You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > HEAD AND NECK ONCOLOGY Conservation Laryngeal Surgery, Vertical Partial LaryngectomyArticle Last Updated: Dec 1, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jon Robitschek, MD, Resident Physician, Department of Otolaryngology, Tripler Army Medical Center Jon Robitschek is a member of the following medical societies: Alpha Omega Alpha Coauthor(s): Christopher Klem, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center; Christopher H Rassekh, MD, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, West Virginia University Editors: David J Terris, MD, FACS, Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Karen Hall Calhoun, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Missouri; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: organ preservation for glottic carcinoma, vertical partial laryngectomy, VPL, laryngofissure and cordectomy, partial laryngectomy with imbrication laryngoplasty, frontolateral partial laryngectomy, muscle flap laryngoplasty, epiglottic laryngoplasty, organ preservation surgery of the larynx, endoscopic cordectomy, neck cancer INTRODUCTIONSection 2 of 12
  Organ preservation therapy of the larynx is offered as a functional alternative to total laryngectomy. The intended goals are to circumvent permanent tracheostomy, to maintain laryngeal speech, and to preserve swallow function. Subtypes of operations classified as organ preservation surgery of the larynx include the following: endoscopic cordectomy (including laser), laryngofissure and cordectomy, vertical partial laryngectomy (VPL), and hemilaryngectomy. VPL is designed specifically to treat early (T1 and T2) and select T3 laryngeal cancers. Despite initial local control and cure rates comparable with those of traditional radiotherapy (RT), VPL is largely reserved for patients with recurrent or persistent T1 and T2 disease in whom such therapy has failed. The intent of this article is to elucidate the clinical indications, contraindications, and technical points of interest that govern the use of VPL in the treatment of early glottic cancer. History of the ProcedureOpen transcervical vertical laryngectomy was initially proposed by Solis-Colen in 1869 to primarily address early (T1 and T2) and select T3 glottic cancer. Moving forward, the advent of primary radiotherapy in the mid-20th century succeeded open procedures as the definitive treatment for T1 and T2 disease. This was, in turn, followed by the introduction of transoral laser excision (TLE), which has been popularized over the last 10 years and is considered a viable alternative to primary RT. Classic hemilaryngectomy, in which the surgeon removes most of the thyroid cartilage on the side of a vocal cord cancer, produces variable speech and swallowing results. This problem led to the development of a plethora of reconstructive techniques. The most common reconstructive technique described in classic hemilaryngectomy uses flaps of strap musculature, with or without mucosal covering. However, some surgeons still leave the hemilarynx without reconstruction. More sophisticated methods have also been described to reconstruct the hemilarynx, with the ultimate goal of maintaining normal laryngeal function. Reconstructions that have received considerable attention include (1) false vocal cord pulldown, (2) cartilage preservation with perichondrial/sternohyoid muscle flap reconstruction, and (3) epiglottic reconstruction for defects involving the anterior commissure. Other methods have also evolved. Selection of reconstructive technique partly depends on surgeon preference but is also dictated by the extent of resection required. ProblemVPL is primarily an operation for early glottic carcinoma. FrequencyEarly carcinoma of the glottis is more common than early carcinoma of other head and neck sites because patients with these lesions present with hoarseness relatively early in the course of the disease. VPL is used relatively infrequently because of the national (and even international) trend toward primary radiation for early glottic cancer. EtiologyEtiology of glottic carcinoma correlates strongly with tobacco abuse, and most patients with the disease smoke. Other etiologic factors include genetic predisposition and laryngeal papillomata. The role of other carcinogens, such as viruses, chemicals, and inflammatory mediators, is being investigated. Some authors believe that gastroesophageal reflux disease may be a contributing factor. PathophysiologyCarcinoma of the larynx usually begins with dysplastic changes in the larynx, which then progress to carcinoma in situ, followed by microinvasion. ClinicalPatients with glottic carcinoma typically present with intermittent hoarseness of up to a few months' duration. A change from intermittent to constant hoarseness indicates vocal cord paralysis. In many cases, no other clinical findings are found in early glottic carcinoma other than hoarseness and indirect laryngoscopic findings of a laryngeal lesion. Early glottic cancer can manifest as leukoplakia (most common; found during examination) or as ulceration, polypoid changes, papilloma, or erythema. Consider all of these findings suggestive, particularly if found in patients who smoke. INDICATIONSSection 3 of 12
