Am
J
Otolaryngol
11:153-160.1990
Partial Vertical Indications and LaryngectomySurgical Technique KERRY
D. OLSEN, MD, AND LAWRENCE W. DESANTO, MD
Partial vertical laryngectomy is a treatment option for certain Tl glottic cancers. Selection criteria and surgical technique are reviewed. Partial vertical laryngectomy for early vocal cord cancer is considered by some to be an obsolete procedure. However, as outlined in this paper, we believe it is a realistic treatment option for Tl glottic cancers that cannot be removed endoscopically. AM J OTOLARYNGOL11 :153-l 60.0 1990 by W.B. Saunders Company. Key words: larynx, cancer, partial laryngectomy, glottic.
vocal cord, as long as cordal mobility is maintained. The terminology used for open operations of the glottic larynx can be confusing. Laryngofissure and cordectomy are incorrectly equated with hemilaryngectomy. Laryngofissure and thyrotomy are terms that refer to the division of thyroid cartilage to expose the laryngeal lumen. Cordectomy is the removal of a vocal cord and can be performed via an open operation or endoscopically. A laryngofissure and cordectomy is the removal of one vocal cord through an external incision. No thyroid cartilage is removed in this procedure. A hemilaryngectomy removes half of the larynx, including one side of the thyroid ala, the arytenoid, and vocal cord. The cricoid cartilage is preserved. Partial vertical laryngectomy encompasses both laryngofissure and cordectomy and hemilaryngectomy. It also includes excision of a portion of the laryngeal cartilage with either the removal of one vocal cord, a portion of the opposite vocal cord, or both. This procedure is also known as frontal lateral partial laryngectomy. Finally, the anterior commissure technique is also included in the umbrella of operations listed under partial vertical laryngectomy. This procedure removes the anterior portion of the thyroid cartilage and the anterior portion of each vocal cord.
Cancer of the larynx is currently the most common head and neck malignancy treated by otolaryngologists. The treatment options for early glottic carcinoma include endoscopic removal of the tumor, radiation therapy, and open surgical procedures. Each treatment option has its place and none exists to the exclusion of the others. This report will focus only on glottic carcinomas for which an open procedure, the partial vertical laryngectomy, is a treatment option. The initial treatment distribution for early glottic carcinoma at our institution is open operation, 55%; endoscopic removal, 25%; and radiation therapy, 2O%.l With earlier diagnosis, the percentage that can be treated endoscopically should increase. Early glottic carcinoma is a curable disease, and death should be a rare consequence of any form of treatment of Tl glottic carcinoma. However, the TNM system oversimplifies the scope of early carcinoma. A Tl cancer, by definition, is any tumor confined to a vocal cord with normal mobility. This definition covers a spectrum, including in situ and invasive carcinoma. It also includes cancers that involve a small portion of one vocal cord, the entire length of a cord, the anterior commissure, or tumors that occupy the full length of each Received July 24, 1989, from the Department of Otorhinolaryngology, Mayo Clinic and Mayo Foundation, Rochester, MN; and the Section of Otolaryngology, Mayo Clinic Scottsdale, Scottsdale, AZ. Accepted for publication October 22, 1989. Address correspondence and reprint requests to Kerry D. Olsen, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. 0 1990 by W.B. Saunders Company. 0196-0709/90/1103-0002$5.00/O
HISTORICAL REVIEW The first recorded operation for laryngeal cancer was a laryngofissure and cordectomy performed by Buck in 1851. From 1894 to 1903, Semon and Butlin reported their results in patients treated with laryngofissure.’ In 1920, Semon
153
154
stated that 80% of his laryngofissure patients were cured.3 In 1928, St. Clair Thomson observed that laryngofissure often included the removal of a portion of one thyroid ala.4 Although he reported a 70% cure rate with this operation, he recognized the limits of its application: the cancer should be limited to a mobile vocal cord, the arytenoid should not be involved with the tumor, and there should be little or no subglottic extension. Between 1940 and 1960, other practitioners, including Schall, Lynch, Jackson, and Clerf, reported a 75% to 92% cure rate with laryngofissure.5 The laryngofissure and cordectomy procedure and its variations have clearly stood the test of time. It should not be dismissed as obsolete by modern day head and neck oncologic surgeons. SURGICAL INDICATIONS Certainly, not all Tl glottic cancers should be treated with an open procedure. Partial vertical laryngectomy is only used for large invasive Tl glottic cancers as described below. In situ carcinoma should be treated endoscopically. If endoscopic exposure is feasible, tumors on mobile vocal cords without extension to the anterior commissure region should be treated endoscopically. Sometimes technical problems with endoscopic exposure also lead us to an open operation or radiation. Large Tl cancers, with or without anterior commissure extension, may be treated by an open approach, since safe oncologic margins cannot be obtained transorally. If a Tl glottic tumor involves the anterior commissure region, it cannot be safely and predictably managed endoscopically.” Therefore, the main indication for partial vertical laryngectomy at our institution is an invasive cancer on a mobile vocal cord that involves the anterior commissure region. The tumor can extend from the arytenoid on one side to the anterior third of the opposite vocal cord and still be removed by partial vertical laryngectomy. The tumor should not involve the body of the arytenoid, subglottic larynx (more than 1 cm below the true cord), or the false vocal cord. Subglottic laryngeal extension is one of the major causes for failure in partial vertical laryngectomy.7 Significant subglottic extension from glottic cancer has an increased incidence of submucosal tumor spread. Also, without the availability of reliable frozen section analysis, partial or conservational laryngeal operations should not be performed. The importance of cordal mobility as an indicator of the suitability of conservation surgery is well established. Indirect laryngoscopy determines cordal mobility. Cordal fixation implies ex-
