Operative Techniques in Otolaryngology (2011) 22, 122-127

Transoral CO2 laser partial laryngectomies using the

digital scanning system
Nayla Matar, MD, Marc Remacle, MD, PhD, Georges Lawson, MD, Vincent Bachy, MD

From the Otolaryngology-Head and Neck Surgery Department, Louvain University Hospital at Mont-Godinne, Yvoir,
Belgium.

KEYWORDS Transoral CO2 laser microsurgery is gaining ground at the expense of external approaches in the
Transoral laser management of laryngeal tumors. Endoscopic surgical indications depend on the location, extension,
microsurgery; and accessibility of the tumor as well as the surgeon’s expertise. The status of surgical margins is a very
Digital Scanning important prognostic factor. One of the major criticisms against endoscopic resection is the difficulty
System; of interpretation of histologic specimens because of the thermal effect of laser on tissues and specimen
Laryngeal cancer; shrinking when formalin fixation is used. This article describes the authors’ experience with transoral
Frozen section; CO2 laser microsurgery for laryngeal tumors resection based on the European Laryngological Society
CO2 laser established classifications for cordectomies and supraglottic laryngectomies as well as systematic
frozen section analysis.
© 2011 Elsevier Inc. All rights reserved.

Many authors use transoral CO2 laser-assisted microsur- Indications

gery (TLM) for the treatment of selected laryngeal tumors
with very good oncologic and functional results.1,2
TLM is now accepted as a reliable treatment for early
laryngeal cancer (T1-T2) and even for selected advanced
cases.3 It has equal local control rates as well as organ
preservation rates compared with those of open surgery. It
ensures tumor resection with less perioperative morbidity
and long-term complications and reduces the duration of the
hospital stay.4 The classification of the different types of
procedures, cordectomies and supraglottic laryngectomies,
has been standardized by the European Laryngological So-
ciety (ELS),5-7 making the treatment strategies and reports
more accurate. As for open approach surgeries, the most
important factor for tumor control is the status of surgical
margins,8 which is why we use frozen section analysis9
systematically to assess surgical margins intraoperatively
and avoid systematic second look procedures.
The authors have no conflicts of interest to disclose.
Address reprint requests and correspondence: Nayla Matar, MD,
Otolaryngology, Head and Neck Surgery Department, Louvain University
Hospital at Mont-Godinne, Yvoir, Belgium.
E-mail address: naylamatar@gmail.com.
1043-1810/$ -see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2011.02.002
In laryngeal tumors, the indication of endoscopic resection
versus an open approach depends on tumor location, tumor
extension, and tumor accessibility as well as on the sur-
geon’s expertise.
Glottic cancers confined to the vocal fold or with limited
extension to the subglottis or supraglottis but without fixa-
tion of the vocal fold (T1, T2 according to the TNM clas-
sification) are resected endoscopically. The involvement of
the anterior commissure is not a contraindication to endo-
scopic resection, if the involvement is not extensive and the
exposure is adequate. However, the treatment of anterior
commissure involvement is more challenging. In the case of
cartilage invasion, endoscopic resection completed by
Shapshey’s technique10 or an external approach must be
considered.
T1 and T2 supraglottic laryngeal tumors are also ame-
nable to endoscopic resection. For supraglottic tumors,
treatment of the neck is selective neck dissection for pa-
tients with clinically positive necks and sentinel node bi-
opsy for N0 neck with close follow-up. The sentinel node
biopsy in N0 neck for patients with supraglottic tumors is an
ongoing study in our institution.
Matar et al Transoral CO2 Laser Partial Laryngectomies
Some cases of T3 glottic or supraglottic cancers (inva-
sion of the preepiglottic space) can be considered for endo-
scopic resection, but these cases need a very careful preop-
erative assessment, a very experienced surgeon, and a
compliant patient for a very close follow-up schedule. Car-
cinomas originating from the subglottis are not suited for
TLM.11
Standardized approaches have been described by the
ELS Working Committee on Nomenclature, concerning en-
doscopic limited and extended cordectomies.5,6 Nine types
of cordectomies are described: subepithelial cordectomy
(type I), subligamental cordectomy (type II), transmuscular
cordectomy (type III), total cordectomy (type IV), extended
cordectomy (type V), with 4 subtypes depending on the
structure removed (Va: controlateral vocal fold; Vb: aryte-
noid; Vc: ventricular fold, Vd: subglottis), and cordectomy
involving the anterior commissure and anterior parts of the
2 vocal folds (type VI).
A proposal of classification has also been published for
endoscopic supraglottic laryngectomies according to the
surgical approach used and the degree of resection com-
pleted.7
This classification comprises 4 types of supraglottic lar-
