Vertical Partial Laryngectomy

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Cancers that arise on the true vocal cord with limited involvement of the anterior commissure (Figure 9-5) or arytenoid can be resected with a vertical partial laryngectomy. The majority of the ipsilateral thyroid cartilage, the true vocal cord, and portions of the subglottic mucosa and false vocal cord are removed (Figures 9-6 to 9-8). The strap muscles are closed over the defect and can be used to form a "pseudocord." A tracheotomy is generally left in place for 3 to 7 days. Anterior commissure involvement can be addressed using a

Figure 9-5. A, Clinical photo of glottic squamous cell carcinoma that had failed external beam radiation therapy. B, Endoscopic examination confirms the suitability of the lesion for vertical partial laryngectomy.

Figure 9-6. A, A midline thyrotomy is used to access the larynx when the anterior commissure is uninvolved by tumor. B, Cut section of the larynx demonstrating the extent of mucosal resection in a vertical partial laryngectomy. C, External view showing resection of the thyroid ala.

A ifinrmuu" B C

Figure 9-6. A, A midline thyrotomy is used to access the larynx when the anterior commissure is uninvolved by tumor. B, Cut section of the larynx demonstrating the extent of mucosal resection in a vertical partial laryngectomy. C, External view showing resection of the thyroid ala.

fronto-lateral partial laryngectomy. Voice quality and airway are not as reliable with this operation which extends the resection to the contralateral cord including the anterior commissure. Contraindications include tumor involvement of the posterior or interarytenoid area, subglottic extension of greater than 10 mm, and poor medical condition or pulmonary reserve.

thyroid cartilage and the supraglottic mucosa. The vallecula is transected superiorly, the ventricles infe-riorly, and the aryepiglottic folds laterally (Figures 9-9 to 9-13). Thus most stage I and II tumors of the laryngeal surface of the epiglottis and false vocal cords can be removed. Margins are close, however, and it appears that 2 to 3 mm of normal mucosa infe-riorly is adequate to prevent local recurrence.27 Clo-

Supraglottic Laryngectomy

A supraglottic laryngectomy removes the epiglottis, hyoid bone, thyrohyoid membrane, upper half of the

Figure 9-7. Surgical exposure for vertical partial laryngectomy. Figure 9-8. Vertical partial laryngectomy, excised specimen.

Figure 9-9. A, and B, Diagram demonstrating the extent of resection during supraglottic partial laryngectomy.

sure is performed by approximating the base of tongue to the lower half of the thyroid cartilage and closing the posterior false vocal cord mucosa to the medial pyriform sinus mucosa. A temporary tracheotomy is required. Elective neck dissections can be done without significant functional deficits occurring. Extensions of this operation have been proposed for more advanced disease. Relative contraindications include tumor involvement of the interarytenoid area, pyriform sinus apex, anterior commissure and preepiglottic space, and poor pulmonary reserve or general medical condition. Supraglottic laryngectomy is usually not appropriate in irradiation failures, although exceptions exist.28

Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

The supracricoid subtotal laryngectomy with cricohyoidoepiglottopexy (SCSL with CHEP) has gained

Figure 9-11. Endoscopic photo of supraglottic carcinoma.

Figure 9-10. Clinical photo of supraglottic carcinoma.

Figure 9-11. Endoscopic photo of supraglottic carcinoma.

Figure 9-12. Surgical exposure for supraglottic partial laryngectomy.

popularity over the past decade, particularly in Europe. SCSL involves removing the entire thyroid cartilage and paraglottic space followed by reconstruction using the epiglottis, hyoid bone, cricoid cartilage and tongue29 (Figures 9-14 to 9-16). A temporary tracheotomy and feeding tube is required. SCSL has been advocated for T1B glottic carcinoma with or without anterior commissure involvement, T1A with anterior commissure involvement, T1 glottic carcinoma with associated areas of severe dysplasia, or unilateral or bilateral T2 glottic carcinoma. It can be extended to include the epiglottis as well. One arytenoid can be removed for a margin but the operation should not be used if the cord is fixed. Contraindications include poor pulmonary reserve, extensive anterior commissure involvement, and sub-

Figure 9-13. Surgical specimen from supraglottic partial laryngectomy.

Figure 9-14. Endoscopic view of tumor amenable to supracricoid subtotal laryngectomy.

Figure 9-15.

gectomies.

A, and B, Diagram of supracricoid subtotal laryn-

Figure 9-13. Surgical specimen from supraglottic partial laryngectomy.

Figure 9-15.

gectomies.

A, and B, Diagram of supracricoid subtotal laryn-

glottic extension below 10 mm. This procedure can be successfully performed after radiation failure.

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