Ebook An atlas of head and neck surgery (Vol II- 4/E): Part 2

20

Indirect Mirror Laryngoscopy

Anatomy of Superior Laryngeal Nerve
(Fig. 20-1)

Highpoints

See Chapter 4 for additional discussion relative to
peroral endoscopy.
1. Equipment:
a. Laryngeal mirror
b. Head mirror with light source or headlight
c. Gauze
d. Hot glass head device; hot water or forced hot air
from small hair dryer
2. Reassure patient: have him or her relax by drooping
shoulders, easing neck muscles, and using moderate
deep breathing.
3. Properly position the patient by having him or her
sit erect, not slouch backward.
4. Topical anesthesia is required in 30% to SO% of
patients: use a cotton swab moistened with 10%
cocaine, 2 % tetracaine, or 4 % lidocaine. Avoid use
of compressed air spray, because too large a dose
with cocaine may be administered. Lidocaine 4% is
probably the agent with the least side effects.
S. Perform orderly visualization of:
a. Larynx with epiglottis, especially base of epiglottis
b. Hypopharynx, especially the pyriform sinuses

and posterior wall
c. Base of tongue and vallecula
6. Realize the optical illusions of the mirror:
a. Anterior commissure appears to be posterior (i.e.,
reversal of anterior and posterior regions).
b. There is no reversal of right and left sides.
c. Overhang of epiglottis tends to obscure anterior
commissure and base of epiglottis, a serious blind
area.
d. Overhang of ventricular bands tends to obscure
ventricles.
e. Overhang of vocal cords tends to obscure subglottic space.

The various relationships of the important nerves extrinsic to the larynx with relationship to the greater vessels
are shown. The internal branch of the superior laryngeal nerve passes through the thyrohyoid membrane
on a line horizontal to the superior corner of the thyroid cartilage approximately 1 cm medially (Lore, Sr.).

FIGURE20-1

1069


Mirror laryngoscopy is a very important means of
evaluation of the larynx, because it affords a full view
of the entire presenting portion of the larynx,
hypopharynx, base of tongue, and inferior tonsillar
pillars. Next in line are optical and direct rigid laryngoscopy with telescopic instruments or the operation
microscope, followed by external palpation of the larynx.
Finally, radiographic examination, purely as an adjunct,
is of aid in estimating subglottic extension of disease.

Plain soft tissue radiography, computed tomography
(CT), and laminograms (planigrams) and laryngograms
can be used and should be obtained before a biopsy
sample is taken.
All patients with hoarseness must have a pathologic,
anatomic, or physiologic reason for their symptoms.
However, tumors arising away from the free edges of
the vocal cords may not and often do not produce any
voice changes in the early stages of the disease. By the
same token, recurrent laryngeal nerve paralysis is not
necessarily associated with hoarseness. For example, to
say that a patient has no injury to the recurrent nerve,
after thyroidectomy, simply because his or her voice
is satisfactory is entirely fallacious. The normal vocal
cord many times compensates for and adapts itself to
the paralyzed cord. The only subjective complaint may
be failure to control the pitch of the voice. On the other
hand, paralysis of the external branch of the superior
laryngeal nerve is almost always associated with hoarseness. The vocal cord is bowed and may be at a lower
level than the normal vocal cord. Paralysis of the
recurrent laryngeal nerve can occur after endotracheal
intubation.
Technique (Fig. 20-2)

A The patient is placed in an erect sitting position,
preferably with the base of his spine resting against the
back of a straight-backed examining chair. The head
should be free of any headrest, because the head and
neck are usually not hyperextended.
The next step is to achieve complete relaxation. The

patient is instructed to let his or her shoulders, neck,
and arms become limp. Regular and moderately deep
breathing aid in minimizing the gag reflex and spasm
in the throat.
A suitable-sized laryngeal mirror-a selection from
NO.3 to NO.6 is ideal-is chosen, depending on the
oropharyngeal width. The mirror is warmed either with
a hot glass bead sterilizer (Premier Dental Products),
hot water, or warm air from a blower, and its temperature is tested on the back of the examiner's hand. The
examiner, using an opened piece of 2 x 2-inch gauze
gently grasps the tongue between the thumb and
middle finger, using the index finger to retract the
upper lip.

The use of topical anesthesia will depend on the
patient's ability to relax. Diazepam (Valium), 10 mg,
orally 30 minutes before examination aids relaxation
significantly. Complete visualization of the vocal cords
will require phonation. The vowel "E" is ideal. If this
fails to expose the vocal cords, have the patient attempt
to laugh or sound "hah-hah-hah." Phonation is also
necessary to check the function of the laryngeal structures as well as "open" the pyriform sinuses. This is
necessary to evaluate the mucosa of the pyriform
sinuses. The apex (inferior) portion of the pyriform
sinus may not be visualized. If suspicious results are
found, direct rigid laryngoscopy will be necessary.
B Labeled parts are as follows: 1, epiglottis; 2, anterior commissure; 3, ventricular band; 4, posterior commissure; 5, corniculate cartilage overlying arytenoid
cartilage; 6, cuneiform cartilage; 7, aryepiglottic fold;
8, glossoepiglottic fold; 9, ventricle; 10, base of tongue;
and 11, pyriform sinus.

Some type of routine checklist should be followed to
perform a complete evaluation, for example, the following:
1. Larynx
a. Vocal cords (free edges and superior surfaces) and
their motion and whether they are straight
b. Arytenoid cartilages and their motion
c. Ventricles and ventricular bands
d. Anterior and posterior commissures
e. Subglottic space; wall of trachea
f. Aryepiglottic folds
g. Lingual and laryngeal surfaces and free edges and
base of epiglottis
h. Glossoepiglottic folds
2. Hypopharynx
a. Pyriform sinuses-especially
the inferior extent,
the apex; constant filling with saliva indicates
esophageal obstruction (Jackson's sign).
b. Posterior and lateral walls-the
more superior
portions can be visualized with a tongue depressor and an examining finger.
3. Tongue (must also be evaluated with an examining
finger), especially base of tongue
a. Vallecula (space between epiglottis and base of
tongue)
b. Juxtaposed inferior tonsillar pole
C Bowing of the vocal cords. This is best demonstrated during phonation of "E." It is usually caused by
a prominent vocal process of the arytenoid cartilages
(which can be amputated with stripping forceps) (see
Fig. 20-5) or paralysis or weakness of the cricothyroid

THE LARYNX

c

D
FIGURE 20-2

Sphincteric Group
muscle, which is innervated by the external branch of
the superior laryngeal nerve. The vocal cord may be at
a lower plane than the normal vocal cord.
D Bilateral adductor cord paralysis. This indicates
paralysis of either the cricoarytenoideus lateralis, interarytenoideus, or thyroarytenoideus or all these muscles
bilaterally. The nerve supply is via the adductor division
of the recurrent laryngeal nerve. The interarytenoideus
muscle may have a motor supply via the internal
branch of the superior laryngeal nerve. This is dubious.
E Bilateral abductor cord paralysis. This indicates paralysis of the cricoarytenoideus posterior muscles bilaterally. Innervation is via the abductor division of the
recurrent laryngeal nerve.
A way to remember easily the action of the significant intrinsic muscles of the larynx is to divide them
into two groups: adductor or sphincteric group and
abductor or dilator group.

An analysis of this group shows that it can be reduced
to simple terms and can be described so it is easily
remembered.
All these muscles pull on or are inserted
into the arytenoids.

The cartilages of origin are the
cricoid, arytenoids, and thyroid. Hence, the letters C, A,
and T may be used to designate the cricoid, arytenoid,
and thyroid cartilages, respectively.
Dilator Group
This is composed of a simple pair of muscles, namely,
cricoarytenoid
posterior, or CAP. This pair abducts the
cords.
Admittedly, this is an oversimplification
of the diversity of opinion regarding the motor function of the
intrinsic muscles of the larynx. Details are beyond the
scope of this atlas.


THE LARYNX

Instruments (Fig. 20-3)
The Lore head light (Karl Storz) with observation side
arm attachment is shown. It was utilized with mirror
laryngoscopy and nasopharyngoscopy both for examination and as a light source during surgery.The observer
could see exactly what the examiner and operator
visualized. Its only drawback for the observer was the
somewhat smaller image seen through the side arm.
This has been replaced with fiberoptic laryngoscopes
that have either observer arms or video capabilities.

