AIJOC

CO2 Laser Surgery for Early Laryngeal and Hypopharyngeal Cancer

ORIGINAL ARTICLE

CO2 Laser Surgery for Early Laryngeal and

Hypopharyngeal Cancer
1
Marzi Mehta, 2Arsheed Hussain Hakeem, 3Jagadish Tubachi, 4R Kannan, 5Sultan A Pradhan
1
Senior Resident, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
2
Head and Neck Surgeon, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
3
Fellow, Department of Head and Neck Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
4
Senior Oncosurgeon, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
5
Chief, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
Correspondence: Sultan A Pradhan, Chief, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai-400010
Maharashtra, India, e-mail: sultanpradhan@gmail.com

Abstract
Recent years have seen paradigm shift in the treatment of early laryngeal tumors towards microscopic CO2 laser resection because of
excellent oncologic and functional results. The coupling of the carbon dioxide (CO2) laser to the operating microscope has greatly simplified,
even revolutionized, microlaryngoscopic surgery. Focus is now not just on oncological outcome but also on preservation of vocal function.
This results in a continuous conflict between the need to remove tissue for oncological stability and the need to preserve tissue for optimal
vocal function.
Keywords: Laryngeal cancer, Hypopharyngeal cancer, CO2 laser.

INTRODUCTION India. The patients ranged in age from 18 to 86 years (median

age, 57 years) and there were 417 males and 31 females
The use of the CO2 laser in the endoscopic management of
with M:F ratio of 13:1. All patients were assessed with rigid
patients with early laryngeal cancer represents an obvious
laryngoscopes and computed CT imaging was only done
extension of the clinical application of conventional cold
when anterior commissure, subglottic, or paraglottic space
instruments for endoscopic resection,1-3 with advantages of
invasion was suspected (e.g. bulky lesions or impairment
precision, hemostasis and decreased postoperative oedema. of vocal fold mobility). TNM staging system was used for
Transoral microlaryngoscopic CO2 laser resection of staging in this study. There were 322 cases of glottic, 72
laryngeal cancer has distinct advantages over treatment with cases of supraglottic and 54 cases of hypopharyngeal
either radiation therapy or open partial laryngectomy.4-10 carcinoma (Table 1). Median post-treatment follow-up was
Resection with the CO2 laser is almost always complete in 46 months.
one sitting as against nearly six weeks of treatment with In glottic series, there were 188 cases of T1a, 45 cases
radiation therapy. The resection is generally performed as a of T1b, and 89 cases of T2 stage (Table 2). None of the
daycare procedure. Most importantly for the patient, a cases had palpable neck nodes at presentation. In supraglottis
tracheostomy is not required. Finally, should treatment with and hypopharyngeal series 28 cases were of T1, 88 cases of
the laser be found to be inadequate, use of other options, T2 and 10 cases of T3 stage (Table 2). The vocal cords
namely radiotherapy and open surgery, are still available. were freely mobile in all cases, including the ones with T3
lesions, 86 cases had N0, 9 cases had N1, 24 cases had N2
PATIENTS AND METHODS
Table 1. Site-wise distribution
Four hundred and forty-eight patients with previously
Site Number Percentage
untreated early laryngeal and hypopharyngeal cancers were
evaluated and treated by transoral endoscopic laser resection Glottic 322 71.87%
Supraglottic 72 16.07%
from January 2000 to May 2010 at the Department of
Hypopharynx 54 12.05%
surgical oncology, Prince Aly Khan Hospital, Mumbai,

