10.14639/0392-100X-N2623
Objective. The aim of the present study is to describe our novel surgical technique of hemicricoidectomy and reconstruction with modified rotational thyro-crico-tracheal anastomosis for the treatment of non-squamous cell subglottic tumours. The procedure has been defined as Type E crico-tracheal resection and anastomosis (CTRA) following the University of Brescia (C)TRA classification introduced elsewhere. Methods. A detailed anatomical step-by-step dissection was reproduced and illustrated on a cadaveric laryngo-tracheal specimen. Moreover, oncological and functional outcomes of the first 5 patients who underwent Type E CTRA at our Institution between October 2016 and September 2022 are described. Results. Three patients underwent Type E CTRA for cricoid chondrosarcoma (CS) and 2 patients for subglottic adenoid cystic carcinoma (ACC). No post-operative complication was reported. All patients maintained intact oral intake and an intelligible voice at discharge. All but one patient with obstructive sleep apnoea hypopnea syndrome and lung comorbidity were successfully decannulated before discharge. At the last follow-up (April 2023), one patient experienced local recurrence of CS that was still amenable to conservative treatment by transoral debulking, while the remaining patients were free of disease. Conclusions. With the proper indications, Type E CTRA is a feasible and effective conservative surgical technique for selected non-squamous cell subglottic tumours.
text/xml
1827-675X
2623
en
Davide Mattavelli
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
adenoid cystic carcinoma
Hemicricoidectomy with modified rotational thyro-crico-tracheal anastomosis: a newborn in the family of crico-tracheal resection and anastomosis techniques
Text.Serial.Journal
https://www.actaitalica.it/
43
Laryngology
2023-10-10
2023-04-25
2023-12-19
2023-12-19
382-389
1
Davide Mattavelli
2023/10/10
10.14639/0392-100X-N2623
382
Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
1827-675X
adenoid cystic carcinoma
en
389
Hemicricoidectomy with modified rotational thyro-crico-tracheal anastomosis: a newborn in the family of crico-tracheal resection and anastomosis techniques
https://www.actaitalica.it/article/download/2623/1046
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:382-389; doi: 10.14639/0392-100X-N2623




Laryngology


Hemicricoidectomy with modified rotational
thyro-crico-tracheal anastomosis: a newborn
in the family of crico-tracheal resection
and anastomosis techniques
Emicricoidectomia con anastomosi rotazionale tiro-crico-tracheale modificata:
una nuova procedura nella famiglia delle resezioni e anastomosi crico-tracheali
Cesare Piazza1,2, Davide Lancini1, Gabriele Zigliani1, Francesca Del Bon1, Michele Tomasoni1, Claudia Montenegro1,
Vittorio Rampinelli1, Davide Mattavelli1,2
1
  Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy; 2 Department of Medical and
Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy


SUMMARY
Objective. The aim of the present study is to describe our novel surgical technique of
hemicricoidectomy and reconstruction with modified rotational thyro-crico-tracheal
anastomosis for the treatment of non-squamous cell subglottic tumours. The procedure has
been defined as Type E crico-tracheal resection and anastomosis (CTRA) following the
University of Brescia (C)TRA classification introduced elsewhere.
Methods. A detailed anatomical step-by-step dissection was reproduced and illustrated on
a cadaveric laryngo-tracheal specimen. Moreover, oncological and functional outcomes of
the first 5 patients who underwent Type E CTRA at our Institution between October 2016
and September 2022 are described.                                                                  Received: April 25, 2023
Results. Three patients underwent Type E CTRA for cricoid chondrosarcoma (CS) and 2                Accepted: May 8, 2023
patients for subglottic adenoid cystic carcinoma (ACC). No post-operative complication             Published online: October 10, 2023
was reported. All patients maintained intact oral intake and an intelligible voice at discharge.
All but one patient with obstructive sleep apnoea hypopnea syndrome and lung comorbidity
                                                                                                   Correspondence
were successfully decannulated before discharge. At the last follow-up (April 2023), one
                                                                                                   Davide Lancini
patient experienced local recurrence of CS that was still amenable to conservative treatment
                                                                                                   Unit of Otorhinolaryngology – Head and Neck
by transoral debulking, while the remaining patients were free of disease.                         Surgery, ASST Spedali Civili of Brescia, piazza
Conclusions. With the proper indications, Type E CTRA is a feasible and effective                  Spedali Civili 1, 25123 Brescia, Italy
conservative surgical technique for selected non-squamous cell subglottic tumours.                 Tel. +39 030 3995319. Fax +39 030 3996142
                                                                                                   E-mail: lancinidavide@gmail.com
KEY WORDS: cricoid, trachea, crico-tracheal resection and anastomosis, chondrosarcoma,
adenoid cystic carcinoma
                                                                                                     How to cite this article: Piazza C, Lancini D,
                                                                                                     Zigliani G, et al. Hemicricoidectomy with modi-
RIASSUNTO                                                                                            fied rotational thyro-crico-tracheal anastomosis:
Obiettivo. Scopo del presente studio è quello di descrivere una nuova tecnica chirurgica             a newborn in the family of crico-tracheal resec-
di emicricoidectomia e ricostruzione mediante anastomosi rotazionale tiro-crico-                     tion and anastomosis techniques. Acta Otorhi-
tracheale modificata per il trattamento di tumori sottoglottici non-squamocellulari. La              nolaryngol Ital 2023;43:382-389. https://doi.
procedura è stata denominata resezione-anastomosi crico-tracheale (CTRA) Tipo E, in                  org/10.14639/0392-100X-N2623
base alla classificazione delle (C)TRA dell’Università degli Studi di Brescia, già descritta
in precedenza altrove.                                                                             © Società Italiana di Otorinolaringoiatria
Metodi. Una dissezione dettagliata è stata eseguita e illustrata su un pezzo anatomico             e Chirurgia Cervico-Facciale
laringo-tracheale proveniente da cadavere. Inoltre, i risultati oncologici e funzionali dei
primi 5 pazienti sottoposti a CTRA Tipo E presso la nostra Clinica nel periodo ottobre                            OPEN ACCESS
2016 - settembre 2022 sono stati qui descritti.                                                    This is an open access article distributed in accordance with
Risultati. Tre pazienti sono stati sottoposti a CTRA Tipo E per condrosarcoma                      the CC-BY-NC-ND (Creative Commons Attribution-Non-
(CS) cricoideo e 2 per carcinoma adenoidocistico (ACC) sottoglottico. Non è stata                  Commercial-NoDerivatives 4.0 International) license. The
                                                                                                   article can be used by giving appropriate credit and mentio-
riscontrata nessuna complicanza post-operatoria. Tutti i pazienti hanno mantenuto una              ning the license, but only for non-commercial purposes and
normale alimentazione per bocca e una voce comprensibile già alla dimissione. Tutti i              only in the original version. For further information: https://
pazienti sono stati decannulati prima della dimissione, tranne una che presentava una              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