Direct optical, both flexible and inflexible, and direct
rigid laryngoscopy and hypopharyngoscopy are described
and depicted in Chapter 4. The images seen on the

optical instruments are in the same position as they are
anatomically and are not reversed as they are with the
mirror; that is, the anterior portion of the larynx and
hypopharynx are visualized anteriorly while with the
mirror the anterior portion of the larynx and hypopharynx are visualized posteriorly. On both optical and
mmor laryngoscopy the right and left sides are seen as
they are in the anatomic position.

FIGURE 20-3


THE LARYNX

Punch Biopsy of lesions of larynx
and Hypopharynx (Fig. 20-4)
Additional endolaryngeal and microlaryngeal procedures
are described in Chapter 4.
Highpoints

1. Use topical anesthesia or general anesthesia plus
topical anesthesia. A small endotracheal tube (No.6)
can be used.
2. Insert laryngoscope from the contralateral position
through the mouth.
3. Stripping is preferred for lesions of the vocal cord
except for bulky tumors, which are obviously malignant.
For details, see the section on direct laryngoscopy in
Chapter 4 and Figure 4-2.

-

With either a Holinger or a Jackson anterior commissure speculum or a standard laryngoscope introduced
from the contralateral oral position, the lesion is exposed
on the opposite side of the larynx. Microlaryngoscopy
is utilized for small lesions (see Fig. 4-5D and E). With
a sharp basket or cup forceps, the biopsy of the
suspected area is performed in one or two locations,
depending on the size of the tumor. Postoperative
bleeding is usually of no concern except with lesions
involving the lingual side of the vallecula. One such
case of carcinoma had uncontrollable bleeding,
necessitating an emergency laryngectomy.
Whenever general anesthesia is used, topical
anesthesia is strongly recommended. This permits a
repeat mirror examination, prevents laryngospasm, and
reduces the amount of general anesthetic agent and the
danger of cardiac arrhythmias. Toluidine blue, 1%,
topically applied to suspicious lesions that are first
cleansed with 1 % acetic acid, has been demonstrated
to be of some aid in localizing early carcinoma (Shedd
and Gaeta, 1971; Strong et aI., 1968).

FIGURE 20-4


THE LARYNX

Stripping (De-Epithelialization)
a Vocal Cord (Fig. 20-5)

of

(Lore Sr., 1934)

This author is concerned about the possibility that some
cells, which may be precancerous or cancerous, could
be vaporized or destroyed and thus missed on histologic examination.

Indications
Highpoints

Stripping of a vocal cord is preferred for virtually all
lesions that involve primarily the true vocal cord. Two
exceptions are the bulky, obviously malignant tumor in
which a simple punch biopsy suffices for diagnosis and
the pedunculated, single, small polyp that may be
removed with cup forceps. The stripping operation is
ideally suited for the removal of other polyps with or
without associated edematous cords. The polyp and
edematous tissue are removed usually in one maneuver. Papillomas, hypertrophic vocal cords (polypoid
edematous cords), and almost any benign lesion may
be thus removed. The resulting free edge of the cord
remains straight, and re-epithelialization occurs in 2
to 4 weeks. Usually, only the surface epithelium
needs to be removed; however, if necessary, one may
go as deeply as the thyroarytenoid muscle or may
operate several times if some diseased tissue has been
left.
Stripping a vocal cord is particularly suited to suspiciously malignant disease (e.g., leukoplakia or keratosis),
which extends over a greater part of the cord or the

entire length of the cord. By stripping the entire cord,
the entire lesion may be removed and serial sections
taken by the pathologist for microscopic examination.
Hence, a complete evaluation of malignancy is possible. If the lesion turns out to be benign, satisfactory
removal has been achieved and no additional operation
is necessary. Miller has shown that this technique
appears to be satisfactory for carcinoma in situ. The
author agrees; others believe that a simple cordectomy
is warranted.
Lengthy lesions of the ventricular bands or in the
floor of the ventricles are also well suited to the stripping procedure. Subglottic tumors are easily sampled
with the child-sized stripping forceps. Essentially, this
is the lmperatori subglottic forceps, which was modified by Lore, Sr. by making the anterior two thirds very
sharp and the posterior third somewhat duller. A subsequent modification (Lore, Jr.) utilizing a telescope is
manufactured by Karl Storz (see Chapter 4).
Bowing of a vocal cord by a prominent vocal process
of the arytenoid cartilage may be improved by inclusion of the vocal process in the stripping forceps.
Carbon dioxide (C02) laser removal of these lesions
is preferred by some surgeons (Strong and Jako, 1972).

1. General anesthesia supplemented with topical anesthesia is preferred. Indiscriminate use and overdosage
of a muscle relaxant is definitely contraindicated,
because the cord will be so relaxed when stripped
that bowing or an irregular free edge of the cord will
result. This danger cannot be overemphasized. A
small endotracheal tube at the posterior commissure
is ideal for an unhurried procedure.
2. Contralateral approach with anterior commissure
speculum is usually necessary.
3. Be certain that the amount of tissue grasped is to the

desired depth and extent. Attempt to complete the
operation in a single maneuver.
4. Strip only one vocal cord at a time. One month should
elapse before stripping the opposite side in bilateral
disease; otherwise webbing at the anterior commissure may occur. This admonition applies where the
de-epithelialization extends to the anterior commissure. If intact mucosa remains for several millimeters
at the anterior commissure, then bilateral stripping
may be done.
5. Microlaryngoscopy is advantageous, especially for
small lesions suspected to be malignant (see Fig.
4-50 and E).
A If the left vocal cord is being operated on, the
anterior commissure speculum is introduced from the
right side of the mouth. The beak of the instrument
extends to the anterior commissure and may be slightly
rotated so that the beak is against the right cord. The
left cord is thus fully exposed and fixed. With the
instrument in this position a full view of the cord is
obtained and the floor of the ventricle, in most cases,
is brought into view. Byinserting the instrument slightly
between the cords, a subglottic lesion may be seen
and a biopsy of it performed. The free edge of the vocal
cord can be "rolled" laterally. This may also facilitate
stripping the inferior portion of the vocal cord.
The left-sided stripping forceps (the lower or medial
blade fixed, the upper or lateral blade hinged) is inserted
with the long axis of the blade parallel to the long axis
of the cord. An adult (9 mm) or child (6 mm) blade is
selected as required.

THE LARYNX

A

B

c

FIGURE 20-5

B The blade is opened and the growth and subjacent cord are engaged gently. The blade is placed
between the anterior commissure and the vocal process
of the arytenoid. The vocal process is usually not included
unless the procedure is performed for bowing of the
vocal cord due to a prominent vocal process. Slight
traction is made toward the free edge until the growth
itself is felt in the forceps. Then the forceps is closed
tighter. At this stage it is important to visualize the
cord to make sure thilt not too much is being removed.
If too much tissue is engaged, the forceps is opened a
little until the proper amount of tissue is included. The
stripping is then begun anteriorly by tilting the handle
of the forceps posteriorly. The entire stripping is performed with a brisk, rapid, single motion.
C The position of the forceps at the end of the single
stripping motion is shown.
D A schematic
depicted in C.

lateral view is similar to the stage

Gross examination
of the tumor will reveal a thin
small strip of cord tissue attached to it anteriorly and
posteriorly.
Postoperatively,
the patient is allowed to speak in a
normal manner. Excess speech, whispering, shouting,
and singing are contraindicated for 3 to 5 weeks. Normal
speech is allowed. The voice is usually very clear immediately postoperatively.
Some hoarseness
may occur
several days later for a short period of time.
In hypertrophic laryngitis (polypoid involvement of
the entire vocal cord), caution should be taken not to
leave a tab of polypoid tissue either at the anterior portion of the vocal cord or in the vicinity of the vocal
process of the arytenoid. Extreme caution must be taken
in this disease not to de-epithelialize the anterior portion
of the contralateral vocal cord; otherwise webbing may
occur.


