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Vertical Partial Laryngectomy Treatment & Management

  • Author: Christopher Klem, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Feb 11, 2016
 

Medical Therapy

Radiotherapy is a well-established treatment for selected laryngeal carcinomas with good oncologic and functional results. Reported failure rates have averaged 9-37% in T1 and 25-45% in T2 lesions.[5] The use of chemotherapy in combination with radiotherapy for early laryngeal cancer remains an active area of research. In the context of advanced-stage disease (T3 or T4), multiple studies demonstrate a synergistic response. In addition, Laccourreye et al have proposed the use of chemotherapy alone as a definitive treatment for select glottic squamous cell carcinoma.

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Surgical Therapy

Because cure rates of surgical therapy equal those of radiotherapy, patient preference should play a large role in the selection of treatment modality.

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Preoperative Details

Inform patients that a temporary tracheotomy is likely required. Patients should also give consent for total laryngectomy in case the cancer is discovered to be understaged. This is especially important in salvage cases, as preoperative understaging occurs in approximately 50% of cases.[4]

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Intraoperative Details

Use a low collar incision. Place the tracheostomy through a separate horizontal incision below the collar incision. Attempt to keep the dissections separate. After developing subplatysmal flaps, expose the larynx by separating the strap muscles vertically in the midline and incising the external perichondrium in the midline and along the superior and inferior borders of the thyroid cartilage. This allows bilateral laterally based flaps to be created.

Cricothyroid entry during laryngofissure is depicted in the image below. Laryngofissure performed with an oscillating saw is also known as midline thyrotomy. This step is performed for all VPL procedures unless the anterior commissure is involved. In such cases, a central segment of thyroid cartilage is included in the resection by making parallel thyrotomy cuts on either side of the midline and preserving both lateral remnants or by making a cut on the contralateral side and removing the entire ipsilateral thyroid ala. Preservation of the ala is preferable for most reconstructions. See the image below.

Laryngofissure performed with an oscillating saw ( Laryngofissure performed with an oscillating saw (also known as midline thyrotomy). This step is performed for all vertical partial laryngectomy (VPL) procedures unless the anterior commissure is involved. In such cases, a central segment of thyroid cartilage is included in the resection by making parallel thyrotomy cuts on either side of the midline and preserving both lateral remnants or by making a cut on the contralateral side and removing the entire ipsilateral thyroid ala. Preservation of the ala is preferable for most reconstructions.

Confirm resection with adequate margins; intraoperative frozen sections with postoperative permanent sections are mandatory to confirm margins. The images below give more particulars about the intraoperative details.

Once laryngofissure is completed and incision in c Once laryngofissure is completed and incision in cricothyroid membrane is made, the vocal cords are inspected from below. If the anterior commissure is free, then the internal mucoperichondrium is divided at or near the anterior commissure, with a margin around the tumor of at least 3 mm. Then the entire vocal cord is resected.
For imbrication laryngoplasty, the cordectomy is p For imbrication laryngoplasty, the cordectomy is performed by excising a segment of thyroid cartilage adjacent to the vocal cord. Care is taken to preserve an inferior strut of thyroid cartilage that is intact and approximately 1 cm in height.

Once the laryngofissure is completed and the incision in the cricothyroid membrane made, the vocal cords are inspected from below. If the anterior commissure is disease free, the internal mucoperichondrium is divided at or near the anterior commissure, with a margin around the tumor of at least 3 mm. The entire vocal cord is then resected. For imbrication laryngoplasty, the cordectomy is performed by excising a segment of thyroid cartilage adjacent to the vocal cord. Take care to preserve an intact inferior strut of thyroid cartilage that is approximately 1 cm in height.

View reconstruction details within the images below for imbrication laryngoplasty. The simplest reconstruction after the laryngofissure and cordectomy is to suture the false vocal cord to the infraglottic mucosa as seen in the image below.

The simplest reconstruction after the laryngofissu The simplest reconstruction after the laryngofissure and cordectomy is to suture the false vocal cord to the infraglottic mucosa. In this image, it is performed without the imbrication technique.

