Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

360
Section 3
Larynx
Gastropharyngeal Refl ux
Repeated exposure to pepsin and acid from gastric
refl ux produces mucosal and submucosal injury and
thereby leads to more scarring (Fig. 45-3).22 Prophylaxis
with antirefl ux medications is recommended after any
laryngeal injury. Patients should be carefully monitored
for gastroesophageal refl ux, and those with recalcitrant
stenosis must be assumed to be suffering from gastro-
esophageal refl ux and be treated accordingly.
PATIENT EVALUATION
Clinical Assessment
Patients with laryngeal stenosis may complain of short-
ness of breath, dyspnea on exertion, stridor, hoarse-
ness, diffi culty swallowing, aspiration, diffi culty clearing
secretions, or any combination of these symptoms and
signs. Although airway symptoms have traditionally
been the primary focus, recent studies have shown a
signifi cant subjective and objective impairment in the
vocal quality of patients with laryngeal stenosis.23,24 Chil-
dren often have a history of recurrent croup or cardio-
pulmonary problems.
In the offi ce setting, fl exible fi beroptic laryngos-
copy is essential for evaluating the site and degree of
stenosis, as well as vocal fold mobility. In a retrospective
review of pediatric cricotracheal resection, multivariate
analysis revealed that unilateral or bilateral vocal fold
immobility was the only signifi cant risk factor for failure
of decannulation after airway reconstruction.25 Video
laryngoscopy and still photographs provide objective
documentation that can be discussed with the patient
and reviewed by other laryngologists. Electromyogra-
phy helps differentiate neuromuscular defi cits from
cricoarytenoid joint fi xation or subluxation.
Rigid direct laryngoscopic examination aided by
the use of rod lens endoscopes, with the patient under
general anesthesia, complements the offi ce examina-
tion. Rigid direct laryngoscopy allows evaluation of the
passive motion of the arytenoids and circumferential
examination of the subglottis and provides an idea of
the fi rmness of the scar tissue. Endoscopic methods of
quantifying the extent and severity of the stenosis, as
well as monitoring the success of treatment, have been
reported.26 When tracheal or laryngeal malacia is
suspected, fi beroptic or rigid laryngobronchoscopy
should be performed with the patient breathing
spontaneously.
Noninvasive methods of improving the diagnosis
and monitoring patients with laryngeal stenosis are
available and have a promising future; however, their
practical role in the clinical setting remains unclear.
Nouraei and colleagues developed and tested a model
based on fl ow-volume loops that can be used to quantify
the mechanical extent and clinical impact of laryngo-
tracheal stenosis.27
Imaging
Computed tomography (CT) is considered the stan-
dard imaging technique to corroborate the integrity of
the cartilaginous framework and evaluate the cricoary-
tenoid joint (Fig. 45-4). Carretta and coworkers28 com-
pared the preoperative endoscopic and CT evaluations
with the intraoperative fi ndings in 12 patients who
underwent airway reconstruction. They found that rigid
endoscopy remains the most reliable tool for accurately
assessing the length, extent, and location of stenosis
preoperatively.28
Other pertinent imaging modalities include mag-
netic resonance imaging (MRI), ultrasound, and fl uo-
roscopy. MRI is useful in the evaluation of extensive
laryngotracheal stenosis and does not involve any radia-
tion exposure. It allows evaluation in the sagittal and
coronal planes, which may be useful in treatment plan-
ning. A major limitation of MRI, however, is that the
patient must lie quietly for a long time, which is not
tolerated by children or by adults with signifi cant steno-
Figure 45-2. Computed tomography scan of a patient with active
relapsing polychondritis demonstrating edema of the perichondrium
of the cricoid cartilage and resorption of the cartilage (arrows).
Figure 45-3. Lower right, vocal cord edema, pachyderma laryngis,
and granuloma at the vocal processes. The other photographs show
punctate and erosive esophagitis at different levels of the
esophagus.

Chapter 45
Acquired Laryngeal Stenosis
361
sis secondary to orthopnea. Ultrasound may provide
a convenient, well-tolerated, noninvasive method of
assessing subglottic airway diameter.29 Fluoroscopy is
most helpful in evaluating areas of tracheomalacia that
may collapse on inspiration but look normal during
rigid direct endoscopy performed under general anes-
thesia. In small children, soft tissue radiographs may be
suffi cient to localize and grade the stenosis.
GENERAL MANAGEMENT
Treatment of laryngeal stenosis has evolved, although
not in a linear fashion, from the “wait-and-see” philoso-
phy to dilatation and eventually to endoscopic proce-
dures with microsurgery. These surgical approaches
have been combined with the use of antibiotics, stents,
corticosteroids, and lumen augmentation procedures
with or without grafts. Unfortunately, none of these
techniques offers a 100% decannulation rate. Most
clinical studies addressing the different therapeutic
options are limited by their retrospective, nonrandom-
ized nature and lack of standard defi nitions. Further-
more, reports on the use of different surgical methods
and ancillary procedures, such as stenting and steroids,
and similar techniques by well-recognized laryngolo-
gists have led to opposite fi ndings and conclusions.
“Wait-and-See” Approach
This approach has been applied to children with con-
genital stenosis in the hope that the patient will outgrow
the defect. When dealing with acquired laryngeal ste-
nosis, the continuous process of scar maturation and
contraction makes this outcome very unlikely. There-
fore, the wait-and-see philosophy is rarely justifi ed for
patients with acquired laryngeal stenosis.
Dilatation
Dilatation is most successful when used for select cases
of thin, congenital webs. Acquired stenosis usually
implies a more severe stenosis that resists dilatation and
is characterized by hyalinization of the connective tissue
and collagen cross-linking that translates into an incom-
pressible, rigid scar.3
The success rate of dilatation improves when the
technique is used for soft or immature scars of minimal
thickness and when it is used as an adjunct to other
techniques (e.g., radial incisions). It may offer pallia-
tion to patients in poor general medical condition.30 A
signifi cant disadvantage of the technique is the need to
repeat the procedure a number of times on each patient.
Overall, approximately three quarters of patients treated
by dilatation as primary therapy will have recurrence of
the stenosis and require a subsequent intervention.31,32
Endoscopic Microsurgery
The outcome after endoscopic microsurgery depends
on the cause, site, and extent of the stenosis; therefore,
appropriate patient selection is essential. Endoscopic
microsurgery for acquired laryngeal stenosis is likely to
fail when used in patients with multiple stenotic sites,
when the stenosis is associated with loss of cartilaginous
support, when it is wider than 1 cm, when the lesion is
circumferential, and when accompanied by the pres-
ence of bacterial infection.30
Endoscopic Laser Microsurgery
Laser surgery offers the unique advantages of hemosta-
sis and a visual fi eld not obscured by instruments.
Whether the laser is less traumatic than microsurgical
instruments is somewhat controversial. Experimental
data suggest that wounds produced by a laser beam
show early re-epithelialization with slow fi broblast pro-
liferation and collagen formation. However, as a general
rule, microsurgical instruments better preserve normal
tissue. Large defects heal by secondary intention (i.e.,
increased scarring) irrespective of the method of inci-
sion.1-3 The main disadvantages of the CO2 laser are
cost, risk of fi re, and corneal burns.
Many patients with posterior glottic stenosis may be
decannulated with preservation of a good to fair voice
after laser excision of the scar via a trapdoor fl ap33 or
arytenoidectomy, or both.34
External Procedures
The basic transcervical approaches include lateral phar-
yngotomy, resection of the stenotic segment with end-
to-end anastomosis, and median thyrotomy. Advocates
of transcervical procedures believe that these approaches
allow precise excision of scar tissue, facilitate primary
closure by allowing the advancement of mucosal
fl aps, and therefore decrease the need for revision
surgery.35
ANCILLARY TECHNIQUES
Stenting
The use of a stent or “lumen keeper” is another subject
of controversy. The intent of stenting is to maintain the
lumen while allowing the dynamics of wound healing
to occur about a relatively inert object that resists the
Figure 45-4. Computed tomography scan, axial view, demonstrat-
ing fractures involving the thyroid and cricoid cartilage (arrows).

362
Section 3
Larynx
contraction process. Surgeons opposed to stenting
suggest that even the most inert material can lead to a
foreign body reaction with exacerbation of the infl am-
matory response, further destruction of tissue, and slow
re-epithelialization.
Stents have been molded with rigid and soft materi-
als. Rigid stents (i.e., lumen keepers) are not recom-
mended because they produce trauma that is similar to
that of endotracheal tubes. The most popular stents are
soft stents such as fi nger cots fi lled with sponge or nasal
packing material, rolled Silastic sheets, and tubular or
solid prefabricated Tefl on or Silastic stents (Fig. 45-5).
Finger cots are easily designed and customized to
the needs of the case and are inexpensive. However,
they produce a signifi cant foreign body reaction and
can become a source of infection if contaminated by
saliva. Silastic stents can be made with softened endo-
tracheal tubes or rolled Silastic sheets. Rolled silicone
sheets induce exuberant granulation tissue. Prefabri-
cated silicone and Tefl on models are available in differ-
ent sizes and lengths and allow modifi cations; these are
the preferred materials (Fig. 45-6). Stents are most
useful in the postoperative setting as an adjunct to most
airway augmentation procedures to support a free graft
or a vascularized fl ap and to preserve the lumen. The
reported ideal period of stenting ranges from 2 weeks
to 10 months.36,37 As a general rule, 2 to 4 weeks of
stenting is suffi cient. Stents can also be used as primary
treatment of complex cases with stenoses at multiple
sites or as a salvage effort in patients who have failed
multiple attempts at airway reconstruction.38 Neverthe-
less, stents can be problematic and require heightened
attention
to
their
potentially
life-threatening
complications.
Corticosteroids
Corticosteroids prevent intracellular sequestration and
stabilize cell membranes, thereby preventing the release
of lysosomes that produce swelling and tissue destruc-
tion. They also inhibit collagen synthesis, enhance col-
lagen breakdown, and reduce mitosis and the active
transport of fi broblasts. Their clinical benefi ts for laryn-
geal stenosis are unproved, but for laryngeal stenosis,
intralesional injections may be of benefi t to soften scar
bands and synechiae.
Mitomycin C
Mitomycin C is generally accepted as a safe and cost-
effective adjunct to laryngotracheal surgery.39 An alkyl-
ating agent that inhibits protein and DNA synthesis, it
acts by impeding fi broblast proliferation, thus decreas-
ing the probability of restenosis.40 Eliashar and associ-
ates41 investigated the use of topical mitomycin C for
the prevention of stenosis after acute injury to the
larynx in dogs. They were able to reduce the incidence
of stenosis from 85% to 27%. Rahbar and coauthors42
reported using topical mitomycin C (at a concentration
of 0.4 mg/mL for 4 minutes) as an adjunct to endo-
scopic laser surgery for laryngotracheal stenosis. Nine
of 12 (75%) patients with subglottic or tracheal stenosis
(or both) were decannulated with this technique. Simi-
larly, in a retrospective review of topical mitomycin C,
patients who were adjuvantly treated with mitomycin C
after endoscopic microsurgery experienced a signifi -
cantly longer symptom-free interval than did those who
underwent endoscopic treatment alone (23.2 versus
4.9 months).43
Antibiotics
Laryngeal surgery is classifi ed as a clean-contaminated
procedure, for which perioperative prophylactic anti-
biotics are recommended. A prolonged therapeutic
course of antibiotics may be indicated in special circum-
stances (e.g., active chondritis). Nouraei and colleagues
noted a highly signifi cant association between stent
colonization with specifi c bacteria (Staphylococcus
aureus and Pseudomonas aeruginosa) and the develop-
ment of airway granulation.44 The theoretical value
of a prolonged course of antibiotics is to control the
infection, thus stopping a vicious cycle of chondritis,
necrosis, granulation tissue formation, and scar
deposition.
Figure 45-5. Prefabricated stents. Left to right are shown the
Eliachar, Montgomery, and Aboulker stents. (Left and center, From
Boston Medical Products, Westborough, MA.)
Figure 45-6. Different sizes of Montgomery laryngeal stents. Left
to right are shown child, small adult, medium adult, and large adult
stents.

Chapter 45
Acquired Laryngeal Stenosis
363
PREOPERATIVE PLANNING
Establishing and securing the airway are the keystones
to all procedures for correction of laryngeal stenosis.
The airway may be secured with an endotracheal tube
or a tracheotomy.
A tracheotomy performed with the patient under
local anesthesia is recommended for patients with sig-
nifi cant airway compromise (e.g., stridor) and those
who require a transcervical approach.
Patients who have a thin web that is amenable to
endoscopic procedures and will require minimal surgi-
cal manipulation and select patients with supraglottic
and subglottic mucosal stenosis may be intubated.
Gentle handling of tissue during surgery is fundamental
to prevent postoperative edema and compromise of the
airway. The use of steroids in the perioperative period,
although their benefi t has not been scientifi cally proved,
may help minimize the edema.
Jet pressure ventilation (e.g., a Venturi system) is
usually ill advised because the stenosis implies a
restricted outfl ow that may lead to increased lung pres-
sure and tension pneumothorax. In select patients,
however, the stenosis can be bypassed and the outfl ow
guaranteed with a rigid laryngoscope, subglottoscope,
or bronchoscope.
SURGICAL TECHNIQUE
Three basic principles are fundamental to the success-
ful outcome of any surgery for laryngeal stenosis:
adequate exposure, preservation of normal tissue,
and prevention of recurrence by promoting primary
healing.
Supraglottic Stenosis
Supraglottic stenosis is amenable to laser excision or
transcervical supraglottic laryngectomy. As opposed to
an oncologic supraglottic laryngectomy, this procedure
preserves the innervation of the superior laryngeal
nerves, the hyoid bone, and the soft tissues adjacent to
the scarred area.45
A horizontal incision is incorporated into a hori-
zontal skin crease over the thyroid cartilage. Subplatys-
mal fl aps are elevated superiorly to expose the insertion
of the suprahyoid musculature and inferiorly to the
level of the cricoid. The infrahyoid strap muscles are
transected at their insertion to expose the portion of
the hyoid bone medial to the lesser cornua (Fig. 45-7).
The strap muscles are dissected from the thyroid carti-
lage. The pharynx is entered as described for transhy-
oid pharyngotomy (see Chapter 29) (Fig. 45-8). This
allows direct visualization of the stenosis. Thyrotomy
cuts are performed with a no. 10 blade or an oscillating
saw if the cartilage is calcifi ed. The superior cornua of
the thyroid cartilage, as well as the superior laryngeal
neurovascular bundles, are spared. The soft tissue inci-
sions include the stenotic area after the thyrotomy cuts
are made (Fig. 45-9). The defect is repaired by suturing
the base of tongue to the perichondrium of the thyroid
ala. If the epiglottis is not sacrifi ced, it is incorporated
into the closure. It is important to tack the epiglottis
anteriorly to the remaining thyroid cartilage or the epi-
glottis will fold down and obstruct the view of the glottis
posteriorly in the postoperative period. The strap
muscles are reapproximated to the hyoid bone and to
each other at the midline. The wound is repaired with
a multilayer technique. Suction drains are left in
place.
In select cases, such as patients with poor general
status, some temporary palliation may be achieved
with a submucosal injection of corticosteroids and
dilatation.
Glottic Stenosis
Stenosis of the glottic area should be further classifi ed
as anterior, posterior, or combined lesions. This simple
classifi cation is important because the cause, treatment,
and prognosis are very different for these types of
stenosis.
Anterior Glottic Stenosis
Anterior glottic stenosis usually develops after disrup-
tion of the anterior commissure by external trauma
(e.g., laryngeal fracture), endoscopic surgery (e.g.,
vocal cord stripping), or oncologic surgery (e.g., partial
vertical laryngectomy). Anterior glottic stenosis causes
foreshortening of the glottis and tethers the abduction
of the true vocal cords (Fig. 45-10A and B).
The method of resection, whether to use a laser or
“cold” microsurgical instruments or to approach the
lesion endoscopically or transcervically, is less impor-
Figure 45-7. Sagittal plane. The dashed line bounds the area to be
resected during partial supraglottic laryngectomy.

364
Section 3
Larynx
A
B
Figure 45-8. Coronal plane. The
dashed lines indicate the level of inci-
sions through the thyrohyoid mem-
brane and the thyroid chondrotomies
(A) and the endolaryngeal incisions
(B).
Figure 45-9. Coronal plane. In a transcervical view after removal
of the median supraglottis, the vocal cords can be seen through the
defect. The hyoid bone has been preserved.
tant than good surgical technique that will widen the
airway and promote primary healing. Magnifi cation of
the surgical fi eld with a microscope or loupes optimizes
preservation of normal tissue, and adequate instrumen-
tation is important to minimize tissue trauma.
Invariably, correction of anterior glottic stenosis
will result in two opposing surfaces with denuded epi-
thelium. These two surfaces will tend to heal together
and form a web (i.e., restenosis). A stent or a keel that
separates these two denuded areas is necessary to
prevent this problem. Alternatively, the web can be
divided into superfi cial and deep layers based laterally
at the anterior one third of the free edge of the true
vocal folds. These fl aps are then rotated to cover the
denuded areas of the cord, thereby precluding the
need for a keel.
Anterior glottic webs less than 1 cm in height are
amenable to endoscopic excision. The patient is placed
in a supine position and the neck is hyperextended with
a shoulder roll. A wide direct laryngoscope that allows
binocular microscopic magnifi cation is suspended in
place after the lesion is adequately exposed. The web
may be lysed with a laser or “cold” microsurgical instru-
ments (Fig. 45-10A to C).
During CO2 laser surgery, the safety of the patient
and operating room personnel is a primary consider-
ation. All operating room personnel should use pro-
tective eyewear. The eyes of the patient are kept closed
with adhesive dressing (e.g., Tegaderm) and then
covered with eye pads soaked in saline solution. The
face, upper part of the chest, and the laryngoscope are
covered with surgical towels soaked in saline solution
(Fig. 45-11). The endotracheal tube, exposed outside
the mouth, should be covered with metal tape or foil.
In the airway the tube is protected with wet cottonoid.
All these maneuvers complement but are not a substi-
tute for good judgment and careful surgical technique.
Before commencement of the surgery, the laser should
be tested to ensure that the aiming beam is aligned
(i.e., coaxial) to the laser beam. “Bouncing” of the laser
beam against the laryngoscope during surgery should
be avoided. Similarly, the laser beam should not be
allowed to hit the subglottis when the surgeon is working
at the free edge of the cord to avoid unwarranted
damage to the subglottis and increase the possibility of
inadvertent endotracheal tube puncture and fi re. The
subglottis may be protected with cottonoid soaked in

Chapter 45
Acquired Laryngeal Stenosis
365
A
B
C
Figure 45-10. A, Anterior glottic
web involving the vocal folds. The
dashed line indicates the ideal level
for lysis of the web to re-create the
free edge of both true vocal cords.
B, Intraoperative view of an anterior
glottic web. C, Intraoperative view
after division of the web with a CO2
laser.
Figure 45-11. Setup for laser microsurgery. The patient and the
laryngoscope are covered with towels soaked in normal saline solu-
tion. The arrow indicates the suspension system.
normal saline solution or by using a nonrefl ecting plat-
form below the free edge of the cord receiving the laser
beam. Laser char is removed frequently with pledgets
soaked in normal saline solution. Anterior webs usually
require low power (e.g., 4 to 6 W) for vaporization and
hemostasis.
When “cold” microsurgical instruments are used,
hemostasis is achieved with a topical 1:10,000 adrena-
line solution applied with a 0.5 × 0.5-inch neurosurgical
pledget. It is important to remember that adrenaline
will be absorbed into the circulation immediately. The
recommended maximal dosage should be observed,
and anesthesia personnel should be notifi ed before
applying the solution. The web is transected with up-
biting microscissors, and granulation tissue is removed
with microcup forceps. Topical application of mitomy-
cin C (a 0.4-mg/mL solution for 4 minutes) reduces
scarring and may decrease the probability of
recurrence.
On lysis of the web, a stent is placed endoscopically
and secured in place with transcutaneous monofi la-
ment suture (Fig. 45-12). The stent is left in place for
10 to 14 days, after which the patient is taken back to
the operating room for removal of the stent and inspec-
tion of the surgical site.
Webs thicker than 1 cm, those involving the sub-
glottis, and those associated with posterior glottic ste-
nosis may require a laryngofi ssure approach (see
Chapter 42). A silicone Montgomery umbrella is left in
place after the web is divided (Fig. 45-13). This pros-
thetic device remains in place for 2 to 4 weeks. The
optimal time for removal is when the anterior one third
of the true vocal cords shows complete epithelialization,
which may be ascertained by fl exible laryngoscopy.
Removal of the stent requires opening the incision with
the patient under local anesthesia and can be done in
the offi ce.

