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36 Transoral Laser Resection forGlottic andSupraglottic Tumours
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363
disease-specic survival rates of 94% and 96%, respectively
[14], and Lucioni etal. achieved disease-specic survival of
100% with 97% laryngeal preservation rates of and local
control with laser alone of 97.5% [15].
Similar survival outcomes are demonstrated by retrospective series for T1b tumours treated with transoral laser surgery although surgery may be more challenging, and as a
type VI cordectomy may be required, the functional result
might be worse than treatment with radiotherapy. Taylor
etal. describe local control of 95 and 100% laryngeal preservation at 2years in a comparative case series from Canada
[16], with signicantly improved survival compared to
patients in the same series treated with radiotherapy. Lucioni
etal. demonstrate disease-specic survival of 97% with 97%
laryngeal preservation and local control with laser of 89%
[15].
Retrospective data for T2 glottic carcinoma demonstrate
local control rates at 5years between 76 and 89% [17–20],
and 5-year disease-specic survival rates range from 91 to
98% [17, 19, 21]. Laryngeal preservation rates remain high
for this group at 90–95% at 5years [17, 22, 23].
Laser excision of supraglottic tumours offers improved
functional outcomes when compared to open partial surgery
[24] and offers the potential to avoid radiotherapy. Early
supraglottic cancers are well suited to transoral laser excision as access is usually good and the resection can be tailored to the extent of the tumour. Consequently, adequate
resection margins are easier to achieve in the supraglottis,
compared to the glottis, without compromising function.
Data describing outcomes after transoral laser surgery for
supraglottic cancers is based upon small case series, resulting in heterogeneity of the data. Cabanillas etal. compared
transoral laser to open surgery for supraglottic tumours stage
T1–T3, with 80% disease specic survival, 70% local control and 86% laryngeal preservation at 5years [25]. These
results were comparable to the patients in the series treated
with open surgery. Breda etal. reported disease-specic survival rates of 89% for T1 and 88% for T2in a smaller case
series of supraglottic SCC treated with transoral laser [21].
In one of the larger series of patients with supraglottic cancer
(45 T1 and 61 T2), Motta etal. demonstrated 5-year local
control of 82% and 63% for T1 and T2, respectively, with
laryngeal preservation rates of 89% and 85% [26].
Overall, the data for laser laryngeal surgery demonstrates
survival outcomes similar to non-surgical treatment, with
similar, if not improved laryngeal preservation rates. There
are a number of perceived advantages to transoral laser surgery for laryngeal carcinomas, including the potential for reresection in cases of residual or recurrent disease.
If local failure occurs after transoral laser surgery, the
options for salvage including further transoral laser surgery,
open partial laryngectomy, total laryngectomy or radiother-
apy are all open for consideration. As laser laryngeal surgery
is typically a single procedure, many patients consider it
more convenient than a course of radiotherapy, and there is a
proven cost benet over radiotherapy [27]. These advantages
are reected in the UK NICE guidelines [28], which state
transoral laser excision should be offered for T1a tumours,
with the option of laser surgery or radiotherapy offered for
T1b and T2 cases. The change in recommendation for T1a
tumours, from the previous guidance of offering either TLM
or RT, follows a rigorous cost effectiveness statistical model.
High-quality evidence on voice outcomes following TLM
or RT for laryngeal cancer is lacking. Although systematic
review data suggests comparable functional outcomes [29],
anecdotally many clinicians feel that TLM may result in
inferior voice outcomes, particularly if the anterior commissure is involved as webbing commonly occurs. The surgeon
should consider the site and extent of the tumour resection,
as well as the patient’s view on voice quality, when discussing expected post-treatment voice outcomes.
Bulky and locally advanced glottic and supraglottic
tumours require larger resection volumes, which can lead to
post-operative voice and swallowing impairment. These factors must be openly discussed with the patient. Ultimately,
careful selection of the ideal cases for laser excision with
detailed preoperative endoscopic assessment by the operating surgeon will provide the best functional and oncological
results.
36.4 Surgical Technique
Transoral laser resection of glottic and supraglottic tumours
may be approached via an en bloc resection approach where
the entire tumour is excised, with a surrounding margin. An
alternative approach, described by Steiner [4], is to transect
the tumour with the laser, to assess depth of invasion and
improve manipulation of the tumour (Fig.36.1). This technique relies upon the ability to distinguish normal tissue
from tumour when cut into with the laser, as cutting through
tumour causes obvious charring when viewed under the
microscope. The distinction can easily be observed when
cutting cleanly through normal tissue. This enables a more
accurate assessment of the depth of invasion and therefore
the required depth of resection.
