Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint

Background This study evaluates the feasibility, functional outcomes, and survival of surgical laryngeal preservation in advanced T3/T4 head and neck disease, based on the principle that an intact cricoarytenoid joint (CAJ) can provide sufficient functional reserve to compensate for resections involving other key contributors to swallowing. Methods Monocentric, observational study (STROBE compliant). 162 consecutive patients with advanced (T3/T4) laryngeal, hypopharyngeal, oropharyngeal, and tongue carcinomas treated surgically. Definitive surgery with either laryngectomy or laryngeal preservation (stage-matched subgroups), stratified by CAJ involvement and surgical approach (transoral vs. open). Results Of 162 patients, 95 (58%) underwent laryngectomy; 90% had CAJ invasion. Among 76 without CAJ involvement, 67 (88%) were suitable for preservation. Functional outcomes: 95.6% decannulated, 3% PEG, 4.4% tracheostomy dependence. Recurrence-free survival did not differ (85.1% preservation vs. 78.9% laryngectomy; log-rank p = 0.56). Overall survival tended lower in laryngectomy (57.9% vs. 79.1%; p = 0.16), explained by non–cancer mortality. Flap reconstruction was required in 43.4% of open non-laryngeal preservation cases, mostly T4 (p < 0.001). Open surgery showed inferior overall survival compared with transoral (70.0% vs. 92.6%; p = 0.038). Conclusion Functional upper airway preservation is feasible in most advanced head and neck cancers when CAJ is not engaged. An intact CAJ provides sufficient functional reserve to compensate for resections involving other key contributors to swallowing, enabling excellent oncologic outcomes with generally favorable functional recovery. Open preservation surgery carries greater morbidity and higher non–cancer-related mortality.