366
Section 3
Larynx
similar to the one described for a laryngofi ssure (see
Chapter 42). When feasible, the thyroid cartilage is
transected at the midline, although the midline may be
diffi cult to establish in the presence of scarring. In these
cases the midline of the anterior commissure may be
estimated through the direct laryngoscope, before
the transcervical procedure is started. In most cases,
however, this point is moot, because severe scarring and
loss of tissue mandate reconstruction of the entire ante-
rior laryngeal anatomy. The thyrohyoid membrane is
incised between the lesser cornua to expose the supe-
rior preepiglottic space. The anterior surface of the
epiglottis is dissected from the soft tissue of the preepi-
glottic space. The petiole of the epiglottis is then
grasped and retracted inferiorly to facilitate lysis of the
median and lateral epiglottic ligaments (Fig. 45-14A).
Continuity of the lateral and superior mucosa with
the base of tongue and vallecula should be preserved
(Fig. 45-14B).
A Montgomery laryngeal stent is placed and secured
with transcutaneous, transcervical monofi lament suture.
Alternatively, an Eliachar laryngeal stent may be used.
The epiglottic cartilage is split in the midline while
preserving the mucosa of the laryngeal surface of the
epiglottis to produce a sharp-angled anterior commis-
sure (Fig. 45-15). The lateral edges of the epiglottis
are sutured to the anterior edges of the thyroid ala
with interrupted absorbable suture. The petiole is also
sutured, usually to the superior margin of the cricothy-
roid membrane. Occasionally, the petiole may be mobi-
lized low enough to augment the anterior cricoid arch,
which may be necessary if the anterior subglottic steno-
sis involves the cricoid cartilage. The strap muscles are
approximated, and the wound is closed in multiple
layers. A soft rubber drain (e.g., Penrose) is left in
place, and a compressive dressing is applied.
Figure 45-12. Sagittal plane. An anterior glottis keel is inserted and
secured with external monofi lament (transcutaneous) sutures.
A
B
Figure 45-13. A, Sagittal plane.
Montgomery’s umbrella is in place
after lysis of an anterior glottic web via
laryngofi ssure. B, Axial plane. The
anterior keel is in place.
Loss of the anterior segment of the thyroid carti-
lage as a result of trauma or oncologic surgery requires
reconstruction of the cartilaginous support. The pre-
ferred method for such reconstruction is the epiglotto-
pexy laryngoplasty described by Kambic and associates.46
This procedure involves a transcervical approach,

Chapter 45
Acquired Laryngeal Stenosis
367
When one arytenoid is fi xed, mobilization is
attempted by displacing the base of the vocal process in
a lateral direction and rocking the arytenoid repeatedly
in all axes. This maneuver has to be performed with
utmost care to avoid fracturing the vocal process.
When mobilization of the arytenoid cartilage is not
possible, a medial arytenoidectomy is performed either
by endoscopic laser microsurgery or transcervically
through a laryngofi ssure or Woodman’s approach. The
latter is more diffi cult to perform, but the mucosa is
preserved and postoperative recovery is faster (see
Chapter 38), although the entire arytenoid is removed
and the patient is left with an increased risk for aspira-
tion. An alternative to arytenoidectomy is posterior
cordotomy.
When the microtrapdoor fl ap fails but the aryte-
noids are mobile or when the posterior stenosis involves
the interarytenoid musculature, maximal scar release
may be achieved via laryngofi ssure. Mucosal coverage is
then provided with a hypopharyngeal advancement
fl ap, which involves less sacrifi ce of voice quality and
less potential for aspiration than noted with transendo-
scopic laser arytenoidectomy.
Subglottic Stenosis
Acquired subglottic stenosis may be segmental or sec-
ondary to collapse or webbing or may involve the entire
circumference of the lumen. The corrective procedure
should strive to address the involved area while preserv-
ing the adjacent normal tissue.
Thin webs are amenable to excision via endoscopic
microsurgery. (A subglottoscope is very useful to visual-
ize the full extent of the lesion.) Wedge excision of the
A
B
Figure 45-14. Coronal (A) and sagit-
tal (B) views. The petiole of the epiglot-
tis is retracted inferiorly to facilitate
dissection of the lingual surface of the
cartilage from the surrounding soft
tissue.
This technique has the advantage of providing
immediate reconstruction of the infrastructure, as well
as the endolaryngeal lining, with local vascularized
tissue, thereby expediting healing. Although the recon-
struction is completed in one stage, the patient must be
returned to the operating room for transendoscopic
removal of the stent. This technique also has the dis-
advantage of a tendency to produce a round anterior
commissure, even with the described method (Fig.
45-16).
Posterior Glottic Stenosis
Posterior glottic stenosis is most commonly the result
of interarytenoid scarring secondary to prolonged
endotracheal intubation or trauma. Regardless of the
method or refi ned surgical technique, the success of
the surgery depends on the degree and depth of the
scarring. For example, a posterior glottic mucosal web
is easier to correct and has a much better prognosis
than does scarring that resulted from necrosis of the
interarytenoid muscles. In fact, the possibility of provid-
ing a long-term functional solution to the latter problem
is low. Another important factor is the mobility of the
cricoarytenoid joints. If the joints are fi xed, lysis of scar
tissue will not restore an adequate airway.
The preferred method for reconstruction of poste-
rior stenosis caused by mucosal scarring is excision of
the scar through a microtrapdoor fl ap, as described by
Dedo and Sooy.33 An inferiorly based fl ap is elevated
from the interarytenoid area with the laser or, prefera-
bly, with microsurgical instruments. The submucosal
scar is removed, and passive mobility of the arytenoids
is tested. The fl ap is repositioned over the operated
area to promote primary healing (Fig. 45-17).

368
Section 3
Larynx
A
B
C
Figure 45-15. Axial (A), coronal (B),
and sagittal (C) views. Reconstruction
of the anterior thyroid cartilage has
been completed. The epiglottic carti-
lage has been divided, with sparing of
the mucoperichondrium on the laryn-
geal side of the epiglottis to re-create
the V-shaped apex of the anterior
commissure.
Figure 45-16. The endolarynx after Kambic’s procedure for recon-
struction of a glottic stenosis after right hemilaryngectomy. Notice the
convex shape of the epiglottis (E). The arrowhead indicates the anterior
commissure.

Chapter 45
Acquired Laryngeal Stenosis
369
A
C
B
Figure 45-17. A to H, Microtrapdoor fl ap to remove a posterior glottic web. Submucosal scar resection is completed with microsurgical
instruments or laser vaporization while taking care to spare the overlying mucosa. (From Bluestone CD, Stool SE [eds]: Atlas of Pediatric Otolaryngol-
ogy. Philadelphia, WB Saunders, 1995, pp 498-499.)

370
Section 3
Larynx
D
E
F
G
H
Figure 45-17, cont’d.
mucosal web at every quadrant or radial incisions
augment the airway and preserve enough epithelium to
prevent restenosis (Fig. 45-18).
When the stenosis is recurrent or when it is thicker
than 1 cm, an external approach and augmentation
procedure are necessary. Cartilage from the septum,
thyroid ala, or rib may be harvested for use as a free
graft. We prefer the latter because it is abundant,
thicker, and easier to carve.
A horizontal incision is performed in a skin crease
over the cricoid cartilage. Subplatysmal fl aps are ele-
vated to expose the thyroid notch and upper trachea.
The strap muscles are separated in the midline to
expose the laryngotracheal complex. A midline cricoid-
otomy is performed and extended into the upper two
tracheal rings. The cricothyroid membrane is opened
horizontally to facilitate lateral retraction of the cricoid
chondrotomy segments. The mucosa is incised to
expose the posterior mucosal surface of the larynx and
trachea. A posterior cricoid chondrotomy is performed
while preserving the integrity of the cricoarytenoid
joints and postcricoid mucosa. If the posterior glottis is
scarred and stenotic, submucosal excision of the scar is
performed. A free cartilage graft is carved to fi t the
posterior cricoid area (Fig. 45-19). Kirschner wires are
passed into the graft to fi x it in place.47 The same
maneuver is used anteriorly.
A rigid fi xation plate may be used to fi x the anterior
graft in place, which has been carved in a lock-and-
key fashion, as described by Zalzal and Cotton (Fig.
45-20).48 Alternatively, Kirschner wires (24 gauge) can
be passed through the cartilage graft and inserted

Chapter 45
Acquired Laryngeal Stenosis
371
A
C
D
E
F
G
B
Figure 45-18. A, Sagittal view of
circumferential subglottic stenosis. B
to G, Tracheal lumen after laser
excision of a wedge-shaped area at
four quadrants. It is not essential to
excise four wedges; two or three
wedges may be adequate for some
patients. (B to F, From Bluestone CD,
Stool SE [eds]: Atlas of Pediatric Otolar-
yngology. Philadelphia, WB Saunders,
1995, p 509.)
through the cartilage of the receiving site (Fig. 45-21).
The ends of the wires are then bent and secured in
place with 28-gauge wire (Fig. 45-22). The strap muscles
and platysma are reapproximated with absorbable
suture. A soft rubber drain (e.g., Penrose) is left in
place. The skin is closed with staples, and a compressive
dressing is applied.
A sternocleidomastoid myoperiosteal fl ap, as
described by Friedman and Colombo, is an alternative
technique for augmentation of the anterior cricoid ring
and cervical trachea.49 The surgical approach and expo-
sure are similar to those already described. The sterno-
clavicular origin of the left sternocleidomastoid muscle
is exposed through the cervical incision and mobiliza-
tion of subplatysmal fl aps (Fig. 45-23). If necessary (e.g.,
in a patient with a long neck), a second horizontal inci-
sion is performed closer to the clavicle. The sternal
head is transected. The clavicular periosteum around
the clavicular insertion is incised and elevated as a myo-
periosteal fl ap (Fig. 45-24). This fl ap is mobilized into
the defect until tension-free closure can be achieved
(Fig. 45-25). The fl ap is then sutured to the anterior
edges of the cricoid and trachea over a Montgomery T
tube (Figs. 45-26 and 45-27). A soft rubber drain is left
in place. The wound is closed in multiple layers, and a
compressive dressing is applied.
Subglottic Stenosis in the Pediatric
Population
Anterior Cricoid Split
Indications for an anterior cricoid split now include the
management of mild anterior subglottic stenosis in neo-
nates and infants. Before any patient is considered for
this operation, the stenosis should be corroborated by
direct endoscopic visualization and at least two attempts
at extubation should have failed. The patient’s weight
should be greater than 1500 g, mechanical ventilation
or supplemental oxygen greater than a fractional
inspired oxygen concentration (Fio2) of 35% should
not be needed, the patient must be free of lower respi-
ratory infection or congestive heart failure for 30 days
before the operation, and antihypertensive medications
should not be required.49
If the patient meets these criteria, the endoscopy
and anterior cricoid split may be performed as a single-
stage operation. It is essential that other causes of
obstruction that may be interfering with extubation be
ruled out during endoscopy because they may infl u-
ence the therapeutic plan. After endoscopy, ventilation
is continued through the bronchoscope, or if feasible,
Text continues on p. 375.

372
Section 3
Larynx
A
B
C
D
Stay
sutures
Posterior perichondrium
Resected portion
Perichondrium
Figure 45-19. A to D, Free cartilage
graft (spindle shaped) to the poste-
rior cricoid. The graft (g) is secured
with Kirschner wires. (A and B, From
Bluestone CD, Stool SE [eds]: Atlas of
Pediatric Otolaryngology. Philadelphia,
WB Saunders, 1995, p 467.)
Figure 45-20. Rib cartilage is carved to fi t the anterior chondrotomy,
as described by Zalzal and Cotton.48 (From Bluestone CD, Stool SE [eds]:
Atlas of Pediatric Otolaryngology. Philadelphia, WB Saunders, 1995, p 470.)

Chapter 45
Acquired Laryngeal Stenosis
373
A
B
A
B
Figure 45-21. A, Placement of wires through the free cartilage graft.
An axial view of the anterior and posterior cartilage shows the graft in
place. B, Placement of wires through the free cartilage graft.
Figure 45-22. Illustration (A) and clinical photograph (B) demonstrating the wiring
technique on a free cartilage graft to reconstruct an anterior tracheal defect.

374
Section 3
Larynx
Figure 45-23. Surgical exposure of the sternoclavicular head of the
sternocleidomastoid muscle and the area of the stenosis.
Figure 45-24. The periosteum is elevated en bloc with the sterno-
clavicular head of the sternocleidomastoid muscle.
Figure 45-25. The myoperiosteal fl ap is elevated. Branches of the
thyrocervical trunk supplying the inferior aspect of the sternocleido-
mastoid muscles are usually sacrifi ced to enhance mobility of the
fl ap.
Figure 45-26. The myoperiosteal fl ap is sutured to the defect. A
Montgomery T tube maintains the shape of the lumen and secures
the airway.

Chapter 45
Acquired Laryngeal Stenosis
375
trachea to facilitate pulling the split laryngotracheal
complex to the surface of the wound (Fig. 45-28). The
inferior one half of the thyroid cartilage is incised at
the midline, but the mucosa and anterior commissure
are left intact. An endotracheal tube is used as a stent.
The patient is kept under heavy sedation in an intensive
care unit for 7 to 10 days. Extubation is attempted in
the operating room so that the patient can be reintu-
bated if the airway is still compromised.
Laryngeal Augmentation
Laryngeal augmentation for subglottic stenosis can be
achieved by anterior or posterior cricoid grafting or by
a combination of the two. Anterior augmentation is
usually recommended for moderate stenosis not associ-
ated with signifi cant loss of cartilage or glottic stenosis.
Posterior augmentation is most useful when the sub-
glottic stenosis is associated with posterior glottic steno-
sis. Nevertheless, a posterior graft is rarely used alone.
Glottic-subglottic combined stenosis is often corrected
with both anterior and posterior grafts, which are most
commonly harvested from rib cartilage.
POSTOPERATIVE CARE
Patients are transferred to an intermediate or intensive
care unit for continuous monitoring and frequent tra-
cheotomy care. The head of the bed is kept elevated 30
degrees to diminish the possibility of gastric refl ux and
to facilitate ventilation. Humidifi ed air is administered
by face or tracheotomy mask, according to the circum-
stances. Delivery of oxygen through hoses with a T
attachment of the tracheotomy tube is not recom-
mended because they exert traction on the tracheotomy
tube and elicit pain and cough. Furthermore, such trac-
tion may break the peristomal sutures and lead to gross
contamination of the wound with tracheal secretions.
Patients are not fed during the fi rst 24 hours after
surgery to diminish the possibility of nausea and vomit-
ing, which may stress the endolaryngeal repair. A naso-
gastric tube for suctioning of stomach contents during
the initial postoperative period and subsequent feeding
is recommended.
Figure 45-27. The myoperiosteal fl ap has been sutured to the
defect.
A
B
Stay
sutures
Drain
C
Figure 45-28. A to C, Anterior
cricoid split. (From Bluestone CD, Stool
SE [eds]: Atlas of Pediatric Otolaryngol-
ogy. Philadelphia, WB Saunders, 1995,
p 467.)
an endotracheal tube is placed. The neck is prepared
and draped with sterile technique. A horizontal incision
following a midneck crease is performed and extended
through the subcutaneous tissue and platysma. Subpla-
tysmal fl aps are elevated to expose the area correspond-
ing to the entire laryngotracheal complex. The strap
muscles are dissected in the midline to expose the
thyroid and cricoid cartilage and the upper trachea.
The cricoid cartilage and the fi rst two tracheal rings and
underlying mucosa are divided in the midline. Mono-
fi lament stay sutures are placed on both sides of the