PARTIAL VERTICAL LARYNGECTOMY
tension into the intrinsic laryngeal musculature, involvement of the paraglottic space, or both. Once the conus elasticus is broached, the tumor has access to the paraglottic space down to the level of the cricoid cartilage. A partial vertical operation then becomes oncologically unsound unless the cricoid cartilage is removed. Removal of the cricoid necessitates a total or near-total laryngectomy. Therefore, normal vocal cord mobility is a prerequisite to the performance of any partial vertical laryngectomy. SURGICAL TECHNIQUE Surgical techniques to be described include laryngofissure and cordectomy, partial vertical laryngectomy with removal of a portion of the thyroid cartilage, and the anterior commissure procedure. Laryngofissure and cordectomy is indicated when a tumor involves the major portion of the vocal cord but spares the anterior commissure region. After the patient is asleep and intubated with a small tube, the larynx is exposed with a laryngoscope. A biopsy specimen of the lesion is taken and sent to the pathologist. After confirmation of invasive cancer, the neck is prepared and draped. A tracheotomy is performed, the trachea is entered with an anesthesia tube, and anesthesia is continued through this site. The skin incision is variable. A midline incision will expose the thyroid cartilage and permit a tracheotomy with one incision, A small apron incision can also be done by using the inferior portion of the incision for the tracheotomy site. More commonly, a separate tracheotomy incision is made followed by a transverse skin incision over the lower border of the thyroid ala. The neck incision extends from the anterior border of one sternocleidomastoid muscle to the other. Superior and inferior skin flaps are then elevated beneath the platysmal muscle to the level of the hyoid bone and the cricoid cartilage. The strap muscles are divided in the midline and retracted. It is important to look for a Delphian lymph node in the soft tissues overlying the cricothyroid membrane (Fig 1). The Delphian lymph node should be sent for pathologic study. Involvement of the Delphian lymph node suggests an increased risk of metastasis to the ipsilateral cervical lymph nodes. ’ A neck dissection on the same side as the cancer is warranted in this situation. After the strap muscles are separated from the thyroid cartilage, a midline vein can be seen in the region of the cricothyroid membrane. The position of this vein is immediately below the midpoint of the vocal cords. Two laryngeal hooks are then placed in the superior portion of each thy-
OLSEN
155
AND DESANTO
Figure
I,
Identification
of Delphian
node.
roid ala and are used to retract the larynx in a superior and lateral direction. Using a Stryker saw, a cut is made in the midline until the cartilage “pops” as the saw passes through (Fig 2). A small cut is made in the cricothyroid membrane with a long-handled knife. The surgeon uses a headlight, and the anesthesiologist paralyzes the patient. Two small hooks are placed through the incision in the cricothyroid membrane. The cut is
Figure
2.
Cartilage
cut.
extended up the cricothyroid membrane and through the thyroid cartilage incision with the scalpel (Fig 3). The midportion of the vocal cords can be identified by the position of the previously cauterized vein in the cricothyroid membrane, by identifying the yellow end of Broyle’s ligament visible beneath the thyroid cartilage, or by looking from below. The larynx is opened in the midline, dividing the anterior commissure and extending the incision up through the preepiglottic space until the larynx is opened like a book. Direct inspection of the tumor should ensure that the cancer has not involved the most anterior portion of the vocal cord. The soft tissues on the involved side of the larynx are reflected off the internal thyroid perichondrium by a periosteal elevator (Fig 4). When one is in the correct plane, the elevator should encounter a smooth surface as the intrinsic musculature is separated from the thyroid perichondrium. If the surface is rough, then the elevator is beneath the thyroid perichondrium. Dissection beneath the perichondrium can cause perichondritis from devitalized laryngeal cartilage. A malleable retractor is used to protect the normal vocal cord. With a cautery, cuts are made through or above the false cord and in the subglottic region (where the cuts are made depends on the size of the tumor) (Fig 5). The final attachment of the vocal cord to the vocal process of the arytenoid is divided with a curved Panzer scissors (Fig 6). Frozen section confirmation of tumor-free margins is then obtained. The wound is closed by approximating the anterior perichondrium on each side (Fig 7). The fascia overlying the strap muscles is closed in layers. A small Penrose drain is inserted, and the skin is closed in the usual manner. A metal tracheotomy tube is inserted at the end of the procedure. Another variation is an open operation that removes a portion of the thyroid cartilage. When the anterior commissure region is involved with cancer, surgical margins can only be ensured by removing a portion of the thyroid cartilage that overlies the tumor. A Tl vocal cord cancer that involves the anterior vocal cord or anterior commissure region is best treated by removal of the overlying cartilage. The amount of cartilage removed is dictated by the extent of the tumor and is almost always less than half of one hemithyroid cartilage. If the cancer involves one vocal cord and crosses the commissure to involve not more than the anterior third of the opposite cord, the initial operation is identical to the technique for laryngofissure and cordectomy. More thyroid cartilage is exposed on the side of the tumor. A cartilage cut is made approximately 1 cm from the midline on the side opposite the cancer. Using a headlight
156
PARTIAL VERTICAL LARYNGECTOMY
Figure 3. Division of the cricothyroid membrane.
