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Vertical Partial Laryngectomy
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PhoebeRoche andJonathanM.Bernstein
38
38.1 Introduction
Vertical partial laryngectomy is suited to a very small selection of cancers affecting one side of the larynx. The operative
approach can avoid the permanent tracheal stoma and some
morbidity of total laryngectomy in functionally well patients.
The purpose of vertical partial laryngectomy is to achieve
adequate surgical extirpation of early malignancies of the
glottic larynx via an open approach while maintaining functional voice, airway and swallow and avoiding total laryngectomy. Vertical partial laryngectomy can achieve local
tumour control in 73–93% of patients.
The great majority of tumours involving one vocal cord
can be cured by either transoral resection or radiotherapy
with excellent functional outcome, avoiding the risks of
any open surgery. Thus, vertical partial laryngectomy is
reserved for occasional salvage surgery and rare radioresistant malignancies affecting one side of the larynx, such as
chondrosarcoma.
38.2 Indications
In patients with good functional status, vertical partial laryngectomy may be considered for radiorecurrent or radioresistant unilateral glottic malignancies. In general, for vertical
partial laryngectomy to be favoured over a transoral surgical
approach, the tumour would have to be far enough lateral or
involving the thyroid cartilage. There should not be tumour
extension beyond the ipsilateral glottic larynx. Tumours with
supraglottic, subglottic or contralateral glottic extension
generally necessitate total laryngectomy.
The principal concerns surrounding vertical partial laryngectomy are the risks of residual or recurrent local tumour,
long-term aspiration, dependence on tracheostomy and
stula.
In addition to tumour factors, patient factors should be
appraised. A thorough evaluation of the patient’s functional
status and their informed preference for treatment is
essential.
The adequacy of the resection and the success of reconstruction are crucial considerations. Surgical unit volume
and surgeon training and experience will inuence the success or failure of vertical partial laryngectomyand whether it
is considered. Outcome also relies on pre- and postoperative
support from highly specialised speech-language therapy,
dietetics and specialist nursing staff.
Multidisciplinary team engagement in patient selection is
essential. Preoperative evaluation includes stagingpanendoscopy, obtaininga denitive histological diagnosis,
contrast-CT scanning to rule out extralaryngeal extension
and distant metastasis, video uoroscopy, pulmonary function testing and other ancillary tests.
P. Roche
Department of Otolaryngology– Head and Neck Surgery, Royal
London Hospital, Barts Health NHS Trust; Head & Neck
Academic Centre, London, UK
Department of Targeted Intervention, University College London,
London, UK
e-mail: Phoebe.roche@nhs.net
J. M. Bernstein (*)
Department of Otolaryngology– Head and Neck Surgery, Imperial
College Healthcare NHS Trust, Charing Cross Hospital,
London, UK
e-mail: j.bernstein@nhs.net
© 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_38
38.3 Preoperative Checklist,
Considerations andAnaesthesia
Patients should undergo counselling on the disease process
and the options for management. Following multidisciplinary review, vertical partial laryngectomy may be offered
and discussed with the patient. Informed consent must
include full discussion of the risks of surgery, which include
bleeding, infection, loss of voice, aspiration with an
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P. Roche and J. M. Bernstein
inadequate swallow, aspiration pneumonitis, granulation or
stenosis, tracheostomy-dependence, residual or recurrent
tumour, intraoperative or laterconversion to total laryngectomy and perioperative death.
38.4 Surgical Technique
38.4.1 Positioning andPreoperative Measures
A decision with anaesthesia is made regarding regular intubation, awake breoptic intubation or tracheostomy under
local anaesthesia. A central line, urinary catheter and nasogastric tube are placed after the induction of anaesthesia. The
WHO checklist is completed.
Once the airway is secure, direct laryngoscopy is performed to gain a current view of the tumour and conrm
whether vertical partial laryngectomy is still appropriate.
The patient is positioned supine in neck-extension.
38.4.2 Tracheostomy Tube Insertion
Initially, a reinforced endotracheal tube is inserted by minimal access via a short transverse cutaneous incision midway
between the cricoid cartilage and suprasternal notch, into a
wide transverse tracheotomy made between tracheal cartilages held open with a cricoid hook. The endotracheal tube is
sutured securely to the sternum with two gure-of-eight 2-0
silk sutures so as not to impede access. At the end of the
operation, the tracheostomy is re-cannulated by exchange
with a regular tracheostomy tube and sutured to the skin of
the anterior neck with ve 2-0 silk sutures.
borders of the thyroid cartilage bilaterally and reected open
to the posterior border of the thyroid ala. The outer perichondrium and the overlying strap muscles are kept attached to
one another to facilitate the reconstruction. The free edges of
the perichondrium are sutured to the strap muscles to prevent
desiccation of the perichondrium.