376
Section 3
Larynx
The tracheotomy tube may be downsized or
changed to a cuffl ess tube no less than 72 hours after
the procedure. This allows the formation of a tract,
which greatly facilitates insertion of the second tube.
Nevertheless, in most cases the tracheotomy tube is not
changed until the patient can swallow saliva and is not
showing signs of aspiration. In cases in which an exter-
nal approach was used, such as a laryngofi ssure, it is
prudent to keep a cuffed tracheotomy tube in place for
5 to 7 days to prevent massive subcutaneous emphysema
and contamination of the cervical wounds when air and
secretions are insuffl ated through the endolaryngeal
wound.
The tracheotomy tube should not be removed until
a patent and competent airway is secured. In other
words, the patient should be able to breathe and protect
the airway from aspiration before the tube is removed.
Clinical signs such as the ability to tolerate a plugged
tube and the absence of bronchorrhea, choking, or
other signs of aspiration suggest that the patient is ready
to be decannulated. A fl exible laryngoscope is an invalu-
able adjunct to ascertain the adequacy of the airway and
the pharyngeal phase of swallowing, as well as to monitor
the healing process.
Patients who need a long-term tracheotomy tube or
T tube stent should be trained in the care of these arti-
fi cial airways. The companions of these patients must
be aware of the possible complications and be profi -
cient in emergency maneuvers such as removal and
reinsertion of the tracheotomy tube. In the case of T
tube stents, the companions should be taught how to
remove the stent and insert a tracheotomy tube.
COMPLICATIONS
Airway
The most dreaded complication after any kind of laryn-
geal surgery is loss of the airway. Airway compromise
may ensue secondary to edema or hematoma within the
soft tissues of the larynx, as in patients managed with
endolaryngeal surgery without a tracheotomy, or may
be due to plugging or accidental decannulation of the
tracheotomy tube or T tube. The old dictum that pre-
vention is the best treatment is most applicable during
laryngeal surgery. Preventive measures have been
addressed throughout this chapter.
Patients in whom airway compromise develops after
undergoing laryngeal surgery without a tracheotomy
will benefi t from humidifi ed oxygen and should be pro-
vided with a surgical airway. A tracheotomy is preferable
to a cricothyroidotomy because the latter may produce
more subglottic scar tissue and possibly complicate
future management of the primary stenosis. Neverthe-
less, if an emergency airway is needed, cricothyroidot-
omy is the most expedient procedure. A mixture of
70% helium and 30% oxygen may be used as a tempo-
rary measure. Helium is less dense than nitrogen and
fl ows with less friction and turbulence, thus diminishing
the respiratory workload. Select patients can be managed
with corticosteroids, racemic epinephrine, and humidi-
fi ed oxygen or heliox, under close monitoring, until the
swelling resolves.
A plugged tracheotomy tube is managed by remov-
ing the inner cannula, which may produce a patent
outer cannula, by displacing or perforating the plug
with a suction catheter, or ultimately, by removing and
replacing the tracheotomy tube. During the early post-
operative period, reinsertion of the tracheotomy tube
after accidental or therapeutic decannulation is facili-
tated by traction on the stay sutures (see Chapter 68).
The stay sutures bring the tracheal window close to the
skin and thus provide better visualization of the opening
and prevent a false passage. A suction catheter or endo-
tracheal tube introducer may be used as a guide if the
stay sutures break or the patient has a very thick neck
that impairs direct visualization of the tracheal window.
If a fl exible laryngoscope or bronchoscope is rapidly
available, it provides direct visualization of the trachea
and is a safer guide than any rubber catheter.
Plugging of a T tube stent with mucus deserves
special consideration because it does not have the safety
mechanism provided by a double cannula. Even if the
mucous plug can be displaced or perforated with a
suction catheter, patency of the tube should be ascer-
tained by direct examination with a fl exible scope. If
the mucous plug cannot be removed with help of the
laryngoscope, the T tube should be removed and
replaced with a tracheotomy tube, inserted as previ-
ously described. The T tube stent can be reinserted after
the airway is stabilized. Nevertheless, in the early post-
operative period, reinsertion has to be undertaken with
the patient under general anesthesia and guided by
visualization through a direct laryngoscope.
Subcutaneous Emphysema
Subcutaneous emphysema may be massive and associ-
ated with pneumomediastinum, which in infants may
produce respiratory compromise. In adults, subcutane-
ous emphysema, though unsightly, is of limited signifi -
cance. Subcutaneous emphysema is the result of
insuffl ation of air into the soft tissues through a laryn-
geal wound during exhalation. The air is usually reab-
sorbed without consequence. Nonetheless, it has to be
remembered that this air may also be accompanied by
secretions (i.e., contamination), so antibiotics are
recommended to prevent wound infection.
Infection
Adequate wound drainage is of utmost importance for
the prevention of infection. The drain should be kept
in place until the tissue fl aps have healed sufi ciently to
prevent accumulation of fl uid. A soft rubber drain
(e.g., Penrose) should be advanced slowly before
removal. Suction drains should be maintained until
drainage is minimal.
A postoperative wound infection may or may not
be associated with a laryngocutaneous fi stula. In any
case, the most signifi cant factor infl uencing the outcome
of any wound infection is adequate wound drainage. If
the rubber drain is still in place, it should be retained

Chapter 45
Acquired Laryngeal Stenosis
377
until it yields minimal or no drainage; only then may it
be advanced and removed. Systemic antibiotics with a
wide spectrum against oral fl ora (e.g., clindamycin) are
administered to prevent sepsis.
References
1. Olson NR: Wound healing by primary intention in the larynx.
Otolaryngol Clin North Am 12:735-740, 1979.
2. Richardson MA: Laryngeal anatomy and mechanisms of trauma.
J Ear Nose Throat 60:346-351, 1981.
3. Toohill RJ, Duncavage JA, Grossman TW: Wound healing in the
larynx. Otolaryngol Clin North Am 17:429-436, 1984.
4. Stell PM, Maran AG, Stanley RE: Chronic laryngeal stenosis. Ann
Otol Rhinol Laryngol 94:108-113, 1985.
5. Alonso WA: Surgical management and complications of acute
laryngotracheal disruption. Otolaryngol Clin North Am 12:453-
460, 1979.
6. Snow JB: Diagnosis and therapy for acute laryngeal and tracheal
trauma. Otolaryngol Clin North Am 17:101-106, 1984.
7. McCaffrey TV: Management of laryngotracheal stenosis on the
basis of site and severity. Otolaryngol Head Neck Surg 109:468-
473, 1993.
8. Hawkins DB, Luxford MW: Laryngeal stenosis from endotracheal
intubation: A review of 58 cases. Ann Otol 80:454-458, 1980.
9. Papsidero HJ, Pashley NRT: Acquired stenosis of the upper airway
in neonates. Ann Otol 89:512-514, 1980.
10. Parkin JL, Stevens MH, Jung AL: Acquired and congenital sub-
glottic stenosis in the infant. Ann Otol 85:573-581, 1976.
11. Whited RE: A retrospective study of laryngotracheal sequelae in
long-term intubation. Laryngoscope 94:367-377, 1984.
12. Sisk EA, Kim TB, Schumacher R, et al: Tracheotomy in very low
birth weight neonates: Indications and outcomes. Laryngoscope
116:928-933, 2006.
13. Nordin U, Linholm CE: The trachea and cuff-induced tracheal
injury: An experimental study on causative factors and preven-
tion. Acta Otolaryngol 96(Suppl 345):1-71, 1977.
14. Whited RE: A study of postintubation laryngeal dysfunction.
Laryngoscope 95:727-729, 1985.
15. Whited RE: A study of endotracheal tube injury to the subglottis.
Laryngoscope 95:1216-1219, 1985.
16. Bryce DP: The surgical management of laryngotracheal injury.
J Laryngol Otol 86:547-587, 1972.
17. Lulenski GC, Batsakis JG: Tracheal incision as a contributing
factor to tracheal stenosis. An experimental study. Ann Otol
84:781-786, 1975.
18. Caparosa RJ, Zavatsky AR: Practical aspects of the cricothyroid
space. Laryngoscope 67:577-591, 1957.
19. Caldarelli DD, Friedberg SA, Harris AA: Medical and surgical
aspects of the granulomatous diseases of the larynx. Otolaryngol
Clin North Am 12:767-781, 1979.
20. Alaani A, Hogg RP, Drake Lee AB: Wegener’s granulomatosis and
subglottic stenosis: Management of the airway. J Otolaryngol Otol
118:786-790, 2004.
21. Mair EA: Caution in using subglottic stents for Wegener’s granu-
lomatosis. Laryngoscope 114:2060-2061; author’s reply 2061,
2004.
22. Gaynor EB: Gastroesophageal refl ux as an etiologic factor in
laryngeal complications of intubation. Laryngoscope 98:972-979,
1988.
23. Ettema SL, Tolejano CJ, Thielke RJ, et al: Perceptual voice analy-
sis of patients with subglottic stenosis. Otolaryngol Head Neck
Surg 135:730-735, 2006.
24. Baker S, Kelchner L, Weinrich B, et al: Pediatric laryngotracheal
stenosis and airway reconstruction: A review of voice outcomes,
assessment, and treatment issues. J Voice 20:631-641, 2006.
25. White DR, Cotton RT, Bean JA, et al: Pediatric cricotracheal
resection. Arch Otolaryngol Head Neck Surg 131:896-899, 2005.
26. Nouraei SAR, McPartlin DW, Nouraei SM, et al: Objective sizing
of upper airway stenosis: A quantitative endoscopic approach.
Laryngoscope 116:12-17, 2006.
27. Nouraei SAR, Winterborn C, Nouraei SM, et al: Quantifying the
physiology of laryngotracheal stenosis: Changes in pulmonary
dynamics in response to graded extrathoracic resistive loading.
Laryngoscope 117:581-588, 2007.
28. Carretta A, Melloni G, Ciriaco P, et al: Preoperative assessment
in patients with postintubation tracheal stenosis. Rigid and fl exi-
ble bronchoscopy versus CT scan with multiplanar reconstruc-
tion. Surg Endosc 20:905-908, 2006.
PEARLS
• Intraoperative control of the airway by either
endotracheal intubation or tracheotomy is
paramount in any surgery for laryngotracheal
stenosis.
• Dilatation can be successfully used as primary
treatment of select cases of thin congenital webs, as
adjuvant therapy for endoscopic microsurgical
techniques, or as palliation in patients who are
medically unsuited for major reconstructive surgery.
• Endoscopic microsurgical techniques, with or
without adjunctive procedures such as intralesional
steroid injection or application of mitomycin C, are
ideally suited for the management of thin webs or
other less severe stenoses with good cartilage
support.
• Anterior glottic webs less than 1 cm in height are
usually amenable to endoscopic excision with
subsequent placement of a stent or keel.
• Posterior glottic stenosis is often successfully
managed by scar excision through a microtrapdoor
fl ap; however, success of surgery depends on the
degree and depth of scarring, as well as the mobility
of the cricoarytenoid joints.
PITFALLS
• Endoscopic microsurgery for acquired laryngeal
stenosis is likely to fail when used in patients with
multiple stenotic sites, when the stenosis is
associated with loss of cartilaginous support, when
it is wider than 1 cm, when the lesion is
circumferential, and when accompanied by the
presence of bacterial infection.
• Failure to control gastroesophageal refl ux in the
perioperative period may contribute to recurrent or
persistent laryngeal stenosis.
• In the offi ce setting, passing a fl exible scope through
a signifi cant laryngeal stenosis may lead to airway
compromise and a clinically unstable situation.
• Changing to a cuffl ess tracheotomy tube too soon
after laryngotracheal reconstruction may lead to
subcutaneous emphysema, contamination of the
cervical wounds, and even a laryngocutaneous
fi stula.
• A persistent postoperative laryngocutaneous fi stula
usually signifi es inadequate wound drainage and
underlying infection.

378
Section 3
Larynx
29. Lakhal K, Delplace X, Cottier J, et al: The feasibility of ultrasound
to assess subglottic diameter. Anesth Analg 104:611-614, 2007.
30. Simpson GT, Strong MS, Healy GB, et al: Predictive factors of
success or failure in the endoscopic management of laryngeal
and tracheal stenosis. Ann Otol Rhinol Laryngol 91:384-388,
1982.
31. Clement P, Hans S, de Mones E, et al: Dilatation for assisted
ventilation-induced laryngotracheal stenosis. Laryngoscope 115:
1595-1598, 2005.
32. Herrington HC, Weber SM, Andersen PE: Modern management
of laryngotracheal stenosis. Laryngoscope 116:1553-1557, 2006.
33. Dedo HH, Sooy CD: Endoscopic laser repair of posterior glottic,
subglottic and tracheal stenosis by division of micro-trapdoor
fl ap. Laryngoscope 94:445-450, 1984.
34. Ossoff RH, Sisson GA, Duncavage JA, et al: Endoscopic laser ary-
tenoidectomy for the treatment of bilateral vocal cord paralysis.
Laryngoscope 94:1293-1297, 1984.
35. Bogdasarian RS, Olson NR: Posterior glottic laryngeal stenosis.
Otolaryngol Head Neck Surg 88:765-772, 1980.
36. Schuller DE: Long-term stenting for laryngotracheal stenosis.
Ann Otol 89:515-525, 1980.
37. Montgomery WW, Gamble JE: Anterior glottic stenosis: Experi-
mental and clinical management. Arch Otolaryngol 92:560-567,
1970.
38. Phillips PS, Kubba H, Hartley BEJ, et al: The use of the Mont-
gomery T-tube in diffi cult pediatric airways. Int J Pediatr Otorhi-
nolaryngol 70:39-44, 2006.
39. Ubell ML, Ettema SL, Toohill RJ, et al: Mitomycin-C application
in airway stenosis surgery: Analysis of safety and costs. Otolaryngol
Head Neck Surg 134:403-406, 2006.
40. Perepelitsyn I, Shapshay S: Endoscopic treatment of laryngeal
and tracheal stenosis—has mitomycin C improved the outcome?
Otolaryngol Head Neck Surg 131:16-20, 2004.
41. Eliashar R, Eliachar I, Esclamado R, et al: Can topical mitomycin
prevent laryngotracheal stenosis? Laryngoscope 109:1594-1600,
1999.
42. Rahbar R, Shapshay SM, Healy GB: Mitomycin: Effects on laryn-
geal and tracheal stenosis, benefi ts, and complications. Ann Otol
Rhinol Laryngol 110:1-6, 2001.
43. Simpson CB, James JC: The effi cacy of mitomycin-C in the treat-
ment of laryngotracheal stenosis. Laryngoscope 116:1923-1925,
2006.
44. Nouraei SAR, Petrou MA, Randhawa PS, et al: Bacterial coloniza-
tion of airway stents. Arch Otolaryngol Head Neck Surg 132:1086-
1090, 2006.
45. Minni A, Gallo A, Croce A, et al: Leroux-Robert-Huet laryngec-
tomy for supraglottic stenosis. Op Tech Otol Head Neck Surg
3:194-198, 1992.
46. Kambic V, Radsel Z, Smid L: Laryngeal reconstruction with epi-
glottis after vertical hemilaryngectomy. J Laryngol Otol 9:467-473,
1977.
47. Montgomery W: Personal communication, October 28, 1992.
48. Zalzal GH, Cotton RT: A new way of carving cartilage grafts to
avoid prolapse into the tracheal lumen when used in subglottic
reconstruction. Laryngoscope 96:1039, 1986.
49. Friedman M, Colombo J: Sternocleidomastoid myoperiosteal fl ap
for reconstruction of subglottic larynx and trachea. Op Tech Otol
Head Neck Surg 3:202-205, 1992.

Conservation Laryngeal
Surgery
Chapter 46
Endoscopic Laser Excision of
Laryngeal Carcinoma
Robert L. Ferris
Approximately 12,000 new cases of carcinoma of the
larynx are discovered each year in the United States.1
Slightly more than half originate on the true vocal cords
(TVCs), and nearly all of the remainder originate in the
supraglottis, with very few originating in the subglottis.
Cancers arising in the supraglottis demonstrate a bio-
logic behavior that is probably due to variability in
embryologic development and lymphatic supply2,3 and
are therefore discussed in a different chapter.
Cancer of the glottis is nearly always squamous cell
carcinoma (SCC) resulting from exposure to environ-
mental carcinogens. Almost all patients with laryngeal
cancer have a history of tobacco exposure. The caus-
ative relationship of tobacco use, particularly cigarette
smoking, has been demonstrated clinically and has not
been in serious dispute since the mid-1950s. Other
probable causative factors include alcohol use, dietary
factors, possibly exposure to petroleum products, and
genetic predisposition. Chronic gastroesophageal refl ux
disease has been implicated by some authors.4 Human
papillomavirus (HPV) viral DNA has been found in a
minority of laryngeal cancers. Interestingly, DNA analy-
sis demonstrates that viral DNA is not as commonly
incorporated into the host DNA in laryngeal cancer as
it is in other HPV-related cancer, thus suggesting that
HPV may be a “passenger” or function as a cofactor in
carcinogenesis.5
SCC of the glottic larynx is a common malignancy
of the head and neck in the United States and is one
of the most curable cancers that head and neck oncolo-
gists treat. With the fortuitous development of early
symptoms such as hoarseness, hemoptysis, or respira-
tory complaints, carcinoma of the glottis can be identi-
fi ed at a more curable stage. Another feature of the
anatomy of the glottis is the paucity of lymphatic drain-
age relative to other laryngeal sites, which results in a
low incidence of cervical metastasis. Studies by McGavran
and colleagues6 and Kirchner2,7 have provided an ana-
tomic explanation for local spread and for the very rare
metastasis of isolated glottic SCC to the cervical nodal
basin as compared with supraglottic and subglottic
cancer. For these reasons, early carcinoma of the glottis
(as well as selected, more advanced tumors) can often
be treated with local surgical techniques performed
mainly through the endoscope.8-10
PATIENT SELECTION
Microsurgical resection is ideally suited for unilateral
(T1a) cancer because the uninvolved vocal fold does
not sustain radiation damage and the involved vocal
fold can be surgically rehabilitated. Glottic reconstruc-
tion can be accomplished through a combination of
endoscopic injection medialization with fat or transcer-
vical implant medialization, or both. Graded narrow-
margin endoscopic microsurgical resection has the
same cure rate as wider-margin resection11; however,
the surgeon must be skilled in the approach. Involve-
ment of the anterior commissure or vocal process of the
arytenoid by T1 glottic cancer is not a contraindication
to microlaryngoscopic resection.12,13
Staging
Staging of carcinoma of the glottis (Table 46-1) is
accomplished by clinical assessment of tumor size,
extent of local tissue infi ltration, and nodal disease. Tis
refers to carcinoma in situ that has not extended
through the basement membrane of the epithelium.
Infi ltrating carcinoma involving the TVCs but without
impaired mobility or extension above or below the level
379