In the image below, imbricating sutures are used to place the superior strut of cartilage medial to the inferior strut, which pulls the false vocal cord down to be sutured to the infraglottic mucosa. This has the advantage of reconstructing the neocord using vascularized, innervated, mucosalized tissue, while avoiding tension, which may result in dehiscence of the mucosa or flattening of the false vocal cord. Both of which can result in a breathy voice. The technique involves 2 pairs of drill holes in the superior and inferior strut, allowing 2 imbricating sutures of 2-0 Prolene. The mucosa is approximated using 4-0 Vicryl or chromic. The laryngofissure is closed with 2-0 Prolene or 2-0 Vicryl sutures.

Imbricating sutures are used to place the superior Imbricating sutures are used to place the superior strut of cartilage medial to the inferior strut, which pulls the false vocal cord down to be sutured to the infraglottic mucosa. This has the advantage of reconstructing the neocord using vascularized, innervated, mucosalized tissue, while avoiding tension, which may result in dehiscence of the mucosa or flattening of the false vocal cord (possibly resulting in a breathy voice). The author prefers this method for every patient with a false vocal cord available for reconstruction. The technique involves 2 pairs of drill holes in the superior and inferior strut, allowing 2 imbricating sutures of 2-0 Prolene. The mucosa is approximated using 4-0 Vicryl or chromic.

The anterior commissure is then re-created by suturing the internal to external perichondrium as seen in the image below. The external perichondrium and cricothyroid membrane are closed with 3-0 Vicryl suture, and the wound is closed with a Penrose drain and a dressing. A cuffed tracheotomy is used.

The laryngofissure is closed with 2-0 Prolene or 2 The laryngofissure is closed with 2-0 Prolene or 2-0 Vicryl sutures. Anterior commissure then should be re-created by suturing the internal to external perichondrium if it has been disrupted. The external perichondrium and cricothyroid membrane are closed with 3-0 Vicryl suture, and the wound is closed with a Penrose drain and a dressing. A cuffed tracheotomy is used.
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Postoperative Details

Penrose drains, sterile dressing, proper tracheotomy care, early oral intake, and decannulation when edema resolves are indicated. Generally, a hospital stay lasts less than one week.

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Follow-up

Regular follow-up care is required for all patients with head and neck cancer, preferably at least every 6-12 weeks during the first postoperative year. Closer follow-up care is necessary in the early postoperative period. In the event of VPL failure, salvage total laryngectomy remains a reasonable option.

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Complications

Major complications are rare but include the following:

  • Wound infection (most common)
  • Seroma
  • Major subcutaneous emphysema
  • Inadequate voice
  • Aspiration
  • Hematoma
  • Conversion to total laryngectomy
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Outcome and Prognosis

In previously untreated patients, reported local control rates as primary therapy are greater than 90% for T1 glottic tumors and 68% for T2 glottic tumors. Increased risk factors for recurrence include anterior commissure involvement, increased T stage, and positive surgical margins.[6, 7]

In patients who undergo salvage therapy secondary to RT failure, the reported local control rates are 84% and 60% for T1 and T2 glottic tumors, respectively. The overall survival for this group of patients is reported at 77%.[5]

With regard to T3 glottic tumors, local control rates vary among different institutions, with reported failure rates as high as 50%.

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Future and Controversies

Primary radiotherapy and transoral laser excision remain the prototypical therapy for early glottic tumors. Vertical partial laryngectomy (VPL) serves as both primary and salvage therapy for T1 and T2 disease with equivocal control rates for T3 tumors. Choosing the ideal surgical modality for tumors that bridge the T2/T3 classification system remains an intense area of controversy, without clear delineation in the literature. The intended goal of this article is to highlight the limits of VPL as much as its therapeutic efficacy.

Advances in transoral surgical approaches have contributed to the development and advances of endoscopic VPL. Future directions in research and technical innovation will likely focus on voice conservation, the role of chemotherapy, and stratification of patients based on tumor biology.

In particular, anterior commissure involvement, supracricoid partial laryngectomy, and the different reconstructions will continue to generate controversy and debate among head and neck surgeons. Patient desire and surgeon bias will continue to play dominant roles in the selection of treatment modality for early laryngeal carcinoma.