yngectomies: type I, limited excision of small size superfi-
cial lesions of the free edge of the epiglottis, the aryepiglot-
tic fold, the arytenoid, or the ventricular fold or any other
part of the supraglottis; type II, medial supraglottic laryn-
gectomy without resection of the preepiglottic space with 2
subtypes: type IIa, superior hemi-epiglottectomy; or type
IIb, total epiglottectomy; type III, medial supraglottic lar-
yngectomy with resection of the preepiglottic space with 2
subtypes; type IIIa, without excision to the ventricular fold;
or type IIIb, with excision of the ventricular fold; type IV,
lateral supraglottic laryngectomy with 2 subtypes: type IVa
includes the ventricular fold and type IVb includes the
arytenoid.
Technique
To select a patient for endoscopic resection of a laryngeal
tumor, a thorough preoperative evaluation is mandatory. As
for open approaches, clinical examination helps to define
the extension of the primary lesion and the involvement of
cervical lymph nodes. However, relying on endoscopic
findings alone results in underdiagnosis in half of the
cases.12 That is why a contrast computed tomographic scan
is used in our practice and, when minimal thyroid cartilage
invasion or paraglottic space involvement is suspected,
magnetic resonance imaging is added because it has a
higher negative predictive value.13
Endoscopic exploration and biopsy of the lesion under
general anesthesia are always performed because it is of
primary importance for planning endoscopic resection. In
this setting, the surgeon can verify the location and extent of
the tumor as well as its adequate exposure. For this purpose,
several operative laryngoscopes can be necessary and as-
sessment of the lesion with 0-degree and 70-degree endo-
123
scopes is very helpful. The use of micro-instruments while
performing rigid endoscopy can be useful to lift the false
vocal fold to inspect the ventricle or to mobilize the aryte-
noid cartilage. Sometimes partial resection of the ventricu-
lar fold is necessary to adequately visualize the vocal fold
and perform a complete tumor resection.
TLM is performed with an endotracheal laser shielded
tube in place. Type I cordectomy can be performed under jet
ventilation if better exposure is needed.
Technical equipment used are as follows: “Digital
AcuBlade” scanning CO2 laser system (Lumenis, Santa
Clara, CA); multiple operating laryngoscopes (set according
to Remacle, available at Richard Wolf, Knittlingen, Ger-
many), multiple suction devices (1 mounted on the operat-
ing laryngoscope and the other held by the surgeon for the
aspiration of blood or retraction of tissues or mounted on
forceps with integrated aspiration lumen), and multiple ded-
icated forceps. The surgeon must have a good knowledge of
laser physics for a good understanding of the unit. He
should also verify that the safety rules for laser use are
respected.
The parameters of the scanning CO2 laser used are a
superpulse scanned mode (A comparable technology is
available with the Ultrapulse, another high-powered pulsed
wave, included in other laser units), an incision line of 2-3
mm provided by the scanning system, and 10-W power
density. The scanner uses computer-guided rotating mirrors,
allowing the beam to sweep rapidly over a given surface.
The software calculates the required power density and
pulse duration depending on the desired length and pene-
tration; however, the user can change the power density
proposed by the unit. Tumors are usually excised and re-
moved “en bloc”; this allows an easier histologic evaluation
of the surgical specimen. Only if “en-bloc” resection is not
possible, then cuts through larger tumors are made and these
tumors are resected in several pieces as advocated by
Steiner and Ambrosch (piece-meal resection).14,15 When
needed, suction cautery is used for hemostasis. If large veins
or arteries are encountered, then clips might be used. For
plume evacuation, 1 aspiration is mounted on the laryngo-
scope, and the other is integrated to the cordectomy forceps.
The surgical specimen is resected and the margins are pre-
cisely oriented to facilitate histolological examination. For
type I cordectomies, the frozen sections are taken on the
surgical specimen to limit vocal fold scarring. For larger
resection, the margins are taken on the operative site after
resection of the tumor. Good communication with the pa-
thologist is mandatory for adequate margins assessment
with frozen section analysis.
The use of the scanning CO2 laser with little thermal
effect makes the frozen section reading possible. The use of
frozen section technique reduces the problem of tissue fix-
ation that induces a shrinking of ⬎30% and can make in
some cases the studying of the margins inaccurate. It allows
the surgeon to remove additional tissue if the margins are
invaded by tumor cells and this can avoid planned second
look procedures. However frozen section analysis is time-
consuming for the histologist, and cold might diminish the
124 Operative Techniques in Otolaryngology, Vol 22, No 2, June 2011