380
Section 3
Larynx
of the glottis is staged as T1. Microinvasion is common
and constitutes a lesion in the spectrum between carci-
noma in situ and true invasive carcinoma. Tumors that
extend above or below the level of the TVCs and in
which vocal cord mobility is not impaired are staged as
T2 tumors. This stage includes tumors that extend only
minimally to the subglottis at the anterior commissure
and those with more extensive, but superfi cial supra-
glottic or subglottic extension. Cancer that invades the
muscle of the TVC and results in fi xation is staged as
T3, and cancer that invades the laryngeal framework is
staged T4. Although staging correlates well with patient
survival and the feasibility of voice preservation, before
the advent of modern imaging the error rate in clinical
staging was nearly a third when compared with patho-
logic staging. Recent improvements in diagnostic
imaging have reduced this error rate signifi cantly, but
the variable pattern of laryngeal cartilage ossifi cation
can lead to overstaging if based on loss of ossifi cation.
Understaging can be common if careful direct laryngos-
copy is not performed with angled rigid endoscopes.1
Indeed, for early glottic lesions, endoscopic excision at
the time of staging laryngoscopy is often feasible and
advantageous for the patient.
Early glottic carcinoma, specifi cally, stage I or II,
can be treated by endoscopic excision, radiation
therapy, or open partial laryngectomy.14 Over the past
2 decades this topic has received intensive interest, and
controversies have often focused on techniques and
outcomes with the use of endoscopic excision versus
radiation therapy. This chapter discusses the philoso-
phy, techniques, and outcomes of resection via the
endoscopic approach to early glottic carcinoma. Opti-
mization through appropriate instrumentation, staging,
and technical details is critical for achieving favorable
postoperative oncologic and vocal outcomes. The
reader must remember that more than 90% of T1
lesions and approximately 75% of T2 lesions are curable,
and therefore adherence to the principles described
later is important to achieve these outcomes. In many
centers, patients are successfully treated with external
beam radiation therapy or an open surgical technique;
however, only the former option is briefl y discussed in
this chapter.
PREOPERATIVE PLANNING
Radiation Therapy
Radiation therapy alone, properly administered in
doses of 66 to 70 Gy, will cure 80% to 90% of patients
with T1 cancer of the TVC.15 With surgical salvage, the
overall cure rate in some studies approaches 95%.16
Radiation therapy is most effective for small lesions
involving the midportion of the membranous vocal
cord and is ideally suited for bilateral glottic disease,
especially if the anterior commissure tendon is not
invaded by cancer. Its effectiveness diminishes with
involvement of the anterior commissure, vocal process,
and arytenoid and in those with bulky lesions or some
limitation of vocal cord mobility. Control rates for T2
cancer with radiation therapy alone are not as high,
although with surgical salvage an overall 5-year survival
rate of approximately 90% is achieved.8 Treatment of
premalignant vocal fold epithelium with radiation
therapy is generally unsound management because the
patient undergoes a single-use cancer treatment when
cancer is not present, thereby “burning a bridge” for
future management. In most cases, irradiating young
patients (<45 years) is unwise because they are at great
risk for metachronous primary cancer.
Nevertheless, radiation therapy represents the stan-
dard therapy for these early lesions in many centers
because it preserves a high-quality voice in most patients
without compromising the chance for cure. Six weeks
of daily therapy is required, and the success of this
modality is highly dependent on the skill of the radio-
therapy team. The edema and histologic sequelae of
radiation therapy impair both visual and histologic
examination in the post-treatment period. Biopsy carries
with it the risk of precipitating chondritis, hence the
admonition to avoid biopsy of an irradiated larynx.
Unfortunately, this policy can result in delayed diagno-
sis of recurrent disease and lessen the likelihood of
successful salvage. In addition, the small radiation ports
used for carcinoma of the vocal cord complicate appli-
cation of radiation therapy to the cervical lymphatics
because of fi eld-matching diffi culties if it is required
later for subsequent cancer of the head and neck. The
lack of histologic confi rmation of disease status is a
major shortcoming of the use of radiation therapy as
primary treatment because the most useful prognostic
factors in current clinical practice are obtained through
pathologic analysis. Clinically and histologically corre-
lated studies suggest that errors in staging based on
clinical criteria are commonplace and may explain the
failure of radiation therapy to control “limited” disease.
For these and other reasons, many centers treat selected
patients with T1 and T2 carcinoma of the TVCs with
laser excision and obtain approximately similar voice
results.14,16,17
Table 46-1
AMERICAN JOINT COMMISSION FOR
CANCER 2002 STAGING FOR GLOTTIC
CARCINOMA OF THE LARYNX
T1
Limited to normal vocal fold mobility
T1a
Limited to one vocal fold
T1b
Involves both vocal folds
T2a
Extends to the supraglottis and/or subglottis
T2b
Impaired vocal cord mobility
T3
Vocal cord fi xation
Invades the paraglottic or preepiglottic space
Erosion of the inner cortex of thyroid cartilage
T4a
Invades cricoid/thyroid cartilage
Extralaryngeal extension (e.g., trachea, tongue,
strap muscles, thyroid, or esophagus)
T4b
Invades the prevertebral space
Encases the carotid artery
Invades mediastinal structures

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
381
Premalignant Glottic Lesions
Leukoplakia of the TVCs is commonly encountered in
a population of smokers (Fig. 46-1). Biopsy of these
lesions may reveal histologic changes ranging from
mild dysplasia to true invasive carcinoma. The level of
risk of these premalignant lesions developing into a
malignancy is unknown. The diffi culty inherent in
differentiating benign lesions from early carcinoma
mandates biopsy of the lesion or preferably complete
excision.
Carcinoma in situ requires removal of the epithelial
layer only; thus, the proper plane of dissection is within
the superfi cial lamina propria. Certainly, underappre-
ciated microinvasive tumors do occur, so adequate
margins should take this possibility into account.
Great care should be taken to not expose the vocal liga-
ment because doing so will remove the gelatinous
superfi cial lamina propria (Fig. 46-2). The postopera-
tive voice result is directly related to preservation of
as much of this pliable, gelatinous lamina propria
as possible to enable maximal vibratory activity of fl exi-
ble re-epithelialized overlying tissue. The patient is
endotracheally intubated, preferably with a metal laser-
proof endotracheal tube (Fig. 46-3A), and draped in
accordance with laser safety techniques (see Figure 46-
3B); the appropriate instrumentation is arranged con-
veniently on a side table (see Fig. 46-3C).
The specimen should be removed en bloc if possi-
ble and properly labeled so that margins may be assessed
by the pathologist. If the specimen is removed piece-
meal, additional margins of the surgical fi eld may be
taken with microcup forceps to verify complete removal.
Figure 46-1. Premalignant (dysplastic) lesions of the true vocal
folds are commonly encountered in the population at risk for squa-
mous cell carcinoma of the larynx. Biopsy of these lesions may reveal
histologic changes ranging from mild dysplasia to verrucous or inva-
sive squamous cell carcinoma. (Courtesy of Dr. Robert Buckmire.)
Epithelium
SLP
V
Muscle
Vocalis
Figure 46-2. Vocal fold layers showing potential planes of dissec-
tion: epithelium, superfi cial lamina propria (SLP), vocalis ligament,
and thyroarytenoid (vocalis) muscle (V).
Some surgeons do not advocate sending margins. Our
approach is to send margins for permanent pathologic
evaluation only in cases in which more extensive cancer
is present because frozen section analysis is not sensitive
enough for clinical decision making.
Patients are instructed to maintain voice rest for 7
to 10 days. If the margins are negative on permanent
histopathology, patients can be assigned to routine sur-
veillance for recurrence or progression every 4 to 6
weeks for the fi rst year and then at 2- to 3-month inter-
vals during the second year. Antirefl ux medication is
given postoperatively for up to 1 month.
Verrucous Carcinoma
Verrucous carcinoma, a histologic variant of SCC,
deserves specifi c discussion because it has a biologic
behavior that is different from that of invasive SCC.
Formerly it was thought that all these cancers occurred
secondary to HPV, although recent investigation sug-
gests that the prevalence of HPV in verrucous carci-
noma is no higher than that in other laryngeal cancers.
Grossly, the tumor resembles a hyperkeratotic papil-
loma, and histologic examination reveals papillomatous
growth. Histologic demonstration of true invasion is
diffi cult, and occasionally the surgeon must elect to
completely excise the lesion to ensure a diagnosis. Deep
invasion and regional metastases are rare, so local exci-
sion is often feasible despite extremely bulky disease
that would appear to suggest the need for more radical
surgery. Pillsbury and Kirchner18 demonstrated an
overall 30% rate of incorrect histologic staging when
compared with pathologic staging for cancer of the
glottis, but the only patients in their series who were
overstaged were two with verrucous carcinoma.
Radiation therapy does not appear to be very
effective in the management of verrucous carcinoma,
and some reports suggest that its use may result in the

382
Section 3
Larynx
A
B
C
Figure 46-3. A, A small laser-
safe endotracheal tube is used
to permit adequate visualization
and surgical access to the anterior
and posterior tumor margins. B,
Boston
University
suspension
gallows and anterior cricoid pres-
sure (left) and Loewy suspension
apparatus (right). The patient is
draped and suspended for micro-
laryngoscopy with laser-safe mate-
rials and soaked wet towels.
Flexion-extension is generally used
for optimal exposure of the ante-
rior laryngeal anatomy. Suspen-
sion with the Loewy suspension
apparatus on a Mayo stand may
be
used.
Suspension
with
a
Boston Gallows is favored by
others because it is attached to the
operative table and moves with
the patient (left diagram). C, Rigid
endoscopes and laryngeal instru-
ments are arranged on the side
table for appropriate endoscopic
visualization and manipulation of
the tumor. Bivalve and anterior
commissure laryngoscopes may
alternatively be used for optimal
exposure as the tumor and its loca-
tion permit. (B and C, Courtesy of
Guy Petruzzelli, MD, PhD.)
development of more aggressive forms of malignancy.
Surgical excision offers the best chance of control.
Endoscopic excision is often feasible, but more advanced
cases may require open excision with partial or total
laryngectomy.
Early Glottic Squamous Cell Carcinoma
Small invasive lesions on the membranous portion of
the TVCs impair the vibrating characteristic of the vocal
fold and result in hoarseness. Hence, early diagnosis of
carcinoma is possible, provided that this hoarseness
leads to an examination of the larynx. Patients may
therefore initially be found to have carcinoma in situ
or early invasive cancer. These patients are curable by
any of several modalities, and treatment choices are
dictated by expected voice quality and expediency
rather than the probability of cure. However, hoarse-
ness may go unnoticed in other patients with preexist-
ing voice abnormalities secondary to scarring and
gastroesophageal refl ux, thereby resulting in delayed
diagnosis. Patients often have advanced cancer at initial
evaluation because of delay in seeking medical care or
delay in referral by their primary practitioners despite
widespread public awareness. Delay as a result of either

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
383
patient factors, such as denial and inattention to per-
sonal health, or health care personnel who fail to fully
evaluate patients with voice disorders is common. The
multitude of benign conditions commonly associated
with hoarseness, as well as lack of pain or constitutional
symptoms, results in complacency on the part of the
patient or physician.
The most important factor leading to early diagno-
sis is recognition of an abnormal voice and subsequent
performance of offi ce laryngoscopy. Further improve-
ment in the control rate of vocal cord carcinoma will
require earlier recognition of the need for laryngos-
copy. The American Academy of Otolaryngology–Head
and Neck Surgery Foundation has established a web-
based educational program for primary care providers
to assist in these educational efforts, of which hoarse-
ness is one module (
accessed April 15, 2005). The use of imaging (usually
computed tomography [CT] or coregistered positron
emission tomography [PET]-CT) for laryngeal carci-
noma is determined by the judgment of the treating
surgeon, and suggested indications are listed in Table
46-2.
The goal of endoscopic management of an isolated
T1 lesion of the musculomembranous vocal fold is
eradication of the cancer with maximal preservation
of the normal glottic substructure (see Fig. 46-2). This
approach optimizes the postoperative voice without
compromising oncologic cure and consists of four com-
ponents: (1) dissection just under the basement mem-
brane with minimal disturbance of the superfi cial
lamina propria for atypical epithelium, (2) dissection
in the deeper aspect of the superfi cial lamina propria
for microinvasive cancer (as suggested via the infusion
technique),19 (3) dissection between the vocal ligament
and the vocalis muscle for lesions that are attached to
the ligament but not through it, and (4) dissection
within the vocalis muscle for lesions penetrating the
vocal ligament and vocalis muscle. This approach can
be further fi ne-tuned by performing partial resection of
any of the layered microstructure. The specimen is
always oriented for whole-mount histologic analysis,
and frozen section margin assessment is used selectively
to verify complete excision.
Relative contraindications to endoscopic excision
of laryngeal carcinoma are listed in Table 46-3. The
surgeon must be guided by previous experience and the
ability to manage each tumor individually based on
location, extent of disease, and ability to expose the
tumor for oncologic resection.
SURGICAL TECHNIQUE
Most cancers involving the membranous TVC that do
not extend onto the arytenoid, into the ventricle, or to
the anterior commissure are easily managed by micro-
laryngoscopy and laser excision (Fig. 46-4). Patients
must be selected carefully by accurate preoperative
evaluation with an emphasis on vocal fold mobility. In
selected patients, excision may be feasible at the time
of initial biopsy. The extent of cancer involvement may
be found to exceed that appreciated in the outpatient
setting; therefore, patients must be counseled that
further therapy, either irradiation or partial laryngec-
tomy, may be necessary after pathologic evaluation.
The CO2 laser is the instrument of choice in most
centers. This laser is directed through an articulated
arm attached to an operating microscope. The CO2
laser has a wavelength of approximately 10,000 nm and
is absorbed by water. The impact of the laser vaporizes
the cells and allows precise excision of tissue via a
micromanipulator attached to an aiming mirror. A low-
wattage helium-neon aiming beam is used for directing
the beam because the CO2 laser beam itself is invisible.
A typical spot size is 0.3 to 1 mm in diameter with a
power output of 3 to 10 W, depending on spot size.
Other centers may elect to use the yttrium-aluminum-
garnet (YAG) or potassium titanyl phosphate (KTP)
laser. These lasers are preferentially absorbed by red
pigment, and hence they have somewhat improved
hemostatic capability over the CO2 instrument. The
KTP laser beam can be delivered either by a microma-
nipulator connected to the microscope or by hand-held
fl exible fi bers. Laryngoscopes are available that permit
simultaneous suctioning of smoke and laser plume with
beam delivery.
Transoral laser excision for Tis, microinvasive
disease and T1, and selected T2 carcinoma of the larynx
is an acceptable modality and can be performed with
minimal morbidity. The postoperative voice can be as
good as that achieved after curative radiotherapy;
however, endoscopic excision can be performed in one
sitting and provides pathologic staging of the disease
process. Most surgeons maintain that optimal outcomes
from laser excision result when the tumor is confi ned
to the membranous cord. Steiner and others, however,
report excellent results with laser excision of larger
tumors, even when the tumor involves the arytenoid,
extends into the ventricle, or crosses the anterior com-
Table 46-2
INDICATIONS FOR IMAGING OF
GLOTTIC CARCINOMA
Severe hoarseness
Limited vocal cord mobility
Signifi cant involvement of the anterior commissure
Transglottic involvement
Cervical lymphadenopathy
Table 46-3
CONTRAINDICATIONS TO
ENDOSCOPIC RESECTION OF
LARYNGEAL CARCINOMA
Subglottic extension (≥5 mm)
Postcricoid extension
Invasion of the iriform sinus
Cartilage invasion
Vocal fold fi xation (relative)
Arytenoid extension (relative)
Involvement of the base of the tongue

384
Section 3
Larynx
A
B
C
D
E
Figure 46-4. A, T1,N0,M0 squamous cell carcinoma of the right vocal
fold. B and C, The CO2 laser is used for spot marking and incision of
the lateral margins of resection. Also evident is a previous vestibulotomy
(arrow), which was accomplished by excising the right false vocal fold for
lateral exposure and future postoperative outpatient tumor surveillance.
D, Resected tumor bed. E, Healed right neocord several months after
resection. The contralateral vibratory epithelium is retained for apposi-
tion to the stiff resection site, which medializes fully for adequate vocal
function.

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
385
missure.20 The author’s experience has generally been
consistent with these extended indications in appro-
priately selected patients. Here, frozen section
margin control may be necessary to ensure removal of
disease. Postoperatively, close follow-up is required,
often including a planned “second-look” endoscopic
evaluation on an outpatient basis. Excision is particu-
larly warranted for early cancer in which radiation
therapy seems to be excessive treatment. Use of the
laser attached to the operating microscope has greatly
facilitated this procedure.
General Procedure
Fundamental to any laryngologic procedure is the
ability to adequately visualize and expose the involved
sites of the larynx. A wide variety of laryngoscopes
that allow binocular exposure are available, as well
as bimanual instrumentation. The evolution of suspen-
sion microlaryngoscopy is predicated on the ability
to use both hands under high-power magnifi cation.
We currently use a Jako-Dedo type V laryngoscope
with a fulcrum-type Loewy suspension apparatus (see
Fig. 46-3).
The patient should be fi tted with a dental guard
after any necessary extractions are performed. Patients
thought to have normal intubating anatomy are given
a muscle relaxant to allow easier visualization of the
glottis. Paramount to safe and effective management
of the airway is clear and open communication between
the otolaryngologist and anesthetist before and during
the procedure. Although these health professionals
“share” the airway, in most situations the otolaryngolo-
gist will be more adept at obtaining adequate airway
exposure and navigating distorted laryngeal anatomy.
Rigid laryngoscopes must be prepared and available
with a second suction in these situations. Because
patency of the airway is not usually a concern, many
head and neck surgeons perform the fi rst evaluation
and intubation before disruption of the baseline appear-
ance of the tumor by standard anesthetic induction
procedures.
Positioning
Laser safety is not to be overlooked despite the preva-
lence of laser use in modern endoscopic practice. The
patient’s eyes, face, and chest are protected with soaked
gauze and towels (see Fig. 46-3B). Despite the use of a
laser-resistant endotracheal tube, moistened cotton
pledgets are used to protect the glottis and subglottis
from stray laser strikes. Familiarity with safe use of the
laser instrument and an action plan in the event of
airway fi re are paramount to responsible application of
this technique. An apneic technique can be used during
times of laser activity, or the oxygen content delivered
by the anesthetist should be decreased below 30% to
prevent an airway fi re from oxygen leaking around the
cuff. An airway fi re should be handled by immediate
extubation, removal of supplemental oxygen, applica-
tion of saline into the airway, and reintubation of the
patient.
Preoperative preparation of the operating suite
with identifying signs, protective eyewear for all person-
nel, and appropriate smoke evacuation equipment is
mandatory. Viral DNA has been recovered from laser
plume; therefore, it is prudent to wear appropriate
high-fi ltration “laser masks” to avoid potential inhala-
tion of virulent viral material. Confi rmation of correct
alignment of the aiming and treatment beams is neces-
sary and should be done before each procedure. Typi-
cally, such confi rmation is achieved by testing the beam
on a moistened wooden tongue blade.
Endotracheal tubes used for general anesthesia
must be fi reproof. Various nonfl ammable tubes are
available; however, recent investigation has suggested
that a metal endotracheal tube is the safest and prefer-
able to coated “laser-safe” tubes. These coated tubes can
still be ignited if subjected for a suffi cient period to
enough energy to penetrate the lining.
The patient is typically intubated in the supine posi-
tion with the head in the “fl exion-fl exion” position.
This can be performed by the surgeon or by an anes-
thesiologist familiar with laryngologic procedures. With
the laser-safe endotracheal tube in place, the patient
and endoscope are then suspended in a “fl exion-
extension” position by a suspension gallows system such
as the Boston University Gallows or a more standard
fulcrum-type device with a Mayo stand (see Fig. 46-3).
The true vector suspension technique with the patient
in cervical fl exion and atlanto-occipital extension is
reported to give the best visualization of the anterior
commissure. An operating binocular microscope is
introduced for visualization of the glottis, usually with
a 400-mm lens and 10× to 40× magnifi cation. Tape may
be applied to the anterior aspect of the neck and table
to provide any necessary counterforce for complete
glottic exposure. It should be noted that digital pres-
sure, though useful for cursory evaluation, may fl uctu-
ate throughout the procedure. Often a 45- or 70-degree
telescope is useful in evaluating the undersurface of the
vocal folds and possible subglottic extension. Use of a
rigid telescope takes advantage of magnifi cation and
enables photodocumentation for the medical record
and teaching purposes. For assessment of a lesion in the
posterior aspect of the larynx, apneic evaluation of the
glottis may be required because the endotracheal tube
obscures this view. Special endoscopes, some that enable
simultaneous ventilation, are also available for this
purpose.
After general anesthesia is induced, the endotra-
cheal tube is inserted and secured. Before excising the
tumor, the patient should undergo formal endoscopy,
including examination of the piriform sinuses, supra-
glottis, and esophagus. The laryngoscope is inserted
and suspended. The patient’s eyes are protected by
moistened eye pads, and moistened towels are placed
around the fi eld to preclude the danger of laser burns
secondary to refl ected or stray laser impact. The binoc-
ular operating microscope with a 400-mm objective lens
is positioned with the attached laser. After careful
examination and palpation of the cancer, moistened
neural felt patties are placed in the subglottic air space

386
Section 3
Larynx
to absorb and protect the tracheal lining and endotra-
cheal tube cuff from laser “overshoot.”
It is imperative that the surgical exposure include
visualization of the entire extent of the tumor; however,
the endoscope might have to be repositioned several
times to achieve such visualization. Some lesions may
need surgical facilitation of the exposure. We advocate
removal of the false vocal fold in nearly all endoscopic
glottic SCC resections, a technique known as laser ves-
tibulotomy (see Fig. 46-4B, arrow). This maneuver pro-
vides improved visualization for endoscopic resection
and enhances follow-up surveillance. In addition, access
to the paraglottic and subglottic space is provided by
this technique if extended tumor removal is required
(Fig. 46-5).
Larger T2 lesions (Fig. 46-6) involving the true
and false vocal folds or the epiglottis (even T3 tumors
with early preepiglottic space involvement, Fig. 46-7)
can be managed by an experienced endoscopic
surgeon.21
A
B
C
D
Figure 46-5. A and C, Schematic and operative images depicting a T2N0N0 glottic squamous cell carcinoma involving the entire right true
vocal fold and inferior surface of the right false vocal fold. Laryngeal mobility was retained except for minor impairment because of tumor
bulk. B and D, Postexcision tumor bed. Frozen section margins may be sent at this point to determine the extent of tumor control. The anterior
commissure is not involved.