Whilst cutting through a tumour does not adhere to the
basic concept of tumour resection, there is no evidence to
suggest that transecting a tumour leads to increased risk of
local recurrence or metastasis. Proponents of this technique
suggest that the risk of an involved deep margin is reduced
by the ability to assess tumour depth, and transecting large
tumours may facilitate resection by enhancing access to inferior components after removal of the tumour bulk.
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Fig. 36.1 (a) Diagram of Steiner method of resecting a glottic tumour. Step 1—transect tumour with laser to assess depth of invasion. (b) Diagram
of Steiner method of resecting a glottic tumour. Step 2—Once the tumour is split, excise tumour in two or more pieces
L. Warner et al.
36.4.1 Glottic Resections
tailored to excise more limited lesions. Type II cordectomy is
suitable for severe dysplasia and micro-invasive carcinoma
Rigid endoscopes (0° and 30°) should be used to gain a
detailed understanding of the 3D anatomy of the tumour
prior to resection. Following assessment of the tumour, either
an en bloc resection or Steiner method should be decided
upon. The European Laryngological Society created a clas-
in situ. With experience, a type II cordectomy can be used for
invasive carcinoma. Proponents of hydro-dissection (injecting saline into the vocal cord to raise the ligament away from
the muscle) claim this can aid carcinoma resection and minimise vocal cord deformity.
sication system in 2000 (updated in 2007) aiming to
improve standardisation of resection for dysplasia and
malignancy of the larynx [30]. Whilst this is a useful framework that enables comparison of published outcomes according to resection type, in practice, the resection area is
determined by the location and extent of the tumour.
Described below are the steps involved for laser resection
of glottic cancers, according to the ELS classication.
Type III: Trans-muscular Cordectomy (Fig.36.5)
A trans-muscular cordectomy involves resection of the vocal
fold epithelium, the lamina propria, the vocal ligament and
the vocalis muscle. The resection extent can encompass the
entire vocal fold, or may be targeted to excise a localised
lesion with an adequate margin. Partial excision of the false
cord may be required to access the entire vocal fold, which
does not normally compromise speech or swallowing func-
Type I: Subepithelial Cordectomy (Fig.36.2)
Subepithelial cordectomy is indicated for dysplasia and carcinoma in situ. The plane for resection is through the supercial layer of the lamina propria, hence unsuitable for
tion. The majority of T1a lesions without widespread muscular inltration can be successfully resected by type III
cordectomy. Fig. 36.6 shows appearances after type III
resection.
treatment of invasive carcinoma. Type I cordectomy typically removes the entire epithelium from the length of the
vocal fold, from the vocal process to the anterior commissure, although the resection can be tailed to the disease and
left well short of the anterior commissure to avoid webbing.
This technique is well suited to the treatment of dysplastic
lesions. Fig.36.3 demonstrates the typical appearance after
type I cordectomy for high-grade dysplasia.
Type IV: Total Cordectomy (Fig.36.7)
Total cordectomy excises the entire vocal fold, from the
vocal process up to (but not involving) the anterior commissure. The deep limit of the resection is the inner perichondrium of the thyroid cartilage. The attachment of the vocal
ligament to the thyroid lamina must be divided anteriorly to
complete the resection.
Type II: Subligamental Cordectomy (Fig.36.4)
Subligamental cordectomy excises the vocal fold epithelium,
Reinke’s space and the vocal ligament, leaving the vocalis
muscle as the deep limit of resection. The resection may
encompass the entire length of the vocal cord, or may be
Type Va: Extended Cordectomy Encompassing the
Contralateral Vocal Fold (Fig.36.8a)
This is performed in a similar fashion to a type IV cordectomy, although includes anterior commissure and may
encompass the anterior aspect of the contralateral cord. This
36 Transoral Laser Resection forGlottic andSupraglottic Tumours
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Fig. 36.2 Subepithelial
cordectomy
I
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Fig. 36.3 Endoscopic photograph of Type I (subepithelial) Cordectomy for high-grade dysplasia
is indicated for T1b lesions affecting the anterior commissure or both anterior vocal folds. This technique is somewhat
controversial as resection of the anterior commissure and
anterior vocal folds is technically challenging and will frequently result in poor vocal outcomes. This procedure is now
largely replaced by the type VI cordectomy, outlined below.
Type Vb: Extended Cordectomy Encompassing the
Arytenoid (Fig.36.8b)
This is similar to a total cordectomy, also excising the ipsilateral arytenoid cartilage. Type Vb cordectomy is indicated for
posterior glottic lesions; however, vocal fold mobility may
be compromised by arytenoid resection, resulting in poor
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Fig. 36.4 Subligamental
cordectomy
L. Warner et al.
II
Fig. 36.5 Trans-muscular
cordectomy
III
36 Transoral Laser Resection forGlottic andSupraglottic Tumours
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Fig. 36.6 Endoscopic photograph of trans-muscular (type III) cordectomy for T1a glottic SCC
Fig. 36.7 Total cordectomy.