and working from below, the surgeon makes cuts up the cricothyroid membrane. Under direct vision, the opposite vocal cord is divided beyond the extent of the cancer. The larynx is opened like a book. A scalpel is used at the cut edge of the thyroid cartilage to reflect the external perichondrium off the anterior half of the thyroid cartilage on the side of the tumor (Fig 8). A second cartilage cut is then made (Fig 9). The amount of cartilage excised depends on the size of the lesion, but one third of the thyroid ala is generally removed. The
Figure 4.
Dissection
on the thyroid perichondrium.
cartilage segment is grasped with a forceps, and an elevator bluntly dissects the intrinsic laryngeal musculature from the remaining internal thyroid perichondrium back to the level of the arytenoid (Fig 10). An inferior cut is made by cautery below the cord and above the cricoid cartilage. A superior cut is then made through the false vocal cord (Fig 11). The intrinsic laryngeal musculature is isolated back to the vocal process of the arytenoid. The necessary amount of the arytenoid is cut us-
Figure 5.
False cord and subglottic
cuts.
157
OLSEN AND DESANTO
Figure 8.
Figure 6.
Division of the vocal process of the arytenoid.
ing Panzer scissors. Confirmation by frozen section of tumor-free margins is essential. The surgical site is inspected for inadvertent entrance into the pyriform sinus and for remnants of the saccule. The remaining portions of the opposite true and false vocal cords are reattached to the external thyroid perichondrium. A suspension suture is placed to reattach the base of the epiglottis to the hyoid region. The perichondrium is closed by using chromic sutures. A feeding tube is inserted
Initial cartilage cut.
and the fascia surrounding the strap muscles is closed in layers. A drain is inserted and the skin is closed in the usual manner. A metal tracheotomy tube is inserted at the end of the procedure. The anterior commissure procedure is a variation of partial vertical laryngectomy. This operation is for cancer that is confined to the anterior commissure region. The larynx is exposed as described earlier. Cartilage cuts are made on each side of the thyroid ala (Fig 12). Under direct vision, the cricothyroid membrane is opened and the incision is connected with the cartilage cuts dividing each vocal cord beyond the cancer. The anterior thyroid cartilage and anterior portion of
-7
Figure 7.
Final closure of laryngofissure.
Figure 9.
Second cartilage cut.
158
PARTIAL VERTICAL LARYNGECTOMY
Figure
Figure 10. Separation roid perichondrium.
of laryngeal musculature
from the thy-
each vocal cord are removed and sent to the pathologist. When confirmation is obtained of tumor-free.margins, a Montgomery laryngeal keel is placed between the thyroid cartilage remnants (Fig 13). The keel is removed under local anesthesia after approximately 6 weeks. After any partial vertical laryngectomy proce-
Figure 11.
False cord and subglottic cuts.
Cartilage cuts for an anterior commissure
12.
cancer.
dure, the tracheotomy tube is corked as tolerated by the patient. Patients are encouraged to talk and eat when the tube is corked. When the tracheotomy tube can be corked for 24 hours, it is removed and feeding is begun. RESULTS An earlier paper reported 182 patients who underwent a laryngofissure and cordectomy for squamous cell carcinoma of the larynx from 1962
Figure
13.
Insertion
of a laryngeal keel.
159
OLSEN AND DESANTO
to 1974.’ Follow-up at 5 years revealed seven patients with recurrent cancer. Four recurrences were in the larynx and three were in the neck (local recurrence rate, 2.2%). Two patients died from cancer. An analysis of the seven patients who had recurrent disease showed one patient with subglottic tumor extension to the cricoid perichondrium; one with a transglottic carcinoma: two with anterior commissure cancers; two with cervical metastasis of Tl glottic carcinoma; and one with a recurrence noted 7 years later, which was possibly a second primary. A later study reviewed 211 patients who underwent a partial vertical laryngectomy for Tl glottic carcinoma between 1970 and 198O.l’ Five-year follow-up in all cases found no apparent recurrences in 201 patients. Ten individuals were treated for recurrent disease (4.7%): three were managed with radiation therapy; six underwent a laryngectomy; and one had a neck dissection. The survival rate of partial vertical laryngectomy patients equalled the expected survival rate in a population of the same age distribution with no cancer. Recurrence, local or regional, with partial vertical laryngectomy is less than 5%. DISCUSSION It is often necessary to justify open operations for Tl glottic carcinoma versus the use of radiation therapy. The 95% 5-year cure rate often attributed to radiation therapy for these carcinomas may not tell the whole story. Some patients have their cancer completely removed at the time of biopsy and therefore undergo radiation therapy when they do not have cancer. Of patients followed for a full 5 years after radiation therapy, up to 20% require some form of salvage operation, usually laryngectomy, because of recurrence. Eight percent of patients will die from their laryngeal carcinoma.“-l4 Radiation therapy can also cause webs, edema, and perichondritis that may adversely affect the voice. The cure rate with radiation therapy alone is less than 95% and the voice is not always normal. Chandler followed 27 Tl cancer patients whom he treated with radiation therapy and found that one third had recurrent disease-l5 All nine patients subsequently underwent total laryngectomy, and three died. A comparable group of 25 patients treated with partial vertical laryngectomy had only two recurrences, one treated with total laryngectomy and one with radiation therapy. No deaths occurred in this group. Radiation therapy retains an important role as an option for treating early laryngeal carcinoma, and, as such, is discussed with every patient. Radiation therapy is most often used by the authors
