Supraglottic surgery of the larynx

Hajek revisited: a histological examination of the quadrangular membrane

OBJECTIVE

The predictability of laryngeal cancer spread is due in part to connective tissue membranes. These membranes function as barriers to cancer and divide the larynx into subunits. The field of laryngeal conservation surgery is based on these concepts. The quadrangular membrane plays an important role, hindering the lateral spread of cancer in the larynx. The composition of this membrane has not been well described in the literature. In this study, we examine basic characteristics of the quadrangular membrane using histological techniques.

METHODS

Whole organ sections of the larynx were used. These sections were examined under a microscope with stains specific for collagen and elastin.

RESULTS

Examination of the sections revealed that the quadrangular membrane is made up of closely woven undulating collagen and elastic fibers.

CONCLUSION

The quadrangular membrane is a fibroelastic structure providing a barrier to cancer spread.

Impact of low-thermal-injury devices on margin status in laryngeal cancer. An experimental ex vivo study

INTRODUCTION

Status of margins significantly affects disease-free survival. This study examines in ex vivo model the effect of thermal-injury on margins status comparing traditional instrument with several low-thermal-injury devices.

METHODS

We conducted a prospective study on 10 excised larynges from patients affected by advanced laryngeal cancer, to assess the thermal-effect due to surgical incisions made at standard distance by using: scalpel, CO2 Laser, harmonic scalpel and electrocautery. Upon histopathological examination, thermal damage (Surgical Artifact, SA), tissue lost/retraction (Shrinkage, S), and tissue alterations were compared for each instrument.

RESULTS

Low-thermal-injury devices increased SA mean value from 800.7 to 11447.85 μm (72%), and S mean value from 2.226 to 2.910 mm (68.4%) (p<0.05).

CONCLUSIONS

The choice of surgical device could influence the histopathological margins status, consequently affecting post operative therapeutic strategies and risk of recurrence.

Disorders of swallowing: palliative care

This article defines palliative care for swallowing disorders as treatment for severe and chronic dysphagia or intractable aspiration when the recovery of normal swallowing is not anticipated and attempts to restore normal swallowing have been unsuccessful. Palliative treatment for dysphagia is not only for the dying patient because patients with difficulty swallowing can live for a long time. Palliative care for dysphagia is aimed at maximizing swallowing function, maintaining pulmonary health, and supporting healthy nutrition despite the impaired ability to swallow. When despite all attempts at intervention a patient becomes totally unable to swallow, the goal of therapy changes toward finding ways to provide adequate nutrition for the patient.

Therapeutic Options in Advanced Laryngeal Cancer: An Overview

Historically, patients with advanced laryngeal cancer have been treated with radical surgery and adjuvant radiation therapy. Intensive surgical research has allowed surgeons to deal with almost any local extension and to propose an appropriate surgical procedure for each case. Several function-sparing surgical options are available to treat moderately advanced/advanced laryngeal cancer. Better understanding of the anatomy and biology of cancer in this anatomical site has enabled us to devise effective oncological strategies associated with a great effort to preserve laryngeal function. Numerous efforts have been made to augment the therapeutic armamentarium with the addition of chemotherapeutic agents combined with radiation therapy. For advanced laryngeal cancer, the debate is still open between partial/subtotal surgical procedures, which are more efficient but sacrifice parts of the larynx, and radiotherapy/chemoradiation protocols which can preserve the larynx and its function even though it requires radical surgery for salvage. Efforts should be made to select patients properly, in an individual basis, based on tumor characteristics, clinical aspects, patient's expectations, and the expertise of the head and neck oncologic team for the various therapeutic strategies in order to get better oncological results in association with the preservation of the laryngeal form and function, when possible.

Más de cinco décadas de laringectomía horizontal supraglótica (técnica de alonso)

In this paper we attempt to prove the relevance of the Spanish and Iberoamerican contribution, in the expansion and development of Alonso's technique for surgical treatment of supraglottic cancer, that began in Spain and South America in the fifties. We mention the most important authors and their ideas, and we explain their contribution to this surgical procedure which has been remained forgotten in the latest publications.

