Early-stage laryngeal carcinoma is managed through either radiotherapy or surgery, with the choice of treatment depending on patient-specific factors, tumour characteristics, and physician expertise. Conservation surgical techniques, including open partial laryngectomy and transoral endolaryngeal surgery, are preferred for their ability to preserve laryngeal function while achieving excellent oncologic outcomes. These procedures are particularly effective for early-stage tumour’s but are generally not suitable for advanced laryngeal cancers. The primary goal of conservation surgery is to maintain speech and swallowing functions while avoiding the need for a permanent tracheostomy.
Principles of Organ Preservation Laryngeal Surgery
- Local Control: Achieving complete tumour resection during the initial procedure is critical, as post-surgical anatomical changes can complicate the detection of recurrence.
- Accurate Assessment of Tumour Extent: Precise preoperative and intraoperative evaluation of tumour extent is essential. Diagnostic tools such as flexible laryngoscopy, CT, MRI, and PET scans are indispensable for assessing vocal cord mobility, arytenoid involvement, and cartilage invasion. Impaired vocal cord mobility in glottic cancer often indicates thyroarytenoid muscle invasion, while in supraglottic cancer, it typically reflects arytenoid cartilage invasion. Direct laryngoscopy under anesthesia provides visualization of deeper structures, while MRI is particularly effective for detecting thyroid cartilage invasion. PET scans are valuable for post-treatment monitoring and early recurrence detection.
- Preservation of the Cricoarytenoid Unit: The cricoarytenoid unit, comprising the arytenoid and cricoid cartilages, associated musculature, and nerve supply (superior and recurrent laryngeal nerves), is vital for physiologic speech and swallowing. Preserving at least one functional unit is a fundamental principle of organ preservation surgery.
Classification of Conservation Laryngeal Surgery Conservation laryngeal surgeries are broadly classified into two categories: open partial laryngeal surgery and transoral endoscopic laser surgery. Both approaches adhere to the same principles of resection, with the primary objective of securing negative margins to ensure oncologic success.
- Open Partial Laryngeal Surgery: This approach involves external access to the larynx, allowing for precise resection of the tumour while preserving critical structures necessary for laryngeal function.
- Transoral Endoscopic Laser Surgery: This minimally invasive technique utilizes endoscopic visualization and laser technology to excise tumour’s transorally, offering the advantage of reduced morbidity and faster recovery.
Open Partial Laryngeal Surgery
Open partial laryngeal surgery includes procedures such as vertical partial laryngectomy and supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP). These techniques are selected based on tumor location, extent, and patient factors.
1. Conservation Surgery of Glottic Laryngeal Cancer
- Vertical Partial Laryngectomy (VPL):
- Indications: It is indicated for early-stage glottic carcinomas, specifically T1 and select T2 lesions of the vocal folds. Ideal candidates include patients with mobile unilateral vocal cord lesions that may extend to the anterior commissure or vocal process, as well as those with limited subglottic extension (less than 5 mm). The procedure is also suitable for unilateral transglottic lesions that do not violate these criteria and for true cord or anterior commissure lesions involving no more than the anterior third of the contralateral cord. Fixed vocal cord lesions that do not cross the midline may also be considered for VPL.
- Technique: The surgical technique involves a vertical resection of the ipsilateral thyroid cartilage, true vocal cord, false cord, and subglottic mucosa. Reconstruction is achieved using strap muscles to form a pseudocord, which helps restore laryngeal function. A temporary tracheostomy is typically required for 3–7 days to ensure airway safety during the initial postoperative period. In cases where the anterior commissure is involved, a frontolateral partial laryngectomy is performed to ensure complete tumour resection while preserving laryngeal structure and function.
