Vertical Partial Laryngectomy Treatment & Management
- Author: Christopher Klem, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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. 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.
Because cure rates of surgical therapy equal those of radiotherapy, patient preference should play a large role in the selection of treatment modality.
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.
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.
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 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.
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.
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.
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.
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.
Major complications are rare but include the following:
Wound infection (most common)
Major subcutaneous emphysema
Conversion to total laryngectomy
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%.
With regard to T3 glottic tumors, local control rates vary among different institutions, with reported failure rates as high as 50%.
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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