THE LARYNX

Endoscopic Removal of Congenital
Cyst of Ventricle in Newborn
(Internal Laryngocele) (Fig. 20-6)
Cysts of the larynx may be congenital or acquired. The
congenital cyst that arises in the ventricle is often indistinguishable clinically from a laryngocele. A true laryngocele is a diverticulum of the mucosa of the ventricle
lined with respiratory epithelium, usually with a communication to the laryngeal lumen. Thus, a laryngocele

may fill with air or mucus and may be internal, entirely
within the lumen of the larynx and presenting as a cystic
mass from the ventricle, or external, extending through
the thyrohyoid membrane and presenting as a compressible cystic mass in the lateral side of the neck
between the hyoid bone and the thyroid cartilage. The
internal laryngocele can usually be deflated and removed
through an endoscope, whereas the external laryngocele
is excised through an external cervical approach. A
horizontal skin incision is made over the cystic mass,
which is dissected down to the thyrohyoid membrane.
Extreme care must be exercised not to injure the internal
branch or external branch of the superior laryngeal
nerve (see Fig. 20-25).
For all practical purposes the congenital ventricular
cyst and internal laryngocele in the newborn present
the same clinical picture of varying degrees of respiratory obstruction and absent or poor cry at birth. The
treatment is the same and often is very urgent.

2. Attempt immediate removal of laryngocele through
the laryngoscope. If this is not possible, aspirate and
deflate cyst with needle or punch.
3. Avoid tracheostomy in a newborn; however, do not
hesitate to perform one if endoscopic methods fail.
Tracheostomy in infants younger than 1 year of age
is associated with high morbidity and mortality. The
alternative is endotracheal intubation. Extubation
may require the anterior cricoid split of Holinger and
colleagues (see p. 1016).
A The larynx is exposed with a wide lumen laryngoscope. A laryngeal grasping forceps is inserted through
the loop of a very fine snare. An ideal snare is the type

used in rectal surgery for the removal of rectal polyps
in infants. The cyst is grasped firmly and pulled upward
while the snare engages the neck or base of the cyst.
Speed is essential, especially because the cyst may break
and mucus may be extruded. The snare is closed, cutting the neck of the cyst, and the forceps are withdrawn with the cyst. Tracheal suction may be necessary if aspiration of mucus occurs. This procedure
requires the aid of an assistant who holds either the
laryngoscope or preferably the forceps after the operator
has grasped the cyst. A Lewy laryngoscope holder,
although large, may be of help.
B A schematic cross-sectional
technique.

Highpoints

1. All newborns with respiratory difficulty and abnormal
or absent cry must undergo laryngoscopy.

FIGURE 20-6

view demonstrates

the


THE LARYNX

CO2 Laser in Laryngeal and
Endobronchial Surgery (See Fig. 4-6)
The CO2 laser has innumerable
applications

in head
and neck surgery. It can be utilized via the microscope
or a hand-held adapter. All of the various adaptations
of this modality are beyond the scope of this atlas but
have been described by many authors. Ossoff and Karlan,
in Ballenger's Diseases of the Nose, Throat, Ear, Head
and Neck (1985, chap. 42), give an excellent overview
of this subject (see also Chapter 4 of this atlas).
Basically, this form of energy can be used to vaporize tissue or for dissection purposes. The device can be
utilized in two modes, either pulsed or continuous, and
operates at a wavelength of 10.6 flm, producing light in
the invisible range of the spectrum.

Microlaryngoscopy Using the CO2 Laser
Indications
•
•
•
•

Papillomatosis
Various degrees of keratosis
Other benign and premalignant lesions
Selected patients with verrucous
carcinoma
who
refuse surgery
• Soft and/or edematous
tissue and some localized
fibrosis that is causing obstructions

• Capillary hemangiomas
Other Indications Reported by Other Authors
• Debulking large malignant lesions to improve the
airway (the present authors would opt for preoperative chemotherapy
as an initial step). Debulking is
not a definitive treatment (JML).
• Webs and noncircumferential
scars
• Carcinoma in situ-no specimen margins-not
recommended (JML)
• T1 carcinomas of the true vocal cord and epiglottis.
no specimen margins-not
recommended
(JML)
• Arytenoidectomy
Endoscopic Removal of Small Noncircumferential
Tracheal Scar
Ossoff et al. (1985) described
stenosis:
1. Granulation

three stages of tracheal

stage

2. Limited scarring

3. Extensive

scarring

They believe the CO2 laser is useful in the first and
second stages but not in the third stage. It is of virtually
no value in treatment of complete thick circumferential
scars of the trachea.

Highpoints and Precautions
Fire is an ever-present complication that must always
be kept in mind in any application of the CO2 laser. Fire
may act as a blowtorch from the trachea and larynx.
The endotracheal
tube must be immediately removed
and the procedure terminated; then a new endotracheal
tube is introduced. In the presence of increasing concentration of oxygen, the heat produced by this laser
can result in the ignition of any combustible material.
Prevention of this catastrophic sequela is based on the
following:
1. Provide special training
for surgeons
and all
personnel.
2. Use a specially coated "laser" endotracheal
tube;
alternatively,
use a tube (preferably red rubber)
carefully wrapped in overlapping fashion with protective V2-inch metallic tape. Water or methylene
blue rather than air is used to inflate the cuff of the
endotracheal
tube. Care must be taken that the
tape used is in fact metallic rather than plastic tape

with the appearance of metallic tape. The authors
have noticed that one flexible metal endotracheal
tube that we have tried actually leaks.
3. Use a nonflammable
anesthetic agent.
4. Use water-saturated
cottonoid pledgets over the
wrapped endotracheal tube in the laser field and in
the subglottic space. These pledgets are to be kept
moist during the entire procedure. Retrieval sutures
are secured to these pledgets. The sutures, however, may be vaporized with the laser; hence, an
accurate count of the pledgets at the close of the
operation is mandatory.
5. Protect all exposed skin and mucous membrane of
the patient with wet towels and sponges even outside the operative field.
6. Protect the patient's eyes with glasses and two
layers of wet towels. Corneal and scleral burns can
occur both to the patient and to operating room
personnel.
7. Protect all personnel in the operating room with
glasses.
8. Place a notice on the operating room doors stating
that a laser is in use and that personnel should not
enter unless glasses are worn.
9. Be cognizant that the laser beam is absorbed by
soft tissues and bone but that it may be reflected
by metal objects.
10. Check that the laser beam exactly coincides with
the target light on a wooden block just before the
use of the laser.

11. When using the CO2 laser on a bilateral lesion, it is
advisable to treat one side at a time.
12. During laryngeal surgery, the subglottic area is
completely occluded around the endotracheal tube


THE LARYNX

with soaking wet cotton sponges and sutures to
facilitate retrieval.
Comments
Basically, this form of energy can be used to vaporize
tissue or for dissection purposes. It can be utilized in
two modes, either pulsed or continuous, and operates
at a wavelength of 10.6 nm, producing light in the
invisible range of the spectrum.
Although many authors use the CO2 laser for excisional biopsy purposes, this author has not followed
this procedure for fear of possibly destroying tissue for
histologic examination. Surgical biopsy is preferred. This
is a personal preference. There is little doubt that minute
areas are best sampled surgically either using telescopic
biopsy forceps (see Chapter 4) or the microscopic laryngeal set-up. Only vessels less than 1 mm in diameter
should be attempted to be coagulated with the laser;
hence, care must be taken when excising larger lesions
that may have large vessels. Under these circumstances
electrocautery and/or pistol grip-type hemostatic surgical applicator clips should be available.
Although the use of the CO2 laser usually requires
the larger lumen laryngoscope, as used in microlaryngoscopy, occasionally it is well nigh impossible to insert
these large laryngoscopes. The authors h"ve occasionally
used the standard Holinger hourglass speculum or the

Jackson anterior commissure speculum with monocular
vision. This adaptation requires a careful preoperative
trial to be certain that the laser beam is aligned with
the target spot on a block of wood.
The one area that the authors find very difficult to
treat with the laser is posterior to the vocal process of
the arytenoid and the posterior commissure because of
the posterior location of the endotracheal tube. One
solution is the use of a 1.3-cm segment of a plastic tooth
guard that is firmly secured with heavy silk sutures to
the anterior aspect of the laryngoscope. The concave
portion of this segment is faced anteriorly to hold the
endotracheal tube at the anterior commissure. This segment is then completely covered with a water-saturated
cottonoid pledget to prevent ignition. Another adaptation of this concept would be the use of a metallic clip
shaped similar to a portion of the tooth guard to hold
the endotracheal tube anterior to the laryngoscope.
Despite the reports of minimal postoperative edema
that may cause airway obstruction, it is best to observe
the patient very carefully after extubation. The patient
may be kept in the hospital overnight to be observed
for 18 hours if there is any suspicion of edema, in
which case corticosteroids are used.
Pain and scarring are reported as uncommon or
entirely absent after the use of the CO2 laser. Although
we have not seen pain as a complication of endolaryngeal laser use, scarring forming a web at the anterior

commissure has occurred when papillomatosis crosses
the anterior commissure. This has not been of any
significance or concern, but it can occur. Pain with
scarring has occurred with the use of the CO2 laser in

the floor of the mouth in at least one patient.
With a hand-held CO2 laser, debulking of massive
lymphohemangiomas of the tongue has been utilized
to vaporize the lesions with varying success. Whether
these lesions arise in the tongue or larynx their treatment usually requires surgical excision along with laser
surgery.
Complications
• Fire
• Edema-usually 1 to 6 hours postoperatively
• Postoperative bleeding after vaporization of large
lesions
• Recurrence of lesions
• Corneal, mucous membrane, and skin burns
• Tracheal perforation and burns
• Glottic web
• Vocal cord fibrosis from vaporizing the underlying
vocalis muscle
• Subglottic stenosis
• Arytenoid perichondritis-use
antibiotics if cartilage
is exposed.
• Delayed airway obstruction
• Foreign bodies from metallic tape or dislodged
cottonoid pledgets
It is obvious from this list of complications that significant expertise and care is necessary with the use of
the CO2 laser. This procedure is not recommended for
the occasional operator or the occasional anesthesiologist.