382
                                                                                 Hemicricoidectomy with rotational thyro-crico-tracheal anastomosis




sindrome delle apnee ipopnee ostruttive notturne e importanti comorbidità polmonari. Durante il follow-up (terminato nell’aprile 2023)
solo una paziente ha evidenziato una recidiva locale di CS, trattata conservativamente mediante debulking per via transorale, mentre i
restanti pazienti sono tuttora liberi da malattia.
Conclusioni. Rispettando le corrette indicazioni, la CTRA Tipo E si è dimostrata una tecnica chirurgica conservativa riproducibile ed efficace
per il trattamento di selezionati tumori sottoglottici non-squamocellulari.
PAROLE CHIAVE: cricoide, trachea, resezione e anastomosi crico-tracheale, condrosarcoma, carcinoma adenoidocistico



Introduction                                                             Materials and methods
Within the wide range of possible malignant laryngeal tu-                Laboratory setting
mours, the subgroup of lesions limited to the cricoid car-               A pre-clinical study on one human laryngo-tracheal
tilage represents a rare clinical finding and a well-known               cadaveric specimen was carried out to accurately describe
therapeutic challenge. Such lesions are usually of cartilagi-            step-by-step the surgical procedure herein demonstrated. In
nous origin, i.e. chondrosarcoma (CS), or arise from minor               detail, a 20% alcohol fixed human male head was employed.
salivary glands, like adenoid cystic carcinoma (ACC) 1,2. In             The specimen, at the time of harvesting, was sectioned at
fact, due to their rapid growth and more aggressive biologic             the base of the neck, maintaining 8 tracheal rings intact. The
behaviour, subglottic squamous cell carcinoma (SCC) lim-                 specimen was provided by Medcure®, USA, and arterial
ited to the cricoid cartilage is a serendipitous diagnosis and,          injection with a bicomponent red silicone was conducted
when encountered, usually requires an aggressive approach                before fixing the specimen with an alcohol solution. All
in the form of total laryngectomy (TL) for the sake of on-               the phases (specimen injection, fixation, and dissection)
cologic radicality 3,4.                                                  took place in the dissection laboratory “L.F. Rodella” at the
Limiting attention to non-SCC subglottic tumours involv-                 Section of Anatomy and Physiopathology of the University
ing less than 60% of the cricoid circumference, with com-                of Brescia, Italy. Photos of each significant step of the Type
plete sparing of at least one crico-arytenoid unit (CAU),                E CTRA were taken and shown herein to demonstrate the
and without involvement of the thyroid lamina and/                       technical details.
or hypopharyngeal and upper oesophageal mucosa, we
herein demonstrate that such a clinical scenario is poten-               Surgical technique
tially manageable by conservative therapeutic strategies,                After orotracheal intubation, the patient is placed on the
which has been heterogeneously described in the modern                   operating table with the head in a hyperextended position.
literature. In fact, in between transoral laser-assisted de-             A cervical horizontal skin incision is performed in between
bulking and TL, several reports describe different open                  the cricoid prominence and the suprasternal notch, and
partial reconstructive techniques, variously described and               subplatysmal/fascial flaps are raised superiorly and inferi-
not widely popularised 1,5-7. In particular, in 2017 Rovò                orly, thus exposing the superficial cervical fascia and the
and coworkers described a case series of 4 patients who                  underlying prelaryngeal muscles. The linea alba is verti-
were surgically treated for low-grade (G1) CS by total                   cally incised and strap muscles separated to expose the un-
cricoidectomy and rotational thyro-tracheopexy 8. Based                  derlying thyroid gland and laryngo-tracheal axis. Thyroid
on this provocative work, we modified the Rovò’s pro-                    isthmusotomy is completed along the midline and thyroid
cedure, making it suitable for lesions involving slightly                lobes lateralized to completely expose the laryngo-tracheal
more than half of the cricoid circumference thus allowing                junction. This manoeuvre must be carefully conducted in
the preservation of an intact CAU unit, and obtaining the                strict adherence to the external tracheal perichondrium, in
best possible compromise between oncological and func-                   order not to damage the recurrent laryngeal nerves (RLNs),
tional outcomes.                                                         especially on the side not affected by the tumour. Laterali-
The aim of the present study is to illustrate our standardised           sation of the thyroid lobes allows protection of the RLNs,
surgical procedure of hemicricoidectomy and reconstruction               moving them away from the tracheal axis and their point of
with modified rotational thyro-crico-tracheal anastomosis;               entry behind the inferior thyroid cornua. An incision is per-
in accordance with the University of Brescia (crico)-                    formed through the crico-tracheal membrane, thus obtain-
tracheal resection and anastomosis [(C)TRA] classification               ing a circumferential laryngo-tracheal separation (Fig. 1A).
previously described 9, we named this procedure Type E                   At this point, after withdrawing the orotracheal tube above
CTRA. Moreover, oncological and functional outcomes of                   the vocal folds, the airway is directly intubated through the
the first 5 patients treated in our centre with this technique           distal tracheal stump to remove the obstacle of the endola-
are described herein.                                                    ryngeal tube during subsequent cricoid resection.