for Tl cancers that involve both vocal cords, making a partial vertical laryngectomy impractical. In other cases, the patient’s physical health may not permit an operation, or the demand for the best possible voice may make radiation therapy preferable. A hemilaryngectomy is rarely done for early glottic carcinoma. It involves the removal of half of the thyroid ala and one arytenoid. This procedure often results in a much poorer voice than does cordectomy and there is a need for laryngeal reconstruction. Stenosis of the larynx and longterm use of a tracheotomy tube may follow. A hemilaryngectomy for Tl cancer gives a wide margin where it is least needed, at the posterior thyroid ala. If cancer involved this area, the vocal cord would not be mobile. Hemilaryngectomy is reserved for the rare tumor that involves the body of the arytenoid so one can get posterior to the cancer. Rare cases of invasive glottic carcinoma in which mobility is compromised are also occasionally managed with a hemilaryngectomy. After a partial vertical laryngectomy, patients are able to breathe and eat normally, although their speech is usually altered. It is not necessary to reconstruct the larynx after a partial vertical laryngectomy. Numerous reports in the literature describe reconstruction options, including resurfacing techniques or the use of perichondrial flaps, muscle, or cartilage. Several of these have been tried by the authors; however, they are no more efficacious than secondary wound healing. It is helpful to reattach the remaining vocal cord after a partial vertical laryngectomy. The operative site is otherwise allowed to heal by secondary intention. Although granulation tissue will form in this area, it will eventually be covered by normal laryngeal mucosa. Recently, 10 individuals who underwent a partial vertical laryngectomy with loss of a portion of the thyroid cartilage were studied by our speech pathologists. All were determined to have intelligible speech. Their voice quality ranged from whispery to hoarse, with one voice judged to be normal. Far from being obsolete, partial vertical laryngectomy is, in our opinion, a realistic treatment option for extensive Tl glottic cancers. When applicable, transoral endoscopic removal should always be done. However, partial vertical laryngectomy for selected and appropriate Tl glottic carcinomas offers excellent curative results, at the cost of an alteration in vocal quality. References 1. DeSanto LW: Surgical perspective, in Thawley SE, Panje WR (eds]: Comprehensive Management of Head and Neck Tumors. Philadelphia, PA, Saunders, 1987, pp 1029-1039
PARTIAL VERTICAL LARYNGECTOMY 2. Semon F, Butlin I-IT (cited by Delavan DB): Recent advances in treatment of malignant disease of the larynx. Trans Am Laryngol Assoc 1904; 26:150-170 3. Semon F (cited by Okada W): The treatment and prognosis of carcinoma of the larynx. Trans Am Laryngol Assoc 1922; 44:162-181 4. Thomson StC: Intrinsic cancer of the larynx, operated on by laryngo-fissure: Immediate and ultimate results. Trans Am Laryngol Assoc 1928; 50:53-71 5. Schall LA, Lynch MG, Jackson CL, et al (cited by Lillie JC, Devine KD): Laryngofissure: Indications and technique. Arch Otolaryngol 1959; 69:589-593 6. Krespi YP, Meltzer CJ: Laser surgery for vocal cord carcinoma involving the anterior commissure. Presented at the American Larvnaoloaical Association, Palm Beach, FL, April 23-25, 1988 (a-b&) _ 7. Kirchner JA: Pathways and pitfalls in partial laryngectomy. Ann Otol Rhino1 Laryngol 1984; 93:301-305 8. Olsen KD, DeSanto LW, Pearson BW: Positive Delphian
lymph node: Clinical significance in laryngeal cancer. Laryngoscope 1987; 97:1033-1037 9. Neel HB III, Devine KD, DeSanto LW: Laryngofissure and cordectomy for early cordal carcinoma: Outcome in 182 patients. Otolaryngol Head Neck Surg 1980; 88:79-84 10. DeSanto LW: Cancer of the larynx--Mayo Clinic experience 1970-1980. Presented at the Mayo Clinic Alumni Meeting, Rochester, MN, June 11, 1983 11. Harwood AR, Hawkins NV, Rider WD, et al: Radiotherapy of early glottic cancer. I. Int J Radiat Oncol Biol Phys 1979; 5~473-476 12. Harwood AR, Tierie A: Radiotherapy of early glottic cancer. II. Int I Radiat Oncol Biol Phvs 1979: 5:477-482 13. DeSantd LW, Lillie JC, Devine I?D: Surgical salvage after radiation for laryngeal cancer. Laryngoscope 1976; 86:649-657 14. Kaiser TN, Sessions DG: The natural history of treated TlNO epidermoid carcinoma of the laryngeal glottis. Presented at the American Laryngological Association, Palm Beach, FL, April 23-25, 1988 (abstr) 15. Chandler JR Cancer trends (cassette). Audio-Digest Otolaryngol 1986; 19:no. 5
J
Otolaryngol
11:153-160.1990
Partial Vertical Indications and LaryngectomySurgical Technique KERRY
D. OLSEN, MD, AND LAWRENCE W. DESANTO, MD
Partial vertical laryngectomy is a treatment option for certain Tl glottic cancers. Selection criteria and surgical technique are reviewed. Partial vertical laryngectomy for early vocal cord cancer is considered by some to be an obsolete procedure. However, as outlined in this paper, we believe it is a realistic treatment option for Tl glottic cancers that cannot be removed endoscopically. AM J OTOLARYNGOL11 :153-l 60.0 1990 by W.B. Saunders Company. Key words: larynx, cancer, partial laryngectomy, glottic.