Lump sensation in the throat caused by tumors in the preepiglottic space

Lump sensation in the throat is a common symptom, which accounts for 4% of first patient visits to Otorhinolaryngologic clinics. The etiology includes abnormalities of the thyroid gland, cysts, tumors and chronic infections of the pharynx, larynx, esophagus and tongue base, gastroesophageal reflux and anxiety disorders. In this article we describe two rare cases of lump sensation caused by masses in the preepiglottic space and we stress the importance of thorough investigation to exclude any possible non functional causes.

Laryngeal compartmentalization after radiation therapy in a canine model

OBJECTIVE

We set out to study the effects of radiation therapy on laryngeal tissue barriers in a canine model as described by Welsh.

STUDY DESIGN

India ink was injected into 1 vocal fold on irradiated and nonirradiated canine larynges.

RESULTS

The india ink dye spread more prominently into the supraglottis of the irradiated specimens by submucosal lymphatics. Larger dye volumes simulating larger tumor bulk spread to the contralateral larynx in irradiated specimens.

CONCLUSION

Conservation laryngeal surgery for laryngeal carcinoma is a popular method of treatment. Some surgeons advocate partial laryngectomy for radiation failures; in other instances, it is the primary modality of treatment. These findings suggest a cautious approach when planning conservative laryngeal surgery after radiation therapy failures of glottic carcinoma.

Treatment of the contralateral negative neck in supraglottic cancer patients with unilateral node metastases (N1-3)

BACKGROUND

Elective treatment of the contralateral N0 neck in supraglottic cancer patients with unilateral metastases is controversial.

METHODS

We reviewed 127 N1-3 cases with contralateral negative necks to compare elective contralateral dissection (ED: 24 cases) with a contralateral wait-and-see policy (WS: 103 cases) and subsequent delayed therapy (SDT: 40 cases) when contralateral disease became evident. Prognostic factors were studied to identify the risk of contralateral disease.

RESULTS

Nine of 24 (37.5%) ED patients had occult contralateral metastases, and 40 of 103 (38.8%) WS patients had a delayed contralateral failure. Supraglottic cancers involving or extending up to the midline had a higher risk of contralateral metastases compared with well-lateralized tumors (p =.049). The risk of contralateral neck disease was more influenced by tumor site and stage than by histopathologic characteristics of ipsilateral metastases. WS patients with contralateral neck relapse showed a higher risk of distant metastases and of level I and V neck involvement than ED cases with no difference in terms of survival.

CONCLUSIONS

The risk of contralateral occult neck involvement in supraglottic laryngeal cancers with unilateral metastases is high (about 40%), particularly for more advanced lesions extending to or involving the midline larynx; thus, a bilateral neck treatment in such cases is recommended.

The role of partial laryngeal resection in current management of laryngeal cancer: a collective review

A spectrum of treatment plans and surgical procedures is available for management of early and moderately advanced laryngeal cancer. While the approach of chemotherapy and irradiation, or irradiation alone, followed by total laryngectomy for failure is often employed in practice by present day clinicians, the options of conventional conservation surgery (CCS), transoral endoscopic laser surgery (TLS) and supracricoid partial laryngectomy (SCPL) provide a wide choice of treatments that may help attain the goal of cure with preservation of laryngeal function and integrity of the airway. While CCS has been supplanted for many early-stage lesions by TLS and for more advanced stages by SCPL, centres throughout the world have reported favourable results with CCS, which is often modified to include resection of more extensive tumours than was previously possible. During the past decade a number of extended CCS procedures have been developed for management of glottic tumours involving both vocal cords and the anterior commissure, the paraglottic space and with vocal cord fixation, and for supraglottic tumours involving the glottis or hypopharynx. TLS has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. The procedure may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary, particularly for moderately advanced supraglottic carcinomas. SCPL has proven effective in management of glottic and supraglottic cancers of all stages, even with involvement of paraglottic space and thyroid cartilage, provided at least one arytenoid unit can be preserved with clear margins. Invasion of cricoid cartilage is the most significant limitation for this procedure. All three surgical approaches have been employed for irradiation failure, but with greatly increased failure and complication rates compared with the results of treatment of non-irradiated patients. Thus a decision to treat laryngeal cancer initially with irradiation may preclude a satisfactory result from partial laryngectomy should radiation fail. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumour, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.

