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Supracricoid Laryngectomy with Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP)

last modified on: Mon, 02/19/2024 - 14:07

See: Supracricoid Laryngectomy case exampleLaryngeal leukoplakia progression to invasive squamous cell carcinoma 2009 to 2013 with supracricoid laryngectomy


  1. Preoperative Evaluation
    1. CT of larynx and neck
    2. Panendoscopy and biopsies
    3. Assess pulmonary and swallowing status 
  2. Indications
    1. Supraglottic lesions with ventricle extension with epiglottic base involvement and anterior one-third of false vocal cord (T1 to T3)
    2. Supraglottic lesions extending to glottis, anterior commissure with or without true cord mobility
    3. T3 transglottic carcinoma with limited true cord mobility
    4. Selected cases of T4 supraglottic and transglottic carcinoma invading the thyroid cartilage
  3. Contraindications
    1. Subglottic extension
    2. Bilateral arytenoid involvement
    3. Cricoid invasion
    4. Unilateral arytenoid involvement will compromise postoperative voice and swallow results.
  4. Consent
    1. Describe procedure: "Through incision in your neck, remove upper and front part of voice box, leaving only back part of one or both vocal cords." Caution about the possibility of the need for total laryngectomy.
    2. Repeat laryngoscopy immediately prior to surgery if more than 2 weeks have passed since diagnostic procedure.
    3. Bleeding, infection, reaction to anesthesia, damage to remaining arytenoid(s)
    4. Tracheostomy
    5. Hoarse voice
    6. Aspiration, feeding difficulties, inability to swallow (average 2 months up to 6 months, occasionally long-term failure requiring total laryngectomy) consider PEG - especially if previous radiation
    7. Do not proceed unless patient is prepared for total laryngectomy.


  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
    2. Special
      1. Tracheotomy Tray
      2. Sterile anesthetic breathing circuit and tubing
      3. Rousch Laryngoflex 7 mm endotracheal tube
      4. Corpak feeding tube
  3. Medications (specific to nursing)
    1. Antibiotic ointment
  4. Prep and Drape
    1. Standard prep, 10% providone iodine (neck and chest)
    2. Drape
      1. Head drape
      2. Towels from nose to upper chest
      3. Split sheet
  5. Drains and Dressings
    1. Penrose drains
  6. Special Considerations
    1. If tracheotomy is done as a separate procedure, a separate setup will be necessary.
      1. The tracheotomy is preferrable done after the crico-hyoid impaction to ensure the appropriate level for entry into the trachea
    2. Panendoscopy and/or neck dissection may be done in conjunction with procedure.


  1. General Anesthesia
    1. Tube position: If tracheotomy is required, consider the tracheal position change that will occur during closure.
    2. Paralysis ("full relaxation") is useful during closure.
  2. Systemic Medication
    1. Antibiotics (see Antibiotic protocol)
    2. Steroids; may aid in postoperative swelling, 10 mg Decadron IV
  3. Positioning
    1. Supine