Endoscopic Intracordal Injection
of Teflon Paste (Fig. 20-7)

When there is a glottic gap of 4 mm or more resulting
in dysphonia and/or aspiration, intracordal injection of
various types of materials has been described to narrow
this gap. The most common indication is adductor
vocal cord paralysis in which the normal vocal cord is
unable to approximate the fixed abducted vocal cord.
The timing of performing the intracordal injection varies
with the underlying etiology and whether sufficient time
has elapsed for spontaneous recovery of the paralyzed
vocal cord (usually 9 to 12 months) and also whether
other procedures are indicated. In general, the treatment of dysphonia can be delayed whereas the treatment
of aspiration may be urgent. Then again other methods
of management of aspiration may be indicated, such as
cricopharyngeal myotomy (which has varied success)
and closure of the glottis.


THE LARYNX

\

THYROID
CART.
2-4mm

THYROARYTENOID

M.
CRICOID
CART.

FIGURE 20-7

Teflon paste injections were very popular in the
1980s. They have been abandoned because of their
propensity to migrate. Gelfoam paste and finely minced
fat are used today for an initial trial because they are
absorbable. Therefore, these absorbable materials could
possibly be used in the treatment of temporary aspiration. The author's experience is limited to only one
patient in whom Gelfoam was injected in both vocal
cords to alleviate aspiration. Unfortunately, this measure
failed, because closure at the posterior commissure could
not be adequately achieved. Gelfoam paste absorbs in
3 to 4 months, depending on the amount injected.
The technique consists of the use of a direct laryngoscope and a laryngoscope holder (e.g., a Holinger anterior commissure speculum and Lewy holder or a
Kleinsasser and a Riecker holder), along with a central
ratchet-type syringe with a long laryngeal 18- or 19gauge needle (e.g., the Briinings syringe and accompanying needles). Anesthesia is topical 10% cocaine
with intravenous supplement of meperidine (Demerol)
and droperidol (Inapsine) administered by an anesthesiologist who is also monitoring the patient for any
cardiac irregularities.
The procedure technique and operating room set-up
are similar to those used for micro laryngoscopy (see
Fig. 4-5D and E) except that the contralateral introduction of the laryngoscope is usually used.
The topical anesthesia facilitates evaluation of the
glottic gap as the patient is asked to phonate during the
procedure, thus indicating the amount of Teflon to be
injected. Depending on the configuration of the glottic
gap, one or two, or possibly three, injection sites are

utilized. The usual sites are in the middle third and

posterior third (juxtaposed to the vocal process of the
vocal cord) of the membranous vocal cord. From 0.3 to
0.4 mL is the usual amount injected at each site, again
depending on the glottic gap. The injection is carefully
made lateral to the free edge of the vocal cord and lateral
to the vocalis muscle. Depth of injection varies from 2
to 4 mm, with care being taken not to go too deep into
the infraglottic tissue of the vocal cord nor too superficial to cause a localized bulge. A metal or plastic guard
(Rubin) located 2 to 4 mm from the tip of the needle
can be used as a guide. The free edge of the vocal cord
should be displaced medially as evenly and uniformly
as possible. At times, 0.1 to 0.2 mL of the Teflon paste
may be required between the two major sites of injection.
Some endoscopists perform this procedure on an
outpatient basis; yet, it is preferred to observe the
patient overnight for any significant edema that might
compromise the glottic airway. Associated edema can
be managed with corticosteroids. If necessary, repeat
injections can be performed in 1 or more months.
Teflon injections have been performed to improve
the "breathy" voice after frontolateral laryngectomy,
with little to no success, depending on the amount of
soft pliable tissue that is present.
The procedure is not without complications, however. A complication rate of 33 % has been reported by
Lewy (1983), indicating that extreme care must be taken
in the selection of patients as well as in the technique
of injection.
Myasthenia laryngis and hypogenesis vocalis are not
indications for these injections. Again, if there is any
question regarding the indication, injection of an

absorbable substance is far better than the injection of
Teflon, which is permanent. Some voices have been
made permanently worse despite the attempt to remove
the Teflon.
The following complications have been reported:
1. Granulomas of the intrinsic larynx as well as of the
neck when the paste extrudes through the cricothyroid membranes. Such a complication can stimulate
a cold nodule of the thyroid or cause a neck mass.
2. Draining sinus tract
3. Airway obstruction necessitating tracheostomy
4. Resulting vocal cord margins at different levels
causing a weak and breathy voice
Oppenheimer has implicated Teflon sheeting as
carcinogenic in the mouse; however, Kirchner and coworkers (1966) have shown no carcinogenic effect of
the powdered Teflon as used in these injections. It
seems that the physical properties rather than the
chemical properties of Teflon are the deciding factor.


THE LARYNX

Thyroplasty /Vocal Cord
Medialization (Fig. 20-8)
Highpoints
1. Equipment:
a. Silas tic block
b. Periosteal elevator
c. Fiberoptic laryngoscope
2. Medialization
is preferably done under local anesthesia. However, it can also be done under general

anesthesia in patients in whom vocal cord paralysis is
anticipated as a result of resection of the vagus nerve
(base of skull surgery or oncologic surgery in the neck].
3. To minimize swelling, intravenous corticosteroids are
administered
at the time of the procedure and for a
few doses postoperatively.
Medialization of the vocal cord is the preferred method
to restore glottic competence in cases of unilateral vocal
cord paralysis, since the use of Gelfoam or Teflon injection of the vocal cord has for the most part been abandoned. Of all the different phonosurgery
procedures,
the thyroplasty type 1, initially described by 1sshiki, is
the most commonly done. The operative technique has
been modified by different surgeons.
The technique described here is Netterville's modification of 1sshiki's technique.
Technique
The patient is placed in the semi-sitting position. A
transverse incision is outlined at about the level of the
middle third of the thyroid cartilage. It measures 6 to
7 em long, and it is located to the side of the paralysis.
It usually extends slightly over the midline. Alternatively,
the incision used in the neck for a neck dissection or a
base of skull procedure can be extended appropriately
to expose the thyroid ala. Flaps are elevated superiorly
and inferiorly for a short distance to expose the entire
height of the thyroid cartilage. The dissection is carried
in the midline down to the level of the thyroid cartilage.
The perichondrium
of the lateral ala of the thyroid cartilage is incised vertically in the midline. It is then elevated from the midline to the oblique line of the thyroid
cartilage or near the posterior edge. It is important to

expose the thyroid ala completely so that the inferior
and superior borders of it can be delineated.