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
387
A
B
C
Figure 46-6. A, Bulky T2 transglottic squamous cell carcinoma involv-
ing the false vocal fold and extending inferiorly to the true vocal fold
and posteriorly to the mucosa of the ipsilateral arytenoid. B, Tumor is
bisected superiorly (arrow) to determine depth and to improve manipula-
tion and exposure. Vocal fold mobility was impaired but involvement of
the cricoarytenoid joint was not present (C).
Operative Technique
The procedure proceeds with the CO2 laser on 5- to 6-W
continuous or super-pulse energy with a 0.27-mm spot
size. Super-pulse settings consisting of 0.6 second on
and 0.2 second off may dissipate heat energy while pro-
viding enhanced “burst” laser-cutting action. The false
vocal fold is resected en bloc from the infrapetiole
region anteriorly and brought posteriorly to the level of
the vocal process of the arytenoids (see Fig. 46-4B,
arrow). It is important to properly orient and label this
specimen so that histologic analysis can refute or confi rm
the presence of malignancy, particularly its undersur-
face. The CO2 laser is especially useful in performing
vestibulotomy because it provides concomitant cutting
and hemostasis. Signifi cant bleeding may be encoun-
tered during this maneuver but can be controlled with
a defocused laser beam. If a laser is unavailable or inef-
fective at obtaining hemostasis, direct pressure with
pledgets soaked in epinephrine (1:100,000) or suction
cautery on low setting (10 to 15 mV) will usually suffi ce.
One should confi rm that a higher concentration of epi-
nephrine (such as 1:1000) is not inadvertently used in
the operating room. Microfl ap technique with cold
instruments may be used for superfi cial lesions with
excellent results. This technique involves preservation
of the superfi cial lamina propria, results in quicker
healing, and provides better voice results.
At this point the entire vocal fold should be visible,
including the confl uence at the anterior commissure.
Subepithelial injection of a saline-epinephrine mixture
or a 1:10,000 dilution of epinephrine alone via a 27-
gauge Brüning or butterfl y needle will help determine
invasion beyond the superfi cial lamina propria into
deeper structures such as the vocal ligament or
thyroarytenoid muscle. Besides its diagnostic utility,
the subepithelial fl uid provides a heat sink to protect
surrounding tissue from laser-generated heat and may
also aid in dissection in the appropriate layer. Before
any dissection is begun, the margins of resection should
be determined and spot-marked with a CO2 laser (see
Fig. 46-4B). Gentle medial traction is achieved with
microcup forceps, and the dissection is preferably
carried out in a lateral-to-medial (and posterior-to-
anterior) direction because this provides reliable iden-
tifi cation and visualization of the planes of dissection.

388
Section 3
Larynx
B
A
C
D
The laser is set on single pulse, and the margins of
the planned excision are marked. The tumor is excised
with a continuous- or repeating-pulse mode. It is not
necessary to remove the lesion in one piece. In fact,
Steiner and associates have demonstrated that bisection
of the tumor permits assessment of the deep planes and
helps ensure complete excision, particularly in larger
lesions.16 It is crucial to avoid tears or fragmentation of
the specimen to maintain registration between the
excised specimen and the surgical bed. Correct orienta-
tion is necessary to permit accurate frozen section anal-
ysis of the margins. Hemostasis can be achieved by
electrocautery either through a suction cautery unit or
via the defocused laser beam.
Intraoperative frozen sections may be useful to
ensure complete tumor removal. Close cooperation
and communication between the surgeon and patholo-
gist are necessary to ensure correct orientation of the
specimen and margins. The margins of excision can be
very small (<2 mm) but require careful orientation of
the specimen. It is usually best if the pathologist can
come into the operating room and observe the proce-
dure through the monitor or the side arm of the micro-
scope to assist in orienting the specimen. Identifi cation
of one end of the resected specimen with a small suture
is helpful for avoiding later confusion.
Additional resections are performed as required to
obtain adequate tumor margins. Care must be taken to
ensure that re-excisions are correctly oriented and
removed from the appropriate area of the specimen
bed. After hemostasis is accomplished, the microscope
and laryngoscope are removed from the fi eld, and the
Figure 46-7. A to C, T3,N0,M0 supraglottic squamous cell carcinoma involving the laryngeal surface of the epiglottis above the petiole with
cartilage invasion and early preepiglottic space invasion. Superior tumor excision (tumor bisected) was performed in staged fashion to permit
visualization of the inferior, immediately supraglottic tumor extent. D, Computed tomography scan indicating early preepiglottic space involve-
ment of tumor.

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
389
E
F
G
patient is awakened and extubated and may be dis-
charged as soon as the airway is adequate. Aspiration is
rarely a diffi culty, although it can occur subclinically,
and voice rest may be used for 1 week.
Care must be taken to ensure that adequate tissue
has been removed. Flexible bronchoscopy with wash-
ings may be indicated as well. If fi nal permanent patho-
logic evaluation reveals tumor at the margins of
resection, repeat laser excision should be performed. If
negative margins cannot be obtained, the patient should
undergo either radiotherapy or open surgical excision
(i.e., vertical or horizontal partial laryngectomy).
Cancer originating from or involving the supraglot-
tis is treated with similar approaches and instrumenta-
tion. A variety of rigid endoscopes must be available to
permit adequate exposure of these structures. As shown
in Figures 46-6 and 46-7, excision of cancer of the epi-
glottis, aryepiglottic fold, and false vocal fold is possible
with direct access to the paraglottic and preepiglottic
spaces. Treatment of the neck, which is at greater risk
for nodal metastasis with supraglottic cancer,22 can be
incorporated into the endoscopic procedure or, more
commonly, staged once the pathologic results of exci-
sion of the primary cancer have been obtained.
POSTOPERATIVE MANAGEMENT
Postoperatively, the patient is treated for laryngopha-
ryngeal refl ux for up to 8 weeks as necessary. Antibiotics
or analgesics (or both) are prescribed selectively accord-
Figure 46-7, cont’d. E and F, Final excision of the inferior and lateral
tumor margin is performed under adequate visualization. The arrows
indicate the aryepiglottic fold (superior to the arytenoid cartilage) as
posterior margins. The specimen is marked and oriented with direct
communication between the surgeon and pathologist. Frozen or perma-
nent section margins may be obtained for additional tumor control as
needed. G, Postoperative result at 3 months.

390
Section 3
Larynx
ing to surgeon and patient preference and the extent
of the surgery. Complete voice rest with head elevation
is advised for 1 week and modifi ed voice use for 2
weeks. A vaporizer at the bedside at home is valuable
for patient comfort. Preoperative and postoperative
appointments with a speech pathologist are scheduled
for objective voice assessment and discussion of vocal
hygiene. Formal voice therapy is initiated as needed.
COMPLICATIONS
Hemorrhage
Bleeding that requires intervention is extremely rare
after endoscopic resection of early glottic cancer
because vessels of a signifi cant diameter are seldom
encountered except during larger resections. If
persistent hemoptysis develops, fi beroptic laryngos -
copy should be performed. Based on this examination
and the character of the bleeding, the patient can
be brought back to the operating room if necessary.
Hemostasis should be achieved with microscopic control
and can be accomplished with the laser or a
microelectrocautery.
Airway Obstruction
As indicated earlier, postoperative airway obstruction is
unusual because careful intraoperative assessment and
appropriate intervention are the tools for airway safety.
If a patient has been left intubated in the initial post-
operative period, extubation should be done in a con-
trolled environment such that the laryngologist can
observe and re-establish the airway in a prepared orga-
nized fashion.
Granuloma Formation
Granuloma formation usually occurs in patients who
have acid refl ux and can arise anywhere in the glottal
surgical fi eld. These lesions probably develop in a de-
epithelialized area from the glottic trauma that results
from talking and coughing in an environment of glottic
mucositis secondary to refl ux. All char should be
removed at the end of the laser resection to avoid the
formation of “charcoal granuloma.”23 Persistent hoarse-
ness after the procedure should alert the surgeon to
this possibility, which must be accompanied by micro-
surgical excision of the granuloma.
Scarring
Scar formation in residual vocal fold soft tissue is an
inevitable outcome of excision of glottic cancer. This
scarring may result in excessive stiffness of the oscilla-
tory capability of the vocal fold. It typically occurs when
the surgical fi eld for cancer excision is wider than onco-
logically necessary to encompass the lesion. Excessive
trauma to normal vocal fold tissue is obviated by care-
fully assessing the three-dimensional characteristics of
the lesion and selecting appropriate instrumentation
for the excision, especially when tangential dissection
in only part of the subepithelial layer is required to
perform an adequate excision.
Excessive Hoarseness and Dysphonia
Patients may have a variety of vocal complaints that
relate not only to the acoustic quality of the voice but
also to vocal effi ciency, that is, the effort or “work of
phonation.” Voice change is inevitable after resecting
glottic cancer. If an exophytic lesion is present on the
medial surface, the voice may even be directly improved
after excision.
The greatest diffi culties with regard to postopera-
tive hoarseness relate to inappropriate expectations by
the surgeon or patient of the unavoidable voice deterio-
ration that sometimes occurs. Precise preoperative
assessment of the lesion and the patient’s phonation
characteristics will minimize this problem. Stroboscopic
evaluation is very valuable for assessing the vibration
characteristics of nonmalignant vocal fold epithelium.
At times, voice therapy can enhance vocal quality by
teaching the patient more effective strategies to over-
come the compromised oscillation characteristics of the
glottal valve. In some cases, medializing a postresection
excavated neocord by means of an external thyroplasty
can enhance glottal effi ciency. A stiff leaking glottal
valve that requires extremely high subglottic pressure
to induce entrained oscillation can be reconstructed so
that glottal closure and oscillation are dramatically
improved.
PEARLS
• Endoscopic microsurgical resection for treating
laryngeal cancer consists of a series of graded
excisions in which the cancer margins are
accommodated precisely to the three-dimensional
characteristics of the tumor.
• A primary oncologic goal is to narrow the cancer-
free margin and decrease patient morbidity while
not altering the cure rate.
• Subepithelial infusion of saline or local anesthetic in
T1 cancer may allow preservation of the entire vocal
ligament and vocalis muscle, as well as part of the
deep portion of the superfi cial lamina propria.
• Whenever possible, cancer resections should be
performed en bloc. At times, especially with T2 and
T3 lesions, serial resections of deep tissues must be
done with frozen sections or repeat (“second-look”)
procedures to control for adequate margins.
• Postoperative swallowing function may be worse in
patients treated by laser excision after radiation
therapy.
PITFALLS
• A small amount of extra glottic tissue that is excised
with the deep margin can have a profound effect on
vocal outcome while not necessarily improving the
cure rate.

Chapter 46
Endoscopic Laser Excision of Laryngeal Carcinoma
391
8. Steiner W: Results of curative laser microsurgery of laryngeal
carcinomas. Am J Otolaryngol 14:116-121, 1993.
9. Ambrosch P, Kron M, Steiner W: Carbon dioxide laser microsur-
gery for early supraglottic carcinoma. Ann Otol Rhinol Laryngol
107:680-688, 1998.
10. Davis RK, Hadley K, Smith ME: Endoscopic vertical partial laryn-
gectomy. Laryngoscope 114:236-240, 2004.
11. Desloge RB, Zeitels SM: Endolaryngeal microsurgery at the ante-
rior glottal commissure: Controversies and observations. Ann
Otol Rhinol Laryngol 109:385-392, 2000.
12. Pearson BW, Salassa JR: Transoral laser microresection for cancer
of the larynx involving the anterior commissure. Laryngoscope
113:1104-1112, 2003.
13. Zeitels SM: Infrapetiole exploration of the supraglottis for expo-
sure of the anterior glottal commissure. J Voice 12:117-122,
1998.
14. Flint PW: Minimally invasive techniques for management of early
glottic cancer. Otolaryngol Clin North Am 35:1055-1066, vi-vii,
2002.
15. Kadish SP: Can I treat this small larynx lesion with radiation
alone? Update on the radiation management of early (T1
and T2) glottic cancer. Otolaryngol Clin North Am 38:1-9, vii,
2005.
16. Steiner W, Vogt P, Ambrosch P, Kron M: Transoral carbon
dioxide laser microsurgery for recurrent glottic carcinoma after
radiotherapy. Head Neck 26:477-484, 2004.
17. van Gogh CD, Verdonck-de Leeuw IM, Boon-Kamma BA, et al: A
screening questionnaire for voice problems after treatment of
early glottic cancer. Int J Radiat Oncol Biol Phys 62:700-705,
2005.
18. Pillsbury HR, Kirchner JA: Clinical vs histopathologic staging in
laryngeal cancer. Arch Otolaryngol 105:157-159, 1979.
19. Kass ES, Hillman RE, Zeitels SM: Vocal fold submucosal infusion
technique in phonomicrosurgery. Ann Otol Rhinol Laryngol
105:341-347, 1996.
20. Steiner W, Ambrosch P, Rodel RM, Kron M: Impact of anterior
commissure involvement on local control of early glottic carci-
noma treated by laser microresection. Laryngoscope 114:1485-
1491, 2004.
21. Rudert HH, Werner JA, Hoft S: Transoral carbon dioxide laser
resection of supraglottic carcinoma. Ann Otol Rhinol Laryngol
108:819-827, 1999.
22. Chiu RJ, Myers EN, Johnson JT: Effi cacy of routine bilateral neck
dissection in the management of supraglottic cancer. Otolaryngol
Head Neck Surg 131:485-488, 2004.
23. Casiano RR, Cooper JD, Lundy DS, Chandler JR: Laser cordec-
tomy for T1 glottic carcinoma: A 10-year experience and video-
stroboscopic fi ndings. Otolaryngol Head Neck Surg 104:831-837,
1991.
• Failure to observe all aspects of laser safety may
result in signifi cant injury to or death of the patient
or treating individuals.
• Poor patient selection, such as those with
compromised pulmonary function, will result in
compromised postoperative swallowing and
aspiration, thus negating the oncologic outcome.
• Laser excision of cancers previously treated with
radiation therapy may lead to diffi culty obtaining
negative margins because of submucosal spread and
radiation-induced changes in the mucosa that
preclude narrow-margin surgery.
• Persistent hoarseness after the procedure should
alert the surgeon to the possibility of a “charcoal
granuloma” formed as a result of retained,
cauterized tissue, which must be treated by
microsurgical excision of the granuloma.
References
1. Thekdi AA, Ferris RL: Diagnostic assessment of laryngeal cancer.
Otolaryngol Clin North Am 35:953-969, v, 2002.
2. Kirchner JA: Glottic-supraglottic barrier: Fact or fantasy? Ann
Otol Rhinol Laryngol 106:700-704, 1997.
3. Kirchner JA, Cornog JL Jr, Holmes RE: Transglottic cancer. Its
growth and spread within the larynx. Arch Otolaryngol 99:247-
251, 1974.
4. Lewin JS, Gillenwater AM, Garrett JD, et al: Characterization of
laryngopharyngeal refl ux in patients with premalignant or early
carcinomas of the larynx. Cancer 97:1010-1014, 2003.
5. Ferris RL, Martinez I, Sirianni N, et al: Human papillomavirus-16
associated squamous cell carcinoma of the head and neck
(SCCHN): A natural disease model provides insights into viral
carcinogenesis. Eur J Cancer 41:807-815, 2005.
6. McGavran MH, Bauer WC, Ogura JH: The incidence of cervical
lymph node metastases from epidermoid carcinoma of the larynx
and their relationship to certain characteristics of the primary
tumor. A study based on the clinical and pathological fi ndings
for 96 patients treated by primary en bloc laryngectomy and
radical neck dissection. Cancer 14:55-66, 1961.
7. Kirchner JA: Fifteenth Daniel C. Baker, Jr, memorial lecture.
What have whole organ sections contributed to the treatment of
laryngeal cancer? Ann Otol Rhinol Laryngol 98:661-667, 1989.