                                                                                                                                             383
C. Piazza et al.




A vertical anterior section of the cricoid arch is then per-                         A                                         B
formed on the midline, with the possibility of slightly
modifying it on the base of the anterior tumour extension.
Care should be paid to avoid any injury to the crico-thyroid
muscle on the healthy side with the aim of preserving the
tension of the corresponding vocal fold. The crico-thyroid
membrane of the hemicricoid to be resected is then incised,
together with the ipsilateral cranial insertions of the crico-
thyroid muscle, maintaining the section line at the level of
the inferior border of the thyroid lamina on the tumour side                         C                                         D
(Fig. 1B). Finally, the inferior cornu of the thyroid cartilage
is sectioned to allow full crico-thyroid separation and direct
endoluminal tumour inspection (Fig. 1C). The lateral crico-
arytenoid muscle is then sectioned, and the crico-arytenoid
joint is disarticulated, thus freeing the posterior-superior
surface of the cricoid plate (Fig. 1D). With the tumour un-
der direct view, a posterior vertical cricoidotomy at the lev-
el of the cricoid plate is now performed, paying attention to
not injure the hypopharyngeal mucosa of the post-cricoid                            Figure 2. (A-D) Left hemicricoidectomy and tracheal re-shaping.
area (Fig. 2A). This posterior cut can be modulated accord-                         AC: arytenoid cartilage; CA: cricoid arch; CAJ: crico-arytenoid joint; CP: cricoid
ing to the specific tumour extension and, potentially, car-                         plate; ICTC: inferior cornu of the thyroid cartilage; PM: pars membranacea;
ried slightly off the posterior midline while preserving an                         RLN: recurrent laryngeal nerve (black asterisk in Figure 2A); TR: trachea; black
                                                                                    asterisks in Figure 2D, planned suture between the inferior portion of the cri-
intact and fully functioning contralateral CAU. No attempt                          coid arch and reshaped trachea; white asterisks in Figure 2D, planned final
                                                                                    position of the posterolateral edge of the superior tracheal ring supporting the
                                                                                    above-placed arytenoid; black arrow, planned 30° tracheal rotation.
 A                                          B

                                                                                    is made to preserve the ipsilateral RLN due to the complete
                                                                                    removal of the intrinsic laryngeal muscles on the tumour
                                                                                    side, including the posterior crico-arytenoid muscle. The
                                                                                    specimen, composed of a hemicricoid and the correspond-
                                                                                    ing inferior thyroid cornu, can now be removed and mucosal
                                                                                    fresh frozen sections performed, if needed (Figs. 2B, C).
                                                                                    Subsequent airway reconstruction is accomplished by re-
                                                                                    shaping the distal tracheal stump to close the subglottic gap
                                                                                    and sustain the disarticulated and paralysed arytenoid. At
  C                                         D                                       least 3 hemi-tracheal rings, equivalent to the cricoid plate
                                                                                    cranio-caudal height, are thus removed from the tracheal
                                                                                    stump, contralaterally to the cricoid defect (Fig. 2D). The
                                                                                    tracheal membranous wall must be completely preserved to
                                                                                    save tissue to cover the post-cricoid hypopharyngeal mu-
                                                                                    cosa from the inside, suturing it to the remaining subglottic
                                                                                    mucosa at the level of the preserved hemicricoid plate. To
                                                                                    prevent excessive swelling and medialisation of the para-
                                                                                    lysed vocal fold, its inferior margin needs to be fixed with
                                                                                    one or two 3-0 polyglactin 910 stitches to the inferior bor-
                                                                                    der of the ipsilateral thyroid lamina.
Figure 1. (A-D) Laryngo-tracheal separation and first steps of the hemicri-         While planning the thyro-crico-tracheal anastomosis, an
coid resection.
AC: arytenoid cartilage; CAJ: crico-arytenoid joint; CAM: lateral crico-arytenoid
                                                                                    approximately 20°-30° tracheal rotation must be consid-
muscle; CC: cricoid cartilage; CT: crico-thyroid muscle; ICTC: inferior cornu of    ered to: (a) position the posterior angle of the first cartilagi-
the thyroid cartilage; TR: trachea.                                                 nous tracheal ring just below the disarticulated arytenoid;