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Table 2. T-stage wise distribution of laryngeal cancers cottonoids are placed in the larynx to prevent thermal
Stage T1 T2 T3 damage to the tissues. Theatre personnel are advised to wear
Site
goggles to protect the eyes from accidentally reflected laser
Glottic T1a-188 89(27.63%) – beam.
(58.38%)
T1b-45 PROCEDURE
(13.97%)
The resection is performed transorally using a suspension
Supraglottis 28(22.22%) 88(69.84%) 10(7.93%)
and hypopharynx laryngoscope and an operating microscope which is coupled
with the CO2 laser. An orotracheal tube is used for general
anesthesia. Tracheotomy is avoided. Proper exposure of the
Table 3. N status at presentation
lesion is vital to ensure an adequate excision with
Site N0 N1 N2 N3 oncologically safe margins.
Glottic 322(100%) – – – The laser beam is now focused accurately to a spot-size
Supraglottis 86(68.25%) 9(7.14%) 24(19.04%) 7(5.5%) and manipulated with the help of a micromanipulator to
and hypopharynx permit precise excision in a relatively bloodless field. For a
small lesion that can be visualized in its entirety, monobloc
and 7 cases had N3 neck status at presentation (Table 3). (Figs 3 and 4) resection is performed by cutting through
All the cases with positive neck nodes were subjected to normal tissue at the margins of the tumor. A larger lesion is
neck dissection and 24 out of 40 cases had delayed neck excised in multiple segments as determined by the field of
dissection 3 to 4 days after CO2 laser resection of their exposure. This method of cutting through tumor tissue,
though unconventional in open surgery is the recommended
primary tumors.
technique. The resection is completed segment by segment,
All patients were allowed to eat on the day after surgery.
as the tumor is excised in wedges till the supple normal
Naso-enteral feeding tubes or tracheostomy was not used
tissue is left behind.
in any patients. Postoperative radiotherapy or reoperation
The CO2 laser is an excellent cutting tool with limited
with an enlargement of previous margins was indicated when
capability for coagulation. Minor ooze is controlled either
surgical margins were found to have squamous cell
with a defocused laser beam or with a cottonoid soaked in
carcinoma on findings from the permanent paraffin section.
1:100,000 adrenaline solution. For control of larger bleeders
If a patient did not wish to undergo a repeat surgery or this as encountered when resecting lesions of the supraglottis,
was not possible for any reason, treatment with postoperative pyriform, or oropharynx, an electrocautery connected to an
radiotherapy was chosen. insulated suction tip is used. For glottic lesions, hemostasis
Postoperatively patients were followed until death or at is generally much simpler.
the longest until June 2010. All the patients who completed Lesions on the anterior commissure, anterior third of
minimum one year of follow-up were included in the study. the vocal cord, infrahyoid epiglottis, valeculla and base of
Local control, disease free survival and organ preservation the tongue, are very often difficult to visualize. Techniques
were the main outcomes. are described to improve the exposure and facilitate
resection. For example, resecting the false cord to expose
SAFETY MEASURES the growth on the anterior third of the true cord and the
When using the CO2 laser certain safety measures are anterior commissure; or resecting the suprahyoid epiglottis
advised in order to prevent injury to the patient and to the to expose the growth on the infrahyoid region.
operating room personnel. The endotracheal tube should
be of non-inflammable material; hence the commonly used INDICATIONS
polyvinyl endotracheal tubes are absolutely prohibited The most widely accepted indication for transoral CO2 laser
during microlaryngeal laser surgery. A red rubber tube is resection of laryngeal/hypopharyngeal cancer is an early
used, preferably wrapped in reflective aluminum foil to cancer with freely mobile vocal cords, no gross invasion of
prevent damage, as a hole created in the tube can cause the paraglottic or the preepiglottic spaces and good exposure
combustion of the anesthesia gases and fire. Soaked on suspension laryngoscopy.

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Lesions with gross invasion of the paraglottis and some

impairment of cord mobility (T2b) can be resected
transorally but the author does not recommend it because
alternatives that are oncologically safer and more effective
are available viz the open partial laryngectomy procedures.

LIMITATIONS
Inadequate exposure of the tumor on transoral micro-
laryngoscopy can make endoscopic resection impossible or
unsafe. Certain conditions can make direct laryngoscopy
Fig. 1: Schematic representation of postoperative voice quality in
extremely difficult or impossible. These include trismus due
supraglottic and hypopharyngeal cancer group: excellent–9.2%, to any cause, such as submucous fibrosis, previous oral
good–80.48, fair–8.7%, poor–1.45%
surgery or radiation therapy; inability to extend the neck
due to severe cervical spondylosis or due to fibrosis as a
result of previous surgery or radiotherapy; anatomical
peculiarities of the dental arch, anteriorly placed larynx or
a tongue. In all these conditions, even lesions that are
seemingly easily resectable as viewed on indirect
laryngoscopy, may have to be offered alternative methods
of treatment.