Chapter 47
Horizontal Partial Laryngectomy
Jonas T. Johnson
Conservation partial laryngeal surgery is defi ned as
removal of a portion of the larynx with preservation of
the respiratory, sphincteric, and vocal functions of the
larynx. Surgical procedures that eliminate one of these
functions, such as near-total laryngectomy, which
requires a permanent tracheostomy, are not described
by the term conservation and are not discussed in this
section. Conservation laryngeal surgery can be divided
into two major categories, horizontal and vertical, the
fi rst of which is discussed in this chapter.
For nearly half a century supraglottic laryngectomy
was the only standard horizontal partial laryngectomy,
and it is appropriate for tumors confi ned to structures
superior to the true vocal cords. The feasibility of this
procedure is based on the fact that most laryngeal
cancers do not cross the laryngeal ventricle until quite
advanced. The procedure requires removal of the supe-
rior portion of the thyroid cartilage in continuity with
the supraglottic structures and often the hyoid bone, as
well as approximation of the inferior laryngeal remnant,
which consists of the true vocal cords with both anterior
and posterior attachments to the musculature of the
tongue base.
In 1990 Laccourreye and coworkers reported their
experience with a new type of horizontal partial laryn-
gectomy that removes both the membranous true vocal
cords and the entire thyroid cartilage (Table 47-1).1
Preservation of the respiratory and sphincteric func-
tions of the larynx relies on tight approximation of the
cricoid cartilage to the hyoid bone and preservation of
at least one innervated cricoarytenoid unit. The larynx
is resected just superior to the cricoid and anterior to
the arytenoids and closed by approximating the cricoid
to the hyoid bone---a procedure termed supracricoid
partial laryngectomy [SCPL]) with cricohyoidopexy (CHP).
This procedure is appropriate for selected patients with
(1) glottic cancer that extends onto the supraglottis, (2)
supraglottic cancer that extends onto the true vocal
cords, (3) cancer involving both entire membranous
vocal cords, or (4) cancer that has infi ltrated the para-
glottic space and has fi xed a vocal cord. All these
situations have traditionally been managed by total
laryngectomy, and specifi c criteria must be met for the
procedure to result in a functional larynx. The epiglot-
tis can be left in place when this operation is performed
for glottic cancer and, in this situation, is incorporated
into the closure (supracricoid partial laryngectomy with cri-
cohyoidoepiglottopexy [SCPL-CHEP]). The cricoid carti-
lage, hyoid bone, and at least one functional (innervated)
cricoarytenoid joint complex are preserved. Arytenoid
sensation is preserved as well through intact superior
laryngeal nerves bilaterally. Both procedures shorten
the larynx signifi cantly in the vertical dimension. Previ-
ous radiation therapy is not a contraindication to SCPL,
as long as the structures required for reconstruction
can be preserved.2,3 The procedure cannot be per-
formed if more than 10 mm of anterior subglottic
extension exists anteriorly because the cricoid cartilage
is used for closure (although a recent report suggests
that the cricoid may spared with up to 15 mm of sub-
glottic extension2). At least one arytenoid must be unin-
volved, as well as the cricoarytenoid joint on the side of
a fi xed vocal cord, because reconstruction depends on
intact cricoid cartilage.
The time until recovery is longer than with a tradi-
tional vertical partial laryngectomy, and a tracheostomy
tube is required for about 3 weeks. The time course
required for postoperative swallowing rehabilitation
more closely parallels that for supraglottic laryngectomy
as well, although nonirradiated patients with glottic
cancer who are able to retain their epiglottis and both
arytenoid cartilages swallow earlier. If properly selected,
393

394
Section 3
Larynx
most patients can be decannulated and will be able to
tolerate a regular diet. Horizontal partial laryngectomy,
therefore, is suitable either for supraglottic cancer,
including that involving the true vocal cords, or for
extensive glottic cancer that might otherwise necessi-
tate total laryngectomy.
ANATOMIC CONSIDERATIONS
The supraglottic larynx is the portion of the larynx
between the tip of the epiglottis superiorly and the
laryngeal ventricles inferiorly (Fig. 47-1). Laterally, the
supraglottic larynx includes the aryepiglottic folds.
However, tumors that originate on the lateral aspect of
the aryepiglottic fold (the medial wall of the piriform
sinus) are considered hypopharyngeal tumors. Anteri-
orly, the supraglottic larynx includes the lingual surface
of the epiglottis. Tumors arising in the adjacent vallec-
ula and tongue base should be considered oropharyn-
geal. Posteriorly, the supraglottic larynx is limited by
the arytenoid cartilage. Tumors in the postcricoid
mucosa are also considered hypopharyngeal.
Squamous cell carcinoma accounts for more than
95% of malignant tumors arising in the supraglottic
larynx. Tumors that originate from minor salivary
glands, such as acinic cell tumors, mucoepidermoid
carcinoma, and adenocystic carcinoma, are encoun-
tered rarely. Other cell types that arise from connective
tissue and the surrounding structures are also consid-
ered rare.
Abuse of both alcohol and tobacco is thought to
play a major role in the development of supraglottic
squamous cell carcinoma.4-7 The relative percentage of
supraglottic and glottic cancer varies from culture to
culture. In Finland8 and much of the rest of Europe,9
two thirds of laryngeal cancers arise in the supraglottis
and one third in the glottis. The ratio is reversed in the
United States.10
The plan of management of squamous cell carci-
noma of the supraglottic larynx must take into consid-
eration the size and location of the primary cancer, as
well as the general condition of the patient and the
propensity for these cancers to metastasize to the cervi-
cal lymph nodes. The relative risk for metastatic cancer
tends to be directly related to the size of the primary
cancer---for instance, the risk to the cervical lymphatics
can be estimated to be at least 20% for patients with
lesions less than 2 cm in diameter11 and may be as high
as 80% in patients with advanced supraglottic carci-
noma.12 It is estimated that metastatic disease in the
contralateral neck may develop in as many as 40% of
patients with metastasis to the lymph nodes in the ipsi-
lateral neck. This observation is somewhat contentious
in view of the fact that nearly half of tumors encoun-
tered in the supraglottic larynx are on or near the
midline. At least 10% of patients with no evidence of
ipsilateral metastases may eventually demonstrate con-
tralateral metastases.13,14
Therapeutic alternatives for patients with squamous
cell carcinoma of the supraglottic larynx include
surgery, radiation therapy, or a combination of the two.
It is generally agreed that patients with small, superfi cial
cancers involving the supraglottic larynx may be treated
by either surgery or radiation therapy with similar thera-
peutic effi cacy.15,16 Surgery improves the opportunity
for disease control in patients with more advanced
disease, such as evidence of deep invasion into cartilage
or the preepiglottic space (Fig. 47-2). Cancer fi lling the
preepiglottic space that approaches or involves the
hyoid bone is a contraindication to SCPL because func-
tional reconstruction (CHP or CHEP) depends on pres-
ervation of the hyoid bone. In the absence of involvement
of the true vocal cords or arytenoids or extensive tongue
base involvement, these tumors are amenable to stan-
dard supraglottic laryngectomy. Patients with extension
of cancer to involve the tongue base or hypopharynx
are at high risk for local recurrence. Accordingly, these
Table 47-1 TYPES OF HORIZONTAL PARTIAL
LARYNGECTOMY
Supraglottic
Extended supraglottic to include:
Tongue or arytenoid
Partial laryngopharyngectomy
Supracricoid with cricoepiglottohyoidopexy (epiglottis
preserved)
Supracricoid with cricohyoidopexy (epiglottis resected)
Figure 47-1. Sagittal view of the larynx. The inferior border of the
supraglottic larynx is at a plane through the level of the true vocal
cord.

Chapter 47
Horizontal Partial Laryngectomy
395
patients are frequently treated with a combination of
surgery and postoperative radiation therapy.14,17
Patients with squamous cell carcinoma confi ned to
the supraglottic larynx benefi t from supraglottic laryn-
gectomy, provided that their general health allows
recovery from surgery. This procedure is highly effec-
tive in controlling local disease and allows preservation
of nearly normal vocal function and deglutition. In a
retrospective review of more than 200 patients with
carcinoma of the supraglottic larynx at the University
of Pittsburgh, 72 of these patients were eligible for
supraglottic laryngectomy.14 Recurrent cancer in the
larynx was not encountered; however, less than 2% of
patients experienced recurrence in the base of the
tongue. Recurrence in this area may indicate that it is
more diffi cult to achieve adequate surgical margins in
patients with extension of tumor into the vallecula, pre-
epiglottic space, and base of the tongue.
Equally effective as open supraglottic laryngectomy
has been endoscopic resection with use of the operat-
ing microscope and carbon dioxide laser. This tech-
nique, in experienced hands, has similar excellent rates
of local control and avoids the need for a temporary
tracheotomy. The reader is referred to the previous
chapter for more in-depth discussion of endoscopic
excision.
A patient with a supraglottic cancer that extends to
involve the anterior commissure is a candidate for
reconstruction with SCPL-CHP. As noted earlier,
involvement of one arytenoid or fi xation of a vocal cord
is not a contraindication to the procedure, but it will
probably result in prolongation of the postoperative
recovery period, similar to the situation of SCPL per-
formed after radiation therapy.
An important contribution of surgery to the man-
agement of patients with squamous cell carcinoma of
the supraglottic larynx is that it affords the pathologist
the opportunity to accurately stage the primary cancer
and the status of the cervical lymphatics. This, in turn,
results in improved accuracy in patient counseling with
respect to decision making regarding the use of
adjuvant therapy.
PATIENT SELECTION
Cancer involving the supraglottic larynx requires histo-
logic confi rmation. The infrequently encountered small
superfi cial cancer confi ned to the suprahyoid epiglottis
may be managed successfully by epiglottectomy with the
CO2 laser, or open excision via transhyoid or lateral
pharyngotomy may be appropriate. Unfortunately, the
asymptomatic nature of supraglottic tumors makes
small lesions relatively unusual, with the majority of
patients generally being found to have more extensive
cancer at initial evaluation. Cancer confi ned to the
supraglottic larynx anterior to the arytenoids may be
ideally suited to supraglottic laryngectomy. Extension
of the cancer to involve a single arytenoid may occasion-
ally be considered for supraglottic laryngectomy, but
bilateral involvement of the arytenoids is a strict contra-
indication to either supraglottic laryngectomy or SCPL
and would require total laryngectomy because the
sphincteric function of the larynx would be lost.
Cancer involving the aryepiglottic fold and medial
wall of the piriform sinus can be treated by supraglottic
laryngectomy. When the cancer extends to involve the
anterior and lateral walls of the piriform sinus, supra-
glottic laryngectomy can be extended to include partial
pharyngectomy, but involvement of the apex of the
piriform sinus (indicating extension below the plane of
the laryngeal ventricles) is a contraindication to supra-
glottic laryngectomy.
Supraglottic laryngectomy can also be extended to
include the vallecula and base of the tongue. The pro-
pensity for cancer arising in the base of the tongue to
infi ltrate submucosally and involve large areas of muscle
must be considered during the preoperative evaluation
inasmuch as resection may create a signifi cantly larger
defect than initially anticipated. The extended supra-
glottic laryngectomy further compromises swallowing
function and should be applied only to patients with
good performance status. Consequently, supraglottic
laryngectomy may not be applicable to many patients
with involvement of the base of the tongue.
All patients undergoing either supraglottic laryn-
gectomy or SCPL experience aspiration for some time.
The magnitude and duration of this aspiration problem
are directly related to the extent of the surgical resec-
tion, removal of the superior laryngeal nerve, and the
Figure 47-2. The preepiglottic space (shaded area) is bounded ante-
riorly by the thyrohyoid membrane. Superiorly, it is contained by the
hyoepiglottic ligament. Tumor limited to the preepiglottic space is
not a contraindication to supraglottic laryngectomy. However, tumor
extension anterior to the preepiglottic space must be recognized and
satisfactorily excised to ensure control of disease.

396
Section 3
Larynx
patient’s age, motivation, and general physical condi-
tion, especially underlying cardiopulmonary reserve.
Accordingly, these factors must be carefully evaluated
and considered in the preoperative planning.
PREOPERATIVE EVALUATION
The principal considerations in the decision-making
algorithm regarding surgical management of a patient
with carcinoma of the larynx are the history and physi-
cal examination, including assessment of the extent of
the primary tumor, evaluation of the cervical lymphat-
ics, and estimation of the patient’s underlying cardio-
pulmonary reserve.
Every patient should undergo direct laryngoscopy
as part of the preoperative evaluation. Further evalua-
tion should also include assessment of the entire upper
aerodigestive tract to rule out a synchronous second
primary carcinoma. A second primary carcinoma arising
in the lung is most common when supraglottic cancer
is the index tumor. The primary cancer should be care-
fully evaluated for evidence of spread to contiguous
structures, which would, in turn, affect the subsequent
management plan. Spread to involve the tongue base,
piriform sinus, true vocal cords, or arytenoid must be
identifi ed. Similarly, transglottic spread must be recog-
nized. Involvement of the paraglottic space inferior to
the plane of the laryngeal ventricle is a contraindication
to supraglottic laryngectomy but not to SCPL (Fig.
47-3). Subglottic extension must be noted and mea-
sured with angled telescopes if SCPL is to be consid-
ered. Vocal cord fi xation must be assessed and the
functionality of the cricoarytenoid joint determined.
Visual inspection and palpation of the supraglottis, true
vocal cords, arytenoids, and vallecula help identify
involvement in these regions. The surgeon must keep
in mind that the true vocal cords and at least one ary-
tenoid must not be involved for the patient to be con-
sidered a candidate for supraglottic laryngectomy,
whereas the cricoid, hyoid, and at least one functional
arytenoid must be preserved for SCPL (Fig. 47-4).
Computed tomography (CT) has been demon-
strated to be an excellent aid in the identifi cation of
tumor extension to the paraglottic space (Fig. 47-5).
Extension of tumor anteriorly into the base of the
tongue is best identifi ed with magnetic resonance
imaging (MRI).
Evaluation of cervical metastases has traditionally
been accomplished by palpation. Imaging with either
CT or MRI is now generally agreed to be more sensitive
than physical examination. Nodes greater than 1 cm
and those with a hypodense center should be consid-
ered highly suspicious for metastatic cancer. Appropri-
ate treatment of the neck should be integrated with the
plan for treatment of the primary cancer. In our depart-
ment, this requires concurrent bilateral neck dissection
in most patients.
We previously reviewed and reported observations
made in a series of 202 patients treated for squamous
cell carcinoma of the supraglottic larynx.14 At the time
of the review, patients with carcinoma of the supraglot-
Figure 47-3. The paraglottic space (shaded area) describes the sub-
mucosal soft tissue of the larynx contained by the thyroid cartilage
externally. Tumor of the supraglottic larynx may spread submucosally
through the paraglottic space. If tumor extends across the plane of
the true vocal cord, as demonstrated in this illustration, supraglottic
laryngectomy would be contraindicated because one would cut across
tumor at the level of the vocal cord.
Figure 47-4. Maximal size of a transglottic tumor that can be
excised via supracricoid partial laryngectomy. Note that only minimal
involvement of the preepiglottic space is permitted. (Redrawn from
Pearson BW, Donald PJ: Larynx. In Donald P [ed]: Head and Neck Cancer:
Management of the Diffi cult Case. Philadelphia, WB Saunders, 1984,
pp 93-148.)

Chapter 47
Horizontal Partial Laryngectomy
397
tic larynx were routinely treated by resection of the
primary tumor (via either supraglottic laryngectomy or
total laryngectomy as indicated) and ipsilateral modi-
fi ed radical neck dissection on the side of predominant
cancer involvement. Postoperative radiation therapy
was frequently administered to patients with evidence
of ipsilateral metastases. The contralateral (unoper-
ated) side of the neck was the most common site of
failure. This observation was similar for patients with
epiglottic (midline) lesions and those with aryepiglottic
fold and false vocal cord (lateral) lesions. When neck
dissection demonstrated histologic evidence of cervical
metastasis in the ipsilateral neck, the recurrence rate in
the contralateral neck was 26%, as opposed to a recur-
rence rate of 13% when no metastases were identifi ed
in the ipsilateral neck. Overall, recurrence manifested
by tumor in the contralateral (unoperated) neck was
observed in 16% of patients treated by surgery on the
ipsilateral neck and postoperative radiation therapy
and in 19% of patients treated by surgery on the
ipsilateral neck only.
Because of these observations, we now recommend
routine bilateral neck dissection in all patients with
squamous cell carcinoma of the supraglottic larynx,
including patients treated by endoscopic resection, as
well as those treated by either partial or total laryngec-
tomy. The site of the lesion (lateral versus midline)
does not change this recommendation. When preop-
erative assessment demonstrates no evidence of cervical
metastasis, bilateral selective neck dissection with
removal of lymph nodes from zones II, III, and IV is
appropriate. Whether to dissect level IIB is a current
area of investigation.
When preoperative assessment indicates cervical
adenopathy, concurrent bilateral neck dissection is per-
formed. In these circumstances we prefer to modify one
neck dissection to preserve the internal jugular vein if
possible. An alternative to preservation of the internal
jugular vein is reconstruction of this vein with a saphe-
nous vein bypass graft. We have not found this necessary
inasmuch as nodes less than 3 cm can routinely be dis-
sected free of the carotid sheath with an adequate
margin. When no cervical adenopathy is present, selec-
tive neck dissection is performed.
The parameters by which the patient’s underlying
cardiopulmonary reserve is to be estimated remain con-
tentious. Arterial blood gas analysis and pulmonary spi-
rometry serve as rough estimates of underlying chronic
obstructive pulmonary disease, but there is no known
objectively defi ned parameter with which to select
A
B
C
D
Figures 47-5. A, Axial computed
tomography scan demonstrating
tumor in the paraglottic space dis-
placing the true vocal cords toward
the midline. The air within the
piriform sinus on the normal side
(arrow) is absent on the involved
side. Involvement of the mucosa of
the true vocal cords cannot be
ruled out on this scan. B, Involve-
ment of the arytenoid and the piri-
form sinus (arrows) by tumor is a
contraindication to supraglottic
laryngectomy. C, This laryngec-
tomy specimen was imaged in
the coronal plane. A supraglottic
tumor with extension medial to
the true vocal cord in the paraglot-
tic space is demonstrated (arrow).
D, Carcinoma extending lateral to
the true vocal cord in the paraglot-
tic space (arrow) is displayed on
this coronal image.