384
                                                                                          Hemicricoidectomy with rotational thyro-crico-tracheal anastomosis




(b) cover the entire posterior vertical cricoid split, allow-                      knots. Finally, patient’s head is flexed, and the sutures are
ing safe suture between this and the mucosa of the tracheal                        symmetrically tied: in first place the posterior ones, then
membranous wall; (c) align the lateral edge of the three                           the “stay sutures”, followed by all the stitches from the
sectioned hemi-tracheal rings with the residual anterior                           posterior-lateral to the most anterior ones.
hemicricoid arch and crico-tracheal membrane; (d) match                            After the anastomosis has been successfully accomplished,
the inferior edge of the thyroid lamina with the superior                          a temporary tracheotomy is performed at least 3 tracheal
margin of the first tracheal ring. The modified thyro-crico-                       rings below the anastomotic line to preserve its vasculari-
tracheal rotational anastomosis is then accomplished in a                          sation. A cuffed cannula (typically a Shiley no. 6) is then
posterior to anterior direction (Figs. 3, 4A-C). The anas-                         positioned and inflated. During the layer-by-layer suture
tomosis technique involves the use of a couple of robust                           of the cervical wound, great care should be paid to isolate
“stay sutures” with 2-0 polyglactin 910 stitches, positioned                       the tracheotomy from the neck by using 4 stitches, thus al-
above and below the anastomotic line and aimed at reduc-                           lowing the suction drainage(s) to maintain their vacuum.
ing its tension. These are positioned in the antero-lateral                        Finally, two heavy sutures are placed from chin to chest in
aspect of the future anastomosis, ideally at 2 and 10 o’clock                      order to maintain the patient’s head in a moderately flexed
positions in an axial view of the airway. Therefore, on one                        position for the following 8 postoperative days.
side the superior stay suture will be placed submucosally in
the cricoid arc, while the correspondent inferior one should                       Case series
be placed at least one tracheal ring below the removed lat-                        Data concerning patients who underwent Type E CTRA
eral tracheal window. On the other side, the superior stay                         between October 2016 and September 2022 for non-SCC
suture will be placed submucosally through the thyroid ala                         subglottic tumours at the Department of Otorhinolaryngol-
(perforated by using a burr if ossified), while the inferior                       ogy – Head and Neck Surgery of the University of Brescia,
matching one should be placed at the level of the second                           Italy, were prospectively collected. In particular, a dedi-
tracheal ring. Care should be taken to foresee the appro-                          cated database was prospectively maintained, collecting
priate tracheal rotation while positioning the stay sutures.                       data about patient demographics, comorbidities, previous
Harvesting of the anastomosis is accomplished by placing                           head and neck treatment(s), details of surgical procedure,
five to seven 4-0 polyglactin 910 stitches between the tra-                        post-operative course, hospitalisation time, and final histo-
cheal membranous wall and the posterior mucosa of the                              pathological examination of the surgical specimen. Moreo-
preserved hemicricoid plate (Fig. 3). The preparation is                           ver, oncological and functional outcomes were assessed
then completed by passing 10 to 15 2- and 3-0 polyglactin                          and confirmed for the last time in April 2023. A descriptive
910 sutures equally distributed along the antero-lateral cir-                      analysis of the collected data was completed.
cumference of the laryngeal and tracheal stumps (Fig. 4A-
C). The endotracheal tube in the distal tracheal stump can                         Results
be now removed and replaced by the previous orotracheal
one by passing it through the anastomosis before tying the                         Five patients were included in the present study, 3 females
                                                                                   and 2 males (Tab. I). Median age at surgery was 57 years,
                                                                                   ranging from 48 to 67. One female was affected by ob-
                                                                                   structive sleep apnoea hypopnea syndrome (OSAHS) and
                                                                                   restrictive lung disease due to extreme scoliosis, while the
                                                                                   remaining patients did not have major comorbidities.
                                                                                   Three patients underwent upfront surgery: 2 for G1-G2 cri-
                                                                                   coid CS, and one for subglottic ACC. Two patients were re-
                                                                                   ferred to us for local recurrence after previous treatments. In
                                                                                   detail, one patient (no. 2 in Tab. I) had been managed by two
                                                                                   carbon dioxide transoral laser microsurgical (CO2 TOLMS)
                                                                                   procedures for a G1 cricoid CS, while the other had been
                                                                                   previously treated for subglottic ACC by radiation therapy
                                                                                   (65 Gy). All patients were without tracheostomy at the mo-
                                                                                   ment of our first evaluation with the exception of patient
                                                                                   no. 2, who was tracheotomised prior to CO2 TOLMS and
Figure 3. Crico-tracheal anastomosis, posterior portion.
AC: arytenoid cartilage; CC: cricoid cartilage; CP: cricoid plate; PM: pars mem-   was never decannulated due to OSAHS and restrictive lung
branacea; TC: thyroid cartilage; TR: trachea.                                      disease.



