Organ-Preserving Laryngeal Surgery

1. Fundamental Principles

1. Local control - the primary oncologic objective
2. Accurate assessment of the 3D extent of the tumor - critical for surgical planning
3. The cricoarytenoid unit as the basic functional unit of the larynx - preservation of at least one functional cricoarytenoid unit is the minimum requirement for a functioning larynx without a permanent tracheostomy
4. Resection of normal tissue to achieve an expected functional outcome - the extent of resection predicts functional outcome

2. Patient Selection

General criteria

• Tumor confined within anatomical boundaries amenable to partial resection
• Sufficient pulmonary reserve - the patient must tolerate some post-operative aspiration. Pulmonary function tests are rarely used; a practical criterion is the ability to climb two flights of stairs without breathlessness
• General health sufficient to withstand surgery

The critical distinction: vocal fold fixation vs. arytenoid fixation

• Vocal fold fixation due to paraglottic space invasion does NOT by itself contraindicate conservation surgery
• Arytenoid fixation (cricoarytenoid joint invasion) IS a contraindication - it signals loss of the functional cricoarytenoid unit

Pre-operative workup

• Indirect laryngoscopy and staging operative endoscopy are mandatory
• CT/MRI for 3D tumor assessment, cartilage invasion, and pre-epiglottic space involvement
• Assessment of neck nodes for concurrent neck dissection planning

3. Classification of Procedures

4. Open Partial Laryngectomy - Vertical Procedures (Glottic)

4a. Vertical (Anterolateral) Hemilaryngectomy

• Exposure of the thyroid cartilage below the strap muscles
• Ipsilateral perichondrium lifted to preserve it
• Vertical midline laryngofissure cuts through the thyroid cartilage
• Resection of the majority of ipsilateral thyroid cartilage, true vocal cord, portions of subglottic mucosa, and false cord
• Reconstruction: strap muscles closed over residual perichondrium to form a pseudocord
• Tracheostomy and feeding tube generally required for 3-7 days

4b. Frontolateral Hemilaryngectomy

4c. Anterior Vertical Laryngectomy

5. Supracricoid Partial Laryngectomy (SCPL) - The Modern Workhorse

What is resected en bloc:

• Both true vocal cords
• Both false cords
• The entire thyroid cartilage
• Both paraglottic spaces
• The preepiglottic space
• A maximum of one arytenoid (when necessary)

What is preserved (minimum requirements):

• The cricoid cartilage
• At least one functional arytenoid (with its recurrent laryngeal nerve supply)
• Both superior laryngeal nerves (SLN) for sensation during swallowing
• Hyoid bone

The cricoarytenoid unit

5a. SCPL with Cricohyoidoepiglottopexy (SCPL-CHEP)

• One in the midline
• Two placed 1 cm paramedian (to avoid suturing lingual arteries, hypoglossal nerve, and SLN)
• The suprahyoid epiglottis is preserved and reapproximated in the cricohyoidopexy

5b. SCPL with Cricohyoidopexy (SCPL-CHP)

General contraindications to SCPL (both CHEP and CHP):

1. Subglottic extension >10 mm anteriorly or >5 mm posteriorly
2. Arytenoid fixation (implies cricoarytenoid joint invasion)
3. Massive preepiglottic space involvement with vallecula involvement
4. Extension to the pharyngeal wall, vallecula, base of tongue, postcricoid region, or interarytenoid region
5. Cricoid cartilage invasion
6. Poor pulmonary reserve

6. Horizontal Supraglottic Laryngectomy (HSPL)

7. Transoral Laser Microsurgery (TLM)

Historical background

The CO2 laser

Endoscopic classification of glottic resections (European Laryngological Society - Remacle classification)

TLM for glottic carcinoma

• Standard of care for T1a mid-cord lesions: Very high cure rate with undeniable advantage of higher laryngeal preservation rates
• T1b (anterior commissure): TLM is effective; RT is preferred in many UK/US centers for anterior commissure disease
• T2 glottic: TLM is an option in expert hands; RT often preferred for impaired mobility or extensive T2
• Key advantage: Preserves more normal laryngeal tissue than open procedures; allows outpatient or short-stay surgery without tracheostomy in most T1 cases

TLM for supraglottic carcinoma

• Excellent for T1-T2 supraglottic lesions as an alternative to open HSPL
• Avoids the morbidity of an open neck approach in early lesions
• Requires excellent exposure (adequate mouth opening, favorable anatomy); poor access is a relative contraindication
• Does not reconstruct the defect - secondary intention healing provides acceptable functional outcome for early lesions

TLM vs. open conservation surgery

• TLM: less morbidity, shorter hospital stay, no tracheostomy (usually), preserves more tissue, allows re-treatment
• Open SCPL: more predictable en bloc margins for larger lesions, no access limitations, broader applicability to T2-T3 disease
• Both provide comparable local control for appropriately selected lesions in expert hands

8. Transoral Robotic Surgery (TORS)

9. Conservation Surgery After Prior Radiation (Salvage)

• Post-irradiation tissue changes (edema, fibrosis, poor healing) increase complication rates
• Only about one in three early laryngeal cancers that recur after primary radiation are still amenable to conservation surgery (the remainder require total laryngectomy)
• Salvage VHL: Weighted-average local control rate of 77% across series
• Salvage SCPL-CHEP or SCPL-CHP: Can be used for larger post-radiation recurrences; reported local control ~70%

1. Tumor involves the arytenoid
2. Subglottic extension >10 mm anteriorly, >5 mm posteriorly
3. Cartilage invasion (thyroid or cricoid)

1. Large primary tumor
2. Recurrence located posteriorly
3. Previous anterior commissure involvement

10. The Spectrum: Matching Procedure to Tumor

11. Post-operative Functional Outcomes Summary

12. Current Status and Philosophy

1. Better understanding of 3D tumor extent from clinicopathologic studies and advanced imaging
2. Long-term outcome data confirming predictable oncologic and functional results
3. Introduction of new techniques (SCPL, TLM, TORS)

The fundamental choice is between the non-surgical approach (preserve anatomy, accept some failures, rely on salvage) versus the conservation surgical approach (progressively resect more tissue as lesions enlarge, accept reduced function for the entire cohort, minimize local recurrence). Both are legitimate, and the decision must be individualized.