The false cord may also be
excised for access
IV
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Fig. 36.8 (a) Extended
cordectomy including anterior
commissure and contralateral
anterior vocal cord. (b)
Extended cordectomy with
excision of ipsilateral
arytenoid. (c) Extended
cordectomy with excision of
ventricular fold. (d) Extended
cordectomy with subglottic
excision
L. Warner et al.
V (A) V (C)
V (B) V (D)
functional outcomes. Posterior glottic tumours can be challenging to excise well. If tackled with TLM, the resection
should be radical in the initial attempt. A partial arytenoidec-
tomy can be performed. Genuine involved margins with
TLM resections are more frequent when excising tumours
off the arytenoid.
36 Transoral Laser Resection forGlottic andSupraglottic Tumours
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Fig. 36.9 Anterior
commissure resection
VI
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Type Vc: Extended Cordectomy Encompassing the
Ventricular Fold (Fig.36.8c)
This is an extension of a total cordectomy, encompassing the
laryngeal ventricle and false vocal fold. This is indicated for
tumours within the laryngeal ventricle, or T2 lesions with
inltration of the ventricle or false cord.
Type Vd: Extended Cordectomy Encompassing the
Subglottis (Fig.36.8d)
This is a total cordectomy with inferior extension onto the
subglottic mucosa, exposing the inner perichondrium of the
cricoid cartilage. This is indicated for T2 glottic carcinomas
with limited subglottic extension.
Type VI: Cordectomy for Anterior Commissure
Carcinoma (Fig.36.9)
This approach is indicated for anterior commissure tumours.
The anterior commissurectomy encompasses the anterior
commissure and anterior aspects of both vocal folds. To gain
adequate access part of the false cords may be removed. The
resection begins at the epiglottic petiole, superior to the attachment of the vocal ligaments and continues through the ligaments, detaching them from the thyroid lamina. If cartilage
invasion is suspected, cartilage may be excised with the specimen. The subglottic mucosa or cricothyroid membrane may
also need to be resected if required for adequate clearance.
Tumours of the infra-hyoid epiglottis are more challenging to excise transorally as pre-epiglottic space extension
may be present even if not detected on staging imaging. If
pre-epiglottic space involvement is suspected, the preepiglottic fat pad must be divided, approached via the vallecula to ensure adequate exposure and visualisation of the
anterior limit of the tumour. To achieve this, the medial
glosso-epiglottic fold is divided, and the suprahyoid epiglottis is transected in the sagittal plane. This exposes the preepiglottic fat and the laryngeal surface of the epiglottis.
Resection of an ipsilateral arytenoid may also be performed,
but to avoid signicant aspiration and laryngeal incompetence, bilateral arytenoidectomy should not be undertaken.
All resected specimens should be assessed for adequacy
of margins, and further marginal biopsies can be taken if
there is any uncertainty. Specimens must be orientated for
accurate histopathological assessment. Glottic resection
specimens may be too small to pin to a board and can be
mounted with tissue glue onto a piece of desiccated cucumber with a triangular cut out to represent the glottic inlet.
Thorough description, ideally with operative photographs
and diagrams on the pathology form, will assist the pathologist in comprehending the area resected, plus the location of
any extramarginal tissue specimens.
36.5 Post-operative Care
36.4.2 Supraglottic Resection
Suprahyoid supraglottic tumours are ideal for transoral laser
resection, particularly those on a free edge of the epiglottis,
on the lingual surface or tumours of the ventricle or aryepiglottic fold. En bloc tumour excision is normally feasible
for such lesions as access is typically good; however, bulkier lesions can be transected to enable access to inferior
aspects.
Although uncommon, post-operative airway compromise is
a potential risk of transoral laser surgery. This mandates a
period of observation for signs of airway obstruction in the
immediate post-operative period, although most patients
undergoing limited laser laryngeal surgery may be safely
managed on a day case basis.
Intravenous dexamethasone is administered on induction
of anaesthesia, with repeated doses post-op if required.
Nebulised adrenaline (5 mL of 1/1000) should be given if
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L. Warner et al.
signs of airway compromise are observed. Analgesic requirements are minimal, and simple analgesics or small doses of
oral morphine solution normally sufce.
Glottic resections rarely compromise swallowing function, in the absence of pretreatment dysphagia. However, all
patients undergoing supraglottic resections should be
assessed preoperatively and post-operatively by a head and
neck speech and language therapist as these patients may be
at risk of aspiration.
Resective pathology should be discussed in a head and
neck multidisciplinary team meeting for cases of invasive
carcinoma. The technique of TLM resection frequently leads
to laser coagulation at tumour margins, which can compromise pathological assessment of tumour clearance. Separate
marginal/patient-side biopsies at time of the TLM resection
can provide additional condence on tumour clearance.
