Pathological validation of supracricoid partial laryngectomy in laryngeal cancer

Objectives: To validate pathologically whether supracricoid partial laryngectomy is an oncologically sound procedure in cases with invasion of the thyroid cartilage, paraglottic space, pre‐epiglottic space, anterior commissure, or subglottis. Design: A retrospective review of case notes was performed. Setting: Patients treated at a single institute in the Republic of Korea. Participants: Sixty‐three patients who underwent supracricoid partial laryngectomy for laryngeal squamous cell carcinoma between June 1994 and May 2005 who were followed for at least 2 years. Main outcome measures: Local control and overall survival rates. Pathological invasion of the thyroid cartilage, anterior commissure, pre‐epiglottic space, paraglottic space, or subglottis was also investigated as a cause of recurrence. Prognostic factors for local control and survival were evaluated with univariate and multivariate models. Results: Invasion of the anterior commissure, paraglottic space, thyroid cartilage, pre‐epiglottic space, or subglottis had no significant impact on the recurrence or overall survival rates. The presence of a positive resection margin was significantly associated with recurrence in the univariate and multivariate analyses (P = 0.026, 0.028, respectively). When considering the prognostic factors influencing survival, the univariate analysis showed that N stage, a positive resection margin and recurrence had significant influences on the overall survival rate (P = 0.010, 0.0004 and 0.000 respectively). In the multivariate analysis, only recurrence affected the survival rate (P = 0.002). Conclusion: Supracricoid partial laryngectomy can be used with oncological safety in selected cases of laryngeal cancer with invasion of the anterior commissure, thyroid cartilage, pre‐epiglottic space, paraglottic space, or subglottis.     

Anterior commissure carcinoma: I-histopathologic study

OBJECTIVES:To study the behavior of anterior commissure carcinoma regarding its tendency for cartilage invasion. METHODS: Histopathological examination of the region of the anterior commissure (AC) was done with whole organ section in 30 randomly selected specimens. Serial sections were prepared and examined histopathologically for evidence of microscopic cartilage invasion in the region of the AC. RESULTS: Microscopic involvement of the thyroid cartilage was detected in the 30 sections studied. CONCLUSION: Whether recurrence was de novo or initiated by residual malignant cells, it is mandatory to excise the anterior portion of the thyroid cartilage with the tumor-bearing mucosa.     

Plattenepithelkarzinome an der vorderen Kommissur

Summary Sixty-one glottic and 57 supraglottic advanced carcinomas of the larynx were investigated histologically by serial coronal sections. Twenty-nine glottic cancers spreading out more horizontally also rose from the anterior commissure. Seven supraglottic and 24 glottic carcinomas with a vertical extension to the sub- or supraglottic space involved the anterior commissure or the anterior subglottic wall secondary. After a short introduction in the actually known principles of the anatomy of laryngeal cancer the behaviour of squamous cell carcinomas at the anterior commissure was reported.Carcinomas of the anterior commissure have a high tendency to involve the anterior subglottic wall. Tumour growth in this area is the most important condition for penetration of the laryngeal framework. Nearly all these cancers broke through the lower frontal ossified part of the thyroid cartilage without or including the cricothyroid membrane. Therefore glottic cancers with subglottic spread also preferred this direction to the prelaryngeal space. The importance of further histological findings for the technique of partial laryngectomy is discussed.More than the half of the investigated carcinomas were treated by a planned preoperative irradiation of 3.000 rad. By comparison with the posterior region the frontal areas of these tumours showed microscopically a lower visible response to the radiotherapy. In our opinion this indicates that radiation failure in carcinomas of the anterior commissure is caused by the usually applied cross field radiation technique.     

喉额侧窗式切除术治疗侵及前联合的T1b期声门型喉癌疗效分析

目的 探讨喉额侧窗式切除术结合甲状软骨外膜瓣修复术治疗侵及前联合的T1b期声门型喉癌的疗效.方法 对确诊为前联合受侵的T1b期声门型喉癌患者22例,均行喉额侧窗式切除术结合甲状软骨外膜瓣修复术治疗;随访5年,观察患者术后呼吸功能、吞咽功能、发音功能、复发率及生存率.结果 所有患者手术均顺利完成,术后二周拔除气管套管,拔管率100％;无一例发生误咽;术后患者发声功能(G分级)较术前改善者为86.4％(19/22),与术前相同者为13.6％(3/22);肿瘤复发2例,1例为原位复发,1例为颈部淋巴结转移复发,复发率为9.1％(2/22);5年生存率为95.5％(21/22).结论 喉额侧窗式切除术结合甲状软骨外膜瓣修复术式适用于前联合受侵的T1b期声门型喉癌,该术式能相对完整地保留喉的骨架及生理功能,不易引起喉狭窄,且修复组织稳定,能有效改善发声质量.     

