Infrapetiole exploration of the supraglottis for exposure of the anterior glottal commissure.

Effective microlaryngoscopic surgery of the anterior glottal commissure depends on adequate exposure of this region. Despite the use of elevated vector suspension and external laryngeal counter-pressure, there are some individuals in whom inadequate exposure precludes execution of the planned surgery. To solve this problem, a procedure was designed in which the anterior vestibular folds and the infrapetiole region of the supraglottis are resected to facilitate complete exposure of the Broyle's ligament. The microspot carbon-dioxide laser is used with cold instruments to resect the anterior vestibular folds and thyroepiglottic ligament in continuity. After this tissue is removed, external counter-pressure then provides clear visualization of the anterior-superior thyroid lamina as well as the superior surface of the anterior commissure of the glottis. This procedure was used in ten cases in which the pathology included carcinoma, keratosis with atypia, and papillomatosis. This approach allows for a clear determination about whether early glottic cancer has invaded the thyroid lamina (T1 versus T4) without altering the structural integrity of Broyle's ligament, which avoids significant impairment of the voice. The exposure also allowed for en-block endoscopic resection of two anterior commissure carcinomas. Endoscopic resection of the infrapetiole region and anterior vestibular folds provides a gateway to the superior surface of the anterior glottal commissure. Furthermore, the procedure establishes an effective means to assess the depth of invasion of epithelial neoplasia to the underlying cartilage framework, as well as to facilitate en-block resection of carcinoma if it is appropriate.