What is the role of criohyopexy in patients undergoing partial laryngectomy?

Cricohyoidopexy in Partial Laryngectomy

Cricohyoidopexy (CHP) is a highly effective larynx-preservation technique for partial laryngectomy that achieves excellent functional outcomes, with over 90% of patients achieving normal swallowing and respiration within the first postoperative year, though it requires careful patient selection and carries a significant risk of early aspiration pneumonia. 1, 2, 3

Role and Indications

Cricohyoidopexy serves as the reconstructive component of supracricoid partial laryngectomy (SCPL), creating a functional neolarynx by suturing the hyoid bone to the cricoid cartilage. 1, 2 This technique is particularly valuable for:

• T2-T4 glottic and supraglottic carcinomas with anterior commissure involvement, where it provides an alternative to total laryngectomy or chemoradiation 3
• Salvage surgery after radiation failure, with functional outcomes comparable to previously untreated cases 4
• Selected T3 cancers not amenable to transoral resection, achieving local control rates exceeding 90% in previously untreated patients 5, 3

The American Society of Clinical Oncology recognizes supracricoid partial laryngectomy with cricohyoidoepiglottopexy (a variant technique) as the organ-preserving surgery of choice for unfavorable T2 glottic cancers 5.

Expected Functional Outcomes

Swallowing Recovery

• Normal swallowing without permanent gastrostomy is achieved in 91-98% of patients by the first postoperative year 1, 2, 3
• Average time to nasogastric tube removal ranges from 16-22 days 1, 2
• Permanent gastrostomy is required in only 0.5-2.5% of patients 1, 2

Respiratory Recovery

• Decannulation is achieved in 98-99% of patients 2, 3
• Median decannulation time is 8-9 days 1, 2, 6
• Permanent tracheostomy is required in less than 1% of patients 1, 3

Complications and Management

Early Complications

Aspiration pneumonia is the most significant early complication, occurring in 8.5-11.5% of patients. 1, 2 Risk factors include:

• Neck dissection significantly increases pulmonary complication risk (p < 0.04) 6
• Delayed decannulation correlates with increased pulmonary complications 6

To minimize aspiration risk:

• Maintain semi-upright positioning (30-45° head elevation) at all times, especially during feeding 7, 8
• Implement chin-tuck posture during swallowing to expand the valleculae and prevent laryngeal penetration 7, 8
• Ensure meticulous oral hygiene to reduce bacterial load in the oropharynx 7, 8

Other Complications

• Cervical wound infection: 4.2% 1
• Symptomatic laryngocele: 3.1% 1
• Laryngeal stenosis: 0.5-9.9% (higher rates include both early and late stenoses) 1, 6
• Ruptured pexis: 1% 1

Late Complications

Late respiratory complications are typically due to laryngeal obstruction from neolaryngeal mucosal flaps, residual false vocal cord folds, or arytenoid edema. 6 These can usually be managed conservatively without requiring permanent tracheostomy 6.

Mortality and Salvage Rates

• Postoperative mortality ranges from 1-4% 1, 2, 6
• Completion total laryngectomy is required in 0.5-7.2% of patients, primarily for persistent aspiration or local recurrence in previously irradiated patients 1, 2, 3
• Five-year actuarial survival is 68% with local control achieved in 84-94.5% of cases 3

Critical Patient Selection Criteria

Preoperative pulmonary assessment is mandatory to identify patients at high risk for respiratory complications. 6 Ideal candidates should have:

• Adequate pulmonary reserve to tolerate temporary aspiration during the recovery period 6
• Tumors amenable to complete oncologic resection while preserving at least one functional arytenoid 5
• No contraindications to temporary tracheostomy and nasogastric feeding 1, 2

Surgical Technical Considerations

Precise surgical technique is essential to minimize complications:

• Ensure accurate impaction of the hyoid bone with the cricoid cartilage to prevent postoperative stenosis 6
• Proper repositioning of the arytenoid can avoid some postoperative stenoses 6
• The procedure eliminates the risk of aspiration seen with total laryngectomy while preserving speech and swallowing function 5

Comparison to Alternative Treatments

Cricohyoidopexy offers superior functional outcomes compared to total laryngectomy while maintaining comparable oncologic control for appropriately selected patients. 3 Unlike total laryngectomy, which eliminates both speech and aspiration risk but requires permanent stoma 5, cricohyoidopexy preserves laryngeal function in over 90% of patients 1, 2, 3.

For T2-T3 cancers, local control rates with supracricoid partial laryngectomy are comparable to chemoradiation (>90%) but with potentially better functional outcomes when RT can be avoided. 5, 3

Common Pitfalls to Avoid

• Do not feed patients with decreased consciousness levels during the early postoperative period, as they are at extremely high risk for aspiration 8
• Recognize that enteral feeding tubes do not reduce aspiration pneumonia risk and may actually increase it by reducing lower esophageal sphincter pressure 8
• Avoid combining surgery with radiotherapy for limited-stage disease, as functional outcomes may be compromised by combined-modality therapy 5
• Do not perform cricohyoidopexy in patients with inadequate pulmonary reserve or those unable to tolerate temporary aspiration 6