侵及前连合的声门型喉癌手术治疗

目的 探讨侵及前连合的声门型喉癌有效的手术方法.方法 回顾性分析侵及前连合的声门型喉癌T1～T3病变,行喉前淋巴结清扫、喉裂开声门上、下联合进路处理的37例完整临床资料.其中T1病变20例,T2病变7例,T3病变10例.采用Kaplan-Meier法计算术后生存率.结果 本组治疗后3个月全部拔除气管套管并恢复了吞咽和发...     

声门癌的组织病理学研究—附62例连续切片观察

目的:探讨声门癌的发病特点,生长方式及向外扩展特点,声带固定的意义,术式选择与肿瘤复发率生和生存率的关系。方法:62例中,T_1 37例,T_2 9例,T_3 16例。仅1例为T_3N_1M_0,均为喉鳞癌。手术方法:喉全切除术16例,喉垂直部分切除术25例,声带切除术21例,N_1者行同侧颈廓清术。单纯声带切除标本采用石蜡包埋技术,其余采用火棉胶包埋技术,进行连续切片观察。结果:声门癌的生长方式与病理分期有一定关系。临床TNM分期与病理分期不符率为27.4％,估计过低是对喉骨架侵犯估计不足,过高是对肿瘤周围炎性浸润误为肿瘤范围。Reinke's层、弹力圆锥、声门旁间隙、喉室、甲状软骨都有一定的“屏障”作用,前联合受侵应考虑喉骨架可能受侵。术后局部复发率为12.8％,复发时间为3个月～8年,复发病例中以T_2为多。颈淋巴结转移率为4.8％,术后3年生存率98.4％,5年生存率95.2％。结论:声门癌颈部淋巴结转移率低,术后复发率低,生存率高。同侧上下扩展多见,晚期才向对侧扩展。前联合腱是肿瘤向对侧声带、甲状软骨和环状软骨侵犯的通道。声门癌侵及前联合者应考虑喉骨架可能受侵。声带固定不是喉部分切除禁忌证,而是扩大手术范围的指征。     

Significance of pre-epiglottic space invasion in supracricoid partial laryngectomy with cricohyoidopexy

Cancerous involvement of the pre-epiglottic space has been known for many years to be an important prognostic factor. The aim of this study was to investigate the prognostic value of pre-epiglottic space invasion, according to the degree of invasion (i.e. absence, minimal or gross), and to assess the oncological suitability for supracricoid partial laryngectomy in patients with supraglottic laryngeal carcinomas. This study included 52 patients with squamous cell carcinomas of the supraglottic and glotto-supraglottic larynx, treated with supracricoid partial laryngectomy-cricohyoidopexy, between 1992 and 2001. Clinical and histopathological parameters were evaluated. Pre-epiglottic space invasion was seen in 35 patients (67.3 per cent); there was gross invasion in seven patients and minimal invasion in 28. Neoplastic invasion of the anterior commissure was seen in 18 patients (34.6 per cent) and thyroid cartilage involvement in eight (15.4 per cent). Neoplastic spread through the extralaryngeal tissues was not seen in any patient. The five-year overall survival was 71.5 per cent for patients with gross pre-epiglottic space invasion, 82.2 per cent for those with minimal pre-epiglottic space invasion, and 76.4 per cent for those without pre-epiglottic space invasion. It was observed that gross or minimal pre-epiglottic space invasion did not have a statistically significant effect on survival. Univariate analysis showed that nodal positivity was associated with a poor prognosis. None of the other parameters analysed showed a statistically significant relationship with survival. Four (7.6 per cent) patients had local laryngeal recurrence. Distant metastasis and a second primary tumour were detected in three (5.8 per cent) and four (7.6 per cent) patients, respectively. The five-year overall survival and cause-specific survival were 78.8 and 82 per cent, respectively. Supracricoid partial laryngectomy with cricohyoidopexy can safely be performed in supraglottic and glotto-supraglottic carcinomas with minimal or gross invasion of the pre-epiglottic space which have no extralaryngeal spread. Nodal status is an important predictor affecting survival.     

