Abstract
A 66 years old patient consults for a progressive dysphonia. The fibroscopic examination reveals a partial immobility of the left
arytenoid without mucosal lesion. The direct laryngoscopy under total anesthesia shows a sub-mucosal deformation of the left
pyriform sinus and the deep biopsy under the hypopharyngeal mucosa shows a grade II chondrosarcoma whose origin � cricoid or
thyroid cartilage � could not be specified neither by the CT scan nor by MRI. After a negative Pet scan, a total laryngectomy was
proposed to this patient which decide to ask for a second opinion. After examination of the patient and the different images, we
proposed a partial laryngectomy with immediate reconstruction in case of safe resection margins. The surgical procedure begins with
a left functional neck dissection preserving the vascularization of the sub-hyoid muscles. After a tracheotomy the hyoid attaches of
the sub-hyoid muscles are released and a fronto-lateral laryngeal approach is performed in order to conserve the anterior commissure
and the vocal folds. Then the progressive sub-mucosal dissection of the thyroid ala demonstrates its healthiness and the presence
of a left hemi-cricoid tumor. The section of the inferior crico-thyroid joint allows developing a sub-hyoid myo-cartilaginous flap
including the left thyroid ala. And the anterior and posterior vertical mucosal and cartilaginous sections allow resecting the left hemicricoid
including the crico-aryt�©noid joint but saving the left vocal cord. After checking the resection margins, the reconstruction
is realized using the pediculed subhyoid myo-cartilagenous flap. The internal side of the thyroid ala is slotted to fold and create an
angle imitating the shape of a closer hemilarynx. This remodeled structure is fixed to the front and rear margins of the cricoid, and
the left vocal cord and surrounding tissues are sutured to this flap. Definitive histological analyses confirm a grade II chondrosarcoma
with safe resection margins and no regional lymph node invasion. Postoperative period begins with an ethyl withdrawal requiring
keeping the patient asleep to the 13th day. After intra-operative antibiotic, an episode of pyrexia necessitated its recovery during one
week. Because of the innovative nature of this technique, postoperative rehabilitation has been slow and cautious. Rehabilitation
of swallowing could begin on the 21st day. The complete oral diet was possible from the 23rd day and the feeding tube was finally
removed on day 35. Because of a glottic gap, this patient has a breathy voice. The 27th postoperative day, by direct laryngoscopy, we
failed to fullfill the glottic leaks with a hypopharyngeal mucosal flap. Finally, the patient was discharged from hospital on the 36th
day with an obturated tracheal cannula. He continues his vocal r�©habilitation ambulatory and his voice quality is improving but the
tracheotomy weaning was postponed because a laryngeal lipofilling has been organized aiming to reduce the glottic leak.
Biography
Email: gilbert_chantrain@stpierre-bru.be
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