- Oncologic Results: VPL demonstrates excellent local control rates for T1 glottic cancers, exceeding 90%. However, involvement of the anterior commissure is associated with a reduced local control rate of 75%, primarily due to an increased risk of subglottic recurrence. For T2 and T3 glottic cancers, recurrence rates are higher, and VPL is generally not recommended for advanced T2 or T3 lesions with subglottic or supraglottic extension or invasion of the cricoid or thyroid cartilage. These limitations highlight the importance of careful patient selection to optimize oncologic outcomes.
- Functional Outcomes: Postoperative hoarseness is common, but dysphagia and stenosis are rare, ensuring good functional outcomes when properly indicated.
- Supracricoid Partial Laryngectomy with cricohyoidoepiglottopexy (CHEP):
- Indications: It is most commonly employed for T1b glottic carcinomas involving the anterior commissure, as well as selected cases of T2 and T3 glottic carcinomas.
- Technique: This procedure involves the resection of bilateral true and false vocal cords, the entire thyroid cartilage, bilateral paraglottic spaces, and up to one arytenoid. Reconstruction is accomplished using the epiglottis, hyoid bone, cricoid cartilage, and tongue. Due to the extensive nature of the resection, a temporary tracheostomy and feeding tube are required to support postoperative recovery and ensure airway patency and nutritional intake during the healing process.
- Oncologic Results: There are favourable oncologic outcomes, particularly for T2 and T3 glottic carcinomas, with local recurrence rates reported at 4.5% and 10%, respectively, which are attributed to the complete resection of the thyroid cartilage and bilateral paraglottic spaces. However, the procedure is less effective for transglottic carcinomas, which exhibit a higher local recurrence rate of 23%. This is due to the inability of CHEP to fully remove the supraglottis. For transglottic tumours, supracricoid partial laryngectomy with cricohyoidopexy is recommended as a more suitable alternative.
- Functional Outcomes: Temporary dysphagia and aspiration are expected, but long-term laryngeal function is preserved in the majority of patients, allowing for adequate speech and swallowing.
2. Conservation Surgery for Supraglottic Laryngeal Cancer
Supraglottic cancers pose unique challenges due to their impact on swallowing. Almost every patient aspirates to a varying degree following surgery. Most patients handle this with little difficulty and can handle most types of foods without significant pulmonary complications. However, patients with a poor pulmonary reserve, advanced stage of emphysema, and those of advanced age are poor candidates for conservation surgery. Surgical options include horizontal supraglottic partial laryngectomy and supracricoid partial laryngectomy with cricohyoidopexy (CHP).
- Horizontal Supraglottic Partial Laryngectomy (HSPL):
- Indications: It is a surgical procedure primarily indicated for tumours involving the supraglottic larynx. It is suitable for primary tumours of the base of the tongue with secondary extension to the supraglottic larynx, tumours of the pyriform sinus involving its medial wall, and bulky tumours of the pharyngeal wall with secondary supraglottic extension. Strict selection criteria must be met to ensure the suitability of the lesion for HSPL. These include: (1) a minimum 5 mm margin at the anterior commissure, (2) mobile true vocal cords, (3) removal of no more than one arytenoid, (4) absence of cartilage invasion, (5) normal tongue mobility, (6) no extension to the interarytenoid or post-cricoid area, (7) a free apex of the pyriform sinus, and (8) lesions generally less than 3 cm in size.
- Technique: The surgical procedure involves the resection of the epiglottis, hyoid bone, pre-epiglottic space, thyrohyoid membrane, upper half of the thyroid cartilage, and supraglottic mucosa. The vallecula is transected superiorly, the ventricles inferiorly, and the aryepiglottic folds laterally. Reconstruction is achieved by approximating the base of the tongue to the lower half of the thyroid cartilage and closing the posterior false cord mucosa to the medial pyriform sinus mucosa. A temporary tracheostomy is required to ensure airway safety during the postoperative period. Bilateral selective neck dissection is routinely performed concurrently. Care must be taken to identify and preserve the internal and external branches of the superior laryngeal nerve. Additionally, tongue base sutures are placed in the midline and 1 cm laterally to avoid injury to the hypoglossal nerves and lingual arteries.