The anatomic limitations of co2 laser cordectomy

The anatomical limitations of CO₂ laser cordectomy in an experimental setting with maximal exposure are presented. The major limitation is the thyroid cartilage. This is reached in the area of anterior commissure tendon by removal of only 2 to 3 mm of soft tissue. Most posteriorly in the larynx, the distance to the thyroid cartilage becomes progressively greater, being 5.3 mm at mid-cord and 9.0 mm at the anterior end of the vocal process of the arytenoid. The inferior limitation is the cricothyroid membrane. Anteriorly this is avoided by not extending laser excision more inferiorly than 5 mm's. Posterolaterally, the limitation is the para-arytenoid musculature. Excisional biopsy or staging with the laser must be within the framework of these limitations.     

CT-scan prediction of thyroid cartilage invasion for early laryngeal squamous cell carcinoma

Treatment choice for laryngeal cancer may be influenced by the diagnosis of thyroid cartilage invasion on preoperative computed tomography (CT). Our objective was to determine the predictive value of CT for thyroid cartilage invasion in early- to mid-stage laryngeal cancer. Retrospective study (1992–2008) of laryngeal squamous cell carcinoma treated with open partial laryngectomy and resection of at least part of the thyroid cartilage. Previous laser surgery, radiation therapy, chemotherapy and second primaries were excluded. CT prediction of thyroid cartilage invasion was determined by specialized radiologists. Tumor characteristics and pathologic thyroid cartilage invasion were compared to the radiologic assessment. 236 patients were treated by vertical (20 %), supracricoid (67 %) or supraglottic partial laryngectomy (13 %) for tumors staged cT1 (26 %), cT2 (55 %), and cT3 (19 %). The thyroid cartilage was invaded on pathology in 19 cases (8 %). CT’s sensitivity was 10.5 %, specificity 94 %, positive predictive value 13 %, and negative predictive value 92 %. CT correctly predicted thyroid cartilage invasion in only two cases for an overall accuracy of 87 %. Among the false-positive CT’s, tumors involving the anterior commissure were significantly over-represented (61.5 % vs. 27 %, p = .004). Tumors with decreased vocal fold (VF) mobility were significantly over-represented in the group of false-negatives (41 vs. 13 %, p = .0035). Preoperative CT was not effective in predicting thyroid cartilage invasion in these early- to mid-stage lesions, overestimating cartilage invasion for AC lesions and underestimating invasion for lesions with decreased VF mobility.     

Laser surgery for vocal cord carcinoma involving the anterior commissure

Endoscopic laser surgery is an established means of treatment for benign laryngeal lesions. Laser surgery for early (stages I and II) squamous cell carcinoma is still being tested. Treatment of glottic tumors extending to the anterior commissure is in itself controversial. Approximately 20% of all glottic tumors involve the anterior commissure, with only 1% of these lesions being purely anterior commissure tumors. The anatomy of the anterior commissure is such that an apparent T1 lesion may actually be a T4 lesion if it involves the thyroid cartilage. The distance between the anterior commissure ligament and the thyroid cartilage is only 2 to 3 mm. A preoperative computed tomographic scan can aid us in evaluating this space. Therefore, tumors of the anterior commissure present as a therapeutic challenge. Radiation therapy has proven to be inadequate, with a high rate of recurrence and increased risk for radiochondronecrosis. The literature with regard to radiotherapy varies widely as to survival rates. Conservation surgery has consistently demonstrated an 80% survival in T1 lesions. Recently, it has been suggested that laser surgery in the region of the anterior commissure might offer satisfactory results. We have found the opposite. We will report on five patients who underwent endoscopic laser surgery on T1 vocal cord lesions involving the anterior commissure. All of these patients had tumor recurrence and subsequently have undergone salvage surgery and/or radiation therapy. The difficulties associated with endoscopic laser surgery of the anterior commissure will be discussed with a supporting animal study.     

Pathologic evaluation of primary laryngeal anterior commissure carcinoma both in patients who have undergone open surgery as initial treatment and in those who have undergone salvage surgery after irradiation failure

Laryngeal anterior commissure (AC) cancer has been the subject of much controversy. Our study was aimed at pathologically evaluating the tendency of AC cancer to invade the thyroid cartilage and analyzing the role of thyroid cartilage invasion by tumor cells at the AC as an anatomic cause for irradiation failure. Our study included 36 patients with glottic cancer involving AC. Patients with recurrent or persistent disease after radiotherapy underwent salvage surgery. Surgical specimens from 22 patients who had open surgery, either as primary or salvage surgery, were available for pathologic examination to identify the presence of cartilage invasion. We found microscopic invasion of the thyroid cartilage in 40.9% of the studied tumors. Only 21.4% of patients who had open salvage surgery showed evidence of cartilage invasion at the AC. We concluded that laryngeal AC cancers are more likely to invade the cartilage, and that anatomic risk factors are not the main cause of irradiation failure.     

