LARYNGOFISSURE AND CORDECTOMY

WITHOUT TRACHEOSTOMY
JAVIER GAVIL~N, MO, MARIA A. CEROEIRA, MO,
CESAR GAVILAN, MO

Cordectomy via thyrotomy is the oldest surgical procedure for laryngeal cancer. The procedure is used for
glottic cancers confined to the membranous portion of a mobile vocal cord. Laryngofissure and cordectomy
consists of resection of the entire vocal cord from the anterior commissure tendon to the vocal process of the
arytenoid. Most surgeons consider tracheostomy as an unavoidable part of the procedure. However, the
operation can be easily performed under general anesthesia without tracheostomy. This article presents the
laryngofissure and cordectomy routinely performed in our institution. Some technical variations along with the
specific details related to the management of the endotracheal tube during tumor excision are also explained.

Some laryngologists believe that laryngofissure and
cordectomy is obsolete and has been supplanted by ra-
diotherapy. However, in our practice, this is the basic
procedure for the treatment of early cordal cancer.
There are several reasons for this policy:
1. Early glottic cancer is highly curable both with sur-
gery and radiation therapy. However, for invasive la-
ryngeal cancer of all stages, radiotherapy leads to a
higher failure rate and a greater percentage of retreat-
ments.'
2. With radiotherapy plus salvage surgery, the mor-
bidity is greater than with surgery alone.
3. Radiotherapy is only as good as the specialists in-
volved and the reliability of the equipment at their dis-
posal?
4. The cost and consequences of treatment must be
kept in mind when planning treatment for early glottic
cancer.
5. The concept of field disease is fundamental. Sec-
ond primary tumors are frequent among patients with
head and neck cancer. Early glottic cancer is very cur-
able and the treatment options for later disease should
not be used up. Radiation treatment for the first cancer
does not prevent the subsequent development of a sec-
ond primary tumor. As stated by DeSanto, an epithelial
field is not made healthier by irradiation.f
Patient factors are more important in choosing between
radiotherapy and surgery. Age, occupation, general
condition, and distance from treatment center are vari-
ables that should be considered. The patient's prefer-
ence is also an important variable. The patient must be
adequately informed of the treatment options and conse-
quences, and then participate in selecting the treatment.
On the basis of these principles at least 80% of our
From the Department of Otorhinolaryngology, La Paz Hospital, Au-
tonomous University, Madrid, Spain.
Address reprint requests to Javier Gavilan, MD, Servicio de ORL,
Hospital La Paz, Paseo de la Castellana, 261, 28046 - Madrid, Spain.
Copyright © 1993 by W.B. Saunders Company
1043-1810/93/0404-0004$05.0010
patients with early glottic cancer undergo surgical treat-
ment, usually laryngofissure and cordectomy. The re-
mainder receive external fractionated irradiation.
INDICATIONS·
The major indication of laryngofissure and cordectomy is
an early glottic tumor confined to the membranous por-
tion of the vocal cord. There must be no limitation to
cordal mobility. The procedure has been also used for
larger tumors involving the anterior commissure or the
vocal process of the arytenoid. However, in our opin-
ion, these tumors are best treated using more extensive
procedures, such as anterior frontal laryngectomy or
hemilaryngectomy, which are also described in this issue.
Laryngofissure and cordectomy are also used for the
treatment of cancers that do not respond to radiation.
In these cases, one must be sure that the tumor was orig-
inally suitable for laryngofissure and cordectomy. If it
was not suitable before radiation, then a more extensive
operation should be performed. Multiple frozen sec-
tions of the surgical margins are required when laryn-
gofissure and cordectomy is used to salvage radiation fail-
ures. The operation performed in irradiated patients
has more frequent complications.
Chronological age alone is not a contraindication to
laryngofissure and cordectomy. Some older patients
might have radiotherapy recommended for two reasons:
they would not be at risk for a second tumor for as long
a period as younger patients, and older patients are less
capable of adapting to the partial loss of the sphincteric
function of the larynx. On the other hand, some elderly
patients may do better with laryngofissure and cordec-
tomy rather than undergo a full course of radiotherapy.
The patient's general health and pulmonary function are
more important variables than age alone.
Occupation and distance from the treatment facility are
also important considerations for treatment selection.?
Patients who use their voice a great deal are good candi-
dates for radiotherapy. Patients living far away from the
treatment center may prefer surgery to shorten the treat-
ment time.