398
Section 3
Larynx
patients for supraglottic laryngectomy. Probably the
most accurate predictor of pulmonary function is the
individual patient’s history of exercise tolerance. A
patient who is unable to walk up two fl ights of stairs
should be considered a poor candidate for supraglottic
laryngectomy. Bedridden persons affl icted with carci-
noma of the supraglottic larynx should not be offered
supraglottic laryngectomy. Similarly, patients unable to
ambulate because of advanced degenerative joint
disease or lower extremity fractures should be consid-
ered poor candidates for supraglottic laryngectomy.
This refl ects the clinical observation that every patient
undergoing horizontal partial laryngectomy can be
expected to aspirate. Such aspiration can be partially
controlled through a cuffed tracheotomy tube, aggres-
sive pulmonary physiotherapy, and a highly skilled
and energetic nursing staff. The ability to cough
and ambulate cannot be underestimated in the suc-
cessful convalescence of these patients. Similarly,
advanced age, in and of itself, is not an absolute con-
traindication to supraglottic laryngectomy, although in
general, patients older than 65 years, even when in
reasonably good health, often do not adapt well to this
surgery.
A relative contraindication to horizontal partial lar-
yngectomy is the planned use of high-dose postopera-
tive radiation therapy after bilateral radical or modifi ed
radical neck dissection. Accordingly, patients with
obvious advanced bilateral cervical metastases who
require bilateral radical or modifi ed neck dissection
may be poor candidates for voice-sparing surgery
because the combination of horizontal laryngectomy
with bilateral radical or modifi ed neck dissection and
postoperative radiation therapy frequently results in
severe, incapacitating edema of the residual arytenoid
mucosa and an incompetent glottis. This complication
may be avoided, however, by communicating to the
radiation oncologist the need to irradiate the neck
metastasis only, thus sparing the remaining laryngeal
structures. Conversely, patients discovered to have his-
tologic evidence of cervical metastasis after selective
neck dissection seem to tolerate postoperative radiation
therapy reasonably well when histologic fi ndings indi-
cate that radiation therapy is necessary.
Either supraglottic laryngectomy or SCPL may be
accomplished in patients who have failed previous treat-
ment with full-course radiation therapy. Voice-sparing
procedures in this setting, however, increase the risk for
postoperative complications and recurrent disease.
Before undertaking partial laryngectomy in a patient
who has previously undergone radiation therapy, the
surgeon must be doubly aware that submucosal spread
of cancer beyond the confi nes of the planned proce-
dure is an absolute contraindication to supraglottic lar-
yngectomy. Clinical examination may be inadequate for
this task inasmuch as recurrent cancer is frequently
submucosal. CT or MRI may detect spread of tumor to
the paraglottic space or involvement of the thyroid or
cricoid cartilage. The routine use of frozen section
for control of surgical margins is mandatory. Post-
operatively, the risk for wound dehiscence and fi stula
formation is somewhat increased because of the radia-
tion-induced fi brosis, reduced resistance to bacterial
inoculation, and prolonged wound healing. We perform
supraglottic laryngectomy selectively in patients with dis-
crete, well-defi ned lesions of the supraglottic larynx
who have failed previous radiation therapy or in patients
in whom previous radiation therapy has been used for
control of other primary tumors and supraglottic carci-
noma ensued as a metachronous primary tumor.
Although others have reported successful performance
of SCPL in patents who have failed radiation therapy,
one must also consider total laryngectomy in such cases
because of the risk for unrecognized submucosal spread
beyond the surgical margins.
Patients must be counseled that if at the time of
surgery the cancer is found to be more extensive than
was thought, total laryngectomy may be necessary. The
consent form signed by the patient should include per-
mission for a possible total laryngectomy, at which time
a primary tracheoesophageal puncture is carried out
for vocal rehabilitation.
SUPRAGLOTTIC LARYNGECTOMY
SURGICAL APPROACH
Supraglottic laryngectomy is always performed with the
patient under general anesthesia (Table 47-2). Trache-
otomy may be accomplished before the initiation of
supraglottic laryngectomy. It is important to note that
a preliminary tracheotomy is not performed before
SCPL because the trachea is pulled up into the neck for
closure and the position of the tracheostomy will be
altered if performed preoperatively. We prefer to under-
take horizontal partial laryngectomy through a large,
superiorly based apron fl ap, which facilitates conver-
sion to total laryngectomy should intraoperative fi nd-
ings mandate conversion and also accommodates the
bilateral neck dissections usually performed before
partial laryngectomy (Fig. 47-6).
The hyoid bone is skeletonized superiorly unless
preoperative evidence of involvement of the tongue
base or preepiglottic space is apparent, in which case a
margin of the musculature of the tongue base must be
included with the specimen. The infrahyoid strap
muscles are released from the hyoid bone (Fig. 47-7).
When a tumor is confi ned to the supraglottic larynx
with no evidence of deep penetration into the preepi-
glottic space, these muscles may be released approxi-
mately 1 cm inferior to their attachment to the hyoid
bone. However, if preoperative assessment indicates
extensive erosion into the preepiglottic space or tongue
base, the strap muscles may be released at the level of
the superior aspect of the thyroid cartilage. Note that
when SCPL is planned, the initial steps of the proce-
dure are altered in that the hyoid bone is not skeleton-
ized and the muscles are transected at the superior
edge of the thyroid bone.
The external perichondrium of the thyroid carti-
lage is incised along the superior border of the thyroid

Chapter 47
Horizontal Partial Laryngectomy
399
Table 47-2
STEPS IN SUPRAGLOTTIC
LARYNGECTOMY
Tracheotomy
Apron fl ap
Neck dissections
Free the hyoid
Transect the infrahyoid strap muscles
Incise the perichondrium along the superior edge of the
thyroid cartilage
Elevate the perichondrium
Mark and cut the thyroid cartilage
Expose the epiglottis (if the lingual surface of the
epiglottis is free)
Open the vallecula
Cut across the aryepiglottic fold
Do not cut the vocal cords!
Connect the endolaryngeal cut to the cartilage cut
Do not disrupt the attachment of the anterior
commissure to the thyroid cartilage
Remove the specimen and examine
Frozen sections as required
Cricopharyngeal myotomy?
Place sutures from the perichondrium/thyroid cartilage
to the tongue base
Offset the tongue base. Do not suture to the tongue
mucosa!
With tension relieved, tie the sutures fi rmly
Close the lateral aspects of the pharyngotomy
Irrigate, place drains, and close the apron fl ap
Separate the tracheostomy site from the wound.
cartilage and refl ected inferiorly as an intact sheet to
preserve its inferior attachment to the thyroid cartilage
in anticipation of using this tissue for reconstruction
(Fig. 47-8).
The greater cornu of the hyoid bone is skeletonized
bilaterally. Care is taken to preserve the integrity of the
hypoglossal nerve, which is found in close proximity to
the greater cornu of the hyoid bone as it courses under
the posterior belly of the digastric muscle. Injury to
one or both nerves effectively makes rehabilitation of
deglutition impossible.
The thyroid cartilage is divided horizontally,
approximately midway between the thyroid notch supe-
riorly and the lower border of the thyroid cartilage
inferiorly, with either a scalpel or an oscillating saw.
This cartilage cut may be carried superiorly as it extends
laterally to allow preservation of the greater cornu of
the thyroid cartilage on the side away from the lesion
(Fig. 47-9). The superior constrictor is separated from
the lateral aspect of the thyroid cartilage bilaterally if
the superior cornu is to be resected.
Figure 47-6. Supraglottic laryngectomy can be accomplished
through a superiorly based apron fl ap. The inferior aspect of the fl ap
should not be extended past the midclavicular line because subse-
quent ischemia may be associated with wound dehiscence.
Figure 47-7. After performance of the necessary neck dissection,
supraglottic laryngectomy begins with division of the infrahyoid strap
muscles to expose the thyroid cartilage.

400
Section 3
Larynx
Mucosal incisions are carried laterally along the
aryepiglottic fold and then directly through the aryepi-
glottic fold just anterior to the arytenoid. The mucosal
cuts are extended through the laryngeal ventricle and
through the thyroid cartilage incisions bilaterally to
complete the supraglottic laryngectomy (Fig. 47-10).
This procedure is facilitated by asking the anesthesiolo-
gist to paralyze the patient, thereby allowing full abduc-
tion of the vocal cords. All supraglottic soft tissue must
be excised. Although it is tempting, for example, to
preserve the contralateral false vocal cord in a patient
with a unilateral false vocal cord lesion, doing so results
in persistent edema of this structure with airway
obstruction.
The specimen should be evaluated by the operating
surgeon. Questionable margins can be assessed histo-
logically with frozen section (Fig. 47-11).
Performance of cricopharyngeal myotomy after
supraglottic laryngectomy has been thought to facilitate
swallowing postoperatively. Not all surgeons agree,
however. Our observations suggest that myotomy is not
required.
Before reconstruction, hemostasis must be ensured.
This is especially important along the free edge of the
tongue base inasmuch as mucosa-to-mucosa reapproxi-
mation is not recommended. Accordingly, bleeding
along the mucosal margin and adjacent tongue muscu-
Figure 47-8. The external perichondrium of the thyroid cartilage
is incised along its superior insertion and refl ected intact as an
inferiorly based fl ap.
Figure 47-9. With an oscillating saw the surgeon cuts the cartilage
midway between the thyroid notch superiorly and the inferior border
of the thyroid cartilage in the midline. The cartilage incision is carried
horizontally to include the greater cornu of the thyroid cartilage on
the side of the lesion. The greater cornu may be preserved on the
side contralateral to the lesion or may be excised according to the
judgment of the surgeon.
If the tumor is confi ned to the supraglottic larynx,
the pharynx can be entered in the vallecula. This allows
the epiglottis to be grasped and the subsequent maneu-
vers to be performed under direct visualization, which
ensures adequate tumor margins of resection and pres-
ervation of normal structures. When tumor involves the
vallecula or tongue base, the pharynx should be entered
in the contralateral piriform sinus, once again affording
the operator direct visualization of the cancer as it is
excised.
Figure 47-10. Mucosal cuts in the larynx are made under direct
visualization. Inferiorly, the cut is made directly through the ventricle
at the level of the true vocal cord. Posteriorly, the mucosal incision
is made across the face of the arytenoid unless extension of tumor
requires an extended procedure.

Chapter 47
Horizontal Partial Laryngectomy
401
lature must be controlled with suture ligatures and
electrocautery.
Reconstruction of this wound requires approxima-
tion of the base of the tongue to the glottic larynx,
which must be accomplished in a manner that mini-
mizes aspiration. Anteriorly, the preserved external
perichondrium of the thyroid cartilage is approximated
to the tongue base with 2-0 nonabsorbable suture.
Sutures in the tongue base should be 12 to 15 mm deep
to the mucosa in the yellow aponeurotic layer of the
tongue (Fig. 47-12). These sutures are laid in at 8- to
10-mm intervals from side to side without tying them
(Fig. 47-13). More laterally, the mucosa of the piriform
sinus can be closed directly to the lateral aspects of the
tongue base. At this point the sutures can be tied
sequentially as an assistant helps relieve tension by
simultaneously drawing down the adjacent suture while
the surgeon ties each succeeding knot. Placing the
patient’s head in fl exion also minimizes tension on the
tissues and facilitates closure. When the external peri-
chondrium of the thyroid cartilage is found to be inad-
equate for this task, the sutures may be passed directly
through drill holes in the superior edge of the residual
thyroid cartilage. These sutures should not include
mucosa or a vocal cord.
This initial layer of closure is then reinforced by
approximating the suprahyoid musculature to the infra-
hyoid strap muscles. The wound is copiously irrigated,
and suction drains are inserted and brought out percu-
taneously through separate stab wounds. Care is taken
to isolate the tracheostoma from the wound by tacking
the skin fl ap to the strap muscle circumferentially
around the superior aspect of the tracheostomy (Fig.
47-14). The skin is closed in layers. We prefer to use a
bulky compressive dressing.
When tumor extends to involve the anterior surface
of the arytenoid cartilage, the dissection must be
extended to resect the arytenoid cartilage in continuity
with the supraglottic laryngectomy. Extended supra-
glottic laryngectomy requires that the free edge of the
ipsilateral membranous vocal cord be approximated in
the midline to the cricoid cartilage postoperatively.
Medialization of the vocal cord is required, however, to
avoid intractable postoperative aspiration as a result of
the removal of arytenoid cartilage. This procedure
results in moderate compromise of the laryngeal airway,
which is not symptomatically perceived by most patients.
Patients requiring extended supraglottic laryngectomy
must have outstanding pulmonary reserve inasmuch as
the potential for postoperative aspiration is increased
Figure 47-11. After supraglottic laryngectomy, the specimen is
carefully inspected. Frozen sections of close margin in the paraglottic
space are routinely taken.
Figure 47-12. The external perichondrium of the thyroid cartilage
is reapproximated to the fi broaponeurotic layer of the tongue base.
This sets the tongue back over the glottis.
Figure 47-13. Schematic drawing demonstrating how the fi broapo-
neurotic layer has been approximated to the external perichondrium
as viewed from the laryngeal side. The surgeon would not be able to
see this view while operating.

402
Section 3
Larynx
and convalescence invariably takes longer. In general,
elderly patients and those with compromised cardiopul-
monary status are poor candidates for extended supra-
glottic laryngectomy.
POSTOPERATIVE MANAGEMENT
Patients are managed in an acute care setting by a pro-
fessional staff expert in wound care and airway manage-
ment. We routinely perform percutaneous oximetry to
augment visual assessment of these patients. Cardiac
monitoring is used in the early postoperative course.
Drainage from the wound is measured every 8
hours, and the drains are aspirated to ensure patency.
The expected “normal” volume of serosanguineous
fl uid after supraglottic laryngectomy is directly related
to the extent of the neck dissections performed in asso-
ciation with the supraglottic laryngectomy. It is common
to encounter 150 mL of drainage in the fi rst 24 hours,
although much more drainage routinely occurs in
patients after bilateral neck dissection, especially when
they have previously undergone radiation therapy.
Drains are maintained until the total daily drainage
is below 15 mL/24 hr, at which time they may be
removed.
The nasogastric tube is maintained on wall suction
until gastrointestinal function is ensured through
resumption of bowel sounds. At this point, feeding
through the nasogastric tube is introduced. Water
should be administered initially, followed by half-
strength feeding solutions and advancing as appropri-
ate to full-strength solutions. Postoperative emesis must
be avoided because it may disrupt the laryngeal recon-
struction. Emesis can be prevented by adequate gastric
decompression, avoidance of inappropriate feeding,
and administration of antiemetics when necessary.
The tracheotomy is used for pulmonary toilet.
Humidifi ed air is routinely administered through a tra-
cheotomy mask, with supplemental oxygen as needed.
A tracheotomy tube with a low-pressure cuff is infl ated.
Early postoperative aspiration may be minimal and is
often attributable to extensive postoperative edema
of the vocal cords. As the edema begins to resolve,
increased aspiration, manifested by coughing and
choking, may be anticipated. As the patient accommo-
dates to the surgery (postoperative days 6 to 10), the
tracheotomy tube cuff may be defl ated and the patient
observed. If aspiration is evident, the tracheotomy cuff
must once again be reinfl ated. If the patient tolerates
cuff defl ation, we change the tracheotomy tube to a no.
4 uncuffed model and observe the patient overnight. If
the patient tolerates an uncuffed tracheotomy tube
during sleep and periods of recumbency, the tube is
plugged with a solid obturator and the patient is
observed for adequacy of the airway. If the plugged tube
is tolerated overnight, the patient is decannulated and
the tracheotomy site allowed to heal before initiating
oral feeding (postoperative days 12 to 14). This allows
the adduction refl exes of the larynx to recover.
Oral feeding is initially attempted under supervi-
sion by trained, professional personnel, which can be
the physician, the nurse, or an interested speech pathol-
ogist. The so-called supraglottic swallow is explained,
demonstrated, and taught to the patient. After taking a
breath, the patient closes the glottis with the Valsalva
maneuver, swallows, and coughs again before inspira-
tion. The use of nonpourable puréed food is recom-
mended inasmuch as clear liquids are far more diffi cult
to handle and far more likely to promote aspiration.
Supraglottic swallow is facilitated by removal of the
nasogastric tube. When patients are successfully ingest-
ing an oral diet of nonpourable purées, they may be
discharged and allowed to advance the diet as tolerated
at home (postoperative days 14 to 17).
A
B
Figures 47-14. A, At the completion of the procedure, the trache-
otomy site must be isolated from the potential dead space created
through fl ap elevation and neck dissection. B, Failure to isolate the
tracheotomy from the potential space created by the neck dissection
may result in transmission of contaminated mucus from the trachea
underneath the cervical fl ap and subsequent wound infection.
PEARLS
• Supraglottic laryngectomy is ideally suited to the
management of squamous cell carcinoma limited to
the supraglottic larynx in patients with adequate
cardiopulmonary reserve.
• Great care should be taken in mobilizing the
external perichondrium of the thyroid cartilage. The
thyroid cartilage is generally divided with a saw. The
saw cut should ordinarily be made midway between
the lower margin of the thyroid cartilage and the

Chapter 47
Horizontal Partial Laryngectomy
403
would require total laryngectomy as the minimal surgi-
cal procedure. Larger supraglottic cancers that cross
the anterior commissure and involve the vocal cords are
also amenable to a modifi cation of this procedure in
which the entire epiglottis is resected with the speci-
men. At least one cricoarytenoid unit must be spared.
It is intuitive that if surgical extirpation of the tumor
requires removal of the entire epiglottis or an arytenoid
(or both), postoperative recovery and rehabilitation will
be proportionately compromised.
PREOPERATIVE EVALUATION
Flexible fi beroptic laryngoscopy, rigid endoscopic eval-
uation, and modern imaging are all performed to accu-
rately stage the extent of tumor involvement. Invasion
of the thyroid cartilage at the anterior commissure can
be determined with thin-section CT.18 Tumors judged
suitable for SCPL may be treated surgically if the patient
has adequate pulmonary reserve to tolerate aspiration
in the fi rst several weeks after surgery. Patients with
compromised pulmonary function should be offered
alternative therapy.
SURGICAL APPROACH
The steps in the procedure are presented in Table
47-3.
A preliminary tracheotomy is not performed because
a tracheostomy will be created after the trachea has
been bluntly dissected within the anterior mediastinum
and retracted into the neck.19 An apron fl ap is raised
and the neck dissections are carried out. The strap
muscles are divided at the superior aspect of the thyroid
cartilage and tagged with Vicryl sutures for reapproxi-
mation as a second layer of closure over the impacted
CHP/CHEP. The perichondrium is elevated from the
thyroid cartilage and rotated, and the pharyngeal con-
strictor muscles are incised along the posterior margin
of the cartilage (Fig. 48-15). Care is taken to preserve
the superior laryngeal nerve. The piriform sinus mucosa
is then elevated from the medial aspect of the thyroid
ala. The cricothyroid joint is disarticulated while being
careful to avoid the recurrent laryngeal nerve just pos-
terior to the joint. This maneuver is facilitated by excis-
ing and elevating the perichondrium from the lateral
surface of the inferior cornu and incising the joint
capsule from the anterior side. This preserves the func-
tion of the cricoarytenoid unit. The joint capsule is
incised and the cricothyroid joints are disarticulated via
an anteromedial vector with care taken to avoid injury
to the recurrent laryngeal nerve (Fig. 47-16).
A cricothyroidotomy is performed and the endotra-
cheal tube is inserted. Any subglottic extent is viewed
directly at this point. The thyrohyoid membrane is
incised and the preepiglottic space entered. Care is
taken to remain inferior to the entry of the superior
laryngeal nerve. At this point the procedure varies
according to whether the superior portion of the epi-
glottis is to be removed or preserved. If the tumor
involves only the true vocal cord and petiole, the lumen
thyroid notch. The thyrotomy must be made just
above the anterior commissure. Accordingly, the
saw cut may be slightly above the midline in
females, in whom the attachment of the anterior
commissure is slightly superior to that in males.
• Before closing the wound, hemostasis must be
ensured, especially along the cut mucosa of the
tongue base and adjacent musculature. Hemostasis
can best be accomplished through the liberal use of
suture ligatures along the tongue base.
• The mucosa of the tongue base must not be
approximated to the glottic larynx. The tongue base
must be “set back” over the larynx by suturing the
thyroid perichondrium to the fi brofatty aponeurosis
of the tongue 12 to 15 mm deep to the mucosa.
This serves as a watershed, which in turn helps
reduce postoperative aspiration.
PITFALLS
• Supraglottic laryngectomy compromises deglutition
and promotes aspiration. We recommend that the
patient be decannulated and the tracheotomy site
closed before initiating oral feeding.
• Intractable aspiration after supraglottic
laryngectomy is a potentially life-threatening
situation. It is never encountered when a procedure
is properly performed on an appropriately selected
patient. Intractable aspiration may require
completion laryngectomy.
• Recurrence in the unoperated part of the neck
infl uences outcome. All patients with cancer of the
supraglottic larynx undergo bilateral neck dissection.
SUPRACRICOID PARTIAL
LARYNGECTOMY WITH
CRICOHYOIDOEPIGLOTTOPEXY
Cancer that involves the pedicle of the epiglottis may
extend to involve the anterior commissure and true
vocal cords as well. These patients can be successfully
treated by SCPL that includes resection of the entire
thyroid cartilage, true vocal cords, and a portion of the
epiglottis. Glottic cancers that involve both membra-
nous vocal cords and are too large for standard fronto-
lateral hemilaryngectomy have often been reconstructed
by epiglottopexy in the past. In most instances, horizon-
tal SCPL results in superior laryngeal function than that
achievable by extended frontolateral hemilaryngectomy
with epiglottopexy.
Exclusion criteria are cancers that extend greater
than 10 mm below the level of the ventricles, cancers
that involve the cricoid cartilage or hyoid bone, and
cancers that extend posteriorly to involve both aryte-
noids. Patients with this kind of cancer involvement