A A rectangular window in the thyroid ala is outlined. There are many descriptions of how to place this
window precisely. A reliable way to place it is to locate
it 5 to 8 mm back from the midline and 4 mm superior
to the inferior border of the thyroid cartilage. The
dimensions of the window average 5 to 6 mm in
height and 13 to 14 mm in length.
B With a scalpel or a drill with a 2- to 3-mm bur, the
cartilage is removed in the outlined window. Keep in
mind that the cartilage is thicker anteriorly than in the
most posterior part of the window.
C The interperichondrium of the thyroid ala is bluntly
elevated. At this point, an assistant introduces a fiberoptic scope through
one nostril that has been
previously anesthetized topically with 2% tetracaine.
Preferably the scope is connected to a camera and a
monitor that the surgeon can visualize directly. Alternatively, the assistant can communicate the findings to
the surgeon. Whereas some surgeons believe that it is
possible to obtain good medialization of the cord by
extensive mobilization of the perichondrium, in most
instances it is necessary to incise the perichondrium
superiorly, posteriorly, and inferiorly to facilitate medialization. The position of the window is checked by
visualizing the vocal cord, and not the false cord, being
mobilized when the perichondrium is pushed medially.
The extent of the medialization necessary to correct
the glottic incompetence
is monitored directly by
asking the patient to phonate. Obviously this is not

possible when the patient is under general anesthesia.
D1, D2 A Silastic implant is carved from a Silastic
block. A commercially available Dow-Corning block
with a block holder is available and it facilitates the
carving. The proper shape and size of the implant is a
key for a good result. The implant is obviously thinner
anteriorly (about 2 mm in thickness) and thicker posteriorly (6 to 7 mm). The dimensions of the implant
can be varied, according to the shape of the thyroid
cartilage and the needs of each individual case. It is
important to avoid overmedialization of the anterior
commissure.
E1, E2
Once the implant's shape has been finalized
it is inserted and it should be self-retaining.


D1

FIGURE 20-8


THE LARYNX

Laryngofissure (Thyrotomy)
(Fig. 20-9)
Indications
A laryngofissure,
thyrotomy, or laryngotomy is a midline anterior incision through the thyroid cartilage that
allows an excellent view of the interior of the larynx,
permitting intralaryngeal

surgery. Cordectomy, certain
vertical laryngectomies,
and arytenoidectomy
for both
bilateral abductor cord paralysis and neoplasms
are
performed through this approach. This exposure is well
suited for various types of partial laryngectomy (except
supraglottic) as well as more precise determination
of
the extent of a transglottic
or subglottic neoplasm.
Excision of webs, correction of strictures, wide resection of large areas of chronic leukoplakia and hyperkeratoses, benign growths, and impacted foreign bodies
that resist removal by peroral endoscopic procedures
are suitable for the laryngofissure approach.
Highpoints
1.
2.
3.
4.

Two horizontal skin incisions are preferred.
Do not skeletonize the larynx.
Preliminary tracheostomy is performed.
Internal branch of superior laryngeal nerves should
not be injured unnecessarily.
5. Use a V extension of a Y incision through the thyrohyoid membrane for better exposure.
6. Attempt preliminary
visualization
of a malignant

tumor through the thyrohyoid incision before section
of the anterior commissure. This will permit resection of the anterior commissure if it is deemed necessary by the extent of tumor.
7. Always drain the wound.

A Two separate horizontal skin incisions are made as
indicated: the upper one for the laryngofissure and the
lower one for the tracheostomy. If so desired, the upper
incision may be midline vertical but it should be kept
separate from the tracheostomy
incision if possible.
The tracheostomy is performed under local anesthesia,
and then general anesthesia can be used or the operation continued under local anesthesia. The upper incision is made midway between the level of the hyoid

bone and the cricoid cartilage, and the upper and
lower skin flaps including the platysma muscles are
developed. Extension into the lateral areas of the neck
is kept to a minimum, yet adequate visualization is still
possible. The lower edge of the hyoid bone is exposed
above and the cricoid cartilage below.
B The fascia enveloping the strap muscles is incised
in the midline, exposing the body of the thyroid cartilage and the thyrohyoid membrane. The location of
the internal branch of the superior laryngeal nerve
is kept in mind as it enters the larynx through the
thyrohyoid membrane. If a horizontal line is drawn
across the upper level of the thyroid cartilage to a
point within 1 em of the superior cornu of this cartilage, this point localizes fairly accurately the site of
entrance of the nerve through the thyrohyoid membrane (X in A). This guide is important because the
midline incision through the thyroid cartilage may
then be converted to a Y incision as it transects the
thyrohyoid membrane. This modification permits a

much'wider and clearer visualization of the larynx and
avoids fracture of the thyroid cartilage when it is
retracted. It also avoids injury to the epiglottis. This
incision is depicted by the dotted line.
C Through a small initial incision at the thyroid notch,
a pair of angulated heavy scissors is inserted under the
cartilage in the midline, with an attempt to stay subperichondrially on the under side. That is, the lumen of
the larynx is not entered at this time.

Cl An alternate method of sectioning the thyroid
cartilage is with the use of an oscillating saw, as depicted,
or a sagittal plane saw or a Clerf saw.
D The V incision through the thyrohyoid membrane
begins at the thyroid notch and is carried upward and
outward toward the greater cornu of the hyoid bone.
The previously described location of the internal branch
of the superior laryngeal nerve is noted. With both
sides of the V incision made, a preliminary survey of
the inside of the larynx is performed. Depending on
these findings, the anterior commissure is transected
either in dead center or off to one side.
Continued


THE LARYNX

Hyoid bone
Thyrohyoid
membrane
Thyroid cart.

c

D

FIGURE 20-9


THE LARYNX

Cordectomy and Arytenoidectomy
Bilateral Abductor Cord Paralysis

for
the posterior commissure and thence over the arytenoid cartilage following the dotted line. If desired,
this mucosal flap may be left partially or completely
attached along its inferior margin as suggested by
Lawson.

(Lore Sr., 1936)
Highpoints
1. Excise internal portion of thyroarytenoideus
2. Excise portion of the cricoarytenoideus
muscle.
3. Remove entire arytenoid.
4. The pedicle of the elevated and preserved
can be based either anterior or posterior.
5. Perform a tracheostomy.

muscle.

lateralis

mucosa

Complications
•
•
•
•

Hematoma, bleeding, and subcutaneous
emphysema
Failure of adequate airway
Edema
Remember, as the airway improves (glottic chink
wider), the voice becomes poorer. The patient should
be made aware of this fact preoperatively.

Thornell (1948) has described an intralaryngeal technique for the treatment of bilateral abductor vocal cord
paralysis. The author has no experience
with this
method.
E Schematic frontal section through the larynx shows
the submucosal excision of a vocal cord for laryngeal
stenosis after bilateral abductor cord paralysis. First
one cord is operated on and then, if necessary, the
other cord can be operated on after evaluation of the
airway. It must be remembered, however, that as the
airway increases the voice will become worse.
F The initial incision consists of separation of the

mucosa with a No. 11 blade knife from the underlying
thyroarytenoid muscle, leaving, however, an anterior
pedicle. Posteriorly, the incision is carried medial to the
vocal process and body of the arytenoid cartilage to

G With the mucosal flap turned forward, the arytenoid cartilage is dissected using a nasal mucosal freer
and fine long scissors and removed. Care must be exercised not to leave any part of the arytenoid cartilage.
H Through the denuded area, the tissues lateral to
the vocal cord are excised down to but not including
the perichondrium. The excised tissues are the internal
portion of the thyroarytenoideus
muscle and part of
the cricoarytenoideus lateralis muscle. The upper part
of the conus elasticus (lateral cricothyroid membrane)
is now undermined for about 1 cm to permit closure.
It may be necessary to electro coagulate the raw area
to control oozing of blood and thus prevent postoperative hematoma. The glottic chink is checked by direct
laryngoscopy. The opening at the posterior commissure
must be about 5 mm wide. Four millimeters is the
minimum required after wound healing has occurred.
If not, additional tissue should be excised.
I The mucosal flap is sutured back in place using 5-0
chromic gut sutures. If there is any persistent ooze, a
1-inch gauze strip impregnated with antibiotic ointment is used as packing and brought out through the
cricothyroid membrane. Closure of the laryngofissure
is shown in Figure 20-13T. Tracheostomy care is discussed on page 116. A laryngeal keel is usually not
necessary unless the opposite vocal cord is denuded at
the anterior commissure. A small Penrose drain is used
to prevent spreading emphysema.

J

A mirror laryngoscopy image
position of operated vocal cord.

shows the lateral


THE LARYNX

Epiglottis

F
Ant. pedicle preserved
Thyroarytenoideus m.