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Contributor Information and Disclosures
Author

Christopher Klem, MD Attending Surgeon, Chief, Head and Neck Oncologic Surgery, Microvascular Reconstructive Surgery, Assistant Chief, Otolaryngology–Head and Neck Surgery Service, Tripler Army Medical Center

Christopher Klem, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Society for Reconstructive Microsurgery

Disclosure: Nothing to disclose.

Coauthor(s)

Jessica J Peck, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Georgia Regents University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

David J Terris, MD, FACS Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia, Georgia Regents University

David J Terris, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Alpha Omega Alpha, Triological Society, Radiation Research Society, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Christopher H Rassekh, MD Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, West Virginia University

Christopher H Rassekh, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Cancer Society, American Head and Neck Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, and West Virginia State Medical Association

Disclosure: Nothing to disclose.

Jon Robitschek, MD Resident Physician, Department of Otolaryngology, Tripler Army Medical Center

Jon Robitschek, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

References
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  2. Luna-Ortiz K, Campos-Ramos E, Villavicencio-Valencia V, Contreras-Buendía M, Pasche P, Gómez AH. Vertical partial hemilaryngectomy with reconstruction by false cord imbrication. ANZ J Surg. 2010 May. 80(5):358-63. [Medline].

  3. Philippe Y, Espitalier F, Durand N, Ferron C, Bardet E, Malard O. Partial laryngectomy as salvage surgery after radiotherapy: oncological and functional outcomes and impact on quality of life. A retrospective study of 20 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2014 Feb. 131(1):15-9. [Medline].

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  7. Kardasz-Ziomek M, Scierski W, Namyslowski G. Operation treatment results of laryngeal cancer in different types of partial laryngectomy based on own material. Otolaryngol Pol. 2014 September - October. 68(5):233-238. [Medline].

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  15. Laccourreye O, Weinstein G, Brasnu D, et al. Vertical partial laryngectomy: a critical analysis of local recurrence. Ann Otol Rhinol Laryngol. 1991 Jan. 100(1):68-71. [Medline].

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  18. Yeager LB, Grillone GA. Organ preservation surgery for intermediate size (T2 and T3) laryngeal cancer. Otolaryngol Clin North Am. 2005 Feb. 38(1):11-20, vii. [Medline].

 
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Laryngofissure performed with an oscillating saw (also known as midline thyrotomy). This step is performed for all vertical partial laryngectomy (VPL) procedures unless the anterior commissure is involved. In such cases, a central segment of thyroid cartilage is included in the resection by making parallel thyrotomy cuts on either side of the midline and preserving both lateral remnants or by making a cut on the contralateral side and removing the entire ipsilateral thyroid ala. Preservation of the ala is preferable for most reconstructions.
Once laryngofissure is completed and incision in cricothyroid membrane is made, the vocal cords are inspected from below. If the anterior commissure is free, then the internal mucoperichondrium is divided at or near the anterior commissure, with a margin around the tumor of at least 3 mm. Then the entire vocal cord is resected.
The simplest reconstruction after the laryngofissure and cordectomy is to suture the false vocal cord to the infraglottic mucosa. In this image, it is performed without the imbrication technique.
For imbrication laryngoplasty, the cordectomy is performed by excising a segment of thyroid cartilage adjacent to the vocal cord. Care is taken to preserve an inferior strut of thyroid cartilage that is intact and approximately 1 cm in height.
Imbricating sutures are used to place the superior strut of cartilage medial to the inferior strut, which pulls the false vocal cord down to be sutured to the infraglottic mucosa. This has the advantage of reconstructing the neocord using vascularized, innervated, mucosalized tissue, while avoiding tension, which may result in dehiscence of the mucosa or flattening of the false vocal cord (possibly resulting in a breathy voice). The author prefers this method for every patient with a false vocal cord available for reconstruction. The technique involves 2 pairs of drill holes in the superior and inferior strut, allowing 2 imbricating sutures of 2-0 Prolene. The mucosa is approximated using 4-0 Vicryl or chromic.
The laryngofissure is closed with 2-0 Prolene or 2-0 Vicryl sutures. Anterior commissure then should be re-created by suturing the internal to external perichondrium if it has been disrupted. The external perichondrium and cricothyroid membrane are closed with 3-0 Vicryl suture, and the wound is closed with a Penrose drain and a dressing. A cuffed tracheotomy is used.
 
 
 
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