vocal cord, as long as cordal mobility is maintained. The terminology used for open operations of the glottic larynx can be confusing. Laryngofissure and cordectomy are incorrectly equated with hemilaryngectomy. Laryngofissure and thyrotomy are terms that refer to the division of thyroid cartilage to expose the laryngeal lumen. Cordectomy is the removal of a vocal cord and can be performed via an open operation or endoscopically. A laryngofissure and cordectomy is the removal of one vocal cord through an external incision. No thyroid cartilage is removed in this procedure. A hemilaryngectomy removes half of the larynx, including one side of the thyroid ala, the arytenoid, and vocal cord. The cricoid cartilage is preserved. Partial vertical laryngectomy encompasses both laryngofissure and cordectomy and hemilaryngectomy. It also includes excision of a portion of the laryngeal cartilage with either the removal of one vocal cord, a portion of the opposite vocal cord, or both. This procedure is also known as frontal lateral partial laryngectomy. Finally, the anterior commissure technique is also included in the umbrella of operations listed under partial vertical laryngectomy. This procedure removes the anterior portion of the thyroid cartilage and the anterior portion of each vocal cord.
Cancer of the larynx is currently the most common head and neck malignancy treated by otolaryngologists. The treatment options for early glottic carcinoma include endoscopic removal of the tumor, radiation therapy, and open surgical procedures. Each treatment option has its place and none exists to the exclusion of the others. This report will focus only on glottic carcinomas for which an open procedure, the partial vertical laryngectomy, is a treatment option. The initial treatment distribution for early glottic carcinoma at our institution is open operation, 55%; endoscopic removal, 25%; and radiation therapy, 2O%.l With earlier diagnosis, the percentage that can be treated endoscopically should increase. Early glottic carcinoma is a curable disease, and death should be a rare consequence of any form of treatment of Tl glottic carcinoma. However, the TNM system oversimplifies the scope of early carcinoma. A Tl cancer, by definition, is any tumor confined to a vocal cord with normal mobility. This definition covers a spectrum, including in situ and invasive carcinoma. It also includes cancers that involve a small portion of one vocal cord, the entire length of a cord, the anterior commissure, or tumors that occupy the full length of each Received July 24, 1989, from the Department of Otorhinolaryngology, Mayo Clinic and Mayo Foundation, Rochester, MN; and the Section of Otolaryngology, Mayo Clinic Scottsdale, Scottsdale, AZ. Accepted for publication October 22, 1989. Address correspondence and reprint requests to Kerry D. Olsen, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. 0 1990 by W.B. Saunders Company. 0196-0709/90/1103-0002$5.00/O
HISTORICAL REVIEW The first recorded operation for laryngeal cancer was a laryngofissure and cordectomy performed by Buck in 1851. From 1894 to 1903, Semon and Butlin reported their results in patients treated with laryngofissure.’ In 1920, Semon
153
154
stated that 80% of his laryngofissure patients were cured.3 In 1928, St. Clair Thomson observed that laryngofissure often included the removal of a portion of one thyroid ala.4 Although he reported a 70% cure rate with this operation, he recognized the limits of its application: the cancer should be limited to a mobile vocal cord, the arytenoid should not be involved with the tumor, and there should be little or no subglottic extension. Between 1940 and 1960, other practitioners, including Schall, Lynch, Jackson, and Clerf, reported a 75% to 92% cure rate with laryngofissure.5 The laryngofissure and cordectomy procedure and its variations have clearly stood the test of time. It should not be dismissed as obsolete by modern day head and neck oncologic surgeons. SURGICAL INDICATIONS Certainly, not all Tl glottic cancers should be treated with an open procedure. Partial vertical laryngectomy is only used for large invasive Tl glottic cancers as described below. In situ carcinoma should be treated endoscopically. If endoscopic exposure is feasible, tumors on mobile vocal cords without extension to the anterior commissure region should be treated endoscopically. Sometimes technical problems with endoscopic exposure also lead us to an open operation or radiation. Large Tl cancers, with or without anterior commissure extension, may be treated by an open approach, since safe oncologic margins cannot be obtained transorally. If a Tl glottic tumor involves the anterior commissure region, it cannot be safely and predictably managed endoscopically.” Therefore, the main indication for partial vertical laryngectomy at our institution is an invasive cancer on a mobile vocal cord that involves the anterior commissure region. The tumor can extend from the arytenoid on one side to the anterior third of the opposite vocal cord and still be removed by partial vertical laryngectomy. The tumor should not involve the body of the arytenoid, subglottic larynx (more than 1 cm below the true cord), or the false vocal cord. Subglottic laryngeal extension is one of the major causes for failure in partial vertical laryngectomy.7 Significant subglottic extension from glottic cancer has an increased incidence of submucosal tumor spread. Also, without the availability of reliable frozen section analysis, partial or conservational laryngeal operations should not be performed. The importance of cordal mobility as an indicator of the suitability of conservation surgery is well established. Indirect laryngoscopy determines cordal mobility. Cordal fixation implies ex-
PARTIAL VERTICAL LARYNGECTOMY
