Extended hemilaryngectomy for T3 glottic carcinoma with preservation of speech and swallowing.

Total laryngectomy is often applied in the treatment of invasive squamous cell carcinomas that fix one side of the larynx. The major drawback, of course, is loss of the voice. In many instances, however, preservation of the uninvolved portion of the larynx is compatible with adequate tumor margins, and the preserved laryngeal remnant, although it cannot be reconstituted to allow breathing, can readily be used for voice. The principle involved is the creation of a valved tracheopharyngeal shunt, which functions as a neoglottis during expiration but constricts to close during swallowing. To accomplish this the recurrent laryngeal nerve and the myomucosal segment of intrinsic glottic musculature to which it is attached is preserved on the uninvolved side. The myomucosal segment is formed into a mucosal lined tube by releasing the soft tissues from the cartilage. The diameter and flaccidity of the tube is augmented by incorporating a flap of hypopharyngeal mucosa. Safe performance of this operation depends on careful preoperative evaluation and laryngoscopic verification and a close-working relationship with an interested surgical pathologist. The first 7 consecutive cases in which this management program has been applied are presented in review. The patients, ranging in age from 58 to 69 years old, had T3 grade 2 or 3 invasive squamous cell carcinoma. The average hospitalization was 13 days. The longest follow-up is 5 years. Clear surgical margins, local control of the disease, and satisfactory voice without significant aspiration have been achieved thus far in each case. The average subglottic pressures measured at the tracheotomy were 25 +/- 6 cm. of water (threshold opening) and 43 +/- 20 cm. of water (for phonation). Whether these encouraging initial results can be widely duplicated will probably depend on the care with which cases are selected. The dangers of applying this surgery to patients with extensive submucosal spread will be obvious to experienced laryngologists.