38.4.5 Laryngossure andTumour Dissection
A 90° oscillating saw is used to make a midline vertical incision (or laryngossure) into the thyroid cartilage, but not the
lumen of the larynx (Fig. 38.1a). A transverse incision is
made into the cricothyroid membrane at a safe distance from
the tumour. The cartilage is opened bilaterally. The anterior
commissure and tumour are inspected before the inner perichondrium is dissected from cartilage (Fig.38.1b).
Alternatively, the thyroid lamina may be resected with the
tumour to ensure a clear margin. If the cartilage is involved
by the tumour, the external perichondrium should not be preserved. If the vocal process is not involved, the arytenoid
should be preserved. A silastic keel or Montgomery laryngeal stent may be used where the contralateral anterior commissure has been excised, to optimise the anteroposterior
length of the glottic airway and reduce the risk of glottic
web.
38.4.6 Margins
Marginal biopsies may be taken from the defect, particularly
at sites of concern. The specimen may also be analysed by
frozen section if the immediate conversion to laryngectomy
was considered.
38.4.3 Incision andExposure oftheLarynx
A transverse cutaneous incision is made over the midpoint of
the thyroid cartilage. A subplatysmal ap is elevated superiorly to the level of the hyoid boneand an inferior subplatysmal ap is elevatedwhile avoiding communication with the
tracheostomy. The sternohyoid and sternothyroid strap muscles are parted at their raphe, keeping their superior and inferior pedicles intact. The larynx is exposed in the midline
from the hyoid bone superiorly to the cricoidcartilage inferiorly, preserving the superior laryngeal neurovascular
bundle.
38.4.4 Elevation ofthePerichondrium
The outer perichondrium of the thyroid cartilage is incised in
the midline anteriorly and along the superior and inferior
38.4.7 Reconstruction
With the outer perichondrium now lining the lumen of the
airway at the site of the resection, vascularized strap muscle
is placed on the inner aspect of the thyroid cartilage graft, or
in replacement of thyroid lamina if excised (see Fig.38.1c–e).
The thyroid laminae are then reapproximated anteriorly with
a ne, absorbable monolament suture on a taper needle. A
passive drain and nasogastric feeding tube are inserted. Parts
of the surgery are best conducted under magnication, such
as with loupes or amicroscope.
38.4.8 Reconstruction ofLarger Defects
Alternative reconstructive techniques can provide a vascularized construct with unirradiated tissueand aphonatory sur-
ab
38 Vertical Partial Laryngectomy
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c
d
External thyroid
perichondrium
Fig. 38.1 Vertical partial laryngectomy via laryngossure approach
with preservation of thyroid lamina (a and b) and reconstruction with a
strap muscle and perichondrium advancement ap (c and d). (a)
Elevation of external perichondrium and laryngossure. (b) Resection
of tumour. (c) Bipedicled muscle ap and external thyroid perichondrium. (d) Bipedicled ap with perichondrium rotated in
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P. Roche and J. M. Bernstein
face. One example is the temporoparietal fascia free ap
reconstruction with cartilage and buccal-mucosa grafts; a
Montgomery laryngeal stent is used in the rst 10days to
helpprevent stenosis.
38.5 Post-operative Care
Prophylactic antibiotics are administered intravenously in
three doses. Patients are mobilised on the rst postoperative
day, chest physiotherapy is administered twice a day and
venous thromboembolism prophylaxis is given. Patients are
fed by nasogastric tube for 1week before a formal swallow
assessment such as video uoroscopy with a highly specialised speech and language therapist.
The tracheostomy is downsized with cuff deated and
capped after aspiration has become minimal. The tracheostomy may be removed from the tenth post-operative day
depending on the degree of aspiration demonstrated on swallow assessments and the patency of the airway. Any silastic
keel or Montgomery laryngeal stent may be removed at a
suitable time after surgery following active rehabilitation of
speech and swallowing function.
