How are strap muscles managed during a total laryngectomy?

Management of Strap Muscles During Total Laryngectomy

During total laryngectomy, strap muscles should be carefully preserved when possible and can be repurposed as protective flaps between the trachea and major vessels to prevent complications such as tracheo-arterial fistula formation. 1

Anatomical Considerations

• Strap muscles (sternohyoid, sternothyroid, thyrohyoid, and omohyoid) are located anterior to the thyroid gland and larynx in the neck 2
• These muscles play an important role in laryngeal function and can be strategically utilized during and after total laryngectomy 3
• The relationship between strap muscles and critical neurovascular structures (carotid artery, jugular vein) must be understood for safe surgical management 3

Surgical Technique for Strap Muscle Management

Initial Approach

• Create appropriate neck incision (U-shaped or apron) at the level of the thyroid cartilage to access the larynx and strap muscles 3
• Identify and carefully dissect the strap muscles from the underlying thyroid cartilage and thyroid gland 2

Preservation Options

• When oncologically appropriate, preserve strap muscles with their natural innervation (ansa cervicalis) 4
• In cases where direct tumor invasion necessitates removal, consider:
  • Partial preservation of uninvolved strap muscle groups 3
  • Strategic reconstruction using remaining strap muscle tissue 1

Innovative Techniques

• "Strap-flap technique" - positioning preserved strap muscles between the trachea and major vessels (particularly carotid arteries) to prevent friction and reduce risk of tracheo-arterial fistula formation 1
• When anatomical variations exist (such as bovine aortic arch), strap muscle flaps become particularly important as protective barriers 1

Functional Considerations

Voice Rehabilitation Applications

• Preserved strap muscles can be utilized for innovative voice rehabilitation techniques 5
• EMG-controlled electrolarynx using preserved strap muscles has shown promise as a hands-free voice restoration option 5, 4
• Recurrent laryngeal nerve (RLN) transfer to strap muscles during laryngectomy can provide better control signals for electrolarynx devices compared to muscles with normal ansa cervicalis innervation 4

Surgical Modifications for Voice Rehabilitation

• During laryngectomy, surgeons can preserve specific strap muscles for later use in voice rehabilitation 5
• Modification options include:
  • Maintaining natural innervation on one side 5
  • Transferring the recurrent laryngeal nerve to strap muscles on the contralateral side 4
  • These modifications allow for potential EMG-based control of electrolarynx devices 5

Postoperative Considerations

Rehabilitation

• Regular exercise of preserved strap muscles is important for maintaining function and flexibility 6
• Creative rehabilitation approaches (such as beatboxing techniques) can help engage patients in exercising these muscles 6
• Comprehensive rehabilitation should address not only voice but also respiratory function and olfactory acuity 7

Monitoring for Complications

• When strap muscles are used as protective flaps, regular monitoring for adequate tissue viability is essential 1
• In cases of strap muscle preservation for voice rehabilitation, periodic EMG assessment can track reinnervation progress 4

Special Considerations

Anatomical Variations

• Preoperative assessment of neck anatomy (particularly vascular structures) is crucial for planning strap muscle management 1
• In patients with vascular anomalies (e.g., bovine aortic arch), strategic positioning of strap muscle flaps becomes even more critical 1

Oncological Safety

• Preservation of strap muscles must never compromise oncological outcomes 2
• In advanced T3 or T4 disease with extensive invasion, complete removal of involved strap muscles may be necessary 2
• For selected low-volume T4 cancers, preservation approaches may still be considered as part of larynx-preservation strategies 2

By carefully managing strap muscles during total laryngectomy, surgeons can potentially reduce complications and improve functional outcomes for patients undergoing this life-altering procedure.