                                                                                                                                                      385
C. Piazza et al.




     A                                                            B                                                          C




Figure 4. (A-C). Modified rotational thyro-crico-tracheal anastomosis.
AC: arytenoid cartilage; CC: cricoid cartilage; CP: cricoid plate; PM: pars membranacea; TC: thyroid cartilage; TR: trachea; black asterisk in Figure 4B, correspond-
ence between the inferior portion of the cricoid arch and reshaped trachea; white asterisk in Figure 4B, final position of the superior edge of the cricoid arch and
the reshaped trachea.


The postoperative course did not show early or late com-                                      paired function of the healthy CAU). No adjuvant therapy
plications requiring surgical re-intervention. On the other                                   was administered.
hand, patient no. 2 required medical therapy for infectious                                   During follow-up, the patient affected by G2 CS with R1
pneumonia. She was also the only in which tracheostomy                                        margins developed a local recurrence at 36 months after
removal was not possible for the underlying pulmonary co-                                     surgery, which was still amenable to conservative treatment
morbidities and need for ventilation with continuous posi-                                    by debulking with CO2 TOLMS. The remaining 4 patients
tive airway pressure during the night (an issue pre-existent                                  underwent regular control visits as of April 2023 with no
to the surgical treatment). This patient keeps a Shiley no. 4                                 endoscopic and radiologic evidence of local, regional and/
tracheostomic cannula plugged during her daily life and nor-                                  or distant recurrence (mean follow-up, 48 months; range,
mal activity, maintaining an intelligible voice and functional                                8-78).
swallowing without aspiration. In the other 4 patients, the
tracheostomy was closed on average on the 9th post-operative
                                                                                              Discussion
day. Overall, oral feeding started after removal of the trache-
ostomy and nasogastric feeding tubes (the latter not before                                   The present work describes the surgical technique and
the 8th post-operative day). Median hospitalisation time was                                  preliminary results of a novel conservative procedure of
15 days (range, 11-21).                                                                       hemicricoidectomy and reconstruction with modified ro-
Definitive histopathological examination showed complete                                      tational thyro-crico-tracheal anastomosis applied to the
tumour removal (R0) in 4 cases and R1 margins in one G2                                       treatment of selected non-SCC cricoid tumours. The well-
CS along the posterior cricoidotomy line (where further                                       known complexity of organ-sparing surgical management
contralateral extension of the resection would have im-                                       of such lesions, due to the pivotal role played by the cricoid


Table I. Demographics, clinical, and post-operative details.
 Patient Age Gender           Previous       Histology Margins                    Decannulation          Oral feeding         Recurrence          Additional          Status
 no.                        treatment(s)                                          (post-op day)         (post-op day)                            treatments
 1            48        M              -              G1 CS            R0                14                    15                  No                 -            NED, 78 mos
 2            59        F        2 CO2 TOLMS          G1 CS            R0                 -                    12                  No                 -            NED, 74 mos
 3            67        F              -              G2 CS            R1                7                      8             Yes, 36 mos        CO2 TOLMS         AWD, 14 mos
 4            56        M             RT               ACC             R0                9                     10                  No                 -            NED, 33 mos
 5            57        F              -               ACC             R0                7                      8                  No                 -             NED, 8 mos
M: male; F: female; CO2 TOLMS: transoral laser microsurgery by carbon dioxide; RT: radiotherapy; G1: well-differentiated; G2: moderately differentiated; CS: chondrosarcoma; ACC: ad-
enoid cystic carcinoma; R0: microscopically negative margins; R1: microscopically positive margins; mos: months; NED: no evidence of disease; AWD: alive with disease.




386
                                                                          Hemicricoidectomy with rotational thyro-crico-tracheal anastomosis