A novel approach to laryngeal suspension after partial laryngectomy

OBJECTIVES

Supraglottic laryngectomy is a well-established surgical therapy for selected carcinomas of the larynx and hypopharynx. Most compromised by this procedure and its variations is the laryngeal mechanism that protects the lower respiratory tract from aspiration. Laryngeal suspension serves to compensate for the loss of the resected laryngeal elevator muscles by pulling the larynx upward and forward beneath the tongue base. In this study we describe a method of laryngeal suspension in supraglottic laryngectomy using a cartilage-anchored suture carrier device.

STUDY DESIGN

Report of this novel approach to laryngeal suspension using seven suture anchors in two patients undergoing supraglottic laryngectomy.

METHODS

Seven Mitek Micro anchors (Mitek, Westwood, MA) were used to perform laryngeal suspension in two patients undergoing supraglottic laryngectomy. Our technique is compared with traditional methods. Operative data as well as postoperative functional results are reviewed.

RESULTS

Laryngeal suspension using suture anchors was successful, with failure of only one anchor. Oral alimentation was quickly reestablished in both patients. There were no perioperative or postoperative complications.

CONCLUSIONS

We describe a novel approach to laryngeal suspension that overcomes some of the technical challenges inherent in traditional suturing techniques. This novel approach is technically easier and more efficient than traditional methods and accomplishes distribution of stress forces on the thyroid cartilage remnant.

Barrier between the supraglottis and the glottis: myth or reality?

Controversial opinions on the existence of a "barrier" between the supraglottic and glottic regions of the larynx are reported. Even if the two areas have different embryological derivations, there is no anatomic evidence of a "barrier" that could prevent supraglottic cancer from extending downward to the glottis. Numerous adequate pathologic studies, including whole organ sections, confirm that for advanced cancers, anatomic compartments delimiting the spread of the neoplastic process from the supraglottis to the glottis do not exist. Therefore, supraglottic laryngectomy should be performed not on the basis of embryological considerations, but on the basis of the actual extension of the neoplastic lesion.

Glottic-supraglottic barrier: fact or fantasy?

An anatomic structure that might act as a barrier between the glottic and supraglottic areas has never been demonstrated in whole organ serial section studies. Nevertheless, most squamous cell carcinomas arising on the supraglottic mucosa remain confined above the ventricle, and this fact is reflected in the high rate of local control obtained by surgeons performing horizontal supraglottic laryngectomy: 80.6% to 98%. Whole organ sections of laryngectomy specimens suggest that a tumor situated above and below the glottic level may have arrived there not by crossing the ventricle, but by encircling it. In so doing, part of the tumor is visible posterior to the ventricle or on the arytenoid cartilage-a finding that contraindicates conventional supraglottic laryngectomy, with or without limited mobility of the true vocal cord.

Morbidity of combined therapy for the treatment of supraglottic carcinoma: supraglottic laryngectomy and radiotherapy

Many surgeons find that patients have increased morbidity after supraglottic laryngectomy if postoperative irradiation is given, but this remains poorly documented. Twenty-nine patients undergoing supraglottic laryngectomy were retrospectively reviewed. Seventeen received postoperative radiotherapy, and 12 did not. The mean follow-up was 64 months. When compared to patients treated with supraglottic laryngectomy alone, irradiated patients had a significantly higher incidence of lifelong gastrostomy dependency (35% versus 0%; p = .03) and acute upper airway obstruction (29% versus 0%; p = .05). There was a trend toward greater tracheotomy dependency (24% versus 0%), aspiration pneumonia (35% versus 9%), and delayed independent swallowing (34.8 weeks versus 7.8 weeks) in the patients treated with combined therapy, but this difference was not significant. A morbidity index score was developed to evaluate the overall lifelong morbidity of these patients, and this was found to be significantly higher in patients treated with surgery and radiotherapy (2.29 versus 0.83; p = .04). Overall survival was equal in both groups. We have shown that radiotherapy increases the morbidity of supraglottic laryngectomy. This should be considered when planning treatment for patients with supraglottic carcinoma.