266 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 4, NO 4 (DEC), 1993: PP 266-270
TECHNIQUE
The patient is placed in the supine position with the
shoulders elevated and the neck extended. The proce-
dure is performed under general endotracheal anesthesia
with transoral or transnasal intubation. To facilitate sec-
tioning the cord from the vocal process of the arytenoid,
the thinnest possible tube should be used.
A collar incision at the level of the cricothyroid mem-
brane is preferred. A vertical incision provides good ex-
posure of the surgical field, but the aesthetic results are
much better with a horizontal skin incision. Skin flaps
are elevated on the plane superficial to the fascia overly-
ing the strap muscles. The superior flap is raised up to
the level of the hyoid bone. The dissection of the infe-
rior skin flap is carried down to the level of the first tra-
cheal rings, completely exposing the thyroid isthmus.
A midline vertical incision is made between the sterno-
hyoid muscles. Several small veins communicating both
anterior jugular veins are divided and should be cauter-
ized. The strap muscles are retracted laterally exposing
the thyroid cartilage and the isthmus of the thyroid gland
(Fig 1).
The thyroid isthmus is divided between clamps, li-
gated, and lateralized by permanent sutures to the ster-
nocleidomastoid muscles on each side, leaving the ante-
rior surface of the cervical trachea just below the skin.
This maneuver will provide easy access to the trachea in
the event that a tracheostomy is needed during the post-
operative period. In our experience over the past 15
years, not a single tracheostomy has been necessary for
patients undergoing laryngofissure and cordectomy
without tracheostomy.
FIGURE 1. The strap muscles are retracted laterally exposing
the thyroid cartilage. The thyroid isthmus is divided showing
the cricoid arch and the first tracheal rings.
GAVILAN ET AL
Using a No. 15 knife blade, the external perichondrium
of the thyroid cartilage is incised vertically in the midline
and dissected laterally for a few millimeters. The thy-
roid cartilage is then divided strictly in the midline with a
circular or an oscillating saw. The endo laryngeal soft
tissues should not be injured by the blade of the saw.
Only the cartilage should be divided (Fig 2).
Before opening the cricothyroid membrane, the pre la-
ryngeal or delphian node is usually found in the prela-
ryngeal fascia between the cricoid and the thyroid carti-
lages. It may be removed for histological examination.
A midline vertical incision is made in the cricothyroid
membrane (Fig 2). The thyroid laminae are slightly re-
tracted laterally with skin hooks and the cricothyroid in-
cision is continued superiorly. Under direct vision, the
vocal cords are separated exactly in the midline using a
No. 15 knife blade or angulated blunt-tipped scissors.
The incision is extended superiorly until a satisfactory
view of the endolarynx is obtained (Fig 3). A self-
retaining retractor placed in the superior angle of the thy-
roid cartilage widely separates the thyroid laminae, ex-
posing the entire endolarynx. At this point a headlight
may be useful.
The endotracheal tube now lies in the laryngeal lumen.
Usually, it can be retracted towards the normal side with
a Langenbeck retractor allowing sufficient space for
cordal excision. However, if the larynx is very small,
even the thinnest possible tube will be large enough to
FIGURE 2. The external perichondrium of the thyroid
cartilage is incised in the midline and dissected laterally. The
thyroid cartilage is divided in the midline and th e incision is
continued along the cricothyroid membrane.
267
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FIGURE 3. View of the endolarynx. The endotracheal tube is
pulled toward the normal side with a Langenbeck retractor.
The diseased vocal cord is clearly visible.
make the cutting difficult at the level of the vocal process
of the arytenoid. In such cases, two solutions are pos-
sible:
(1) The endotracheal tube is partially removed from the
larynx by the anesthesiologist. The tip of the tube is left
within the larynx at the level of the epiglottis. Simulta-
neously, a thin endotracheal tube is inserted through the
divided cricothyroid membrane (Fig 4). The anesthesia
is continued through this tube until cordal resection is
completed. Before closing the larynx, the cricothyroid
tube is removed and the transoral or transnasal tube is
reinserted into the trachea.
(2) A gauze sling is passed through the endotracheal
tube and the assistant retracts the tube toward the normal
side, pulling it partially out of the larynx (Fig 5). Care
must be exercised when pulling the tube to avoid discon-
necting the respirator. After removal of the vocal cord,
the endotracheal tube is replaced within the larynx and
the thyroid cartilage is closed.
With the involved vocal cord clearly visible, the limits
of the resection are marked. A conventional cordectomy
should include only the vocal cord, from the anterior
commissure to the vocal process of the arytenoid, and
from the subglottis to the ventricular band (Fig 6). With
a No. 15 blade, the lower cut is made first so that blood,
running in a downward direction, will not obstruct the
vision of the upper incision. The lower cut is made in
the subglottis below the inferior limit of the vocal cord,
leaving a free margin of at least 5 mrn. The upper inci-