H

FIGURE 20-9 Continued

G


THE LARYNX

Lateralization of Arytenoid
Cartilage (Arytenoidopexy)
for Bilateral Abductor Vocal Cord
Paralysis (Fig. 20-10) (After King,
1945, as modified by Clerf, 1950;

A Schematic lateral view depicts topographic
The skin incision is either made through a
thyroidectomy scar (if one exists) or placed
tally in a natural skin crease at the level of the
tenoid joint (solid line).

anatomy.
previous
horizoncricoary-

Woodman, 1946)
Highpoints
1. Correct evaluation of level of cricoarytenoid articulation.
2. Complete mobilization of arytenoid cartilage:
a. Transect interarytenoid
and posterior cricoarytenoideus muscles.
b. Transect cricoarytenoid ligament (joint capsule).
c. Maintain vocal cord attachment to the vocal process of the arytenoid.
3. Keep all mucosa intact during dissection and placement of arytenoid sutures.
4. Handle arytenoid cartilage with very fine hooks to
avoid fragmentation.
S. Mobilize the arytenoid cartilage and fix it hard
against the thyroid ala and slightly lower than its
normal position. Fixation may be too far lateral for
some patients (follow Highpoint No.6).
6. Check position of vocal cord with direct laryngoscope before closure of wound. Space at posterior
commissure should be at least 5 mm at the end of
the operation. (Four millimeters is the ideal final
result after the healing has occurred.)

7. Perform careful hemostasis.
8. Remember to inform the patient that as airway is
improved, voice may well become poor.
9. A cordectomy and arytenoidectomy
may be the
better choice than arytenoidopexy
when the patient
has had a malignant lesion (e.g., carcinoma of the
thyroid). The cordectomy
and arytenoidectomy
would avoid violation of the lateral neck, which
could make detection of early metastasis difficult
and neck dissection even more difficult. Also, arytenoidopexy can be very difficult to perform after
neck dissection because of scarring and lack of
protection for the common carotid artery. Hence,
the cordectomy and arytenoidectomy
may be the
operations of choice (see Fig. 20-9E to J).
10. Dissect along the inner aspect of the thyroid cartilage to reach the arytenoid. Keep posterior and
somewhat superior; otherwise, the cricoid cartilage
will be unnecessarily exposed too much.

B Detailed relationship is shown of the arytenoid
cartilage to the cricoid and thyroid cartilages. The level
of the vocal cord is along the long horizontal broken
line in the adult male, which is located at the midportion of the thyroid cartilage anteriorly. In the female
or small male, the level is one third of the distance
from the thyroid notch.
C Upper and lower skin flaps have been developed.
The omohyoid muscle is retracted or may be transected, exposing the inferior pharyngeal constrictor

muscle as it crosses the posterior edge of the thyroid
ala. An incision is made along the edge of the thyroid
ala transecting
the inferior pharyngeal constrictor
muscle along the dotted line.
D With careful blunt dissection, using a moist peanuttype sponge, the posterior cut edge of the inferior
pharyngeal constrictor muscle is retracted posteriorly
and the thyroid ala is retracted anteriorly, exposing the
inner anterior aspect of the slightly bulging mucosa of
the pyriform sinus. This mucosa should not be incised
or torn. The inferior cornu of the thyroid cartilage may
be separated from the cricoid cartilage or resected for
additional exposure.
E Continuing with blunt dissection, the mucosa is
now freed from the underlying arytenoid muscles and
retracted posteriorly and laterally. The two important
muscles to be transected are exposed: the interarytenoideus and the posterior cricoarytenoideus.
The
smaller lateral cricoarytenoideus muscle may either be
left intact or cut.
Continued


THE LARYNX

INF. PHARYNGEAL

CONSTRICTOR

M.

POSTERIOR EDGE
THYROID ALA

D

c
POST. CRICOARYTENOID

E
LAT. CRICOARYTENOID

FIGURE 20-10

M.


THE LARYNX

Lateralization of Arytenoid
Cartilage (Arytenoidopexy) for
Bilateral Abductor Vocal Cord
Paralysis (Continued) (Fig. 20-10)
(After King, 1945, as modified by C1er(
1950; Woodman, 1946)

the other hand,
the tracheostomy
is absolutely
necessary in bilateral abductor cord paralysis. Closure
of the wound is in layers with a small Penrose drain. Be

sure to approximate the transected inferior pharyngeal
constrictor
muscle. In I to 2 weeks the airway is
evaluated;
and if the airway is satisfactory,
the
tracheostomy tube is removed.

Complications
•
•
•
•

Postoperative hematoma causing edema
Breakage or slipping of arytenoid cartilage sutures
Chondritis if mucosa is torn
Cicatrization with gradual narrowing of glottic chink.
If necessary, this procedure can then be repeated on
the opposite side or an arytenoidectomy
can be performed (see Fig. 20-9E to J) on the opposite side via
thyrotomy.

F Detailed view of the muscles. The dotted lines indicate the sites of transection. A pair of small angulated
scissors is used to cut the interarytenoideus
muscle,
taking care not to violate the mucosa.
G The joint capsule is now transected circumferentially. The arytenoid cartilage must not be fragmented.
A very fine double-pronged
hook is used for traction

on the cartilage. Again, take care not to open the mucosa
overlying the cartilage.

TABLE 20-1 Incidence of Cancer of the
Larynx in the United States, 1992-1998
Age-Adjusted Rates

Sex
Year of
Diagnosis
1992
1993
1994
1995
1996
1997
1998

Male and Female

Male

Female

7.5500
6.7649
6.8814
6.7387
6.3641
6.1806

5.6070

1.4410
1.2577
1.5817
1.3599
1.4656
1.2988
1.3153

Male and Female

Male

Female

0.0050
0.0000
0.0112
0.0114
0.0332
0.0548
0.2031
0.4827
1.3744
2.8614
6.1889
11.4793
16.1877
19.6324

20.7099
18.7289
15.0734
9.4967

0.0000
0.0000
0.0109
0.0222
0.0431
0.0689
0.2784
0.6313
2.1783
4.6134
10.3436
18.9683
27.1383
34.5380
38.0920
36.3899
33.0439
25.0200

0.0103
0.0000
0.0115
0.0000
0.0228
0.0404

0.1270
0.3340
0.5887
1.1518
2.1892
4.4506
6.3640
7.2717
7.3302
6.4203
4.6692
3.1012

4.1714
3.7037
3.9650
3.7909
3.6679
3.4879
3.2436
Crude Rates

Sex
Two sutures of 3-0 Tevdek or 4-0 braided nylon or
Mersilene are carefully placed around the vocal process
and body of the arytenoid cartilage. If the arytenoid
cartilage is not calcified, a fine needle may be used to
pass the suture through the cartilage. Clerf has designed
special needles for this purpose. The needles must be
stout enough so that they will not break. Two holes

slightly lower than the level of the arytenoid cartilage
are made in the thyroid cartilage to secure these lateralizing sutures, thus dropping and tensing the vocal cord.
Depending on the consistency of the thyroid cartilage,
a 19-9auge needle can be hand-drilled through the cartilage and used as a guide to pass the securing suture.
The arytenoid cartilage is tacked firmly against the inner
aspect of the thyroid ala. This is best for men, whereas
for women, the glottic chink can be somewhat smaller.
The position of the vocal cord is now checked with
direct laryngoscopy. The glottic chink should be about
5 mm at the vocal processes. A slightly wider opening is
more desirable, because scarring can narrow the glottic
chink. When healing is complete, the usual4-mm width
will then be achieved. A tracheostomy,
if not already
present, should be performed. Tracheostomy may not
be necessary if there is unilateral vocal cord paralysis.
Actually, it is rarely used under such circumstances.
On

Age at
Diagnosis
00-04
05-09
10-14
15-19
20-24
25-29
30-34
35-39
40-44

45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85 +

Rates are expressed as cases per 100,000; race/ethnicity = all races;
age at diagnosis ~ all ages.
Statistics are provided by the SEER Program for research purposes
only, available at / Accessed
January 9, 2002.


THE LARYNX

INTERARYTENOID

F

M.

POSTERIOR CRICOARYTENOID

INTERARYTENOID

M.

M.

INTACT MUCOSA
ARYTENOID CART.
JOINT SURFACE
CRICOID CART.

H
POSTERIOR CRICOARYTENOID

M. '

FIGURE 20-10 Continued

H Posterior view of basic anatomy depicts relationship of arytenoid cartilage and the transected muscles.

Cancer of the Larynx

This accounts for approximately 25 % of all head and
neck cancers and 1.5% of all cancers. The trend during
the period 1992-1998 appears to be somewhat
downward: 4.2 to 3.2. The bulk of patients are in the
sixth and seventh decades of life with a few patients
younger than the age of 20. Incidence data are shown
in Table 20-1.

Incidence
Etiology

The incidence (age adjusted) of carcinoma of the larynx
is 3.2 (SEER, 1998) (age-adjusted rates) patients per
100,000 population in the Un~ted States. This is the
lowest incidence since 1973 (females,1.3; males, 5.6).
When based on age at diagnosis, in those younger than
65 the incidence is 6.9; in those 65 and older it is 2.3.

