Functional long-term results following hemipharyngo-hemilaryngectomy and microvascular reconstruction using the radial forearm flap

BACKGROUND: The surgical treatment of advanced hypopharyngeal carcinomas with infiltration of the laryngeal skeleton often includes total laryngectomy for functional reasons, although tumor infiltration is limited to only one half of the larynx. When not only the infiltrated half of the thyroid cartilage but also the cricoid cartilage of the involved side has to be removed, in spite of adequate reconstruction using local or pedicled flaps (f. e. pectoralis major flap) persistent dysphagia and aspiration prevent oral food intake and closure of the tracheostoma. These functional disturbances are increased by the negative effects of postoperative radiotherapy, which has to be applied in most of the cases for oncological reasons. The routine use of free, microvascularly anastomosed flaps for reconstruction of defects following removal of extended carcinomas of the mouth, the tongue or the oropharynx as well as in total pharyngolaryngectomy led to considerable improvements in functional rehabilitation of swallowing and speech. An improved functional outcome is also reported following partial resections of the hypopharynx and reconstruction by means of these thin and pliable transplants (f. e. replacement of the entire posterior hypopharyngeal wall). METHOD: Since 1991 in 30 patients with a T3 or T4 squamous cell carcinoma of the piriform sinus a complete hemipharyngo-hemilaryngectomy including resection of the involved thyroid and cricoid cartilage was carried out. For reconstruction a radial forearm flap was dissected with two separate epithelial islands: The smaller island was used to create an epithelialized endolarynx, which allows complete closure of the glottis by the healthy vocal chord. With the bigger second island the hypopharynx was replaced, creating a highly mobile, adaptable neo-piriform-sinus, which was suspended to the ipsilateral half of the hyoid bone. Parts of the both islands were sutured together to create a new aryepiglottic fold. The laryngeal skeleton intentionally was not reconstructed. RESULTS: One year evaluation revealed 25 of the 30 patients swallowing normal diet and being decannulated. 4 patients could take up a soft diet, 1 patient with a severe stricture at the entrance to the esophagus however had to be laryngectomized for functional reasons. Most of the patients judged their postoperative voice as satisfactory, although there was a different impairment of the voice (quite normal up to a marked hoarseness). During follow-up (up to 10 years) 4 patients developed a local recurrence, in 3 cases a secondary metastasis after neck dissection occurred. In 3 patients a second primary was detected (oropharynx 2, esophagus 1), 3 patients died with lung metastases. CONCLUSION: Rehabilitation of normal swallowing and a satisfying voice restoration without a permanent tracheostoma following complete hemipharyngo-hemilaryngectomy can obviously be improved by the use of microvascular transplants (here radial forearm flap) in comparison to other surgical techniques. The necessary radical extirpation of these extended carcinomas also is guaranteed like in total laryngectomy, so that in spite of the advanced tumor stage an organ preserving surgery can be offered. A prolonged course of swallowing rehabilitation however has to be taken into consideration.