tension into the intrinsic laryngeal musculature, involvement of the paraglottic space, or both. Once the conus elasticus is broached, the tumor has access to the paraglottic space down to the level of the cricoid cartilage. A partial vertical operation then becomes oncologically unsound unless the cricoid cartilage is removed. Removal of the cricoid necessitates a total or near-total laryngectomy. Therefore, normal vocal cord mobility is a prerequisite to the performance of any partial vertical laryngectomy. SURGICAL TECHNIQUE Surgical techniques to be described include laryngofissure and cordectomy, partial vertical laryngectomy with removal of a portion of the thyroid cartilage, and the anterior commissure procedure. Laryngofissure and cordectomy is indicated when a tumor involves the major portion of the vocal cord but spares the anterior commissure region. After the patient is asleep and intubated with a small tube, the larynx is exposed with a laryngoscope. A biopsy specimen of the lesion is taken and sent to the pathologist. After confirmation of invasive cancer, the neck is prepared and draped. A tracheotomy is performed, the trachea is entered with an anesthesia tube, and anesthesia is continued through this site. The skin incision is variable. A midline incision will expose the thyroid cartilage and permit a tracheotomy with one incision, A small apron incision can also be done by using the inferior portion of the incision for the tracheotomy site. More commonly, a separate tracheotomy incision is made followed by a transverse skin incision over the lower border of the thyroid ala. The neck incision extends from the anterior border of one sternocleidomastoid muscle to the other. Superior and inferior skin flaps are then elevated beneath the platysmal muscle to the level of the hyoid bone and the cricoid cartilage. The strap muscles are divided in the midline and retracted. It is important to look for a Delphian lymph node in the soft tissues overlying the cricothyroid membrane (Fig 1). The Delphian lymph node should be sent for pathologic study. Involvement of the Delphian lymph node suggests an increased risk of metastasis to the ipsilateral cervical lymph nodes. ’ A neck dissection on the same side as the cancer is warranted in this situation. After the strap muscles are separated from the thyroid cartilage, a midline vein can be seen in the region of the cricothyroid membrane. The position of this vein is immediately below the midpoint of the vocal cords. Two laryngeal hooks are then placed in the superior portion of each thy-
OLSEN
155
AND DESANTO
Figure
I,
Identification
of Delphian
node.
roid ala and are used to retract the larynx in a superior and lateral direction. Using a Stryker saw, a cut is made in the midline until the cartilage “pops” as the saw passes through (Fig 2). A small cut is made in the cricothyroid membrane with a long-handled knife. The surgeon uses a headlight, and the anesthesiologist paralyzes the patient. Two small hooks are placed through the incision in the cricothyroid membrane. The cut is
Figure
2.
Cartilage
cut.
extended up the cricothyroid membrane and through the thyroid cartilage incision with the scalpel (Fig 3). The midportion of the vocal cords can be identified by the position of the previously cauterized vein in the cricothyroid membrane, by identifying the yellow end of Broyle’s ligament visible beneath the thyroid cartilage, or by looking from below. The larynx is opened in the midline, dividing the anterior commissure and extending the incision up through the preepiglottic space until the larynx is opened like a book. Direct inspection of the tumor should ensure that the cancer has not involved the most anterior portion of the vocal cord. The soft tissues on the involved side of the larynx are reflected off the internal thyroid perichondrium by a periosteal elevator (Fig 4). When one is in the correct plane, the elevator should encounter a smooth surface as the intrinsic musculature is separated from the thyroid perichondrium. If the surface is rough, then the elevator is beneath the thyroid perichondrium. Dissection beneath the perichondrium can cause perichondritis from devitalized laryngeal cartilage. A malleable retractor is used to protect the normal vocal cord. With a cautery, cuts are made through or above the false cord and in the subglottic region (where the cuts are made depends on the size of the tumor) (Fig 5). The final attachment of the vocal cord to the vocal process of the arytenoid is divided with a curved Panzer scissors (Fig 6). Frozen section confirmation of tumor-free margins is then obtained. The wound is closed by approximating the anterior perichondrium on each side (Fig 7). The fascia overlying the strap muscles is closed in layers. A small Penrose drain is inserted, and the skin is closed in the usual manner. A metal tracheotomy tube is inserted at the end of the procedure. Another variation is an open operation that removes a portion of the thyroid cartilage. When the anterior commissure region is involved with cancer, surgical margins can only be ensured by removing a portion of the thyroid cartilage that overlies the tumor. A Tl vocal cord cancer that involves the anterior vocal cord or anterior commissure region is best treated by removal of the overlying cartilage. The amount of cartilage removed is dictated by the extent of the tumor and is almost always less than half of one hemithyroid cartilage. If the cancer involves one vocal cord and crosses the commissure to involve not more than the anterior third of the opposite cord, the initial operation is identical to the technique for laryngofissure and cordectomy. More thyroid cartilage is exposed on the side of the tumor. A cartilage cut is made approximately 1 cm from the midline on the side opposite the cancer. Using a headlight
156
PARTIAL VERTICAL LARYNGECTOMY
Figure 3. Division of the cricothyroid membrane.