The significance of pre-epiglottic space invasion in supraglottic laryngeal carcinomas

It is widely accepted that tumoral invasion of the pre-epiglottic space (PES) has a significant prognostic importance in supraglottic laryngeal carcinomas. The lymphatics of the supraglottic larynx drain to cervical lymph nodes via the PES. Since the supraglottic larynx is an embryological unit that contains the PES, malignant lesions of this region must be resected with en bloc surgery, including the PES. Tumors with PES invasion are already considered to be T3 in TNM staging. The purpose of this study was to review the clinical experience we have had with these tumors at Ankara University. The study comprised 150 patients with squamous cell carcinomas of the supraglottic larynx treated with either partial or total laryngectomies. Findings suggested that PES invasion occurred at early stages of supraglottic tumor progression. Suprahyoid epiglottic lesions behaved less aggressively than tumors originating from other supraglottic subsites and did not invade the PES until advanced stages. PES invasion was not considered to be a significant prognostic factor because the majority of the supraglottic lesions studied demonstrated PES invasion regardless of cervical lymph node metastases. Analysis of oncological and functional results revealed that en bloc resection of the supraglottis with the PES was facilitated by preservation of the hyoid bone.

Do positive resection margins after ablative surgery for head and neck cancer adversely affect prognosis? A study of 352 patients with recurrent carcinoma following radiotherapy treated by salvage surgery

It is generally accepted by surgeons that failure to eradicate malignant disease at the primary site has an adverse effect on survival. The present study investigates 352 patients with squamous carcinoma of the head and neck treated by primary radical radiotherapy and who subsequently underwent surgical ablation for a recurrent carcinoma. A total of 303 (86%) patients had a negative resection margin and 49 (14%) had a positive resection margin. Oral carcinoma was 1.7 times more likely to be associated with a positive margin than other tumours (P = 0.0292). Actuarial calculations demonstrated that 47% of patients with negative margins and 66% of patients with positive margins developed a primary site recurrence (P = 0.0286). Neck node recurrence occurred in 10% of those patients with negative margins and 12% of patients with positive margins. Patients with positive margins had a significantly poorer survival than those with negative margins (P = 0.022). Multivariate analysis failed to confirm any independent adverse effect from a positive margin. The 5 year tumour-specific survival of patients with a positive margin was poorer by 12% than for those patients with a negative margin. The pattern of failure differed between the two groups, with patients having positive margins tending to die of local recurrence.

Hyoepiglottic ligament in supraglottic cancer

The hyoepiglottic ligament (HL) is a connective tissue structure that serves as the roof of both the paraglottic and the preepiglottic spaces and thereby anatomically separates the supraglottic larynx from the tongue base. Whole mount serially sectioned larynges with supraglottic cancer were reviewed to help clarify cephalad spread of cancer in this region. The whole mount slides were analyzed from 70 laryngectomy specimens that were resected for supraglottic cancer. The HL was breached by cancer in 13 specimens, and all of these displayed clinical and histopathologic invasion of the preepiglottic and paraglottic spaces. Invasion of the suprahyoid epiglottis was noted in 9 specimens, and invasion of the aryepiglottic fold in 4. There were no instances in which cancer escaped from the deep compartments of the supraglottic larynx to the tongue base without synchronous erosion of the suprahyoid epiglottis (insertion of the medial HL) or the pharyngoepiglottic fold (lateral HL). The HL is a resilient connective tissue barrier to the spread of cancer from the supraglottis to the tongue base. This investigation reinforced the concept that, typically, the HL acts as a deep cephalad surgical boundary in resecting supraglottic cancer that 1) is confined to the laryngeal membranes and 2) does not clinically invade the suprahyoid epiglottis.