The incidence of thyroid cartilage invasion through the anterior commissure in clinically early-staged laryngeal cancer

In this study, the incidence of thyroid cartilage invasion in early-stage laryngeal tumors involving anterior commissure was assessed. Medical charts and pathology reports of 62 patients who underwent supracricoid partial laryngectomy as the primary treatment of early-staged laryngeal squamous cell carcinoma were retrospectively reviewed. Patients were divided into two groups according to the macroscopic examination of the surgical specimen: tumors limited to the glottis with the involvement of anterior commissure (TLG); tumors invading both supraglottis and glottis with the involvement of anterior commissure (TISG). Thirty-seven of the cases were classified as TLG group (59.7 %) and the remaining 25 of them were classified as TISG group (40.3 %). Thyroid cartilage invasion was observed totally in ten patients (16.1 %), as macroscopic invasion in two cases and microinvasion in eight patients. Only two were in the TLG group (cartilage invasion rate of 5.4 %), the remaining eight were in the TISG group (cartilage invasion rate of 32 %). Thyroid cartilage invasion rate of TISG group was significantly higher than that of TLG group (p = 0.011, p < 0.05). Tumors limited to the glottis with AC involvement may be more suitable for endoscopic resection; on the contrary, tumors with vertical extension invading both AC and supraglottis should be evaluated more suspiciously due to high rate of thyroid cartilage invasion, which may still necessitate external laryngectomy techniques.     

Management of thyroid gland invasion in laryngopharyngeal cancer

BACKGROUND AND OBJECTIVES: The incidence of thyroid gland involvement in laryngopharyngeal cancer ranges from 0 to 23%. Therefore, ipsilateral hemithyroidectomy and isthmusectomy are routinely performed with total laryngectomy in many clinics. Hemithyroidectomy causes hypothyroidism in 63% of patients, and if combined with radiotherapy, the incidence increases to 89% of patients. But there is no consensus about using thyroid surgery in the treatment of laryngopharyngeal cancer. The purpose of this study was to identify criteria to use in the decision of whether, in cases of laryngopharyngeal cancer, hemithyroidectomy should be performed with total laryngectomy. MATERIALS AND METHODS: The study group consisted of 28 patients with a mean age of 63.2 years (range 42-77 years). All patients were treated by thyroidectomy with total laryngectomy. We evaluated the incidence of thyroid gland invasion, clinical predisposing factors, pathologic features, and prognosis in cases of laryngopharyngeal cancer. RESULTS: The incidence of thyroid gland invasion was 14% (4/28). Subglottic extension was the only statistically significant factor in thyroid invasion. All cases of laryngopharyngeal cancer that invaded the thyroid gland had vocal cord fixation, anterior commissure invasion, and were advanced stage. The most common mechanism of spread to the thyroid was by direct extension through thyroid cartilage and anterior commissure. While the prognosis of patients with thyroid gland invasion was worse than that of patients with no invasion, the difference was not statistically significant. CONCLUSION: Prophylactic thyroidectomy should be performed in cases of laryngopharyngeal cancer where there is subglottic extension of the tumor.     

The intraoperative management of the thyroid gland during laryngectomy

The standard of care of laryngeal cancer surgery is wide field excision of the larynx combined with ipsilateral thyroid lobectomy. A retrospective review of 247 laryngectomies performed between 1979 and 1989 was undertaken to determine specific intraoperative indications for thyroid gland removal. The incidence of thyroid disease in our patients with laryngeal cancer was compared to the normal population. Eight percent of thyroid specimens removed during laryngeal cancer surgery demonstrated invasion by squamous cell carcinoma. All patients having thyroid invasion had T3 or T4 laryngeal lesions that were stage IV at the time of surgery. All these lesions were found to have transglottic growth and laryngeal cartilage invasion by the pathologist. All of these patients also had abnormal thyroid glands intraoperatively and laryngeal cartilage destruction that was evident intraoperatively. Total thyroidectomy with bilateral paratracheal and pretracheal lymph node dissection is indicated when squamous cell carcinoma of the larynx involves the thyroid gland. Prophylactic ipsilateral thyroid lobectomy and isthmusectomy is warranted for large laryngeal cancers (T3, T4) that involve the anterior commissure, the subglottic area, or extend transglottically. Routine thyroid gland removal is not indicated for the majority of laryngeal cancers that do not meet the aforementioned criteria. Finally, abnormal thyroid histopathology was diagnosed in 37% of the surgical thyroid gland specimens removed during laryngectomy.     