Suggested Reading
Ambrosch P, Fazel A.Functional organ preservation in laryngeal and
hypopharyngeal cancer. GMS Curr Top Otorhinolaryngol Head
Neck Surg. 2011;10:Doc02. https://doi.org/10.3205/cto000075.
Biller HF, Lawson W.Partial laryngectomy for vocal cord cancer with
marked limitation or xation of the vocal cord. Laryngoscope.
1986;96:61–4.
Gilbert RW, Goldstein DP, Guillemaud JP, Patel RS, Higgins KM,
Enepekides DJ. Vertical partial laryngectomy with temporoparietal free ap reconstruction for recurrent laryngeal squamous cell
carcinoma: technique and long-term outcomes. Arch Otolaryngol
Head Neck Surg. 2012;138:484–91. https://doi.org/10.1001/
archoto.2012.410.
Laccourreye O, Weinstein G, Brasnu D, Trotoux J, Laccourreye
H.Vertical partial laryngectomy: a critical analysis of local recurrence. Ann Otol Rhinol Laryngol. 1991;100:68–71.
Olsen KD, DeSanto LW. Partial vertical laryngectomy—indications
and surgical technique. Am J Otolaryngol. 1990;11:153–60.
Vega SF, Scola B, Vega MF, Martinez T, Scola E. [Laryngeal vertical
partial surgery. Surgical techniques. Oncological and functional
results]. Acta Otorhinolaryngol Ital. 1996;16:272–80. Italian.
Horizontal Partial Supracricoid
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Laryngectomy with Crico-Hyoidopexy
or Crico-Hyoido-Epiglottopexy
GiovanniSucco, GiuseppeRizzotto, andErikaCrosetti
39
39.1 Introduction
Several approaches are available for the treatment of laryngeal cancer at the different primary tumour (T) and nodal (N)
stages, with comparable rates of overall survival, locoregional control and laryngectomy-free survival.
Surgery can be offered to patients as a valuable method to
preserve part of the larynx and its functions (phonation and
swallowing), avoiding the negative physical and psychosocial impact of a permanent tracheostomy [1]. A model for a
rational classication of open partial horizontal laryngectomies (OPHLs) was proposed in 2014 by the European
Laryngological Society (ELS), based on the cranio-caudal
extent of laryngeal resection. It dened three types: supraglottic partial laryngectomy (type I, SGPL), supracricoid
partial laryngectomy (type II, SCPL) and supratracheal partial laryngectomy (type III, STPL) [2].
OPHL type II is considered the most established solutions
for the treatment of intermediate-stage to advanced-stage
laryngeal tumours affecting the supraglottis and glottis [3,
4]; a signicant number of supraglottic, glottic or transglottic
tumors are amenable to be safely treated by supracricoid laryngectomies. Supracricoid partial horizontal laryngectomies
with crico-hyoido-epiglottopexy [5] (SCPL–CHEP or OPHL
type IIa) and supracricoid partial horizontal laryngectomies
G. Succo (*)
Department of Otolaryngology- Head and Neck Surgery,
University of Turin- Oncology Department, San Giovanni Bosco
Hospital, Turin, Italy
e-mail: Giovanni.succo@ircc.it
G. Rizzotto
Otolaryngology Department Unit, Vittorio Veneto Hospital,
Treviso, Italy
e-mail: Giuseppe.rizzotto@ulss7.it
E. Crosetti
Head and Neck Oncology Unit, FPO IRCCS, Candiolo Cancer
Institute, Turin, Italy
e-mail: erika.crosetti@ircc.it
with crico-hyoidopexy (SCPL–CHP or OPHL type IIb) [6]
have been used extensively with excellent results as upfront
treatment in early laryngeal cancer (stage I–II), as well as in
more advanced stages (stage III). In selected cases, this type
of surgery also can be adopted in advanced laryngeal cancer
with very limited extralaryngeal extension, especially when
the patient categorically refuses the option of total laryngectomy. In even more advanced cases, OPHLs have shown very
good oncological outcomes, high laryngectomy-free survival, relatively low morbidity and mortality rates and nally
acceptable functional outcomes, as long as patients are carefully selected (good general and functional conditions, cN0,
patient compliance to an intensive rehabilitation protocol,
different subcategories based on local T extent) [7, 8]. After
appropriate selection-based essentially on pre- and posttreatment tumour extent, OPHLs also can be used as salvage
procedures in radio-recurrent [9] and laser-recurrent [10]
laryngeal cancer, achieving comparable survival rates, an
acceptable (although higher) morbidity, effective swallowing
and a sufciently intelligible voice.