Endoscopic laser management of supraglottic cancer

Current concepts of endoscopic management of supraglottic cancer are an extension of precepts fostered by Jackson. The current approach has been facilitated by a half century of technological developments: the surgical microscope, the CO2 laser, improved laryngoscopes, and general endotracheal anesthesia. Selected small-volume cancers can be curatively resected, whereas excisional biopsy can be performed on larger neoplasms. With this cost effective minimally-invasive surgical approach, there is less disturbance of normal tissue, thereby minimizing morbidity rate and hospitalization. If the transoral excision is inadequate, radiotherapy can not be depended on to eradicate known residual disease. Endoscopic resection of supraglottic cancer should not alter the surgeon's standard management of the neck.

Preepiglottic space invasion in "early" epiglottic cancer

The tendency of epiglottic cancer to invade the preepiglottic space and the significance of this invasion was evaluated in 36 surgical specimens of epiglottic carcinoma originally staged T1 or T2. None of the 9 lesions originating above the hyoepiglottic ligament invaded the preepiglottic space. Twenty-four of the 27 (89%) lesions originating below the hyoepiglottic ligament showed invasion of the preepiglottic space and were clinically understaged. Of the 3 infrahyoid lesions showing no invasion of the preepiglottic space, 1 was a verrucous carcinoma and another was a mucoepidermoid carcinoma arising on the petiole. All other lesions were squamous cell carcinoma. In 12 of the 24 patients (50%) with preepiglottic space invasion, cervical node metastasis was present despite the preoperative staging of T1 or T2.

Sixteenth Daniel C. Baker, Jr, memorial lecture. Surgical management of supraglottic cancer and its lymph node metastases in a conservative perspective

Supraglottic laryngectomy combined with functional elective or curative neck dissection is a priceless contribution toward treatment of supraglottic cancer and its lymph node metastases. The history and background of this conservative approach is reviewed. Results related to staging are presented. Irradiation as a combined or alternative therapy is considered.

Internal anatomy of the larynx and the spread of cancer

This project investigated the potential spread of cancer within the larynx by an analysis of the permeability and resistance of the subepithelial spaces. Permeation and diffusion of dye injections in the loose connective tissues below the epithelium was analyzed by histologic preparations in the sagittal plane. The margins of the infusion were identified grossly and microscopically, and the influence of the fibrous, elastic, and muscular components was analyzed with reference to the dispersion of the dyes. A close correlation between laboratory data from normal postmortem larynges and clinical problems of laryngeal cancer was observed in this study.

Supraglottic laryngectomy: short- and long-term functional results

A supraglottic laryngectomy offers the possibility of resection of a large portion of the larynx leaving the true vocal cords. From 57 supraglottic laryngectomies performed between 1971 and 1984 in the Department of Otolaryngology and Head and Neck Surgery of the University of Nijmegen, the 5- and 10-year actuarial survival rates were 80% and 59%, respectively. The deaths after 5 years were not directly related to the original tumour. The functional results with respect to the voice were excellent. In this study particular attention has been paid to the postoperative results with regard to swallowing and aspiration. More than half of the patients (56%) had occasional complaints of aspiration, especially when taking liquids. It is concluded that supraglottic laryngectomy is an excellent alternative, especially for the treatment of extensive supraglottic tumours without involvement of the true vocal cords.