sion is made through the ventricle. Both cuts should be
268
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FIGURE 4. While the endotracheal tube is partially removed
from the larynx by the anesthesiologist, a thin endotracheal
tube is inserted through the cricothyroid membrane. This
second tube is used for ventilation during tumor removal.
The tip of the first tube remains within the larynx. Once the
tumor is completely extirpated, the cricothyroid tube is
removed and the first tube is reinserted into the trachea.
carried deep to the internal perichondrium of the thyroid
ala. Using a sharp dissector, a cleavage plane is opened
between the thyroid ala and the vocal cord. The anterior
commissure is then separated from the thyroid cartilage.
Finally, an incision is made with curved scissors through
the vocal process of the arytenoid. The cordectomy is
thus completed and the specimen can be oriented and
submitted to the pathologist.
Although resurfacing of the surgical defect is not nec-
essary, we do prefer to cover the wound with a mucosal
flap to lessen the risk for bleeding and edema in the early
postoperative period. After bleeding has been com-
pletely controlled to avoid aspiration, the false vocal cord
is undermined to create a mucous membrane flap. This
flap is advanced inferiorly to cover the defect and is su-
tured to the subglottic margin of the resection with 2-0
polyglycolic acid sutures (Fig 7). If the uninvolved cord
was released from its anterior insertion, it should be re-
fixed to the anterior edge of the thyroid ala with a suture
passing through the perichondrium or through the carti-
lage.
LARYNGOFISSURE AND CORDECTOMY
FIGURE 5. Using a gauze sling, the endotracheal tube is
gently retracted toward the normal side. Once the vocal cord
has been removed, the endotracheal tube is replaced within
the larynx.
The cricothyroid membrane is repaired and the two
halves of the thyroid cartilage are carefully approximated
in the midline using sutures through the perichondrium.
If the perichondrium cannot be used, two small holes are
drilled through both margins of the thyroid alae. The
thyroid cartilage is then sutured with 2-0 chromic catgut
sutures. Passing the suture through these holes is easy
when the needle goes from the outside to the inside of
the larynx. The internal orifice of the hole drilled in the
opposite cartilage ala can be more difficult to find. To
help this maneuver, a straight intramuscular needle is
inserted through the hole drilled in the thyroid cartilage
until its end can be seen in the laryngeal lumen. The
curved needle of the suture is then inserted into the bore
of the intramuscular needle and the ensemble is pulled
out of the larynx (Fig 8).
The strap muscles are approximated in the midline and
a drain is introduced to deal with wound secretions and
air accumulating between the soft tissues of the neck.
The platysma muscle is sutured with 2-0 chromic catgut
sutures and skin clips are used for the skin.
DISCUSSION
Laryngofissure and cordectomy consist of resection of the
vocal cord through an open cervical approach. The con-
GAVILAN ET AL
FIGURE 6. Only the vocal cord should be included in a
conventional cordectomy. The lower cut is made in the
subglottis, leaving a free margin of at least 5 mm.
ventionallaryngofissure and cordectomy removes the en-
tire vocal cord from the anterior commissure to the vocal
process of the arytenoid, and from the subglottis to the
ventricular band. In most American textbooks, part of
the ventricular band is also included in the resection.
This "cordo-bandectomy" for cancer on mobile cords
gives an extra margin where it is less needed: superiorly.
For early glottic and supraglottic cancer, the glottis can be
divided from the supraglottis cutting through the ventri-
de without violating sound principles of cancer surgery.
The same holds true for hemilaryngectomy in the treat-
ment of early glottic tumors on mobile cords. There is
no oncological benefit from removing one thyroid carti-
lage ala along with some extra soft tissue from within the
larynx when there is cordal mobility. The lateral extra
margin obtained with hemilaryngectomy is not needed in
early glottic cancer because cancer cannot spread very far
laterally and still leave a mobile cord.P
These "extra safe" operations are probably due to the
discomfort produced in the surgeon by the small resec-
tion margins obtained with conservation surgery of the
larynx. However, the oncological safety of conservation
surgery has stood the test of time. Histological free mar-
gins of more than 2 mm produce results generally com-
parable to widely clear margins."
The tracheostomy is another "extra-safe" maneuver
usually linked to laryngofissure and cordectomy. Most
269
 surgeons consider the tracheostomy to be a required part
of the surgical technique. Our experience does not sup-
port this idea. Between January 1984 and December
1992, 44 patients with early glottic cancer have been
treated with laryngofissure and cordectomy without tra-
cheostomy at La Paz Hospital. None of them required a
tracheostomy during the postoperative period.
A needed tracheostomy can save the patient's life. An
unnecessary tracheostomy is only a source of infection
and discomfort for the patient. It can extend the recov-
ery period without providing a benefit other than the
surgeon's reassurance. Therefore, for laryngofissure
and cordectomy, it is more the surgeon than the patient
who "needs" the tracheostomy.

