Int

The ultimate goal of treatment of glottic malignancy is eradication of the cancer and preservation of maximum function. Ideally this would mean return of normal speech, respiration and deglutition. The foundation of vertical partial laryngectomy (VPL) is based on the knowledge of laryngeal anatomy and an understanding of how cancers invade the larynx. The VPL surgery of the glottic cancer is based on oncological sound principles, which will be further disscussed in this article. For the purpose of description we briefly presented 3 of our cases that underwent vertical partial laryngectomy for glottic cancer.

Mr MTR a 69-year-old Malay man, who was a non-smoker, was noted to have hoarseness during regular check up by ENT Surgeon for his right chronic suppurative otitis media. Examination of the larynx revealed a mass on the right vocal cord (VC) with irregular mucosa. However, the VC mobility was normal. Direct laryngoscopy and biopsy of the lesion showed squamous cell carcinoma. The tumour was staged T_1aN_oM_x. He underwent right vertical partial laryngectomy (VPL). Postoperative recovery was uneventful. Few months later he developed anterior glottic web that was subsequently ablated by CO2 laser under general anaesthesia. He is still under regular follow up for more than fifteen months with no evidence of recurrence (fig. 1). He is able to phonate with some degree of hoarseness and no symptoms of aspiration.

Mr KLH, a 54-year-old, Chinese man, was referred from private hospital for residual glottic carcinoma stage II after irradiation. Examination showed lesion on the right VC with limited cord mobility. Biopsy of the lesion confirmed residual cancer staged as T₂N₀M_x. Right VPL was performed on him. He developed subcutaneous emphysema following early decanulation of the tracheostomy tube on 4^th postoperative day, which completely resolved with conservative management. Subsequent follow up for more than a year showed no evidence of recurrence (fig.1). He does not have any aspiration problem.

Mr PSB, a 72-year-old diabetic with chronic obstructive airway disease (COAD) was diagnosed to have carcinoma of esophagus in 1997. He had radiotherapy and the disease was in complete remission. Seven years later he presented with worsening hoarseness and a lesion on the left VC. Biopsy confirmed diagnosis of squamous cell carcinoma of the left vocal cord. He underwent left VPL with left lateral neck dissection. Postoperative recovery was uneventful until twelve months post-operatively he died following severe exacerbation of COAD with pneumonia. Prior to this event, he did not complain of aspiration and no evidence of tumour recurrent in laryngoscopic examination (fig. 2).


Fig. 1: Laryngoscopic view of the larynx in case 1 and case 2 one year after operation.

Fig. 2: Laryngoscopic view of the larynx in case 3 six months after operation.

Embryologically and anatomically, the larynx is an organ of considerable complexity. It is important to understand the important features of laryngeal anatomy that influence the spread of laryngeal cancer in order to get a successful conservative surgical approach in the treatment of laryngeal malignancy. The site of origin of the primary tumour determines the growth and spread of laryngeal cancer.

The glottic region develop from paired structures that fuse in the midline at the anterior commissure. The anterior commissure tendons form a barrier for spread from one vocal cord to the other and this formed the basis of vertical partial laryngectomy of glottic cancer, but it are different for supraglottis and subglottis where the circumferential spread is not restricted.¹ The glottic level arises from lateral cells masses that come together and the lymphatic drainage tend to be ipsilateral.

There are a number of options in organ preservation surgery (OPS) available to treat cancer of the glottis. The approaches either endoscopically or open surgical techniques. This surgery in a very selective and appropriately chosen lesion can gain good local control. The surgical options for open surgical techniques are laryngofissure with cordectomy, vertical partial laryngectomy, frontolateral hemilaryngectomy, hemilaryngectomy, anterior commisure resection or subtotal laryngectomy.

Weinstein et. al.² has proposed three important points for OPS which are (a) accurate assessment of the origin and extent of the cancer (b) accurate assessment of the patient as a surgical candidate and (c) a thorough understanding of available surgical technique and the pre-operative management issues.

The evaluation of the primary site comprises a routine clinical examination, direct laryngoscopy under general anaesthesia and radiological studies. Pain at the level of the thyroid ala at the time of palpation is indicative for thyroid cartilage invasion. Neck palpation also important to rule out any cervical lymphadenopathy. Flexible nasolaryngoscopic examination allow for analysis of the site of origin, surface extent and laryngeal mobilities together with the characteristics of airway impairment. Examination under anaesthesia with direct laryngoscope is an important adjunctive measure, which allows for close up views to assess the extension into the ventricle or subglottic extension, ability to palpate the arytenoid mobility and to take adequate tissue biopsy. High resolution computerized tomography (CT) or magnetic resonance imaging (MRI) of the larynx supplements the clinical and endoscopic evaluation at the primary site especially the status of the paraglottic and pre-epiglottic spaces and the subglottic extent of the tumor as well as thyroid and cricoid cartilage invasion.^2,3 No matter how precise the pre-operative evaluation, the final decisions for the appropriateness of VPL must be made at the time of the laryngeal exploration. Therefore the consent must include the possibility of total laryngectomy. It is also important to evaluate the patient general medical status. The most crucial system to be evaluated is the respiratory system, where the successful rehabilitation after partial laryngectomy is dependent on adequate pulmonary reserve. One of the complications for VPL approach is aspiration.

Certain contraindications exist for VPL ie. fixation of the cricoarytenoid joint, extensive thyroid cartilage invasion, transglottic tumour and tumour involving both the arytenoid cartilages. Others are tumour involving one entire cord with anterior commisure and greater than one third of the contralateral cord that cannot be functionally reconstructed after adequate tumour free margins are obtained, tumour extent to the posterior commisure and subglottic extension greater than 10 mm anteriorly and 5 mm posteriorly.^2,4,5Vertical partial laryngectomy can be used to treat T₂ and when limited T₃ cancer of the glottis with minimal subglottic extension and supraglottic involvement confined to the inferior surface of the false cord.⁶

The neo-glottis can be reconstructed by rotating into the larynx an unpedicled omohyoid muscle or a bipedicle sternohyoid muscle. In all of our cases the neo-glottis was reconstructed by the later technique. There are many other ways of reconstructing the glottis, which are not going to be disscussed in this article but whatever the way is, the goals of reconstruction include an adequate airway, normal deglutition with airway protection and good voice strength. A surgical drain should be placed and pressure dressing to help minimize subcutaneous emphysema and perioperative antibiotic should be commenced to diminish the likelihood of infection. Nasogastric feeding during this period minimizes coughing, gastroesophageal reflux and aids formation of airtight seals. The tracheostomy tube used is non-cuffed to avoid necrosis of the tracheal rings and to reduce local infection. It is removed once the laryngeal oedema has subsided usually on the 7 to 10 postoperative day. Oral intake is commenced after the tracheostoma healed to allow for adequate of glottic closure.

The complications of VPL includes wound complications such as seroma or hematoma, subcutaneous emphysema, delay in decannulation due to persistent airway oedema, stenosis, some degree of permanent hoarseness, long-term dysphagia and aspiration pneumonia. In all the cases demonstrated above the surgical margins were reported to be free from the cancer. Subsequent follow up for more than 12 months revealed no evidence of residual tumour, except for Case 3 who died of severe exacerbation of COAD.

Even though the number of cases in this report are limited but we strongly feel that in a properly selected glottic cancer vertical partial laryngectomy is a feasible surgical treatment.

Correspondence address:
Dr. Raja Ahmad.
Department of Otolaryngology - Head & Neck Surgery,
Kulliyyah of Medicine,