and working from below, the surgeon makes cuts up the cricothyroid membrane. Under direct vision, the opposite vocal cord is divided beyond the extent of the cancer. The larynx is opened like a book. A scalpel is used at the cut edge of the thyroid cartilage to reflect the external perichondrium off the anterior half of the thyroid cartilage on the side of the tumor (Fig 8). A second cartilage cut is then made (Fig 9). The amount of cartilage excised depends on the size of the lesion, but one third of the thyroid ala is generally removed. The
Figure 4.
Dissection
on the thyroid perichondrium.
cartilage segment is grasped with a forceps, and an elevator bluntly dissects the intrinsic laryngeal musculature from the remaining internal thyroid perichondrium back to the level of the arytenoid (Fig 10). An inferior cut is made by cautery below the cord and above the cricoid cartilage. A superior cut is then made through the false vocal cord (Fig 11). The intrinsic laryngeal musculature is isolated back to the vocal process of the arytenoid. The necessary amount of the arytenoid is cut us-
Figure 5.
False cord and subglottic
cuts.
157
OLSEN AND DESANTO
Figure 8.
Figure 6.
Division of the vocal process of the arytenoid.
ing Panzer scissors. Confirmation by frozen section of tumor-free margins is essential. The surgical site is inspected for inadvertent entrance into the pyriform sinus and for remnants of the saccule. The remaining portions of the opposite true and false vocal cords are reattached to the external thyroid perichondrium. A suspension suture is placed to reattach the base of the epiglottis to the hyoid region. The perichondrium is closed by using chromic sutures. A feeding tube is inserted
Initial cartilage cut.
and the fascia surrounding the strap muscles is closed in layers. A drain is inserted and the skin is closed in the usual manner. A metal tracheotomy tube is inserted at the end of the procedure. The anterior commissure procedure is a variation of partial vertical laryngectomy. This operation is for cancer that is confined to the anterior commissure region. The larynx is exposed as described earlier. Cartilage cuts are made on each side of the thyroid ala (Fig 12). Under direct vision, the cricothyroid membrane is opened and the incision is connected with the cartilage cuts dividing each vocal cord beyond the cancer. The anterior thyroid cartilage and anterior portion of
-7
Figure 7.
Final closure of laryngofissure.
Figure 9.
Second cartilage cut.
158
PARTIAL VERTICAL LARYNGECTOMY
Figure
Figure 10. Separation roid perichondrium.
of laryngeal musculature
from the thy-
each vocal cord are removed and sent to the pathologist. When confirmation is obtained of tumor-free.margins, a Montgomery laryngeal keel is placed between the thyroid cartilage remnants (Fig 13). The keel is removed under local anesthesia after approximately 6 weeks. After any partial vertical laryngectomy proce-
Figure 11.
False cord and subglottic cuts.
Cartilage cuts for an anterior commissure
12.
cancer.
dure, the tracheotomy tube is corked as tolerated by the patient. Patients are encouraged to talk and eat when the tube is corked. When the tracheotomy tube can be corked for 24 hours, it is removed and feeding is begun. RESULTS An earlier paper reported 182 patients who underwent a laryngofissure and cordectomy for squamous cell carcinoma of the larynx from 1962
Figure
13.
Insertion
of a laryngeal keel.
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OLSEN AND DESANTO
to 1974.’ Follow-up at 5 years revealed seven patients with recurrent cancer. Four recurrences were in the larynx and three were in the neck (local recurrence rate, 2.2%). Two patients died from cancer. An analysis of the seven patients who had recurrent disease showed one patient with subglottic tumor extension to the cricoid perichondrium; one with a transglottic carcinoma: two with anterior commissure cancers; two with cervical metastasis of Tl glottic carcinoma; and one with a recurrence noted 7 years later, which was possibly a second primary. A later study reviewed 211 patients who underwent a partial vertical laryngectomy for Tl glottic carcinoma between 1970 and 198O.l’ Five-year follow-up in all cases found no apparent recurrences in 201 patients. Ten individuals were treated for recurrent disease (4.7%): three were managed with radiation therapy; six underwent a laryngectomy; and one had a neck dissection. The survival rate of partial vertical laryngectomy patients equalled the expected survival rate in a population of the same age distribution with no cancer. Recurrence, local or regional, with partial vertical laryngectomy is less than 5%. DISCUSSION It is often necessary to justify open operations for Tl glottic carcinoma versus the use of radiation therapy. The 95% 5-year cure rate often attributed to radiation therapy for these carcinomas may not tell the whole story. Some patients have their cancer completely removed at the time of biopsy and therefore undergo radiation therapy when they do not have cancer. Of patients followed for a full 5 years after radiation therapy, up to 20% require some form of salvage operation, usually laryngectomy, because of recurrence. Eight percent of patients will die from their laryngeal carcinoma.“-l4 Radiation therapy can also cause webs, edema, and perichondritis that may adversely affect the voice. The cure rate with radiation therapy alone is less than 95% and the voice is not always normal. Chandler followed 27 Tl cancer patients whom he treated with radiation therapy and found that one third had recurrent disease-l5 All nine patients subsequently underwent total laryngectomy, and three died. A comparable group of 25 patients treated with partial vertical laryngectomy had only two recurrences, one treated with total laryngectomy and one with radiation therapy. No deaths occurred in this group. Radiation therapy retains an important role as an option for treating early laryngeal carcinoma, and, as such, is discussed with every patient. Radiation therapy is most often used by the authors
