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Laryngectomy

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==Preepiglottic space==
 
==Preepiglottic space==
 
*A deep tissue plane, lying between the mucosa and the supporting skeleton of the larynx, largely consisting of adipose tissue.
 
*A deep tissue plane, lying between the mucosa and the supporting skeleton of the larynx, largely consisting of adipose tissue.
*This deep tissue space is superiorly bordered by the hyoepiglottic ligament.
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*This deep tissue space is superiorly bordered by the hyoepiglottic ligament.
*Anteriorly it is bordered by the thyroid cartilage, thyrohyoid membrane and cricothyroid membrane.
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Anteriorly it is bordered by the thyroid cartilage, thyrohyoid membrane and cricothyroid membrane.
*The posterior border consists of the epiglottis, quadrangular membrane and the anterior reflection of the pyriform sinus mucosa.
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*
*Its inferior border is formed by the conus elasticus.
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The posterior border consists of the epiglottis, quadrangular membrane and the anterior reflection of the pyriform sinus mucosa.
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*
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Its inferior border is formed by the conus elasticus.
   
 
==Paraglottic space==
 
==Paraglottic space==
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*The paired paraglottic spaces are lateral to the pre epiglottic space.
 
*The paired paraglottic spaces are lateral to the pre epiglottic space.
 
*At the level of the glottis, the paraglottic space is limited to a narrow band of fatty tissue lateral to the thyroarytenoid musle, continuous with the supraglottic submucosal fat. This deep fat plane at the level of the true vocal cord continues inferiorly as a thin infraglottic fat plane, bordered by the conus elasticus.
 
*At the level of the glottis, the paraglottic space is limited to a narrow band of fatty tissue lateral to the thyroarytenoid musle, continuous with the supraglottic submucosal fat. This deep fat plane at the level of the true vocal cord continues inferiorly as a thin infraglottic fat plane, bordered by the conus elasticus.
*The line of resection in a supraglottic laryngectomy goes through the laryngeal ventricles, between the true and false vocal cords.
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*
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The line of resection in a supraglottic laryngectomy goes through the laryngeal ventricles, between the true and false vocal cords.
 
*If a supraglottic cancer spreads inferiorly along the ventricle, in the paraglottic space at the level of the true vocal cord, then speech conservation surgery will not be possible
 
*If a supraglottic cancer spreads inferiorly along the ventricle, in the paraglottic space at the level of the true vocal cord, then speech conservation surgery will not be possible
   
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It is good practice to photograph the oriented specimen. Make a printout of the photo.
 
It is good practice to photograph the oriented specimen. Make a printout of the photo.
 
Once you have sufficient information about the specimen, it can be fixed in formalin.
 
Once you have sufficient information about the specimen, it can be fixed in formalin.
 
 
   
 
==Total laryngectomy==
 
==Total laryngectomy==
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*Photograph the specimen.
 
*Photograph the specimen.
*Ensure that margins are adequately inked. Insufficient ink will make the case difficult to sign out.
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*Ensure that margins are adequately inked. Insufficient ink will make the case difficult to sign out.
 
*Find the lesion and describe in two dimensions. Describe color, size, quality (exophytic, flat, verrucous, ulcerated, necrotic), location, and extent of involvement of anatomic landmarks (e.g., vocal folds, ventricle, epiglottis, commissures, across midline).
 
*Find the lesion and describe in two dimensions. Describe color, size, quality (exophytic, flat, verrucous, ulcerated, necrotic), location, and extent of involvement of anatomic landmarks (e.g., vocal folds, ventricle, epiglottis, commissures, across midline).
 
*Make longitudinal cross-sections through the specimen in order to measure the third dimension of the tumor and estimate extent of invasion (into submucosa, into cartilage, through cartilage).
 