- Oncologic Results: HSPL demonstrates excellent local control rates for T1 and T2 supraglottic tumours. However, local control declines significantly for T3 and T4 lesions, with recurrence rates of 75% for T3 and 67% for T4 tumours.
- Functional Outcomes: Aspiration is common, but most patients achieve functional swallowing within three months.
- Supracricoid Partial Laryngectomy with CHP:
- Indications: Supracricoid partial laryngectomy with cricohyoidopexy (CHP) is a surgical technique used for supraglottic carcinomas unsuitable for supraglottic laryngectomy due to glottic involvement, pre-epiglottic space invasion, decreased cord mobility, or limited thyroid invasion. The indications are T1 and T2 supraglottic lesions with ventricle or glottic extension, T3 transglottic carcinomas with limited cord mobility, and selective T4 lesions with thyroid cartilage invasion.
- Technique: The procedure involves resection of both true and false vocal cords, thyroid cartilage, paraglottic spaces, and up to one arytenoid, with reconstruction using the hyoid bone, cricoid cartilage, and tongue. A temporary tracheostomy and feeding tube are required.
- Oncologic Results: Studies report excellent local control, with recurrence rates as low as 3.3%, attributed to en bloc resection of paraglottic spaces, pre-epiglottic space, and thyroid cartilage.
- Functional Outcomes: Postoperative dysphagia and voice instability are common, with nasogastric feeding required for 30–365 days. Careful patient selection and rehabilitation are crucial for success, though total laryngectomy may be necessary in up to 10% of cases.
3. Conservation Surgery for Radiation Failure
Patients who experience local recurrence after radiotherapy may still be candidates for conservation surgery, provided the tumor has not progressed. Salvage procedures include vertical partial laryngectomy, supracricoid partial laryngectomy, and transoral laser resection. Careful patient selection and intraoperative assessment are critical to achieving successful outcomes.
Transoral Endoscopic Laser Resection
Transoral endoscopic laser resection has emerged as a minimally invasive alternative to open partial laryngeal surgery and radiotherapy for early-stage laryngeal cancer. Transoral endoscopic laser resection minimizes surgical trauma, blood loss, and the need for reconstruction by avoiding dissection through healthy tissue. It preserves speech and swallowing, ensuring faster recovery and reducing the need for tracheostomy.
- Technique: This technique involves the removal of the tumor through a transoral route using specialized rigid laryngoscopes and a CO₂ laser under microscopic visualization. The tumour is resected in a blockwise manner using a CO2 laser under microscopic visualization which allows precise differentiation between malignant and non-malignant structures and enables tailored safety margins.
- Oncologic Results: Transoral endoscopic laser resection (TELR) has demonstrated excellent oncologic and functional outcomes for glottic, supraglottic, and pyriform sinus cancers. For early-stage (T1, T2) glottic cancers, five-year local control rates are high (96%–98%), with larynx preservation rates of up to 99%. TELR is also effective for T3 glottic cancers, with a 69% five-year local control rate and 84% larynx preservation. For supraglottic cancers, similar success rates have been reported, with improved functional outcomes. Pyriform sinus cancers treated with TELR show five-year survival rates of 47%–71%, with high organ preservation. TELR preserves speech and swallowing, enabling faster recovery and repeatability for recurrences.
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Conservation Surgeries for Carcinoma Larynx Best Lecture Notes Dr Rahul Bagla ENT Textbook
Reference Textbooks.
- Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
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Author:
Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India
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Keywords: Conservation surgery for laryngeal cancer, Larynx carcinoma surgery, Laryngeal cancer treatment, Partial laryngectomy, Organ-preserving laryngeal surgery✅, Early-stage larynx cancer treatment, Voice-preserving surgery, Endoscopic laryngeal surgery, Transoral laser microsurgery (TLM), supracricoid laryngectomy, Laryngeal cancer survival rates