Clinical effectiveness of thyroidectomy on the management of locally advanced laryngeal cancer

Objective

The incidence of thyroid gland invasion in patients with advanced laryngeal cancer was reported to be 0–50%. However there is a controversy in necessity and extent of routine thyroidectomy in these patients due to the difficulty in diagnosis of tumor invasion to thyroid gland and the risk of possible postoperative hypothyroidism and hypocalcemia.

Methods

The medical files of 47 patients who underwent thyroidectomy as part of surgical treatment for advanced laryngeal cancer were reviewed.

Results

Fourty-four (93.6%) patients underwent hemithyroidectomy, 3 (6.3%) patients underwent total thyroidectomy. Thyroid gland invasion was found in 2 (4.2%) patients. Hypothyroidism occurred in 15 (31.9%) patients, and their hormone levels were regulated with medical treatment during follow-up. Hypocalcemia was not found in any patients.

Conclusion

We recommend that at least a hemithyroidectomy should be performed in patients with advanced laryngeal cancer, if they have any predictive factor (subglottic extension more than 1 cm, invasion of paraglottic space, thyroid cartilage, cricoid cartilage and prelaryngeal tissue detected by radiological examination) for thyroid gland invasion.     

喉内结构在甲状软骨板上的投影位置关系

Objective：To provide anatomic basis of locations of laryngeal interior structures for laryngeal operating through lateral laryngeal approaches in clinic. Method： Thirty cadavers laryngeal cartilage specimens（ 19 male and 11female）was collected. Using pin pierced method under direct vision to locate the projections of muscle process of arytenoids cartilage and vocal fold on thyroid ala,then to observe their relationships. Result：The projection of vocal fold is the line that connecting a little bit superior of the middle point of anterior commissure of thyroid cartilage and the point on the crosspoint of superior 3/4 and inferior 1/4 of the posterior edge of thyroid cartilage ala. The angle of the line and anterior commissure of thyroid cartilage is sixty-five degrees, The projection of muscle process is locating on the projective line of vocal fold. The projection of pyriform fossa is locating at the posterior superior portion of thyroid cartilage ala. Conclusion： The interior structures of larynx have a intact relationship of projective position on thyroid cartilage ala,which providing anatomic references for clinical surgeries relating to vocal fold through laryngeal framework.     

Efficacy of preoperative laryngogram for localization of the ventricle at the anterior commissure

The localization of the ventricle exactly above the anterior commissure of the vocal cords is important in performing supraglottic laryngectomy. The lateral projections of pre-operative laryngograms are examined and the following two dimensions are measured on the film: (1) distance between the bottom of the thyroid notch and the inferior border of the thyroid cartilage and (2) distance between the anterior part of the ventricle and the inferior border. The ratio of these two distances is obtained and is designated as distance ratio (DR). The DR is similarly calculated from the actual measurements of the laryngeal specimens and is compared with the DR based on the laryngograms. Differences between these two DR's are nonsignificant (0.5 <p <0.6). Also, there is a high degree of relationship between these two DR's (P <0.001). Thus, the DR based on the laryngogram is an accurate index to determine the level of the ventricle just above the anterior commissure in performing a transection of the thyroid cartilage. When the thyroid cartilage is exposed completely during surgery a measurement between the bottom of the thyroid notch and the inferior border is made. Actual distance between the inferior border and the anterior part of the ventricle can be calculated by the DR obtained from the preoperative laryngogram. This method ensures that neither anterior commissure nor pre-epiglottic space is violated when the thyroid cartilage is transected.     