within the upper airway, forced surgeons to find new thera-        tracheal tumours of various histotypes treated by laryngo-
peutic solutions for such an unmet need. In fact, complete         tracheoplastic procedures and reported very sound results.
or partial cricoid removal may bring about several altera-         Dealing with cricoid G1-G2 CS, Piazza et al. 21 reported
tions in terms of airway patency, swallowing and voice             11 cases of subtotal cricoidectomy, variably extending the
production 10,11. For this reason, historically, the simplest      resection to the cricoid arch and plate, but always maintain-
choice of treatment for tumours involving the cricoid was          ing a slender portion of posterior cricoid plate as support
TL, which still remains the gold standard in most subglot-         to the above placed arytenoids and in front of the posterior
tic SCC with cricoid cartilage infiltration 3,4. On the other      cricoarytenoid muscles in order not to damage the RLNs.
hand, in case of subglottic tumours of other histotypes, e.g.      According to the authors’ classification 9, this procedure
G1-2 CS or minor salivary gland neoplasms, various open            will be subsequently named as Type C CTRA.
conservative procedures might be taken into account. In            For what concerns further extended resections, Guinchard
this scenario, in fact, CO2 TOLMS is mostly indicated for          et al. 22 reported on the use of inferior vertical hemilaryn-
surgical debulking of endolaryngeal lesions to obtain sam-         gectomy for a patient with synovial sarcoma of the aryte-
ples for histological examination and temporarily restore          noid in which the resection encompassed one CAU togeth-
the airway patency avoiding tracheostomy, while oncologi-          er with the ipsilateral hemicricoid and the inferior portion
cal radicality is often difficult (if not impossible) to achieve   of the thyroid ala. In this case, airway reconstruction was
by such an approach 12-14.                                         accomplished by employing the ipsilateral hemitracheal
In order to maximise oncologic radicality while preserving         stump, sacrificing the contralateral one, and accomplishing
laryngeal functions, two main rules need to be respected:          a thyro-crico-tracheal anastomosis by placing the superior
1) the anatomical and functional integrity of at least one         edge of the tracheal flap inside the thyroid cartilage, in or-
CAU; 2) the maintenance of a rigid structure framing the           der to replace the removed vocal fold 22. The patient main-
airway patency 11. In light of these principles, airway recon-     tained an LT-Mold laryngeal stent 23 in place for 6 weeks,
struction after cricoid resection may be carried out either        and the tracheostomy was surgically closed after 2 months,
by interposition of a revascularised or pedicled flap, or by       with satisfactory functional outcomes. Finally, Rovò et al. 8
direct laryngo-tracheal anastomosis.                               described a peculiar way to support the arytenoid cartilages
The first reconstructive option requires complex techniques,       in case of total cricoidectomy, trying to avoid the functional
frequently carried out by multiple-staged procedures, of-          sequalae proper of this type of procedure 6,24. The authors
ten deserving prolonged laryngeal stenting 7,15-17. Another        proposed a rotational thyro-tracheoplasty, performing a 90°
shortcoming of these types of procedures is the impossibil-        rotation of the distal tracheal stump to support the paralysed
ity to completely reproduce the laminated airway structure,        arytenoid cartilages by means of the cartilaginous portion
composed by a cartilaginous skeleton in support to a res-          of the first tracheal ring. In detail, the paper reports 3 total
piratory epithelium. Therefore, the most successful surgi-         and 1 subtotal cricoidectomy for CS. Three of 4 patients
cal interventions imply the use of composite flaps with the        required soft laryngeal stenting and the same underwent
association of various grafts 16,17. In this regard, Delaere and   a second operation for single or bilateral arytenoid later-
coworkers described tracheal auto- and allotransplantation         opexy. All patients were decannulated after surgery, and 3
techniques, which were also applied with good results in           patients were able to regain oral feeding 8.
cases of cricoid CS 18,19. The authors described a two-step        The new surgical procedure described herein is a modifi-
procedure to restore the defect of a vertical hemilaryngec-        cation of the technique reported by Rovò et al. 8, aimed
tomy, using a composite flap. In detail, a fascial forearm         at treating the case of an hemicricoid (or slightly more
free flap was used to enwrap and revascularise a tracheal          than hemicricoid) resection. The final result is a procedure
graft harvested from the same patient or from a donor. In          providing complete resection of (potentially slightly more
the latter scenario, the buccal mucosa of the recipient was        than) half of the cricoid, while preserving a fully functional
also used to resurface the inner tracheal portion. Naturally,      CAU and supporting the paralysed arytenoid with a solid
the completion of the procedure required several months            structure, thus providing a further barrier to aspiration and
and immunosuppressive therapy in case of allotransplanta-          an ideal condition for good swallowing and voice com-
tion 18,19.                                                        pensation. Different from the abovementioned procedures,
On the other hand, airway reconstruction by direct anas-           Type E CTRA is characterised by a lesser amount of ro-
tomosis, when feasible, represents a straightforward pro-          tation of the distal tracheal stump (maximum 30°) from
cedure that allows maintenance of airway structure and             one side, and a tracheal reshape that reduces the anasto-
preservation of an intact respiratory mucosa. Gaissert and         motic tension and the asymmetry of airway reconstruc-
coworkers 20 described a series of 25 patients with laryngo-       tion from the other. These features, together with sparing



