return to: Laryngeal Surgery (Malignant Disease) Protocols

click to see: Vertical Partial Laryngectomy Case Example

Note Jan 2024: the open approach to hemilaryngectomy described below is less commonly used due to expanded use of endoscopic resection as well as common treatment with irradiation

(for an update see reference: Syme 2021)

GENERAL CONSIDERATIONS

1. Definitions
   1. Hemilaryngectomy is defined as an operation to remove the anterior soft parts of the larynx in continuity with the underlying thyroid cartilage. Vertical partial laryngectomy is similarly defined but may include modifiers to more specifically define the extent of laryngeal removal.
      1. Laterovertical partial laryngectomy is a standard hemilaryngectomy wherein a vocal cord, up to the anterior commissure, is resected with underlying cartilage extending posteriorly to include part of the arytenoid if necessary.
      2. Anterovertical partial laryngectomy includes resection of the anterior commissure, which generally requires that part of the contralateral vocal cord is resected as well. Anterolateral-vertical partial laryngectomy is a larger resection including both the anterior commissure, ipsilateral vocal cord, and underlying cartilage.
   2. These terms describe procedures designed to remove cancer yet still maintain the three primary functions of the larynx: breathing, swallowing, and phonating. Strictly defined, these procedures are limited by preservation of the cricoid inferiorly. It is possible to extend beyond traditional resection limits and maintain laryngeal function employing advanced reconstructive techniques. For example, a functional subglottic airway may be maintained after resection of half the cricoid cartilage if reconstruction is effected through long-term stenting or free tissue transfer employing microvascular technique.
   3. A vertical partial laryngectomy can also be extended to remove a more extensive cancer without preserving all laryngeal function. A three-quarters (near-total or Pearson) laryngectomy preserves swallowing and a laryngeal-based phonating mechanism but requires a permanent tracheostomy to maintain breathing.
   4. Cancer involving the glottic larynx that extends beyond that encompassed by strictly defined vertical partial laryngectomy may be successfully resected with preservation of laryngeal function employing supracricoid laryngectomy (see Supracricoid Laryngectomy with Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP) protocol).
2. Indications for Vertical Partial Laryngectomy
   1. Debate continues regarding which cases are best treated with surgery and which with irradiation. Most cases of laryngeal cancer affecting the glottis that can be treated with vertical partial laryngectomy can be successfully managed with irradiation as a primary modality, reserving surgical salvage for irradiation failures. The strongest arguments favoring surgery (vertical partial laryngectomy) as a primary treatment of early (T1 or T2) glottic cancers are made for glottic cancer with subglottic extension, glottic cancer involving the anterior commissure, T2 glottic cancer with impaired vocal cord mobility, and when the histology is the radiation-resistant verrucous variant of squamous cell carcinoma.
   2. General indications for vertical partial laryngectomy:
      1. T ~1 or T ~2 glottic cancers not amenable to endoscopic laser excision or irradiation
      2. T ~2 glottic cancers with impaired vocal cord mobility
      3. rT ~1 or rT ~2 glottic cancers recurrent after irradiation
      4. T ~1 or T ~2 glottis cancers in patients who prefer to avoid XRT
      5. T ~1 or T ~2 verrucous carcinoma of the glottis
      6. Selected T ~3 glottic cancers with cord fixation
      7. T ~1 or T ~2 glottic cancers affecting the anterior commissure
3. Contraindications
   1. Subglottic extension greater than 10 mm anteriorly or 5 mm posteriorly
   2. Most T ~3 glottic cancers
   3. Involvement of an entire vocal cord and more than one-third of the contralateral vocal cord (see Supracricoid Laryngectomy protocol) 