*Make longitudinal cross-sections through the specimen in order to measure the third dimension of the tumor and estimate extent of invasion (into submucosa, into cartilage, through cartilage).
*Submit entirely, in a way you will be able to reconstruct later (for example, proceeding from medial to lateral). It may be useful to draw your sections on a printout of the specimen photograph.
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*Submit entirely, in a way you will be able to reconstruct later (for example, proceeding from medial to lateral). It may be useful to draw your sections on a printout of the specimen photograph.
*The first and last sections should be sectioned and submitted perpendicular to the[[File:Perpendicular_tips.jpg|thumb|Perpendicular tips]] principal axis, if there are margins to demonstrate in these areas. See diagram.
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*The first and last sections should be sectioned and submitted perpendicular to the principal axis, if there are margins to demonstrate in these areas. See diagram[[File:Perpendicular_tips.jpg|thumb|Perpendicular tips]].
 
 
   
 
==Larger specimen (hemilaryngectomy or total laryngectomy)==
 
==Larger specimen (hemilaryngectomy or total laryngectomy)==
*Larger partial laryngectomy specimens and total laryngectomies will have to be selectively submitted. They may contain bone (hyoid) or ossified cartilage. You will therefore need to be somewhat invasive in processing them.
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*Larger partial laryngectomy specimens and total laryngectomies will have to be selectively submitted. They may contain bone (hyoid) or ossified cartilage. You will therefore need to be somewhat invasive in processing them.
 
*Find the lesion and describe in two dimensions. Describe the lesion including color, size, quality (exophytic, flat, verrucous, ulcerated, necrotic), location, and extent of involvement of anatomic landmarks (e.g., vocal folds, ventricle, epiglottis, commissures, across midline).
 
*Find the lesion and describe in two dimensions. Describe the lesion including color, size, quality (exophytic, flat, verrucous, ulcerated, necrotic), location, and extent of involvement of anatomic landmarks (e.g., vocal folds, ventricle, epiglottis, commissures, across midline).
 
*Find the hyoid bone. If grossly distant from tumor, you can dissect it off and handle it separately. If it seems to be involved by tumor, you will need to leave it on the specimen.
 
*Find the hyoid bone. If grossly distant from tumor, you can dissect it off and handle it separately. If it seems to be involved by tumor, you will need to leave it on the specimen.
*Make longitudinal cross-sections through the specimen in order to measure the third dimension of the tumor and estimate extent of invasion (into submucosa, into cartilage, through cartilage). A large knife and mallet are often required. Don’t hesitate to ask for help.
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*Make longitudinal cross-sections through the specimen in order to measure the third dimension of the tumor and estimate extent of invasion (into submucosa, into cartilage, through cartilage). A large knife and mallet are often required. Don’t hesitate to ask for help.
 
*Take sections (see diagram)[[File:Laryngectomy_sections.jpg|thumb|Laryngectomy sections]]. The following items should be sampled for every case. But remember, one section can show multiple sites, so the total number of slides will be less than the number of sites that need to be evaluated histologically.
 
*Take sections (see diagram)[[File:Laryngectomy_sections.jpg|thumb|Laryngectomy sections]]. The following items should be sampled for every case. But remember, one section can show multiple sites, so the total number of slides will be less than the number of sites that need to be evaluated histologically.
**Tumor showing deepest level of invasion with relationship to adjacent structures (usually 4 sections):
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**Tumor showing deepest level of invasion with relationship to adjacent structures (usually 4 sections):
**Tumor in relationship to deepest level of invasion
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**Tumor in relationship to deepest level of invasion
**Tumor in relation to paraglottic space
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**Tumor in relation to paraglottic space
**Tumor in relation to pre-epiglottic space
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**Tumor in relation to pre-epiglottic space
 
**Tumor in relationship to adjacent normal mucosa to show precursor lesion
 
**Tumor in relationship to adjacent normal mucosa to show precursor lesion
 
**At least one rep sec of the closest soft tissue margin, which will usually be a shave or perpendicular block of the anterior radial margin (use judgment based on tumor extension).
 