The major etiologic factors for carcinoma of the larynx
are the extended use of tobacco and/or alcohol, with
cigarette smoking as the primary etiologic agent. Any
patient with a history of smoking of one pack of cigarettes per day for 10 or more years must be carefully


THE lARYNX

evaluated and followed when there are any signs or
symptoms relative to the voice or suspicious changes in
the laryngeal mucosa.
Carcinoma of the larynx may be seen rarely in the
nonsmoker. There appears to be a relationship of these
patients to an environment of tobacco smoke inhalation. Examples of this exposure to secondary smoke are
demonstrated in the three following patients: One was
an 18-year-old girl whose parents were exceedingly
heavy smokers, another was an elderly lady who spent
considerable time playing bridge with companions who
were heavy smokers, and a third patient was a middleaged woman whose husband was a heavy smoker and
who developed carcinoma of the larynx.
There is some evidence that early exposure to therapeutic radiation as well as industrial exposure to smoke
and toxic fumes may be contributing agents.
Pathology

Malignant tumors of the larynx arise from the mucous
membrane as well as the supporting related structures.
From 85% to 90% of the malignant epithelial tumors
are squamous cell carcinoma, ranging from the well
differentiated through the undifferentiated, with the
majority being at least moderately well differentiated.
Glottic lesions tend to be well differentiated. Verrucous
carcinoma is a distinct clinicopathologic entity, with an
incidence of approximately 1% to 2 % of laryngeal carcinomas. The remaining (less than 10%) malignant
tumors include fibrosarcoma, chondrosarcoma, chemodectoma, rhabdomyosarcoma, malignant minor salivary
gland tumors, adenocarcinoma, oat cell carcinoma,
adenosquamous cell carcinoma, and giant cell and
spindle cell carcinoma.
Discussion of the precancerous lesions of the larynx
is limited to those of epithelial origin. The gross appearance may range from a whitish and/or reddish patch,
slight roughness, and irregularity of the mucosa, to a
minimally detectable break or minor ulceration of the
mucosa, to a thick pile-up of whitish irregular mucosa.
Although clinical diagnosis indicates suspicion, histologic
examination is the only way to be certain. However, it
is emphasized that biopsy must consist of complete
removal of the suspected area when frank carcinoma is
not obvious. The histologic changes of these precancerous lesions include dysplasia and cytological atypia
(see Chapter 3).
The clinician is cautioned that when the clinical diagnosis is malignant, but the biopsy does not confirm this,
the clinician should review the slides with the pathologist and, if necessary, repeat the biopsy. If the lesion
involves the membranous true vocal cord and it is not
obvious squamous cell carcinoma, a stripping biopsy of
the entire edge of the vocal cord is more fruitful than
multiple small biopsies of the area.

Natural History
The natural history of larynx cancer varies widely,
depending on the anatomic site of the origin of the
tumor. The larynx is divided into supraglottic, glottic,
and subglottic. These divisions are very useful; however, in advanced disease they may not be precise. The
supraglottis of the larynx extends from the tip of the
epiglottis to the apex of the ventricle. This includes the
ventricular bands or false vocal cords and the superior
wall of the ventricle. The glottis extends from the apex
of the ventricle inferiorly to the area beneath the true
vocal cord where the squamous epithelium changes to
respiratory epithelium. The subglottis extends from the
junction of the squamous and respiratory epithelium to
the inferior edge of the cricoid cartilage. Patients with
tumors arising from other than the true vocal cord
usually do not experience any voice changes until a
neoplasm becomes so large that it interferes with the
glottis. Even then, voice changes may not be apparent
or significant. Surprisingly enough, very large bulky
lesions of the epiglottis occur that defy an explanation
of the paucity of symptoms. Although dysphagia can
occur in these large tumors, the real threat is airway
embarrassment, leading to obstruction. Although more
common in glottic tumors, airway problems are the
terminal symptoms of virtually all stage IV malignant
lesions. Table 20-2 outlines the symptoms.
Supraglottic carcinomas are generally more aggressive both in direct extension (e.g., into pre-epiglottic
space [adipose tissue] and lymph node metastases).
Approximately one third to one half will have positive

nodes. Lymphatic channels drain into the jugulodigastric, middle, and inferior levels of the internal jugular
chain. All adjacent structures may become involved.
This includes the lateral wall of the hypopharynx along
the glossoepiglottic fold as well as the base of the tongue.
Yet extension to the true vocal cords or subglottically is

TABLE20-2
Larynx

Symptoms of Carcinoma of the

Hoarseness or change in the voice
Irritation or tickle in the throat
Lump in the neck
Dysphagia and/or odynophagia
Sore throat
Dyspnea or orthopnea leading to airway obstruction
Hemoptysis
Stridor
Cough
'Earache
Asymptomatic


THE lARYNX

relatively rare except for those tumors that involve the
base of the epiglottis.
Kirchner (1969) has pointed out in serial sections of
over 50 supraglottic cancers that when the tumor is

limited to the supraglottic portion of the larynx, the thyroid cartilage is not destroyed or even invaded. However,
when the fixed growth does involve the true cord and
the ventricle, the thyroid ala is invaded, particularly in
growths over 2 cm in diameter. If lymph nodes are
positive on one side of the neck, then the possibility of
contralateral node metastases is high.
In the clinical evaluation of supraglottic carcinoma,
the inferior wall of the ventricle should not be involved.
Once this becomes involved, then the disease has spread
to the glottis, and as noted previously, the thyroid ala
can then become involved.
These tumors arising from the laryngeal surface of
the epiglottis tend more to lead toward potential airway
embarrassment. When a tumor reaches such a size,
however, it is often quite difficult to ascertain the exact
site of origin. After preoperative adjuvant chemotherapy when there is some residual disease, this location
seems to indicate the site of origin.
Glottic carcinomas tend to be well differentiated, grow
slowly, and metastasize late, with metastases usually
occurring only when the disease has spread beyond the
limits of the true cord. This characteristic is related to
the limited lymphatic drainage of the vocal cords. Submucosal extension of the anterior third of the vocal
cord toward the anterior commissure may be a relatively early occurrence; and, subsequently, the lesion
may extend across the midline to the opposite side,
invade the thyroid cartilage specifically at the anterior
commissure, and then extend superiorly into the walls
of the ventricle, the ventricular bands and aryepiglottic
fold, and/or inferiorly into the subglottic space, although
rarely below the superior border of the cricoid arch.
Significant invasion and breakthrough of the thyroid

cartilage may be characterized by broadening of the
thyroid cartilage. Posterior extension of the posteriorly
situated cord lesions is to the cricoarytenoid articulation and into the arytenoid region. Ten to 20 % of glottic
carcinomas with fixed vocal cords present as lymph
node metastases. These fixed vocal cords are usually a
result of local extension rather than nerve involvement,
although the latter can occur. Fixation of the vocal
cords usually indicates invasion of the thyroarytenoid
muscle. On the other hand, limitation of motion of the
vocal cord may be due to the bulk of the tumor, with
surface extension rather than direct invasion of the
thyroarytenoid muscle. Nevertheless, it should be
emphasized that with impaired mobility of either the
true cord or, for that matter, the ventricular band in
supraglottic carcinomas, one must be suspicious of a
deeply invasive lesion that may well have started in the
ventricle.