The primary treatment indications for vertical partial laryngectomy (VPL) include initial therapy, as well as recurrent or persistent early glottic cancer (T1 and T2 stages) that has been refractive to primary radiotherapy or transoral laser excision. In select cases, T3 lesions may be addressed with this family of operations; however, prudence is warranted because the operation is best suited for T1 or T2 lesions. Specifically, for T1 lesions that do not involve the anterior commissure, laser cordectomy can be performed. False vocal cord reconstruction is feasible for T1 lesions, and one excellent option is imbrication laryngoplasty. This operation facilitates false vocal cord reconstruction while maintaining the bulk of the neocord by transferring vascularized innervated false cord to oppose the contralateral true vocal cord. This procedure can also be performed for T2 lesions classified as such by impaired mobility. For T2 lesions that involve the supraglottis, the false vocal cord usually cannot be pulled down. If a VPL is selected, a different reconstruction, such as the perichondrial/sternohyoid muscle flap procedure or a muscle/free mucosal flap procedure, should be considered. For lesions that involve the anterior commissure, bilateral muscle flaps may be used as an alternative to the epiglottic pulldown described by Kambic et al. RELEVANT ANATOMYSection 4 of 12
CONTRAINDICATIONSSection 5 of 12
Note that cancer that involves the anterior commissure is close to the Broyle ligament, an anatomic structure that may make tumor invasion of the thyroid cartilage more accessible. This danger has prompted some authors to question vertical partial laryngectomy (VPL) for such lesions in favor of a different organ preservation technique such as supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP). Although voice results following SCPL are predictably worse than after VPL, the local control rates following SCPL are perhaps better for selected T2 and T3 lesions of the glottis. Each case must be individualized for the patient's particular tumor and preoperative function. Absolute contraindications to VPL include arytenoid fixation, thyroid cartilage invasion, interarytenoid invasion, subglottic extension to involve the cricoid cartilage, lesions that extend outside the larynx, and preepiglottic space invasion. Because of the relative lack of lymphatics in the glottic division of the larynx, glottic cancers tend to metastasize only in advanced stages, so nodal disease findings indicate more advanced disease and are probably another contraindication to VPL. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic FindingsHistology usually reveals squamous cell carcinoma that arises from dysplasia. Minor salivary carcinomas, most commonly adenoid cystic carcinoma, are rare. Small cell carcinoma, other neuroendocrine tumors, and sarcoma are extremely rare. Granular cell tumors, plasmacytoma, and other lesions that resemble malignancy should also be considered in the differential diagnoses. TREATMENTSection 7 of 12
Medical therapyThe use of chemotherapy in combination with radiotherapy for early laryngeal cancer remains an active area of research. In addition, Laccourreye et al have proposed the use of chemotherapy alone as a definitive treatment for select glottic squamous cell carcinoma. In the context of advanced-stage disease (T3 or T4), multiple studies demonstrate a synergistic response. Surgical therapyBecause cure rates of surgical therapy equal those of radiotherapy, patient preference should play a large role in the selection of treatment modality. Preoperative detailsInform patients that a temporary tracheotomy will likely be required. Patients should give consent for total laryngectomy in case cancer is discovered to be understaged. This is an extremely remote possibility with adequate preoperative evaluation that includes telescopic and microscopic direct laryngoscopy with tumor mapping. Intraoperative detailsUse a low collar incision. Place the tracheostomy through a separate horizontal incision below the collar incision. Attempt to keep the dissections separate. After developing subplatysmal flaps, expose the larynx by separating the strap muscles vertically in the midline and incising the external perichondrium in the midline and along the superior and inferior borders of the thyroid cartilage. This allows bilateral laterally based flaps to be created. Cricothyroid entry during laryngofissure is depicted in Image 1. Laryngofissure performed with an oscillating saw is also known as midline thyrotomy. This step is performed for