**At least one rep sec of the closest soft tissue margin, which will usually be a shave or perpendicular block of the anterior radial margin (use judgment based on tumor extension).
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****Left aryepiglottic fold, left epiglottic, left arytenoid
 
****Left aryepiglottic fold, left epiglottic, left arytenoid
 
****Right aryepiglottic fold, right epiglottic, right arytenoid
 
****Right aryepiglottic fold, right epiglottic, right arytenoid
***Hemilaryngectomy will have either the left or the right set of mucosal margins, plus two medial mucosal margins where the larynx was divided in two—these margins are adjacent to the half of the larynx that is still in the patient.
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***Hemilaryngectomy will have either the left or the right set of mucosal margins, plus two medial mucosal margins where the larynx was divided in two—these margins are adjacent to the half of the larynx that is still in the patient.
 
**All will have a tracheal margin (take a circumferential shave).
 
**All will have a tracheal margin (take a circumferential shave).
**Sample margins closest to the tumor most extensively. All margins taken as perpendicular sections.
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**Sample margins closest to the tumor most extensively. All margins taken as perpendicular sections.
 
**Some specimens will have other designated margins or will lack some of these. Just follow the surgeon’s designations.
 
**Some specimens will have other designated margins or will lack some of these. Just follow the surgeon’s designations.
   
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=Sample dictation=
 
=Sample dictation=
 
The specimen consists of a (total, partial) laryngectomy (___ x ___ x ___ cm), including hyoid bone and larynx from epiglottis to subglottis. The specimen is inked and oriented by the surgeon as follows: (describe). There is an irregular tan-white mass (___ x ___ x ___ cm), with central ulceration, located in the glottis, completely involving the left true vocal cord. The mass crosses the midline and involves the medial aspect of the right true vocal cord. The false vocal cords are not involved. The mass is 2.8 cm from the closest proximal mucosal margin (left aryepiglottic fold) and 5 cm from the distal tracheal margin. The mass invades in to the lamina propria and focally appears to invade into, but not through, the thyroid cartilage. The anterior surface is covered by red-brown muscle which is grossly unremarkable. 0.5 cm from the distal margin there is a 1.5 x 1 cm trachostomy. Sections are submitted as follows: (list)
 
The specimen consists of a (total, partial) laryngectomy (___ x ___ x ___ cm), including hyoid bone and larynx from epiglottis to subglottis. The specimen is inked and oriented by the surgeon as follows: (describe). There is an irregular tan-white mass (___ x ___ x ___ cm), with central ulceration, located in the glottis, completely involving the left true vocal cord. The mass crosses the midline and involves the medial aspect of the right true vocal cord. The false vocal cords are not involved. The mass is 2.8 cm from the closest proximal mucosal margin (left aryepiglottic fold) and 5 cm from the distal tracheal margin. The mass invades in to the lamina propria and focally appears to invade into, but not through, the thyroid cartilage. The anterior surface is covered by red-brown muscle which is grossly unremarkable. 0.5 cm from the distal margin there is a 1.5 x 1 cm trachostomy. Sections are submitted as follows: (list)
 
 
   
 
=Review and signout=
 
=Review and signout=
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:A. Invasive squamous cell carcinoma, X cm, (well, moderately, poorly) differentiated, (non) keratinizing, involving the (right/left glottis vs. supraglottis vs. subglottis vs. other location) to a depth of Y cm (with extension across the midline), (perineural invasion present), smd(F9).
 
:A. Invasive squamous cell carcinoma, X cm, (well, moderately, poorly) differentiated, (non) keratinizing, involving the (right/left glottis vs. supraglottis vs. subglottis vs. other location) to a depth of Y cm (with extension across the midline), (perineural invasion present), smd(F9).
 
:B. Tracheal, laryngeal, mucosal, and anterior soft tissue margins free of involvement.
 
:B. Tracheal, laryngeal, mucosal, and anterior soft tissue margins free of involvement.
:C. Tracheostomy site with skin.
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:C. Tracheostomy site with skin.
:D. Thyroid, no tumor identified.
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:D. Thyroid, no tumor identified.
:E. Parathyroid, no tumor identified.
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:E. Parathyroid, no tumor identified.
 
:F. X lymph nodes, no tumor seen (0/X).
 
:F. X lymph nodes, no tumor seen (0/X).
   
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