  1. Elevate skin flap extending across the midline at the level of the laryngeal prominence (still permitting space below for either the tracheotomy or possibly a permanent tracheostome if a total laryngectomy is needed). If a neck dissection is needed, the incision should then be extended straight across to the trapezius muscle with superior and inferior limbs developed as needed overlying the trapezius. Efforts to keep as much of the neck dissection separate from the tracheostome should be entertained as the procedure is performed. Raise the flap at subplatysmal layer to a level 1 to 2 cm above the hyoid bone.
  2. Perform neck dissection if indicated.
  3. Cut thyrohyoid and sternohyoid muscles along the immediate inferior border of the hyoid and detach the sternothyroid from the inferior border of the thyroid cartilage. Maintain the inferior pedicle of the strap muscles, as well as innervation and blood supply as much as possible.
  4. Preserve the superior laryngeal neurovascular bundle for laryngeal innervation.
  5. Cut pharyngeal constrictors and external perichondrium along the posterior border of the thyroid cartilage and release the piriform sinus mucosa.
  6. Carefully (preserve the recurrent laryngeal nerve) disarticulate the cricothyroid joints with parallel movement of a scalpel or narrow Freer elevator.
  7. Perform thyroid isthmusectomy and mobilize upper trach with blunt finger dissection well into superior mediastinum.
  8. The tracheotomy is done only after the tumor is resected and the margins are determined to be clear. This delay in tracheotomy permits more accurate placement of the skin incision (done as a separate incision below the neck incision). The cricohyoid impaction will necessarily move the tracheotomy site superiorly, hence at a higher level in the skin than would be determined before the cricohyoid impaction. The oral endotracheal tube needs to be changed to a tracheotomy before the final impaction. However, a 'trial impaction' with the oral tube in place will help determine the site for the tracheotomy skin incision.
  9. Incise the hyoid periosteal layer and dissect pre-epiglottic space from hyoid.
  10. Entry from external to the aerodigestive tract is done either through the pre-epiglottic space (if the epiglottis is to be preserved resulting in a cricohyoidoepiglottopexy [CHEP] or immediately above the lingual surface of the epiglottis if the epiglottis is to be removed resulting in a cricohyoidopexy [CHP]). This entry is done in the immediate midline with efforts to preserve lateral structures intact to both decrease the risk of fistula and preserve sensory innervation (superior laryngeal neurovascular pedicle). Inferiorly, transversely cut through the cricothyroid membrane at the superior border of the cricoid cartilage. Transect the cricothyroid muscle attached to the thyroid cartilage.
  11. Visualize and assess the tumor from above and below.
  12. In case of a planned CHP (resection of the epiglottis), grasp the epiglottis with a sharp hook and pull inferiorly. If the epiglottis is to be preserved (CHEP), palpate its preserved attachment to the base of tongue and work inferiorly to advance the resection.
  13. Cut vertically from the aryepiglottic fold to the cricoid level while preserving as much pyriform sinus mucosa as feasible (removes true vocal cords, preserving arytenoids).
  14. Cut uninvolved cords at the level of the vocal process.
  15. Pull larynx anteriorly for exposure and cut one ipsilateral vocal cord at the vocal process or remove one arytenoid if involved. Paraglottic and pre-epiglottic contents are removed with the specimen
  16. Closure
    1. Suture only the mucosa of the upper part of the arytenoid.
    2. Leave the inferior portion open.
    3. Suture the arytenoid cartilage with 3-0 vicryl anteriorly to the cricoid cartilage to prevent posterior sliding.
    4. No other mucosal sutures are placed. The cricoid and hyoid are brought together with three submucosal 0 vicryl sutures placed in the midline and 1 cm to each side. Incorporate 1 to 2 cm of tongue base sutures. Place NG tube before closure.
    5. Suture the strap muscles to the base of tongue.
    6. Place two narrow Penrose drains or suction drains if closure is airtight.
    7. "Grillo" stitch (extending from chin to sternum) may be placed if tension existing in closure. This suture ensures that the head is flexed forward on the chest. Alternatively (and preferred to Grillo stitch) is to suspend the larynx from the periosteum of the mandible with a subcutaneous 0-vicryl.


  1. Additional considerations
    1. Section the epiglottis at or below the hyoepiglottic ligament.
    2. Remove the inferior one-third of the epiglottis along with the pre-epiglottic space.
    3. Release the hyoepiglottic ligament.
    4. During closure, suture the epiglottic remnant to the anterior cricoid.
    5. Complete closure as with cricohyoidopexy.


  1. Change tracheotomy tube on postoperative day 5.
  2. Remove drains as per drainage.
  3. Involve speech pathologist. Begin gelatinous foods after patient can swallow own saliva and increase amount of ingested fluid as tolerated. If no effective swallowing achieved, place gastrostomy tube.


de Vincentiis M, Minni A, Gallo A. Supracricoid laryngectomy with cricohyoidopexy (CHP) in the treatment of laryngeal cancer: a functional and oncologic experience. Laryngoscope. 1996;106:1108-1114.

Chevalier D, Piquet JJ. Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma; review of 61 cases. Am J Surg. 1994;168:472-473.

Laccourreye O, Brasnu D, Merite Drancy A, et al. Cricohyoidopexy in selected infrahyoid carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg. 1993;119:881-886.

Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope. 1990;100:735-741.

Piquet J. Functional laryngectomy (cricohyoidopexy). Clin Otolaryngol; 1976;1:7-16.

Dworkin JP, Meleca RJ, Zacharek MA, et al. Voice and deglutition functions after the supracricoid and total laryngectomy procedures for advanced stage laryngeal carcinoma. Otolaryngol Head Neck Surg. 2003 Oct;129(4):311-20.