Manofluorography of deglutition after supraglottic laryngectomy

Manofluorography (mano: manometry, fluoro: videofluoroscopy, graphy: picture) provides a simultaneous display of manometry and fluoroscopy on one video screen. This study uses manofluorography to analyze the swallowing patterns of nine patients who had undergone supraglottic laryngectomy. The results show that during swallowing the pharyngeal mechanism for preventing aspiration depends upon three processes: (1) tight lingual-laryngeal contact, (2) coordination of the swallowing reflex, and (3) tongue base and pharyngeal constrictor clearing of the hypopharynx and laryngeal inlet. Anterior suspension of the larynx under the tongue base serves to improve lingual-laryngeal contact. This close contact during deglutition protects the airway from the bolus and also opens the postcricoid region, aiding bolus passage into the esophagus. Impairment of the swallowing reflex, which can cause severe aspiration before the swallowing reflex is triggered, can be rehabilitated by swallowing therapy. Minor aspiration is commonly caused by impaired clearing of the superior hypopharynx after supraglottic laryngectomy.

Coronal sections of larynges from radiation-therapy failures: a clinical-pathologic study

Serial coronal sections of 89 wide-field laryngectomies were examined. Twenty were specimens obtained from laryngectomies to treat patients for whom primary radiation therapy failed to cure early laryngeal cancer. These specimens were compared to 69 specimens from laryngectomies for T3 and T4 laryngeal cancers. The irradiation-failure group showed a significantly greater invasion of cartilage and extension into subglottic areas. The extension of tumors along blood vessels and mucous glands appeared to contribute to the spread of tumors in the irradiation-failure group. These findings have implications for the surgical management of irradiation failures in the treatment of laryngeal cancers.

A personal experience with subtotal and conservation surgery as treatment for laryngeal cancer

A personal technique for laryngeal cancer reconstructive surgery is presented and discussed. The functional and therapeutic purpose of this surgery is to broaden its indications and to improve functional results. In particular, our surgical technique involves removal of the soft internal part of the cricoid cartilage (mucosa, submucosa and perichondrium), which is otherwise conserved. Satisfactory functional results can be achieved by: modeling of two symmetrical pseudoarytenoids; an anterior epiglottiplasty or the use of a Hiranandani base-of-the-tongue flap to close the anterior gap (if present); muscular flap lateral-plasty avoiding a cricoidhyoidpexy.

False-positive and false-negative neck nodes

We report our experience of the incidence of false-positive (i.e., clinically positive and histologically negative) and false-negative (i.e., clinically negative and histologically positive) neck nodes and define their relationship to the primary site, T-stage, and the histologic grade of the primary lesion. Clinical and pathologic records of 255 patients with squamous cell carcinoma (SCC) of the head and neck who underwent 266 radical neck dissections were reviewed. We did not find any relationship between the T-stage of the primary tumor and the incidence of the false-positive and false-negative neck nodes. Regarding the primary site, the benefit of an elective neck dissection is likely to be maximum in oropharyngeal SCC and minimum in supraglottic SCC. The incidence of false-negative neck nodes was lower in well differentiated primary lesions.

The place of partial laryngectomy in the treatment of laryngeal cancer--a view from the U.K

Attention is drawn to the problems of surgical resection by partial laryngectomy after full therapeutic dosage of Telecobalt irradiation. Material is presented from two treatment centres to indicate trends in surgical treatment and the complications experienced. Results will be given which confirm a reasonable expectation of cure and functional conservation by vertical partial laryngectomy for recurrence of glottic cancer after irradiation. The results of treatment of recurrent supraglottic cancer by horizontal partial laryngectomy gave more cause for concern in terms of complications and survival. In conclusion an attempt is made, based on the quoted experience, to define the position of conservation surgery in two centres for laryngeal cancer in the United Kingdom.

Topographic anatomy of the external branch of the superior laryngeal nerve. Its importance in head and neck surgery

The authors have studied the anatomy of the external branch of the superior laryngeal nerve in its entirety on 40 fresh cadavers, and they have drawn the following conclusions: the nerve ramifies from the vagus immediately below the nodose ganglion or in the ganglion itself. The nerve splits into two branches approximately 1.5 cm below the ganglion nodosum. In four cases, both branches originated from the vagus itself. In one case, anastomosis of the external branch of the superior laryngeal nerve with the recurrent nerve was found. The external branch of the superior laryngeal nerve is not usually severed at supraglottic laryngectomy but the nerve is at risk during neck dissections, resection of Zenker's diverticula and thyroidectomy. An accurate knowledge of its course should reduce the incidence of injury to the branches of the superior laryngeal nerve during surgery.