True subglottic carcinomas are uncommon (perhaps
5% of all laryngeal carcinomas); however, subglottic
extension does occur with glottic carcinoma; and when
it does occur, the disease progresses rapidly and is an
ominous sign. Lymphatics from the subglottic area drain
to the middle and inferior levels of the internal jugular
chain, to the prelaryngeal (cricothyroid or delphian)
nodes (from which lymph vessels pass to the pretracheal
and supraclavicular nodes), and tothe paratracheal and
tracheoesophageal nodes and then into the mediastinum. Dye studies have demonstrated the existence of a
plexus of lymphatics at the surface of the cricothyroid
membrane, with channels leading bilaterally to the deep

cervical nodes. This supports the observation that carcinomas with subglottic extension have a greater tendency
toward bilateral cervical metastases and have a poorer
prognosis. Hence, these tumors require extensive paratracheal and tracheoesophageal node dissection as well
as superior mediastinal node dissection. In addition, an
ipsilateral thyroid lobectomy is performed. As a matter
of routine, an ipsilateral thyroidectomy is recommended in all total laryngectomies. Glottic carcinomas with
subglottic extension have a higher incidence of stomal
recurrence, probably owing to the nodal spread.
It is significant that in more recent years, tracheal
stoma recurrence after total laryngectomy has significantly decreased. Tracheal recurrence could be the result
of a number of factors. Three possibilities are:
1. Tumor implantation in the tracheal wound. Tracheostomies years ago were more common because
of airway obstruction. Today, if a patient arrives at a
hospital in airway distress, there are three options:
a. Immediate commencement of chemotherapy with
Decadron
b. Debulking of the lesion with the CO2 laser providing a temporary airway
c. Emergency laryngectomy
2. Untreated paratracheallymph node metastases
3. Undetected presence of tumor at the tracheal margin
of resection. This was a significant possibility with
the so-called narrow field laryngectomy, which virtually is skeletonization of the thyroid cartilage and
all the surrounding tissue, which constituted a "shelled
out" larynx with no contiguous tissue and positive
margins. If there is any question regarding margins
in any operation, frozen sections are utilized. This
likewise would be true if there is extension of the
laryngeal carcinoma into any portion of the hypopharynx, particularly the pyriform sinus.
Diagnostic

Methods

1. Inspect and palpate the neck for cervicallymphadenopathy and broadening of the thyroid cartilage
(broadening of the thyroid cartilage is suspicious of


THE lARYNX

neoplasm of larynx). Always palpate the base of the
tongue.
2. Perform laryngoscopy (see Chapter 4).
a. Indirect mirror. This is probably the most important overall diagnostic measure. It gives an overall
view of not only the larynx but also the base of
the tongue and hypopharynx.
b. Direct optical laryngoscopy. This includes the use
of the various types of fiberoptic and opticallaryngoscopes. There are a number of these available;
one of them is the Bercie-Ward, which utilizes
Hopkin's rod principle (Karl Storz). It affords an
excellent view of the larynx, particularly the anterior commissure and the base and petiolus of the
epiglottis. The instrument must be defogged using
a chemical defogger or by dipping the end in "hot
beads" or in hot water. This water should be
changed from patient to patient.
c. Another instrument is the flexible fiberoptic laryngoscope, which is inserted through one of the
nares and facilitates an overall view not only of
the nasopharynx but also of the base of the tongue,
hypopharynx, and larynx. This instrument gives
a much less magnified view, and it may be difficult to detect very small lesions. It is excellent for
visualizing the motion of the vocal cords and is
usually very well tolerated by the patient.

d. Direct rigid laryngoscopy. The Holinger hourglass
anterior commissure speculum is excellent. Another
instrument, interestingly enough, is the Jesberg
short adult esophagoscope. Both this and the
Holinger anterior hourglass speculum can be inserted well into the intrinsic structures of the
larynx for careful visualization of the walls of the
ventricle as well as the pyriform sinus of the hypopharynx. Evaluation of the medial wall of the
pyriform sinuses is most important in all moderately and advanced carcinomas of the larynx.
e. Microlaryngoscopy. This can be done utilizing a
standard operating microscope or an optical telescope inserted through a rigid laryngoscope.
3. Diagnostic radiology
a. Soft tissue radiographs
b. Pharyngoesophagogram
c. CT and magnetic resonance imaging (MRI) are
used when additional soft tissue detail is necessary. Some clinicians prefer MRI in the evaluation
of larynx cancers because it provides excellent
actual (not computer reconstructions as in CT)
coronal and sagittal views of the larynx.
d. Laryngogram and tomograms are not utilized and
are very selective.
4. Esophagoscopy and bronchoscopy
5. Photography of the larynx and hypopharynx. These
photographs can quite easily be obtained using a
Hopkin rod type of fiberoptic laryngoscopy (e.g., the

Bercie-Ward scope). These photographs afford a very
careful and leisurely examination of the larynx and
hypopharynx and serve as a record for the extent of
the tumor prior to preoperative chemotherapy.
6. Video recordings are excellent, not only for recording the extent of the neoplasm but also for the evaluation of the mobility of the vocal cords. Combined

with voice evaluation-stroboscopy-additional
data
are obtained regarding voice function and comparative analysis with vocal cord motion. Video recordings are excellent for presentation at tumor conferences, and this combined with video presentation of
the histopathology is a sine qua non for an up-todate head and neck tumor conference, as well as a
record regarding the extent of disease if chemotherapy is to be used (e.g., before operation or chemoirradiation) .
After these various diagnostic modalities, a biopsy is
then performed, usually through a direct laryngoscope.
If there is some question as to the site of biopsy,
particularly with multiple suspicious areas, staining of
the mucous membrane can be performed with the use
of 1% toluidine blue. Acetic acid (1 % solution) is used
to cleanse the lesion before and after staining (see
Chapter 3, p. 91). Although there is some difference of
opinion regarding the validity of the staining, nevertheless, it is believed to be of help with multiple suspicious areas. In lesions of the membranous vocal cord in
which clinical diagnosis is not clear cut, stripping of
the entire edge of the free vocal cord is preferred over
small multiple punch biopsies. This stripping specimen
corresponds to the free membranous cord, and horizontal multiple small sections can then be obtained.
With a large lesion, a simple punch biopsy will suffice.
A variant of direct laryngoscopy is the operation
microscope, which is utilized for small lesions, particularly multiple suspicious areas. Telescopic instruments
designed by the author and manufactured by Karl Storz
are ideal for careful scrutiny of the entire intrinsic larynx
(see Chapter 4).
Anesthesia

Many indirect laryngoscopies can adequately be performed without any form of anesthesia. If anesthesia is
necessary, there are basically three types of agents: 2 %
tetracaine (Pontocaine), 10% cocaine, and 4% lidocaine.
Side effects can occur with any of these agents. Careful

history of any untoward reaction is important. More
laryngoscopies using the various types of opticallaryngoscopes do require some type of anesthesia, although the
Hopkin rod type may be used without any anesthesia.
The Machida optical scope requires anesthesia and
decongestion of the nasal mucous membrane as well as
of the oropharynx and hypopharynx.


THE LARYNX

When direct rigid laryngoscopy is done, anesthesia
is always necessary, and although in the past topical
anesthesia
was used primarily, at the present time
general anesthesia through a small endotracheal tube is
preferred. This allows the surgeon to make a careful
evaluation of the areas of the larynx and hypopharynx.
In the large, bulky lesions in which there may be some
compromise of the airway, topical anesthesia alone is
utilized because of the danger of airway obstruction
after general anesthesia and intubation.

Staging
Staging that involves the TNM classification (Tables 20-3
and 20-4) is based on a pretreatment diagnostic evalua-

TABLE20-3

tion of the extent of disease and is classified according
to the supraglottic, glottic, and subglottic larynx. There

are a number of problems with staging, not the least of
which are the various methods of TNM classification
and the change in the TNM classification in anyone
system. It is suggested to the clinician that a very careful delineation of the tumor is made so that if there is
a change in the TNM classification from one system to
another, or within one system, this can be easily interpreted and cross-referenced.
Kaufman and Lore (1978)
have described a TNM classification and disease description that accomplishes
this type of TNM classification
and can be converted from one system to another. The
stage relates only to the site of the lesion and to a
clinical estimate of the extent of the disease. It does not

TNM Classification of Cancer of the barynx

Primary Thmor (T)

Minimum requirements to assess the primary tumor cannot be met.
No evidence of primary tumor
Carcinoma in situ

TX

TO
Tis
Supraglottis

Tumor limited to one subsite of supraglottis with normal vocal cord mobility
Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis or
region outside of supraglottis (e.g., mucosa of base of the tongue, vallecula, medial wall

of pyriform sinus) without fixation of the larynx
Tumor limited to larynx with vocal cord fixation and/or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage
erosion (e.g., inner cortex)
Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
Thmor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Tl
T2

T3

T4a

T4b
Glottis
Tl
Tla
Tlb
T2
T3

T4a

T4b

Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with
normal mobility

Tumor limited to one vocal cord
Tumor involves both vocal cords
Thmor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility
Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space,
and/or minor thyroid cartilage erosion (e.g., inner cortex)
Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including thyroid deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Subglottis
Tl
T2
T3

T4a

T4b

Tumor limited to the subglottis
Thmor extends to vocal cord(s) with normal or impaired mobility
Tumor limited to larynx with vocal cord fixation
Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of the neck including deep extrinsic muscles of the tongue,
strap muscles, thyroid, or esophagus)
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

From American Joint Committee on Cancer, 2003.