                                                                                                                                      387
C. Piazza et al.




of one functional CAU, may provide major stability of the         follow-up will allow for assessment of the reproducibility
reconstructed airway and easier functional recovery. Fur-         of the procedure.
thermore, preservation of both arytenoids (even if one is
paralysed), the entire thyroid cartilage, and the whole su-       Conclusions
praglottic and glottic structures confer superior functional
outcomes compared to other procedures, such as open par-          Subglottic non-SCC tumours represent a rare entity and
tial horizontal laryngectomy Types IIIa or IIIb 25. Our initial   a demanding surgical challenge, which may often require
results, with no surgical complications, 80% decannulation        more aggressive treatments in the form of TL. The present
rate and 100% of functional swallowing, confirm the feasi-        work describes the surgical technique and initial encour-
bility of this technique and adequately safe oncological and      aging results of a novel conservative approach of hemic-
functional profiles. In fact, only one patient experienced a      ricoidectomy and reconstruction with modified rotational
tumour relapse of a G2 CS at 36 months after a Type E             thyro-crico-tracheal anastomosis, named Type E CTRA.
CTRA, and during this period she completely maintained            With the appropriate indications and adequate surgical ex-
laryngeal functions and continued to work as a lawyer. An-        pertise of the airway, we believe that this type of procedure
other patient was unable to remove the tracheostomy due to        will be able to provide an additional effective and standard-
severe OSAHS and lung comorbidities, but maintained nor-          ised option in the armamentarium of surgeons dealing with
mal oral intake and an intelligible voice, as did all the other   tumours of the crico-tracheal junction.
patients in the present series. Moreover, Type E CTRA has
the great advantage to be a standardised single-stage pro-        Conflict of interest statement
cedure, with the possibility to be extended anteriorly to the     The authors declare no conflict of interest.
cricoid arch and first hemitracheal ring inferiorly. Our case
series confirmed that no laryngeal stenting or further sur-       Funding
gical re-interventions to maintain the airway patency are         This research did not receive any specific grant from fund-
usually required.                                                 ing agencies in the public, commercial, or not-for-profit
However, airway surgery in general, and this type of proce-       sectors.
dure in particular, requires very strict and watchful indica-
tions. Type E CTRA as described herein should be limited          Author contributions
to non-SCC lesions of the subglottis, involving no more           CP, DL, DM: concept; DL, GZ, CM, FDB: data collection;
than 60% of the inner cricoid circumference, with complete        CP, DL, VR: anatomical dissection; DL, MT, GZ, CP: pic-
sparing of one CAU, and without infiltration of the thyroid       tures editing; CP, DL, MT: writing – original draft; FDB,
cartilage and/or the hypopharyngeal and upper oesopha-            CM, VR, DM: writing – review/editing.
geal mucosa. Another theoretically possible indication, not
encountered in the present series, may be represented by a        Ethical consideration
single sided cricoid infiltration by well-differentiated ad-      This study was approved by the Institutional Ethics Com-
vanced thyroid cancer.                                            mittee (CE Spedali Civili) (protocol number 4267). The re-
Regarding patient selection, Type E CTRA seems less de-           search was conducted ethically, with all study procedures
manding than the other types of CTRA applied for man-             being performed in accordance with the requirements of
agement of various neoplastic and non-neoplastic airway           the World Medical Association’s Declaration of Helsinki.
stenoses of the crico-tracheal junction, usually performed        Written informed consent was obtained from each partici-
without post-operative tracheostomy. As demonstrated by           pant/patient for study participation and data publication.
patient no. 2 of the present series, in fact, even severe pul-
monary comorbidities may allow the patient to be treated          References
radically while preserving effective voice and swallowing,        1
                                                                      Chin OY, Dubal PM, Sheikh AB, et al. Laryngeal chondrosarcoma:
using the tracheostomy just for nocturnal positive-pressure           a systematic review of 592 cases. Laryngoscope 2017;127:430-439.
ventilation.                                                          https//doi.org/10.1002/lary.26068
The small number of patients, due to the rarity of the dis-       2
                                                                      Karatayli-Ozgursoy S, Bishop JA, Hillel AT, et al. Malignant
ease and the very strict surgical indications followed by us          salivary gland tumours of the larynx: a single institution re-
in applying Type E CTRA, remains the major limitation of              view. Acta Otorhinolaryngol Ital 2016;36:289-294. https//doi.
                                                                      org/10.14639/0392-100X-807
this work, together with the relatively short-term follow-        3
                                                                      Coskun H, Mendenhall WM, Rinaldo A, et al. Prognosis of subglottic
up. After the desirable diffusion of such a technique, multi-         carcinoma: is it really worse? Head Neck 2019;41:511-521. https//
centric studies with a larger number of patients and longer           doi.org/10.1002/hed.25172




388
                                                                                       Hemicricoidectomy with rotational thyro-crico-tracheal anastomosis