Carcinoma of the laryngeal margin

The laryngeal margin constitutes an anatomic and clinical entity that differs from what is commonly referred to as supraglottic. The present retrospective study reviews 189 cases of carcinomas occurring in this specifically defined region. Local, nodal, and distant metastatic spread of these tumors varied depending on whether the initial tumor site was located in the anterior or lateral margin. Treatment regimens were planned according to the tumor's origin. Primary tumor site surgery associated with a modified or radical neck dissection according to N staging, followed by postoperative radiation is advocated for treatment of these tumors. Cervical nodal metastases are frequent and often bilateral (36%) in cases of anterior margin carcinoma suggesting that bilateral neck dissection sparing two jugular veins for N0 staged carcinoma and one jugular vein when there is evidence of a palpable node, be routinely used. Nodal involvement in cases of lateral margin carcinoma is also frequent but is almost exclusively confined to the ipsilateral nodes. It is suggested that homolateral neck dissection therefore be systematically associated with primary tumor site surgery for these tumors. The various anatomical aspects and pathways of extension of laryngeal margin carcinoma are discussed and a modified TNM classification is proposed.

The preepiglottic and paraglottic spaces in relation to spread of carcinoma of the larynx

The submucosal compartments of the larynx were examined using a whole-organ sectioning technique. Seven specimens of normal larynx and 35 specimens of carcinoma of the larynx were studied. Victoria blue and van Gieson stains were used to demonstrate connective tissue elements. The preepiglottic space was distinctly separated from the paraglottic spaces by membranous partitions made up of collagen and elastic fibers. These partitions offer some resistance to tumor invasion in the early stages of laryngeal cancer, keeping the tumor from extending to the adjacent compartment while allowing it to spread freely within the same compartment. In the absence of mucosal extension across the midline, submucosal spread of tumor to the opposite side is unlikely. In view of possible cranial spread of tumor along the preepiglottic and paraglottic spaces, excision of all these spaces, together with the hyoid bone, is indicated in total laryngectomy.

Supraglottic laryngectomy: 30 years of experience

A review of 467 cases of supraglottic laryngectomy operated during the last 30 years is presented. Cases have been subdivided into groups according to stage and TNM classification. By far the most numerous in this series were T2 cases. No cases prevailed over N+ by 4:1. Stage II cases represented about 60% of the total. Results are analyzed according to TNM and staging. The average overall 5-year cure rate is 75%. The influence of factors other than TNM and staging upon results is also considered. Supraglottic laryngectomy may be extended to include one arytenoid, the base of the tongue, or both, with approximately equal results. Practically all cases had en bloc bilateral functional or classic neck dissection for threatening or actual lymph node metastases. This may have contributed to a higher number of successes. Combined surgery and radiotherapy is occasionally indicated, but rarely improves the prognosis of severe cases. Site and type of recurrences are considered and their treatment and prognosis are discussed. On the basis of the present study the clinical value of supraglottic laryngectomy is further assessed.

Combined pre-operative telecobalt therapy and supraglottic laryngectomy

At Groote Schuur Hospital, Cape Town, over a 5-year period (1974 to 1978) 15 patients with squamous cell carcinoma of the larynx or hypopharynx have had planned 2,000 Rad Telecobalt therapy followed by supraglottic horizontal laryngectomy. Five patients following surgery had a further 3,600--4,000 Rad Telecobalt therapy. The peri-operative complications, in addition to those of whole organ resection, included debilitating laryngeal incompetence in three patients, two of whom underwent total laryngectomy. All 15 patients have remained free of recurrent disease for 2 years and 10 have been free for 3 or more years. One patient died 4 years after surgery from a primary bronchial carcinoma.