REFERENCES
1. Hawkins NV: The treatment of glottic carcinoma: An analysis of 800
cases. Laryngoscope 85:1485-1493, 1975
2. Pearson BW: Management of the primary site: Larynx and hy-
popharynx, in Pillsbury HC, Goldsmith MM (eds): Operative Chal-
lenges in Otolaryngology Head and Neck Surgery. Chicago, IL,
Year Book Medical, 1990, pp 346-376
3. DeSanto LW: Controversy in the management of laryngeal tumors.
Surgical perspective, in Thawley SE, Panje WR (eds): Comprehen-
sive Management of Head and Neck Tumors, vol 1. Philadelphia,
PA, Saunders, 1987, pp 1029-1039
4. Batsakis JG: Tumors of the Head and Neck (ed 2). Baltimore, MD,
Williams & Wilkins, 1979

./
FIGURE 7. The false vocal cord is used for resurfacing of the
surgical defect. A mucous membrane flap is designed to cover
the defect by suturing it to the subglottic margin of the
resection with 2-0 polyglycolic acid sutures.

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FIGURE 8. The thyroid cartilage is approximated in the midline. When the perichondrium cannot be sutured, two small holes
are drilled at both margins of the thyroid alae and 2-0 chromic catgut sutures are then passed through these holes. (A) The
suture is first passed into the larynx through one of these holes (curved needle), (B) An intramuscular needle inserted through
the opposite hole is used to pull out the suture from the larynx. The curved needle of the suture is inserted into the bore of the
intramuscular needle and (C) the ensemble is pulled out from the larynx.

270 LARYNGOFISSURE AND CORDECTOMY