Level of vocal folds as projected on the exterior thyroid cartilage

Objective: This study aims to identify the level of the vocal folds as projected on the exterior thyroid cartilage. Study Design: Anatomic study of human cadaver larynges. Methods: The study includes 83 fresh larynges harvested at autopsy from 62 male and 21 female cadavers. The larynges were excised and divided in the midline posteriorly. One needle was inserted at the level of anterior commissure from endolarynx, and the other was inserted at the thyroid ala just anterior to the vocal process along the superior surface of the right vocal cord. Measurements of vocal cord projections on the thyroid ala were done with a caliper. Results: The mean value of the ratio of the distances from the superior thyroid notch to anterior commissure and the midline height from thyroid notch to the inferior border of thyroid cartilage was found to be 0.41 in males and 0.38 in females. No statistical differences were observed between these two groups (P = .062). We found that the distance from the anterior commissure to the inferior thyroid border in midline “c” was longer than the distance from the posterior border of the vocal cord to the inferior border of the inferior tubercle of the thyroid ala “d” in 44 (71%) males and in 7 (33%) females. On the other hand, “d” was longer than “c” in 8 (12.9%) males and in 8 (38.1%) females. These two distances were equal in 10 (16.1%) males and in 6 (28.6%) females. Conclusion: In this study, we found that the anterior commissure lies approximately at the juncture of the upper two fifths and lower three fifths of the midline height of thyroid cartilage in the majority of the larynges of the male and female cadavers. The position of the posterior border of the vocal cords was found to be at a lower level than anterior commissure in two thirds of males and in one third of females. This means that the vocal cords slope downward posteriorly in the majority of the larynges of the males. This may be one of the causes of failure of some type I thyroplasties.     

CO2激光声带切除术后复发相关因素分析

目的 探讨早期声门癌经CO2激光手术后,其复发相关因素对患者预后的影响。方法 回顾经CO2激光治疗声门癌患者76例病历资料,所有新鲜标本标记切缘,肉眼切缘2mm,甲醛液中固定。石蜡包埋,HE染色,光镜观察。Kaplan–Meier法计算生存率和无瘤生存率,单因素分析应用log rank test方法。结果 局部复发11例(14.5%),5年生存率92.0%,5年无瘤生存率81.9%,喉保存率96.1%。单因素分析显示,前联合受侵和甲杓肌受侵导致5年无瘤生存率降低(P=0.002,P=0.001),而病理切缘阳性并不影响5年无瘤生存率(P=0.065)。结论 前联合受侵和甲杓肌受侵将增加CO2激光治疗早期声门癌术后复发风险,切缘阳性并不影响5年无瘤生存率,对术后切缘阳性患者采取密切随访观察,避免过度治疗。     

Indications and results of fronto-lateral laryngectomy using a combined endolaryngeal and external approach

Patients with laryngeal anterior commissure, cord-commissure, bilateral anterior cord-commissure carcinomas (T1 and T2 N0 M0) were subjected to a new method of frontolateral laryngectomy using a combined endolaryngeal and external approach. The proposed surgical procedure allowed the removal of the anterior commissure and part of one or both vocal cords in a single unit, together with the cartilaginous framework, respecting the integrity of the superior portion of the thyroid cartilage. The internal procedure permitted an accurate delimitation of the posterior part of the laryngeal neoplasm. In particular, this was performed during suspension microlaryngoscopy using the CO₂ laser or traditional cutting tools for section of the laryngeal visceral structures to the internal surface of the thyroid cartilage. Following this, the external approach included incision of the external perichondrium along the superior edge of the thyroid cartilage and along the median line, from the incisura to the inferior edge of the thyroid cartilage. The superior opening of the larynx is made side-to-side and the epiglottis separated at the level of the superior edge of the thyroid cartilage. The ends of the section are joined together with the superior parts of the section created during the laryngeal approach. Then progressive craniocaudal detachment of the internal perichondrium is performed backwards until the endolaryngeal sections are reached and downwards to the insertion of the cord ligaments. The inferior opening of the larynx is made by a horizontal section of the cricothyroid membrane at the level of the superior edge of the cricoid cartilage. Section of the thyroid cartilage is therefore performed in a trapezoidal shape. This section involves the inferior part of the protruding corner of the thyroid cartilage. After joining the ends of the cricothyroid section with the inferior extremities of the endolaryngeal sections, the surgical specimen is removed as a single unit. The method must be used only after accurate clinical evaluation. It is mostly recommended in subjects with cord-commissure carcinomas previously treated with radiotherapy. The results obtained were extremely satisfactory both as regards survival and functional results. In all, 27/28 patients (96.4%) were free from disease. The quality of voice was satisfactory but hoarse in 30% and breathy in 70% of the patients. Received: 26 September 1998 / Accepted: 12 February 1999