PREOPERATIVE PREPARATION

1. Evaluation
   1. CT of larynx (thin cut, with contrast) (see Head and Neck CT Protocols) in all anterior commissure lesions, selected other lesions to assess for paraglottic, pre-epiglottic, and extralaryngeal extension. CT is generally used for all but the most superficial T ~2 glottic lesions and for all supraglottic lesions.
   2. Panendoscopy (see Panendoscopy protocol) with biopsies to include microscopic direct laryngoscopy and tumor mapping
   3. Radiation oncology consult to discuss alternatives to surgery
   4. Videoendoscopy to record voice and dynamic appearance of larynx (see Videostroboscopy protocol)
   5. Chest x-ray
   6. Tumor Board discussion
2. Consent
   1. Describe procedure: "Through incision in your neck, part of the voice box/retain part of the vocal cords. If tumor extends further than we have assessed, may require removal of entire voice box." "A tracheotomy, incision into your windpipe will be made to permit you to breathe as the healing progresses."
   2. Describe potential complications: Bleeding, infection, reaction to the anesthetic, damage to structures
      1. Loss of voice
      2. Aspiration with inability to swallow
      3. Long-term dependence on tracheotomy
   3. General principle: Do not offer a partial laryngectomy to a patient unless they are prepared for total laryngectomy if the tumor extent at the time of surgery is found to be greater than initially anticipated
3. Counseling
   1. Include services of a speech pathologist to identify what to expect regarding potential "life without the larynx"

NURSING CONSIDERATIONS

1. Room Setup
2. See Basic Soft Tissue Room Setup
   1. Instrumentation and Equipment
      1. Standard
         1. Major Instrument Tray 1, Otolaryngology
         2. Major Instrument Tray 2, Otolaryngology
         3. Oto Extraction Tray
         4. Oto Silverglide Bipolar Tray 2 Test
         5. Bien Otologic Electric Drill Tray
         6. Direct Laryngoscope Tray
         7. Anspach Drill Tray
         8. Hall Micro Sagittal Saw Tray (Pneumatic)
      2. Special
         1. Tracheotomy Tray (if tracheotomy done before procedure)
         2. Sterile anesthesia breathing circuit, adult
         3. Halsted micro-line artery forceps, curved, 5 in
         4. Rousch Laryngoflex 7 mm endotracheal tube
         5. Silk enteral feeding tube, 12 fr, 42 in (Corpak)
         6. Nerve stimulator control unit and instrument
   2. Medications (specific to nursing)
      1. Antibiotic ointment
   3. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
         1. Head drape
         2. Square off the neck with towels from chin to clavicle
         3. Plastic orthopedic drape, placed under head and shoulder to make a trough to prevent solutions from pooling
         4. Split sheet
   4. Drains and Dressings
      1. Antibiotic ointment to suture line
      2. Passive Penrose drains
   5. Special Considerations
      1. Confirm if the Tracheotomy will be done first, as a separate procedure, or as part of the procedure
      2. Possibility of a Skin Graft done in conjunction with procedure

ANESTHETIC CONSIDERATIONS

1. Induction
   1. Systemic medications
      1. Antibiotics (see Antibiotic protocol)
      2. Consider Decadron 8 to 10 mg to diminish postoperative edema
   2. Oral endotracheal intubation may require critical attention to management of an uncertain airway. Discussion between the surgeon and anesthesiologist improves safety. The difficult airway may best be managed by:
      1. Management of the airway as if treating supraglottitis
      2. Flexible fiberoptic awake intubation
         Narrowing at the level of the glottis is a relative contraindication to use of fiberoptic intubation in the placement of the fiberoptic scope may obstruct the airway. Fiberoptic intubation is most useful when the obstruction is above the level of the larynx (ie oropharynx).
      3. Tracheotomy under local anesthesia
2. Positioning
   1. A tracheotomy under local anesthesia is done with the patient's head toward anesthesia (turned 0°).
   2. Panendoscopy, if it is to precede the vertical partial laryngectomy, may be done at 0°, but more commonly with the table turned 90° away from anesthesia, head facing the door.
   3. The vertical partial laryngectomy is performed with the table turned 180° to permit access to both sides of the neck.
   4. A shoulder roll may be placed for the tracheotomy (if it is tolerated), panendoscopy, and laryngectomy. More commonly extension of the head support may be used to achieve the same goal without placement of a shoulder roll.
   5. The head of bed is elevated to diminish bleeding.