all vertical partial laryngectomy (VPL) procedures unless the anterior commissure is involved. In such cases, a central segment of thyroid cartilage is included in the resection by making parallel thyrotomy cuts on either side of the midline and preserving both lateral remnants or by making a cut on the contralateral side and removing the entire ipsilateral thyroid ala. Preservation of the ala is preferable for most reconstructions. Confirm resectability with VPL resection with adequate margins (see Image 2, Image 4). Once laryngofissure is completed and the incision in the cricothyroid membrane is made, the vocal cords are inspected from below. If the anterior commissure is free, the internal mucoperichondrium is divided at or near the anterior commissure, with a margin around the tumor of at least 3 mm. The entire vocal cord is then resected. For imbrication laryngoplasty, the cordectomy is performed by excising a segment of thyroid cartilage adjacent to the vocal cord. Take care to preserve an inferior strut of thyroid cartilage that is intact and approximately 1 cm in height. View reconstruction details within Images 3-6 for imbrication laryngoplasty. The simplest reconstruction after the laryngofissure and cordectomy is to suture the false vocal cord to the infraglottic mucosa. Imbricating sutures are used to place the superior strut of cartilage medial to the inferior strut, which pulls the false vocal cord down to be sutured to the infraglottic mucosa. This has the advantage of reconstructing the neocord using vascularized, innervated, mucosalized tissue, while avoiding tension, which may result in dehiscence of the mucosa or flattening of the false vocal cord (possibly resulting in a breathy voice). The technique involves 2 pairs of drill holes in the superior and inferior strut, allowing 2 imbricating sutures of 2-0 Prolene. The mucosa is approximated using 4-0 Vicryl or chromic. The laryngofissure is closed with 2-0 Prolene or 2-0 Vicryl sutures. The anterior commissure is then re-created by suturing the internal to external perichondrium if it has been disrupted. The external perichondrium and cricothyroid membrane are closed with 3-0 Vicryl suture, and the wound is closed with a Penrose drain and a dressing. A cuffed tracheotomy is used. Other modifications are described previously for historical interest. Postoperative detailsPenrose drains, sterile dressing, proper tracheotomy care, early oral intake, and decannulation when edema resolves are indicated. Generally, a hospital stay lasts less than 1 week. Follow-upRegular follow-up care is required for all patients with head and neck cancer, preferably at least every 6-12 weeks during the first postoperative year. Closer follow-up care is necessary in the early postoperative period. COMPLICATIONSSection 8 of 12
Major complications are rare but include the following:
OUTCOME AND PROGNOSISSection 9 of 12
In previously untreated patients, reported local control rates as primary therapy are greater than 90% for T1 glottic tumors and 68% for T2 glottic tumors. Increased risk factors for recurrence include anterior commissure involvement, increased T stage, and positive surgical margins. In patients who undergo salvage therapy secondary to RT failure, the reported local control rates are 84% and 60% for T1 and T2 glottic tumors, respectively. The overall survival for this group of patients is reported at 77%. With regard to T3 glottic tumors, local control rates vary among different institutions, with reported failure rates as high as 50%. FUTURE AND CONTROVERSIESSection 10 of 12
Primary radiotherapy and transoral laser excision remain the prototypical therapy for early glottic tumors. Vertical partial laryngectomy (VPL) serves as both primary and salvage therapy for T1 and T2 disease with equivocal control rates for T3 tumors. Choosing the ideal surgical modality for tumors that bridge the T2/T3 classification system remains an intense area of controversy, without clear delineation in the literature. The intended goal of this article is to highlight the limits of VPL as much as its therapeutic efficacy. Advances in transoral surgical approaches have contributed to the development and advances of endoscopic VPL. Future directions in research and technical innovation will likely focus on voice conservation, the role of chemotherapy, and stratification of patients based on tumor biology. In particular, anterior commissure involvement, supracricoid partial laryngectomy, and the different reconstructions will continue to generate controversy and debate among head and neck surgeons. Patient desire and surgeon bias will continue to play dominant roles in the selection of treatment modality for early laryngeal carcinoma. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Conservation Laryngeal Surgery, Vertical Partial Laryngectomy excerpt Article Last Updated: Dec 1, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||