Figure 1 Top: Superficial cancer of the right vocal fold treated by transmuscular cordectomy (type 3 according to the ELS classification)
with the limits of the resection marked by the dashed line. Bottom left: Coronal view of the limits of the resection for the type 3 cordectomy
according to the ELS.5 Bottom right: Axial view of the limits of the resection for the type 3 cordectomy according to the ELS.5 (Color
version of figure is available online.)

quality of the specimen that will be examined later with
routine histologic staining. However, this does not have
significant impact since our survival data are similar to other
series published in the literature.9
After tumor excision, the surgical field is cleaned with
swabs soaked in epinephrine solution (1:100,000) diluted in
saline solution. Then a thin film of fibrin glue (Baxter,
Vienna, Austria) is applied on the surgical field. Appling a
thick film can cause its dislodgment, which reduces the
effect of the fibrin glue and, if inhaled, might induce airway
obstruction.
Examples of tumors and the appropriate resection type
are presented in Figures 1-3.
Intraoperatively, patients receive 125 mg of methylpred-
nisolone IV and 2 g of amoxicillin-clavulanic acid IV.
Postoperatively, patients are treated with antibiotics amoxi-
cillin-clavulanic acid 875 mg three times a day for 7 days,
inhalation steroids betamethasone twice a day for 10 days,
and proton pump inhibitors omeprazole 20 mg twice a day
for 6 weeks or until complete healing.
Patients are observed for 3 hours in an intermediate care
setting for airway control. In the case of extensive surgery,
associated neck dissection, arytenoids edema, previous ra-
diation therapy, or if the patient has comorbidities such as
obstructive sleep apnea, or coronary disease, admission to
the intensive care unit is planned.
The first follow-up visit is at 10 days postoperatively. In
our surveillance protocol, the patient has a clinical exami-
nation every month until the healing is completed, then
every 3 months for 3 years, then every 6 months for 2 years,
Matar et al Transoral CO2 Laser Partial Laryngectomies 125

Figure 2 Top: T1a cancer of the left vocal fold infiltrating the vocal ligament treated by total or complete cordectomy (type 4 according
to the ELS classification) with the limits of the resection marked by the dashed line. Bottom left: Coronal view of the limits of the resection
for the type 4 cordectomy according to the ELS.5 Bottom right: Axial view of the limits of the resection for the type 3 cordectomy according
to the ELS.5 (Color version of figure is available online.)

