Sphincter
463
fascia. Bipolar cauterization of the fascia covering the
pharyngeal musculature will reveal the UES muscles.
This maneuver should be performed close to midline
to avoid injury to the recurrent laryngeal nerve. The
cricoid cartilage will mark the level of the cricopharyn-
geal sphincter; therefore, if the myotomy is performed
at the level of the cricoid cartilage and extended above
and below this level, it will be successful.
Using a small hemostat, the oblique muscle fi bers
of the inferior constrictors are separated from the hypo-
pharyngeal mucosa (Fig. 54-9). The muscle fi bers are
divided with a bayonet-type, insulated bipolar electro-
cautery as the hemostat is advanced along the plane
between the muscles and mucosa. Change from an
oblique to a horizontal direction of the muscle fi bers
marks the change from the inferior constrictor to the
cricopharyngeal muscle. These steps are repeated until
the entire height of the cricopharyngeus is divided.
After the transection has been carried out, a strip of
muscle is undermined and excised to prevent recur-
rence. The wound is then irrigated with normal saline
solution and closed in layers.
If the pharynx is entered inadvertently, a nasogas-
tric tube is introduced and secured to the nose. Any
opening into the pharynx is closed with absorbable
suture. The wound is then irrigated and closed in layers
over a suction drain, which is inserted into the area of
the prevertebral fascia between the operative site and
the carotid sheath.
Excision of Zenker’s Diverticulum
External Approach
Direct laryngoscopy is performed and the contents of
the diverticulum aspirated. The mucosal surface is thor-
oughly examined to rule out squamous cell carcinoma,
Figure 54-9. Muscle fi bers of the upper esophageal sphincter are
separated from the hypopharyngeal mucosa in the midline with a
hemostat.
which occurs in a small percentage of patients with
Zenker’s diverticulum. Cricopharyngeal myotomy is
accomplished as described in the previous section. For
most patients a myotomy suffi ces to alleviate symptoms
caused by Zenker’s diverticulum, especially when the
diverticulum is small. Large pouches, however, are
excised to prevent retention of secretions or food and
regurgitation on assuming a recumbent position. The
diverticulum is dissected from the surrounding tissue as
the myotomy is performed (Fig. 54-10). If a diverticu-
lectomy is to be performed, the neck of the diverticu-
lum may be treated in one of two ways. The classic
technique is to grasp the tip of the sac with a clamp and
excise the sac (Fig. 54-11). Excessive traction on the sac
may lead to over-resection of hypopharyngeal mucosa
and result in a stricture. A 3-0 or 4-0 gastrointestinal
suture is then used to close the mucosa. Alternatively,
a stapler may be used to excise the sac and repair the
pharyngeal mucosa. The muscles should not be closed
over the mucosa. Diverticulopexy was developed to
avoid the risks inherent in entering the pharynx. If
diverticulopexy is to be carried out, the fundus is
inverted and sewn to the prevertebral fascia (Fig.
54-12). The wound is then irrigated and closed in layers
over a suction drain, which is inserted into the area of
the prevertebral fascia between the operative site and
the carotid sheath.
Endoscopic Approach
The endoscopic approach for the treatment of Zenker’s
diverticulum requires a bivalved endoscope, one blade
of which is inserted into the cervical esophagus and the
other into the diverticulum (Fig. 54-13). The endo-
scope is suspended. If an endoscopic stapling device is
Figure 54-10. The diverticulum is dissected from surrounding
tissue.

464
Section 4
Hypopharynx and Cervical Esophagus
to be used, visualization is achieved with a 0-degree
rigid endoscope. The “bar” between the pouch and the
esophagus, which consists of the cricopharyngeus
muscle, is stabilized by grasping it with alligator forceps
or by using endostitches. The Endo-GIA stapler is then
used to divide the party wall between the esophagus
and diverticulum, with several rows of staples being
deposited on each side in the process (Figs. 54-14 and
54-15).13 A modifi cation of the Endo-GIA stapler as
described by Lang and colleagues includes shortening
Figure 54-11. Diverticulectomy is performed by excising the sac.
Figure 54-12. Diverticulopexy is performed by sewing the sac to
the prevertebral fascia.
Figure 54-13. Endoscopic view of the “bar” dividing the esophagus
and pouch (the esophagus is anterior) (arrow).
Figure 54-14. The Endo-GIA stapler is positioned on the “bar”
between the esophagus and pouch before stabilization with alligator
forceps.
Figure 54-15. The party wall between the esophagus and diverticu-
lum has been divided and the resulting esophagostomy stapled in the
process.