OPERATIVE PROCEDURE

1. Tracheotomy
   1. Use horizontal skin incision to avoid connection with neck incision (as may occur with a vertical tracheotomy incision). In almost all other cases a vertical incision is made.
2. Hemilaryngectomy or Vertical Partial Laryngectomy
   1. Transverse skin incision is made at midpoint of thyroid cartilage.
   2. Separate strap muscles in the midline and elevate off the underlying thyroid cartilage as perichondrium is conjointly lifted.
   3. Incise perichondrium vertically across midline toward uninvolved side (so that closure will overlie the opposite thyroid ala).
   4. Incise perichondrium transversely at superior and inferior margins of ala and elevate to within 8 mm of posterior ala. Preserve the perichondrium. 
   5. Liberally inject 1% lidocaine with 1:100,000 epinephrine into all soft tissue before making incisions to improve hemostasis. This injection helps with "hydrodissection" in elevation of the perichondrium.
   6. Make incision in cricothyroid membrane and spread open with hemostat to define location of anterior commissure and tumor before making cartilage cuts; alternatively, enter superiorly.
   7. Open larynx anteriorly with vertical cartilage cut (with saw or rotating drill) at midline or across midline, as determined by where tumor is located. Enter laryngeal lumen with scalpel cut from inferior to superior margin of thyroid cartilage.
   8. With tumor well exposed through this laryngofissure, make posterovertical cartilage cuts with saw or drill approximately 8 mm from posterior margin.
   9. Use scissors to complete superior and posterior cuts.
   10. Continue vertical cuts to cricoid and join the two along it. May take one-half the height of the cricoid.
   11. When the vocal process is uninvolved, save the arytenoid.
   12. Send margins for frozen section analysis.
   13. Place nasogastric tube.
   14. Tuck strap muscles inside perichondrium and close vertical incision. Consider placement of a Penrose drain.
   15. If the contralateral vocal cord is partially resected it may be useful to place an umbrella keel which is removed 6 weeks later. Placement of the keel is designed to maintain additional anterior-posterior dimension of the glottis to improve the airway.

POSTOPERATIVE CARE

1. With uneventful recovery, may feed orally as soon as postoperative days 2 or 3, if arytenoid not taken.
2. Decannulation dependent on amount of resection and reconstruction (may be as soon as postoperative day 7 or it may be months later).

REFERENCES

Hoffman HT, Karnell LH. Laryngeal cancer. In: Steele GD, Jessup JM, Winchester DP, Menck HR, Murphy GP, eds. National Cancer Data Base Annual Review of Patient Care 1995. Atlanta, Ga: American Cancer Society; 1995: 84-99.

Hoffman HT, McCulloch TM. Management of early glottic carcinoma. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. 3rd ed. St. Louis, Mo: Mosby. 1998;2187-2200.

McCulloch TM, Hoffman HT. Changing trends in the treatment of laryngeal cancer. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. 2nd ed. Update 1. St. Louis, Mo: Mosby. 1995:11-34.

Shah JP, Karnell LH, Hoffman HT, et al. Patterns of care for cancer of the larynx in the United States. Arch Otolaryngol. 1997;123:475-483.

Hoffman HT, Porter K, Karnell LH, Cooper JS, Weber RS, Langer CJ, Ang KK, Gay G, Stewart A, Robinson RA.  Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope, 2006 Sep; 116(9 Pt 2 Suppl 111):1-13.

McWorter AJ, Hoffman HT. Transoral laser microsurgery for laryngeal malignancies. Curr. Probl Cancer, 29 (4):180-9, 2005 July-August.

Kim DR, Kevin h, Smith ME. Endoscopic vertical partial laryngectomy.  Laryngoscope 2004; 114 (2):236-240

Syme NP , Henry T. Hoffman,Carryn Anderson, Nitin A. Pagedar. 106 Management of Early Glottic Cancer. Cummings Otolaryngology. Elsevier. 2021