and then yearly. Radiologic examination is performed strongly advised and patients are referred to a specialized
yearly for the first 5 years of follow-up for advanced tumors. team to help them reach these goals.
For surgeries involving the vocal folds, voice rest for 10
days is advised, and then voice therapy is advised for 1 year.
For supraglottic tumors, swallowing therapy is initiated
the day following surgery and maintained until the patient Complications
achieves adequate oral intake. When the risk of aspiration is
too great, a feeding tube is inserted for a few days or weeks. Possible complications reported in the literature include
Smoking cessation and reduced alcohol consumption are bleeding, dental injuries, mucosal tears, local infection, em-
126
Figure 3 Left: Superficial tumor of the laryngeal side of the epiglottis. Right: Sagittal view of the limits of the resection for the medial
supraglottic laryngectomy without resection of the preepiglottic space (IIb) according to the ELS.7 (Color version of figure is available
online.)
physema, fistulization, respiratory distress due to stenosis or
edema, swallowing difficulties and aspiration pneumonia,
synechia and dysphonia, granulation tissue, and postopera-
tive chondritis, especially if patients had previous or post-
operative radiation therapy. In our practice, we encountered
the following complications and used the discussed treat-
ment strategies.
Secondary bleeding can be controlled endoscopically
under general anesthesia using electrocautery or surgical
clips. It can happen especially in supraglottic tumors and is
due to bleeding from the superior laryngeal artery that can
be found under the pharyngo-epiglottic fold. In this setting
a surgical clip can be placed easily. In our experience, no
open surgery for bleeding control has been performed.
Careful handling of endoscopic instruments can help
prevent dental injuries and mucosal tears.
Infection is usually prevented by antibioprophylaxis.
Emphysema can happen in extended resections involving
the cricothyroid membrane; in these cases, placement of a
tight dressing can prevent or limit the extension of the
emphysema.
Early respiratory distress is very rare, but may happen
following extensive surgery; in these cases monitoring in
the intensive care unit for 24 hours might be indicated. In
the case of severe distress, intubation for 24 to 48 hours
might be necessary. Tracheostomy was never needed in our
series.
Postoperative aspiration may follow large supraglottic
surgeries or cordectomies extended to the arytenoid carti-
lage. When aspiration is possible, preoperative and postop-
erative swallowing therapy is advised, and if the oral intake
is limited, feeding can be assured using a small nasogastric
tube inserted at the end of the surgery.
Dysphonia is observed after types 3-6 cordectomies. If
the dysphonia is troublesome, medialization thyroplasty or
vocal folds injection techniques can be considered after 1
year of follow-up without evidence of recurrence. Anterior
commissure laryngoplasty with the placement of a Monnier
Operative Techniques in Otolaryngology, Vol 22, No 2, June 2011
stent16 can be considered in the case of anterior commissure
synechia.
Granulation tissue might be observed in cases where
cartilage is exposed; the use of fibrin glue reduces its oc-
currence in our experience.
Complications are less frequent for early cancers in non-
irradiated patients compared with more advanced cancers or
patients with previous radiation therapy, and they seem to
be more limited as the experience of the surgeon increases.
Discussion
The main advantages of TLM for resection of laryngeal
tumors are the reduced perioperative morbidity and hospital
stay compared with open approaches. Tracheostomy is
never needed in our experience. The possibility of limited
resection depending on tumor extension and the preserva-
tion of external structures that have an important role in
swallowing function like the hyoid bone, prelaryngeal mus-
cles, the cartilaginous framework, and the superior laryn-
geal pedicule allow a faster recovery of the swallowing
function.17
Tumor resection being the most frequently performed
with a few millimeters of safe margins, an important factor
to ensure an adequate treatment is regular follow-up with
recording of the endoscopic examination, associated to stro-
boscopy, to be able to compare the findings, which can lead
to the early diagnosis of local and regional recurrence.
Frozen section analysis plays an important role too. In our
series,9 frozen section analysis allowed us to enlarge the
resection margins in 9.3% of the patients.
If recurrence is suspected, many treatment options re-
main available. The choice depends on the site and depth of
the recurrence. Superficial recurrences may be treated by a
second endoscopic resection. More profound or massive
recurrences not amenable to endoscopic resections can be
Matar et al Transoral CO2 Laser Partial Laryngectomies
treated by partial open surgery, total laryngectomy, radia-
tion therapy, or concomitant radiation and chemotherapy,
depending on the degree of spreading and the treatment
algorithm followed in the institution.
Acknowledgment
The authors would like to thank Mr Deneffe and Mme
Jacqmain for photographs editing and illustrations.
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