39.2 Preoperative Checklist,
Considerations andAnaesthesia
The rst and probably most important selection is conducted
on the basis of patient-related factors and the most accurate
work-up possible. Before surgery, all patients should undergo
a number of examinations:
• Flexible videolaryngoscopy to check the extent of the
tumour and, in particular, the true vocal cord and arytenoid mobility, as well as involvement of the anterior/posterior commissure
• Intraoperative endoscopy by 0°/30°/70° telescopes with
and without an orotracheal tube in place and biopsy during microlaryngoscopy
© 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_39
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• Neck CT scan or MRI in order to study the pre-epiglottic
space (PES), the superior and inferior paraglottic space,
the subglottic extent, the cartilage status and the possible
presence of adenopathies
• Bronchoscopy and esophagoscopy to rule out synchronous tumours
• Chest X-ray or CT scan to exclude lung tumours or distant metastases
• Clinical assessment of bronchopulmonary function (ability to climb two ights of stairs without shortness of
breath) [11]
• Comorbidity assessment for at-risk patients
• Nutritional evaluation
Inclusion criteria require a Karnofsky index higher than
80. Exclusion criteria due to severe comorbidities are repre-
sented by severe diabetes mellitus, severe bronchopulmonary chronic obstructive disease, neurological problems
impairing the ability to expectorate and/or swallow, severe
cardiac disease and impairment of swallowing before treatment. Caregiver availability is also an important issue, considering the possible long and ‘difcult to manage’ period
required for the recovery of normal swallowing function.
Advanced age, an important cut-off for relative surgical
indications, is not considered an exclusion criterion in itself;
much importance is given today to the biological age of the
patient [12]. In any case, as shown by Benito etal., advanced
age and a more extensive surgery (OPHL type IIb) represent
a negative prognostic factor for a prompt recovery of natural
swallowing [13].
The surgery is performed with the patient in the supine
position. After orotracheal intubation, a nasogastric tube is
placed, and support under the shoulders is used to obtain
good neck hyperextension. Tracheotomy is always performed during the procedure.
not—of a vertical virtual plane tangential to the arytenoid
vocal process and perpendicular to the ipsilateral thyroid
lamina, as well as functional data regarding arytenoid xity),
in order to identify homogeneous subcategories of T3 and
T4a laryngeal cancer treatable by OPHL with the best possibilities of success [17]. For both T2–T3 and cT4a glottic
and supraglottic tumours, the most important negative prognostic factor seems to be involvement of the inferior paraglottic space (IPGS), which is generally associated with
impaired mobility or xity of the homolateral arytenoid.
This simple criterion of anterior versus posterior anatomofunctional compartmentalisation of the larynx proved to be a
useful additional parameter in preoperative planning.
Anterior tumours sparing the posterior IPGS and not affecting arytenoid mobility are denitely manageable by such a
surgical approach, with excellent oncological outcomes.
OPHLs could also be offered to patients affected by early
anterior cT4aN0, who are strongly motivated to avoid total
laryngectomy and who decline concurrent chemoradiotherapy (CCRT).
On the other hand, posterior lesions are more difcult to
manage by conservative treatment and represent a more difcult clinical scenario. Even using OPHLs, T3 posterior
tumours with a xed vocal cord and arytenoid, as well as T4a
posterior tumours, showed signicantly worse oncologic
outcomes when compared with anterior tumours.
OPHL type IIa (SCPL–CHEP) is normally selected to
manage glottic or transglottic laryngeal cancer without
involvement of the pre-epiglottic space and with minimal
involvement of the superior paraglottic space (SPGS) (early
transglottic). OPHL type IIb (SCPL–CHP) is normally chosen to manage supraglottic or transglottic laryngeal cancer
with involvement of the pre-epiglottic space and the SPGS
and with extension to the anterior commissure, to the glottis
and the IPGS.
39.3 Indications
Historically, type II OPHLs (supracricoid partial laryngectomies) were rst used for early laryngeal cancer and recently
also have been suggested for ‘selected’ T1b-T2-T3 laryngeal
cancers [7, 14, 15]. In current practice, the term ‘selected’
means that a patient is in good general condition (prerequisite to cope successfully with probable and prolonged dysphagic sequelae) when it is reasonable to expect OPHL to be
the exclusive treatment. The same principle has sometimes
been applied, albeit with great caution, as the upfront option
in very restricted T4a cases, with minimal anterior extralaryngeal extent, when it is reasonable to expect an exclusive
treatment [8, 16].
