eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Conservation Laryngeal Surgery, Vertical Partial Laryngectomy: Treatment

Author: Jon Robitschek, MD, Resident Physician, Department of Otolaryngology, Tripler Army Medical Center
Coauthor(s): Jessica J Peck, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center; Christopher Klem, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center; Christopher H Rassekh, MD, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, West Virginia University
Contributor Information and Disclosures

Updated: Jan 14, 2009

Treatment

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.2  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. 

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.

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.1

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 Image 1. 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.

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.

[ CLOSE WINDOW ]
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 (see Image 2 and Image 4).

Once laryngofissure is completed and incision in ...

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.

[ CLOSE WINDOW ]
Once laryngofissure is completed and incision in ...

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 ...

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.

[ CLOSE WINDOW ]
For imbrication laryngoplasty, the cordectomy is ...

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 Images 3-6 for imbrication laryngoplasty. The simplest reconstruction after the laryngofissure and cordectomy is to suture the false vocal cord to the infraglottic mucosa. Imbricating sutures are used to place the superior strut of cartilage medial to the inferior strut, which pulls the false vocal cord down to be sutured to the infraglottic mucosa. This has the advantage of reconstructing the neocord using vascularized, innervated, mucosalized tissue, while avoiding tension, which may result in dehiscence of the mucosa or flattening of the false vocal cord. 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. 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.

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.

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.

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

More on Conservation Laryngeal Surgery, Vertical Partial Laryngectomy

Overview: Conservation Laryngeal Surgery, Vertical Partial Laryngectomy
Workup: Conservation Laryngeal Surgery, Vertical Partial Laryngectomy
Treatment: Conservation Laryngeal Surgery, Vertical Partial Laryngectomy
Follow-up: Conservation Laryngeal Surgery, Vertical Partial Laryngectomy
Multimedia: Conservation Laryngeal Surgery, Vertical Partial Laryngectomy
References
[ CLOSE WINDOW ]

References

  1. Zbaren P, Christe A, Caversaccio MD, et al. Pretherapeutic staging of recurrent laryngeal carcinoma: clinical findings and imaging studies compared with histopathology. Otolaryngol Head Neck Surg. Sep 2007;137(3):487-91. [Medline].

  2. Yiotakis J, Stavroulaki P, Nikolopoulos T, et al. Partial laryngectomy after irradiation failure. Otolaryngol Head Neck Surg. Feb 2003;128(2):200-9. [Medline].

  3. Brumund KT, Gutierrez-Fonseca R, Garcia D, et al. Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience. Ann Otol Rhinol Laryngol. Apr 2005;114(4):314-22. [Medline].

  4. Bailey BJ. Head and Neck Surgery-Otolaryngology Atlas. Baltimore, Md:. Lippincott Williams & Wilkins;1996.

  5. Bailey BJ, Calcaterra TC. Vertical, subtotal laryngectomy and laryngoplasty. Review of experience. Arch Otolaryngol. Mar 1971;93(3):232-7. [Medline].

  6. Brasnu D, Laccourreye O, Weinstein G, et al. False vocal cord reconstruction of the glottis following vertical partial laryngectomy: a preliminary analysis. Laryngoscope. Jun 1992;102(6):717-9. [Medline].

  7. Davis RK, Hadley K, Smith ME. Endoscopic vertical partial laryngectomy. Laryngoscope. Feb 2004;114(2):236-40. [Medline].

  8. 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. Feb 2005;38(1):1-9, vii. [Medline].

  9. Kambic V, Radsel Z, Smid L. Laryngeal reconstruction with epiglottis after vertical hemilaryngectomy. J Laryngol Otol. May 1976;90(5):467-73. [Medline].

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

  11. Pleet L, Ward PH, DeJager HJ, et al. Partial laryngectomy with imbrication reconstruction. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. Sep-Oct 1977;84(5):ORL882-9. [Medline].

  12. Vachin F, Hans S, Atlan D, et al. [Long term results of exclusive chemotherapy for glottic squamous cell carcinoma complete clinical responders after induction chemotherapy]. Ann Otolaryngol Chir Cervicofac. Jun 2004;121(3):140-7. [Medline].

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

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

laryngeal surgery, conservation laryngeal surgery, glottic carcinoma, organ preservation, neck cancer, organ preservation for glottic carcinoma, vertical partial laryngectomy, VPL, laryngofissure and cordectomy, partial laryngectomy with imbrication laryngoplasty, frontolateral partial laryngectomy, muscle flap laryngoplasty, epiglottic laryngoplasty, organ preservation surgery of the larynx, endoscopic cordectomy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

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.

Coauthor(s)

Jessica J Peck, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center
Disclosure: Nothing to disclose.

Christopher Klem, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, 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, and American Society for Reconstructive Microsurgery
Disclosure: Nothing to disclose.

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.

Medical Editor

David J Terris, MD, FACS, Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia
David J Terris, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Association for the Advancement of Science, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Phi Beta Kappa, Radiation Research Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.