404
Section 3
Larynx
Table 47-3
STEPS IN SUPRACRICOID PARTIAL
LARYNGECTOMY WITH
CRICOHYOIDOEPIGLOTTOPEXY
Percutaneous endoscopic gastrostomy or nasogastric
tube?
Apron fl ap
Neck dissections if indicated
Cut the strap muscles on the thyroid cartilage
Cut the constrictor muscles, free the piriform mucosa
from the thyroid undersurface
Cut and disarticulate the cricothyroid joint
Cricothyroidotomy—insert the tube
Infrahyoid laryngotomy
Divide the epiglottis above petiole
Separate the vocal cord from the arytenoid
Crack the thyroid cartilage open
Complete the resection
Resect the arytenoid if the vocal cord is fi xed
Fix the arytenoids anteriorly with suture(s)
Pass three sutures, 1 cm apart
Mobilize the trachea (stay anterior with fi nger
dissection!), pull up
Place the tracheotomy, move the endotracheal tube to
the appropriate level
Tie the sutures
Close the inferior constrictor/piriform mucosa anteriorly
Close the strap muscles
Bring the tracheostomy through the incision
Separate the tracheostomy site from the remainder of
the wound
is entered via a transverse incision through the infrahy-
oid epiglottis (Fig. 47-17). If the entire epiglottis is to
be removed, dissection is carried superiorly and the
lumen entered via the vallecula. If there is extensive
tumor in the preepiglottic space or vallecula, the patient
is not a proper candidate for SCPL because the hyoid
bone cannot be preserved. The tumor is visualized from
above, and resection of the cancer begins by transecting
the uninvolved vocal cord just anterior to the vocal
process of the arytenoids (Fig. 47-18). It is critical that
the entire vocal cord be resected, even if not involved
with cancer, because leaving it attached will impair ary-
tenoid mobility. The incision is extended inferiorly with
curved scissors to connect with the cricothyroidotomy
along the superior aspect of the cricoid cartilage while
being careful to remain anterior to the path of the
recurrent laryngeal nerve. This frees the more unin-
volved side of the thyroid cartilage so that it can be
cracked anteriorly to open the larynx like a book for
visualization of the endolarynx, vocal cords, and tumor
margins. The involved vocal cord is resected, and if
Figure 47-15. The strap muscles and pharyngeal constrictor
muscles are cut. Care is taken to avoid the superior laryngeal nerve.
(Reprinted with permission from Weinstein G, Laccourreye O, Brasnu D,
Laccourreye H: Organ Preservation Surgery for Laryngeal Cancer. San Diego,
CA, Singular, 2000, p 80.)
Figure 47-16. After the joint capsule is incised, the cricothyroid
joint is disarticulated with care taken to avoid injury to the recurrent
laryngeal nerve. (Reprinted with permission from Weinstein G, Laccourreye
O, Brasnu D, Laccourreye H: Organ Preservation Surgery for Laryngeal
Cancer. San Diego, CA, Singular, 2000, p 81.)

Chapter 47
Horizontal Partial Laryngectomy
405
fi xed, the arytenoid is resected as well (Fig. 47-19).
Partial removal of arytenoid cartilage is possible, but
mucosal covering must be restored with Vicryl sutures.
Freed of the tethering effect of the true vocal cords,
the arytenoid or arytenoids will be pulled posteriorly by
the unopposed tension of the posterior cricoarytenoid
muscle. Correct arytenoid position is maintained by
one or more sutures placed from the arytenoids to the
midcricoid. This suture is an “air knot” and is tied so
that the arytenoids are pulled anteriorly to facilitate
swallowing by “opening” the postcricoid space (Fig.
48-20). This suture is needed only until fi brosis forms
to maintain the arytenoids in the erect position.
The key step in this horizontal partial laryngectomy
procedure is impaction of the hyoid bone to the cricoid
cartilage with three carefully placed sutures. Before
pulling up the cricoid, however, the trachea must be
freed by fi nger dissection along the anterior wall into
the superior mediastinum. After retraction of the
trachea superiorly, the tracheotomy is then created,
usually around the fourth or fi fth ring. Note that a tra-
cheotomy was not performed earlier because the proper
position cannot be determined until the trachea is
pulled up. Three large sutures (1-Ovicryl) on long
curved needles are placed submucosally around the
cricoid cartilage and hyoid bone while picking up the
epiglottic cartilage (if the epiglottis remains in situ) and
Figure 47-17. A cricothyroidotomy is performed and the endotra-
cheal tube is inserted. The thyrohyoid membrane is incised while
being careful to remain inferior to the entry of the superior laryngeal
nerve. The lumen is entered via a transverse cut through the infrahy-
oid epiglottis. (Reprinted with permission from Weinstein G, Laccourreye O,
Brasnu D, Laccourreye H: Organ Preservation Surgery for Laryngeal Cancer.
San Diego, CA, Singular, 2000, p 82.)
Figure 47-18. The tumor is visualized superiorly and the epiglottis
is transected just above the petiole. The uninvolved vocal cords are
freed from the arytenoid. It is important that the entire thyroaryte-
noid muscle be removed, even if not involved with tumor, to facilitate
mobility of the arytenoids. (Reprinted with permission from Weinstein G,
Laccourreye O, Brasnu D, Laccourreye H: Organ Preservation Surgery for
Laryngeal Cancer. San Diego, CA, Singular, 2000, p 82.)
Figure 47-19. The thyroid ala is cracked open along the anterior
midline and tumor resection is accomplished. If the involved vocal
cord is fi xed, the arytenoid must be resected as well. (Reprinted with
permission from Weinstein G, Laccourreye O, Brasnu D, Laccourreye H:
Organ Preservation Surgery for Laryngeal Cancer. San Diego, CA, Singular,
2000, p 83.)

406
Section 3
Larynx
Figure 47-20. The remaining ary-
tenoid or arytenoids are tethered
anteriorly with a suture or sutures to
counter the posterior pull of the
posterior
cricoarytenoid
muscle.
(Reprinted with permission from Wein-
stein G, Laccourreye O, Brasnu D, Lac-
courreye H: Organ Preservation Surgery
for Laryngeal Cancer. San Diego, CA,
Singular, 2000, p 83.)
several centimeters of tongue base in the process (Fig.
47-21A and B). Each suture is separated by 1 cm. With
tension relieved by retraction, the sutures are tied
tightly.
The net result of these impacting sutures is shorten-
ing of the larynx in a superior-to-inferior direction,
which essentially obliterates the space previously fi lled
by the thyroid cartilage, true vocal cords, and the para-
glottic spaces (Fig. 47-22). Loose 4-0 Vicryl sutures are
placed through each piriform mucosal remnant and
tied anteriorly to tighten these structures so that pooling
of secretions and swallowed material is avoided. Closure
is completed by closing the inferior constrictors and
strap muscles. Skin closure is similar to that for other
partial laryngectomy procedures, with particular care
taken to ensure that the tracheostomy site is separated
from the remainder of the surgical wound.
POSTOPERATIVE CARE
Dysphagia with aspiration secondary to valvular dys-
function of the larynx is the most signifi cant postopera-
tive diffi culty encountered. Laccourreye and colleagues’
initial report noted that nearly all their patients were
able to swallow within 6 months,1 and more recent
reports note that most patients are able to resume a
normal diet by 4 weeks.2 A nasogastric or percutaneous
endoscopic gastrostomy (PEG) feeding tube is required,
and many surgeons routinely place a PEG tube because
of the prolonged postoperative recovery period. Post-
operative care is similar to that for supraglottic laryn-
gectomy in that swallowing typically remains more
of a problem than airway function for a longer period.
Swallowing function may be greatly enhanced after
decannulation; nonetheless, recovery requires weeks,
not days. The patient is instructed to expectorate
saliva into a basin for 3 to 5 days as physical therapy/
rehabilitation.
PEARLS
• Supracricoid partial laryngectomy is a procedure
that extends the indications for partial
laryngectomy, but it carries with it a longer recovery
period than other forms of laryngeal conservation
surgery do. It does not replace supraglottic
laryngectomy or vertical hemilaryngectomy but
should be viewed as an alternative to total
laryngectomy in some patients whose tumors
extend beyond the more traditional forms of
partial laryngectomy.
• Patients who are candidates for supracricoid partial
laryngectomy must be highly motivated to keep their
larynges. Selection should be based not only on
patients’ overall medical status and tumor
characteristics but also on their psychological well-
being and motivation. They must understand that
1 or more months may pass before they can be
decannulated and begin to eat. Extending the
indications for supracricoid partial laryngectomy
will extend the recovery period, and patients must
understand and accept this procedure as a less than
perfect alternative to total laryngectomy.
PITFALLS
• Supracricoid partial laryngectomy, like other forms
of conservation laryngectomy, is extremely detail
oriented. Both the superior and recurrent laryngeal
nerves must be preserved, as well as the cricoid
cartilage and hyoid bone. Excess true vocal cord
tissue must not be left attached to the vocal
processes of the arytenoids. The impaction sutures

Chapter 47
Horizontal Partial Laryngectomy
407
A
B
1
2
3
4
5
Figures 47-21. A and B, Impaction sutures are placed after the trachea is freed from the mediastinum with fi nger dissection anteriorly, and
the tracheotomy is created at the expected level of the skin incision. Three large (no. 1) polyglycolic acid sutures are placed submucosally
around the cricoid, through the epiglottis (if present), around the hyoid, and approximately 2 cm into the tongue base. Care is taken to avoid
injury to the hypoglossal nerves or lingual arteries. (Reprinted with permission from Weinstein G, Laccourreye O, Brasnu D, Laccourreye H: Organ Pres-
ervation Surgery for Laryngeal Cancer. San Diego, CA, Singular, 2000, p 84.)
Figure 47-22. The impaction
sutures are tied tightly so that they
approximate the cricoid complex
to the hyoid bone. Care is taken to
ensure adequate impaction and
that the space previously taken by
the thyroid cartilage and thyrohy-
oid membrane is obliterated.
(Reprinted with permission from Pinel
J, Cachin Y, Laccourreye H [eds]:
Cancers du Larynx [Indications,
Thérapeutiques,
Résultats].
Paris,
Librairie Arnette, SFORL, 1980.)

408
Section 3
Larynx
SURGICAL APPROACH
The patient is prepared as for supraglottic laryngec-
tomy. The superiorly based apron fl ap is developed in
the subplatysmal plane. Bilateral simultaneous neck dis-
section is performed in most circumstances. The choice
of neck dissection refl ects preoperative evaluation of
the status of the cervical lymphatics. Patients with no
evidence of metastatic disease should undergo bilateral
selective neck dissection encompassing zones II, III,
and IV. Neck dissection requires careful removal of all
the fatty lymphatic aponeurosis adjacent and medial to
the carotid artery and jugular vein.
Tracheotomy is performed through the second or
third tracheal cartilage. The endotracheal tube is then
withdrawn and anesthesia continued through the
tracheotomy.
The suprahyoid musculature is released from the
hyoid bone, and the infrahyoid musculature is released
approximately 2 cm inferior to the hyoid bone. This
effects resection of the preepiglottic soft tissue en bloc.
The larynx should be entered in either the vallecula or
the piriform sinus contralateral to the side of the lesion.
Great care must be taken to preserve all useful mucosa
on the side contralateral to the lesion.
With the infrahyoid strap muscles refl ected inferi-
orly, the external perichondrium of the thyroid carti-
lage is incised along the superior aspect of the thyroid
cartilage and refl ected as an inferiorly based fl ap.
Cartilage cuts are made with either a scalpel or an
oscillating saw through the thyroid cartilage midway
between the inferior border of the cartilage and the
superior notch. Preservation of the superior cornu of
the thyroid cartilage on the side contralateral to the
lesion is appropriate, although the entire hemicartilage
must be removed on the side of the lesion.
As the pharynx is opened, incisions in the mucosa
are made under direct visualization. Scissors are placed
just anterior to the arytenoid, with one blade in the
ventricle and the other in the divided cartilage (Fig.
47-23). This incision is carried to the anterior commis-
sure. On the contralateral side, the incision is then
carried through the ventricle and again up anterior to
the arytenoid while preserving the arytenoid bilaterally.
Mucosal cuts are then extended to encompass the
medial, anterior, and lateral walls of the ipsilateral piri-
form sinus as indicated. A 1-cm margin of uninvolved
mucosa is considered the minimum, and frozen section
control is advised. Hemostasis is achieved with suture
ligatures and ties as indicated.
The deep margin of resection should include the
constrictor muscle that overlies the area of the lesion.
After resection is completed, all soft tissue between
the lesion and the great vessels should have been
removed.
Reconstruction is similar to that described after
supraglottic laryngectomy. The external perichondrium
of the thyroid cartilage is sutured to the deep fi broapo-
neurosis of the tongue base. This projects the cut
surface of the tongue over the residual vocal cords and
affords some form of watershed that tends to protect
must be placed accurately and tied tightly. If they
are improperly placed and tied, all three must be
removed and replaced.
• Performing the tracheotomy late in the procedure
after the trachea has been dissected free in the
anterior mediastinum separates the cricohyoid
impaction from the contaminated stoma. A previous
high tracheostomy with exposure of the cricoid
performed for airway compromise will impair
successful impaction, and another procedure
should be selected.
EXTENDED PROCEDURES:
PARTIAL
LARYNGOPHARYNGECTOMY
Tumors that involve the superior aspect of the piriform
sinus may be removed effectively by partial laryngophar-
yngectomy. This procedure, originally popularized by
Ogura, was designed to allow tumors of the aryepiglot-
tic fold to be completely removed while preserving
voice.16 The medial wall of the piriform sinus is, in fact,
the lateral wall of the aryepiglottic fold. Tumors that
spread to involve the anterior or even the anterior
lateral wall of the piriform sinus may be excised success-
fully with this technique. As a general rule, the use of
horizontal partial laryngectomy for other indications
may be expected to result in increased rehabilitative
diffi culty and the potential for local recurrence of
carcinoma.
Partial laryngopharyngectomy depends on the
observation that tumors involving the superior aspect
of the medial and anterior walls of the piriform sinus
are embryologically similar to carcinoma arising in the
supraglottic larynx and most commonly metastasize
through the hyothyroid membrane to the upper jugular
nodes. In-continuity resection may result in local
regional control.
Contraindications to partial laryngopharyngectomy
include involvement of the apex of the piriform sinus
because it is caudal to the plane of the laryngeal ven-
tricle. Accordingly, tumor may persist in the laryngeal
remnant after procedures performed for improper
indications.
Additionally, the surgeon must be aware of the
potential for submucosal spread, which is well docu-
mented in patients with cancer involving the hypophar-
ynx. Wide margins (>1 cm) with frozen section control
are prudent, and postoperative radiation therapy is
commonly recommended.
Similarly, patients with a deeply invasive cancer
involving the lateral wall of the piriform sinus may
exhibit direct extension into and through the constric-
tor muscle. This requires wide resection, probably best
accomplished by total laryngopharyngectomy.

Chapter 47
Horizontal Partial Laryngectomy
409
Figure 47-23. The supraglottis is separated from the glottis through
the ventricle on the side opposite the tumor.
PEARLS
• Supraglottic cancer that involves the anterior
commissure is effectively treated by supracricoid
resection.
• The patient’s ability to walk up two fl ights of stairs
without stopping reasonably predicts adequate
pulmonary function for partial laryngeal resection.
• Bilateral neck dissection is appropriate for all
patients undergoing surgery for supraglottic cancer.
• Excellent hemostasis along the tongue base should
be secured before closing the defect.
• Suction drains are always used.
the larynx from aspiration. Before closure, absolute
hemostasis of the tongue base must be ensured, which
is most effectively achieved with interrupted suture
ligatures.
Closure of the soft tissue of the piriform sinus
results in effacement of the ipsilateral piriform sinus.
The mucosa of the sinus has been removed; accord-
ingly, there will be a direct watershed into the
esophagus. Rehabilitation of swallowing after partial
laryngopharyngectomy is predictably more diffi cult and
requires greater cardiopulmonary reserve on the part
of the patient. Consequently, partial laryngopharyngec-
tomy is ill advised in patients with signifi cant chronic
obstructive lung disease. As a rule of thumb, we require
patients to demonstrate an active lifestyle and to be fully
ambulatory. One reasonable indication of cardiopul-
monary reserve is the ability to climb two fl ights of stairs
without stopping. Pulmonary function studies, such as
arterial blood gas analysis and spirometry, may be of
some help in estimating respiratory function, although
no guidelines based on objective fi ndings are available
to direct the surgeon in this important therapeutic
decision.
SPECIAL INSTRUCTIONS
Patients in whom cancer extends to involve the superior
surface of the arytenoid cartilage can be considered for
extended supraglottic laryngectomy. However, surgical
resection will require removal of the arytenoid. The
glottis must be reconstructed by approximating the free
edge of the involved vocal cord to the cricoid cartilage
posteriorly.
PITFALLS
• Tumor with greater than 10-mm subglottic extension
may fail conservation resection.
• Preepiglottic extension to involve the hyoid bone
may fail supracricoid resection.
• Approximation of the mucosa of the tongue base to
the true vocal folds may result in intractable
aspiration.
• Patients requiring postoperative radiation therapy
may suffer poorer function.
• Failure to administer antibiotic prophylaxis
perioperatively may result in wound infection.
References
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laryngectomy with cricohyoidopexy: A partial laryngeal proce-
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Laryngoscope 100:735-741, 1990.
2. Sparano A, Chernock R, Feldman M, et al: Extending the inferior
limits of supracricoid partial laryngectomy: A clinicopathological
correlation. Laryngoscope 115:297-300, 2005.
3. Makeieff M, Venegoni D, Mercante G, et al: Supracricoid partial
laryngectomies after failure of radiation therapy: Laryngoscope
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