Recently, our group identied and adopted simple
clinical- radiological criteria (matching the transgression—or
39.4 Surgical Technique withHelpful
Suggestions
Roux-Berger’s bilateral incision is made in order to obtain a
U-shaped apron ap (Fig. 39.1). The apron ap is set up
along the subplatysmal plane from 2 to 3cm cephalad to the
sternal notch toward the mastoid; this incision allows an
eventual concurrent neck dissection as well as good exposure of the suprahyoid area at least 2–3cm above the hyoid
bone. Later during the procedure, the tracheostomy will be
included in the central portion of the incision in continuity
with the latero-cervical spaces, placing them at risk of pollution from tracheal secretions. To avoid this problem, a complete tracheostomy is required, suturing the trachea to the
skin; otherwise, the tracheostomy is prepared by a lower
incision separated from the apron ap.
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39.4.1 Strap Muscle Management
The management of the strap muscles differs according to
the T-stage. In fact, when this procedure is adopted to treat
locally advanced tumours with risk of even minimal extralaryngeal extension (even minimal involvement of the
thyroid cartilage, involvement of the cricothyroid membrane,
or suspected metastasis to the Delphian lymph node), it is
preferable to resect these muscles in order to obtain the same
anterior radicality as that of total laryngectomy (Fig.39.2a).
We have found that sacrice of these structures does not
adversely affect functional recovery in terms of swallowing.
If the strap muscles are to be retained (Fig.39.2b), it is
generally preferred not to dissect the supercial cervical fascia, but to cut it vertically on the midline, together with the
middle cervical fascia, from the hyoid bone to the jugulum,
and then separate the infrahyoid muscles. The anterior jugular veins are ligated and sectioned at the level of or superior
to the hyoid bone. The strap muscles are sectioned at their
insertion with the hyoid bone and reversed downward, also
sectioning the second layer insertion to the oblique line on
the thyroid cartilage.
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39.4.2 Larynx Release
Before starting to release the larynx from its attachment in
Fig. 39.1 Roux-Berger’s bilateral incision, including the tracheostomy
ab
the neck, the supercial lymphatics from the hyoid bone to
Fig. 39.2 Management of strap muscles: (a) Strap muscle resection. (b) Strap muscle retention
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the thyroid isthmus, and in particular the Delphian node and
prelaryngeal tissue, are removed and immediately sent for
frozen sections. Positivity due to the presence of metastases
to the Delphian lymph node (obviously in the absence of
invasion of the laryngotracheal axis due to extranodal extension) can represent a further indication for execution of the
more extended OPHL type III (supratracheal partial laryngectomy or OPHL type IIIa), allowing a block resection of
the cricothyroid membrane, the cricoid ring and the isthmus
of the thyroid. In the case of invasion of the laryngotracheal
axis, the only choice is to convert the procedure into an
enlarged total laryngectomy. Finally, a gentle pretracheal nger blunt dissection is performed in order to release the trachea as far as the level of the carina, in order to facilitate the
subsequent cricohyoidopexy.
At this point, the larynx should be skeletonised before
proceeding with the resection. The larynx is rst rotated and
retracted downward, exposing the constrictor muscles and
facilitating the superior laryngeal pedicle placement above
the superior cornu of the thyroid cartilage. The ligation and
section of the vascular component of the superior laryngeal
pedicle are optional (Fig.39.3a), as they can also proceed to
punctual haemostasis during resection (Fig. 39.3b). In any
case, it is important to preserve the upper laryngeal nerve in
its lateral component because it is responsible for the sensitivity of the piriform sinus mucosa.
The pharyngeal constrictors are then incised along the lateral thyroid cartilage lamina (Figs.39.4 and 39.5) from the
superior cornu to the inferior cornu. On the side of the arytenoid to be spared, the inferior cornu is sectioned in order to
avoid any risk of injury to the underlying recurrent laryngeal
nerve, which runs at a lower level (Fig.39.6).