for Tl cancers that involve both vocal cords, making a partial vertical laryngectomy impractical. In other cases, the patient’s physical health may not permit an operation, or the demand for the best possible voice may make radiation therapy preferable. A hemilaryngectomy is rarely done for early glottic carcinoma. It involves the removal of half of the thyroid ala and one arytenoid. This procedure often results in a much poorer voice than does cordectomy and there is a need for laryngeal reconstruction. Stenosis of the larynx and longterm use of a tracheotomy tube may follow. A hemilaryngectomy for Tl cancer gives a wide margin where it is least needed, at the posterior thyroid ala. If cancer involved this area, the vocal cord would not be mobile. Hemilaryngectomy is reserved for the rare tumor that involves the body of the arytenoid so one can get posterior to the cancer. Rare cases of invasive glottic carcinoma in which mobility is compromised are also occasionally managed with a hemilaryngectomy. After a partial vertical laryngectomy, patients are able to breathe and eat normally, although their speech is usually altered. It is not necessary to reconstruct the larynx after a partial vertical laryngectomy. Numerous reports in the literature describe reconstruction options, including resurfacing techniques or the use of perichondrial flaps, muscle, or cartilage. Several of these have been tried by the authors; however, they are no more efficacious than secondary wound healing. It is helpful to reattach the remaining vocal cord after a partial vertical laryngectomy. The operative site is otherwise allowed to heal by secondary intention. Although granulation tissue will form in this area, it will eventually be covered by normal laryngeal mucosa. Recently, 10 individuals who underwent a partial vertical laryngectomy with loss of a portion of the thyroid cartilage were studied by our speech pathologists. All were determined to have intelligible speech. Their voice quality ranged from whispery to hoarse, with one voice judged to be normal. Far from being obsolete, partial vertical laryngectomy is, in our opinion, a realistic treatment option for extensive Tl glottic cancers. When applicable, transoral endoscopic removal should always be done. However, partial vertical laryngectomy for selected and appropriate Tl glottic carcinomas offers excellent curative results, at the cost of an alteration in vocal quality. References 1. DeSanto LW: Surgical perspective, in Thawley SE, Panje WR (eds]: Comprehensive Management of Head and Neck Tumors. Philadelphia, PA, Saunders, 1987, pp 1029-1039
PARTIAL VERTICAL LARYNGECTOMY 2. Semon F, Butlin I-IT (cited by Delavan DB): Recent advances in treatment of malignant disease of the larynx. Trans Am Laryngol Assoc 1904; 26:150-170 3. Semon F (cited by Okada W): The treatment and prognosis of carcinoma of the larynx. Trans Am Laryngol Assoc 1922; 44:162-181 4. Thomson StC: Intrinsic cancer of the larynx, operated on by laryngo-fissure: Immediate and ultimate results. Trans Am Laryngol Assoc 1928; 50:53-71 5. Schall LA, Lynch MG, Jackson CL, et al (cited by Lillie JC, Devine KD): Laryngofissure: Indications and technique. Arch Otolaryngol 1959; 69:589-593 6. Krespi YP, Meltzer CJ: Laser surgery for vocal cord carcinoma involving the anterior commissure. Presented at the American Larvnaoloaical Association, Palm Beach, FL, April 23-25, 1988 (a-b&) _ 7. Kirchner JA: Pathways and pitfalls in partial laryngectomy. Ann Otol Rhino1 Laryngol 1984; 93:301-305 8. Olsen KD, DeSanto LW, Pearson BW: Positive Delphian
lymph node: Clinical significance in laryngeal cancer. Laryngoscope 1987; 97:1033-1037 9. Neel HB III, Devine KD, DeSanto LW: Laryngofissure and cordectomy for early cordal carcinoma: Outcome in 182 patients. Otolaryngol Head Neck Surg 1980; 88:79-84 10. DeSanto LW: Cancer of the larynx--Mayo Clinic experience 1970-1980. Presented at the Mayo Clinic Alumni Meeting, Rochester, MN, June 11, 1983 11. Harwood AR, Hawkins NV, Rider WD, et al: Radiotherapy of early glottic cancer. I. Int J Radiat Oncol Biol Phys 1979; 5~473-476 12. Harwood AR, Tierie A: Radiotherapy of early glottic cancer. II. Int I Radiat Oncol Biol Phvs 1979: 5:477-482 13. DeSantd LW, Lillie JC, Devine I?D: Surgical salvage after radiation for laryngeal cancer. Laryngoscope 1976; 86:649-657 14. Kaiser TN, Sessions DG: The natural history of treated TlNO epidermoid carcinoma of the laryngeal glottis. Presented at the American Laryngological Association, Palm Beach, FL, April 23-25, 1988 (abstr) 15. Chandler JR Cancer trends (cassette). Audio-Digest Otolaryngol 1986; 19:no. 5