Cases where margins are close or involved warrant further
microscopic assessment, potentially with repeated resection
to ensure clearance, at approximately 6 weeks postoperatively [31]. Regular follow-up with breoptic laryngoscopy is indicated in all cases, ideally with serial endoscopic
pictures for case notes to allow comparison. Narrow band
imaging is benecial in endoscopic surveillance and should
be utilised where available.
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G.Glottic laser surgery: outcomes according to 2007 ELS classication. Eur Arch Otorhinolaryngol. 2011;268:1771–8.
16. Taylor SM, Kerr P, Fung K, Aneeshkumar MK, Wilke D, Jiang Y,
etal. Treatment of T1b glottic SCC: laser vs. radiation—a Canadian
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17. Peretti G, Piazza C, Cocco D, De Benedetto L, Del Bon F, Redaelli
De Zinis LO, Nicolai P. Transoral CO(2) laser treatment for
T(is)-T(3) glottic cancer: the University of Brescia experience on
595 patients. Head Neck. 2010;32:977–83.
18. Fang TJ, Courey MS, Liao CT, Yen TC, Li HY.Frozen margin
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Iro H. Comparison of different surgical approaches in T2 glottic
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Part XV
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Laryngeal Surgery: Open Approaches
Total Laryngectomy
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HansEdmundEckel andMiquelQuer
37
37.1 Introduction
Total laryngectomy for the treatment of laryngeal cancer was
rst performed in Vienna in 1873 by Theodor Billroth. It
became the rst standardised major procedure in head and
neck oncological surgery and still has a place in the era of
chemo-radiation. Advanced laryngeal and hypopharyngeal
cancer is the main indication for performing total laryngectomy. The aim of the operation is the removal of the entire
larynx from the tongue base down to the cervical trachea.
The procedure generally requires general anaesthesia with
intubation of the airway and post-operative monitoring of the
patient at an intermediate care unit. If total laryngectomy is
done for previously untreated cancer of the larynx or hypopharynx, a unilateral or bilateral neck dissection will invariably be an integral part of the surgical concept, and
postoperative (chemo-) radiotherapy will usually be recommended after surgery. In hypopharyngeal cancer, a partial or
total pharyngectomy is included in the procedure, frequently
together with a unilateral or subtotal thyroidectomy. The
operation results in a complete separation of the alimentary
tract from the airway and requires a permanent tracheostomy. Post-operatively, the patient will depend on a nasogastric feeding tube or intravenous alimentation for a couple of
days, before an oral diet can be resumed. Major complications include wound infection, wound dehiscence, pharyngocutaneous stula and secondary bleeding. Although
nonsurgical organ-preservation protocols have now replaced
total laryngectomy for the treatment of many moderately
advanced tumours, it is still the standard of care for most
H. E. Eckel (*)
Department of Oto-Rhino-Laryngology, Klinikum Klagenfurt am
Wörthersee, Klagenfurt am Wörthersee, Austria
e-mail: hans.eckel@kabeg.at
M. Quer
Department of Otorhinolaryngology–Head and Neck Surgery,
Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de
Barcelona, Barcelona, Spain
e-mail: mquer@santpau.cat
high-volume tumours and for those with gross cartilage inltration. In spite of the deleterious impact on quality of life, it
is the only viable option for recurrent disease after initial
nonsurgical treatment and for chronic aspiration in patients
with a nonfunctioning larynx [1].
37.2 Indications
Current indications for total laryngectomy are essentially the
following ones [2]:
• Advanced laryngeal and hypopharyngeal malignant
tumours (mostly squamous cell carcinoma) [3]
• Recurrent laryngeal and hypopharyngeal cancer after
failed radiation or chemo-radiation therapy [4]
• Severe and not otherwise manageable chronic aspiration
in a nonfunctioning larynx (resulting from nonsurgical or
surgical organ-preservation approaches to laryngeal cancer or from neurological disorders) [5, 6]
Prior to advising and scheduling total laryngectomy, alternative approaches to the disease need to be discussed in an
institutional tumour board. Relevant alternatives to total laryngectomy include partial laryngectomy (open or via a transoral route), radiotherapy and chemo-radiation. For recurrent
primary cancer, the best supportive care and/or chemotherapy
alone need to be discussed. For chronic aspiration, simple tracheostomy and provision of an inatable cannula, laryngotracheal separation or closure of the larynx may be considered.
Because total laryngectomy is essentially not reversible, the
indication should be checked meticulously, and alternatives
should be considered with the patient.
Prior to discussing the indications for total laryngectomy,
a thorough preoperative assessment is required, which will
include a general medical assessment, basic laboratory studies and pulmonary function tests. The latter are particularly
important in patients with a longstanding history of smoking
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_37
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