On the side of the patient’s larynx where the arytenoid
must be sacriced (i.e. where there is suspected tumour
involvement of the cricothyroid space), disarticulation of the
cricothyroid joint should be performed. The resection then
proceeds with a meticulous and delicate bilateral release of
the piriform sinus (see Fig.39.5) and paraglottic spaces from
the thyroid cartilage, as well as the release of the cricothyroid muscle insertion from the superolateral edge of the
cricoid.
39.4.3 Inferior Access totheResection
Inferior access to the resection is made immediately above
the cricoid ring, allowing the surgeon a complete inferior
visualisation to check the distance from the tumour
(Fig.39.7a). In the case of lesions extending for a few millimetres in the anterior subglottic region, it is possible to proceed with a subperichondrial dissection of the cricoid ring
mucosa, consequently entering the lumen lower, at the level
G. Succo et al.
a
b
Fig. 39.3 Management of the superior laryngeal pedicle: (a) Ligation
and section of the vascular component. (b) Punctual haemostasis during
resection
of the inferior border of the cricoid ring, in order to obtain a
safer supercial resection margin (Fig.39.7b).
39.4.4 Superior Access totheResection
In SCPL–CHP, the upper limit of the resection is represented
by the subperiosteal plane of the hyoid bone (Fig. 39.8a).
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Fig. 39.4 Pharyngeal constrictor muscle incision along the lateral thyroid cartilage lamina
Fig. 39.5 Careful detachment of the piriform sinus
Fig. 39.6 Sectioning of the inferior cornu of the thyroid cartilage in
order to avoid any risk of injury to the underlying recurrent laryngeal
nerve, which runs at a lower level
Emptying the contents of the pre-epiglottic space (PES) is an
integral part of the intervention (Fig.39.8b), considering the
possible involvement by the tumour. It begins with incision
of the internal periosteum of the hyoid bone and its subsequent detachment. The contents of the PES are dissected
downward, exposing the submucosa of the vallecula and the
glosso-epiglottic ligaments in transparency, which are then
removed with the specimen. Finally, the airway is entered by
incision of the glotto-epiglottic valleculae.
In the case of SCPL–CHEP, the upper limit of the resection is represented by a transepiglottic laryngotomy, perpendicular to the superior border of the thyroid cartilage and
extending through the pre-epiglottic space (Fig.39.9).
39.4.5 Resection
In our institutions, the incision is extended from above,
downward through the aryepiglottic fold, the false vocal cord
just anterior to the body of the arytenoid cartilage, the thyroarytenoid muscle anterior to the vocal process of the arytenoid and the conus elasticus, including part of the lateral
cricoarytenoid muscle and the cricothyroid membrane
(Fig.39.10a).
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Fig. 39.7 Inferior access to the resection immediately above the cricoid ring (a), or via subperichondrial dissection of the cricoid ring mucosa (b)
This incision is made from the side not involved or less
The resection is completed from the inside (Fig.39.10b):
involved by the tumour, where the arytenoid is spared, taking
care to ensure preservation of the superior laryngeal nerves
by following the lateral edges of the epiglottis. Next, the vertical incision is connected to the inferior access to the resection already performed, encompassing the whole subglottic
mucosa. The same surgical step can also be carried out from
the bottom upwards.
Only at this point can the surgeon ascertain the possibility
of completing the partial laryngectomy by visually checking
the extent of the tumour; in order to improve visualisation in
the larynx, the thyroid cartilage can be fractured along the
• Joining the incision lines along the mucosa anteriorly to
the contralateral arytenoid, in the case of a resection sparing both arytenoids
• Joining the incision lines resecting the whole lateral cricoarytenoid muscle along the superolateral aspect of the cricoid, entering the crico-arytenoid joint and resecting the
arytenoid, in the case of an operation extended posteriorly
to encompass the arytenoid
• Careful and meticulous dissection of the piriform sinus
and postcricoid mucosa
midline. At this point, the orotracheal tube can be withdrawn
into the pharynx and replaced by an endotracheal tube
inserted through the crico-tracheotomy. It is not advisable to
perform the tracheostomy before rst being sure of the true
macroscopic limits of the tumour; a tumour extending
beyond the cricoid would require a total laryngectomy
enlarged to the tracheal rings.
To avoid damaging the mucosa, it is useful to digitally
relax the ipsilateral piriform sinus, allowing a safe dissection
along the submucosa.
After haemostasis, the resection margins are always
checked with frozen sections. While waiting for the results of
the frozen sections, a tracheostomy is now made, incising
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