4
     Yu H, Tao L, Zhou L, et al. Results of surgical treatment alone for      15
                                                                                   Banaszewski J, Gaggl A, Buerger H, et al. Functional results after total
     primary subglottic carcinoma. Acta Otolaryngol 2019;139:432-438.              cricoidectomy with medial femoral condyle free flap reconstruction.
     https//doi.org/10.1080/00016489.2019.1575519                                  Eur Arch Otorhinolaryngol 2016;273:3869-3874. https//doi.
5
     Rinaldo A, Howard DJ, Ferlito A. Laryngeal chondrosarcoma:                    org/10.1007/s00405-016-4017-2
     a 24-year experience at the Royal National Throat, Nose and              16
                                                                                   Jackson RS, Martin EJ, Moore EJ. Prefabricated auricular cartilage
     Ear Hospital. Acta Otolaryngol 2000;120:680-688. https//doi.                  radial forearm free flap reconstruction for cricoid chondrosarcoma.
     org/10.1080/000164800750000199                                                Laryngoscope 2015;125:2514-2517. https//doi.org/10.1002/lary.25510
6
     Bertolin A, Lionello M, Baldovin M, et al. The glottic-subglottic        17
                                                                                   Rich JT, Goldstein D, Haerle SK, et al. Vascularized composite
     laryngectomy: surgical technique, oncological, and functional                 autograft for adult laryngotracheal stenosis and reconstruction. Head
     outcomes. J Surg Oncol 2022;125:145-150. https//doi.org/10.1002/
                                                                                   Neck 2016;38:253-259. https//doi.org/10.1002/hed.23887
     jso.26675
                                                                              18
                                                                                   Delaere P, Goeleven A, Poorten VV, et al. Tracheal autotransplantation
7
     Hantzakos A, Evrard AS, Lawson G, et al. Posthemicricoidectomy
     reconstruction with a composite hyoid-sternohyoid osseomuscular               for functional reconstruction of extended hemilaryngectomy
     flap: the Rethi-Ward technique. Eur Arch Otorhinolaryngol                     defects: a single-center experience in 30 patients. Ann Surg Oncol
     2007;264:1339-1342. https//doi.org/10.1007/s00405-007-0361-6                  2016;23:1674-1683. https//doi.org/10.1245/s10434-015-5033-y
8
     Rovó L, Bach Á, Sztanó B, et al. Rotational thyrotracheopexy
                                                                              19
                                                                                   Delaere P, Vranckx J, Meulemans J, et al. Learning curve in tracheal
     after cricoidectomy for low-grade laryngeal chrondrosarcoma.                  allotransplantation. Am J Transplant 2012;12:2538-2545. https//doi.
     Laryngoscope        2017;127:1109-1115.       https//doi.org/10.1002/         org/10.1111/j.1600-6143.2012.04125.x
     lary.26142                                                               20
                                                                                   Gaissert HA, Grillo HC, Shadmehr BM, et al. Laryngotracheoplastic
9
     Piazza C, Lancini D, Filauro M, et al. Post-COVID-19 airway                   resection for primary tumors of the proximal airway. J Thorac
     stenosis treated by tracheal resection and anastomosis: a bicentric           Cardiovasc Surg 2005;129:1006-1009. https//doi.org/10.1016/j.
     experience. Acta Otorhinolaryngol Ital 2022;42:99-105. https//doi.            jtcvs.2004.07.043
     org/10.14639/0392-100X-N1952                                             21
                                                                                   Piazza C, Del Bon F, Grazioli P, et al. Organ preservation surgery for
10
     Zeitels SM, Burns JA, Wain JC, et al. Function preservation                   low- and intermediate-grade laryngeal chondrosarcomas: analysis of
     surgery in patients with chondrosarcoma of the cricoid cartilage.             16 cases. Laryngoscope 2014;124:907-912. https//doi.org/10.1002/
     Ann Otol Rhinol Laryngol 2011;120:603-607. https//doi.                        lary.24416
     org/10.1177/000348941112000908                                           22
                                                                                   Guinchard AC, Monnier P, Jaquet Y, et al. Modified technique
11
     Piazza C, Paderno A, Nicolai P. Conservative surgery for laryngeal            of functional vertical hemilaryngectomy for cancer invading 1
     chondrosarcoma: a review of the most recently proposed approaches             hemicricoid. Head Neck 2016;38:1722-1727. https//doi.org/10.1002/
     Curr Opin Otolaryngol Head Neck Surg 2017;25:93-100. https//doi.              hed.24476
     org/10.1097/MOO.0000000000000337
                                                                              23
                                                                                   Alshammari J, Monnier P. Airway stenting with the LT-Mold™ for
12
     Merrot O, Gleizal A, Poupart M, et al. Cartilaginous tumors of the
                                                                                   severe glotto-subglottic stenosis or intractable aspiration: experience
     larynx: endoscopic laser management using YAG/KTP. Head Neck
     2009;31:145-152. https//doi.org/10.1002/hed.20932                             in 65 cases. Eur Arch Otorhinolaryngol 2012;269:2531-2538. https//
                                                                                   doi.org/10.1007/s00405-012-2080-x
13
     Pelliccia P, Del Pero MM, Mercier G, et al. Transoral endoscopic
     resection of low-grade, cricoid chondrosarcoma: endoscopic
                                                                              24
                                                                                   de Vincentiis M, Greco A, Fusconi M, et al. Total cricoidectomy
     management of a series of seven patients with low-grade cricoid               in the treatment of laryngeal chondrosarcomas. Laryngoscope
     chondrosarcoma. Ann Surg Oncol 2014;21:2767-2772. https//doi.                 2011;121:2375-2380. https://doi.org/10.1002/lary.22337
     org/10.1245/s10434-014-3668-8                                            25
                                                                                   Damiani V, Crosetti E, Rizzotto G, et al. Well and intermediate differ-
14
     Rüller K, Sittel C, Kölmel JC, et al. Organ preservation strategies in        entiated laryngeal chondrosarcoma: toward conservative surgery? Eur
     laryngeal chondrosarcoma. Laryngoscope 2022;132:838-843. https//              Arch Otorhinolaryngol 2014;271:337-344. https://doi.org/10.1007/
     doi.org/10.1002/lary.29826                                                    S00405-013-2656-0




                                                                                                                                                     389