RESULTS
Positive or close margins on paraffin sectioning were
reported in 9 cases of glottic cancers and 23 cases of
Fig. 2: Schematic representation of postoperative voice quality in glottic supraglottic and hypopharyngeal cancers (Table 4). In glottic
cancer group: excellent–9.4%, good–77.35%, fair–11.32%, poor–1.8% series, re-laser was possible in 5 cases and 4 cases were
treated with adjuvant radiotherapy. While in supraglottic
Presence of metastatic lymph node does not preclude and hypopharyngeal series all 23 cases were treated with
endoscopic resection of the primary. In fact, in many cases adjuvant radiotherapy (Table 4).
Postoperative adjuvant radiotherapy was given in 57
it strengthens the case for endoscopic resection of the
cases of supraglottis and hypopharynx series as 23 cases
primary prior to neck dissection.
had because of positive or close margins and 34 cases had
The following are the main indications for transoral
positive neck nodes.
resection:
Voice quality was excellent in 9.4%, good in 77.35%,
• Dysplasia/Ca in situ (TIS) of the vocal cord.
fair in 11.32% and poor in 1.8% in supraglottic and
• T1/T2 mid cord lesion.
hypopharyngeal cancers (Fig. 1). Voice quality was excellent
• Select cases of T1/T2 lesions of the anterior commissure in 9.2%, good in 80%, fair in 8.7%, and poor in 1.45% of
with only superficial invasion and very good exposure glottic series (Fig. 2).
on laryngoscopy. In the glottic series, 61/322 (19%) had recurrences; 60
• T1/T2 lesions of the supraglottis, marginal zone, hypo- recurred locally and 1 developed cervical lymph node
pharynx. metastasis (Table 5). Of the 60 local recurrences 45(73%)
There is potential for expanding the indications of underwent organ preserving salvage treatment. This
transoral laser resection to include lesions that are more included another transoral laser resection in 22 cases, open
advanced than the ones mentioned above for e.g. partial laryngectomy in 11 cases and radiotherapy in 12
superficially invasive T3 lesions of the supraglottis/ cases. The remaining 15/60 cases had to under go total
hypopharynx. It depends on the surgeon’s experience, laryngectomy. Thus, the larynx preservation was possible
expertise and treatment philosophy. in 307/322 (95%) cases.

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Marzi Mehta et al

Table 4. Positive cut margins and adjuvant treatment given Table 5. Patterns of recurrences

Site Number(%) Adjuvant treatment Recurrence Number Local Regional Locoregional

Re-laser Radiotherapy
Glottic 61(18.94%) 60(18.63%) 1(0.3%) 0
Glottic 9(2.7%) 5 4
Supraglottis 24(19.04%) 20(15.87%) 3(2.38%) 1(0.79%)
Supraglottis and 23(18.25%) 0 23 and hypopharynx
hypopharynx

developed locoregional disease was salvaged by re-laser and

neck dissection followed by radiotherapy and 11 cases could
not be salvaged because of the advanced stage of the disease.
Thus larynx preservation of this entire series was 119/
126(94.44%).
Distant metastases was seen in 4/126 (3.17%) cases of
the supraglottic and hypopharyngeal series while 7/322
(2.17%) of the glottic series. Second primary tumors were
seen in 2/126 (1.58% cases) of supraglottic and
hypopharyngeal series and 5/322 (1.55%) cases of glottic
carcinoma.
The over all survival for the glottic series was 96% and
for the supraglottic/hypopharynx series was 88%.

Fig. 3: Microlaryngoscopic picture of T1 right mid cord lesion DISCUSSION

Glottic Ca in Situ
Patients present with persistent hoarseness. Laryngoscopy
reveals leukoplakia, erythroplakia. It may be localized or
diffuse. It may involve both vocal cords separately sparing
the anterior commissure or the two vocal cords may be
involved incontinuity across the anterior commissure.
Two experienced pathologists may report the same lesion
differently – one calling it “Severe dysplasia”, the other
calling it “Carcinoma in situ”. To the clinician both represent
entities of a biological continuum. Both demand the same
treatment, viz., mucosal excision, sparing the deeper tissues.
The patient must quit smoking. Dysplastic/carcinoma in situ
lesions often have a tendency to recur after excision or cord
stripping and may call for multiple excisions over a period
Fig. 4: En bloc CO2 laser resection of right mid cord lesion of years. Even so, radiotherapy is best avoided and reserved
only for infiltrative cancer.
In the supraglottic and hypopharyngeal series, there were As mentioned above, the endeavor should be to excise
24 recurrences. Of which 20 were local recurrences, 3 cases the lesion completely and prevent damage to the lamina
had regional and 1 case had both locoregional recurrence propria so that the voice quality remains good. Zeitels has
(Table 5). Of 20 local recurrences, 5 were salvaged by Near described a phonomicrosurgical technique for this.11-13
total laryngectomy with partial pharyngectomy, 2 by total It involves injecting 1:100,000 adrenaline in saline
laryngectomy, 2 by supracricoid partial laryngectomy with submucosally with a 26 guage needle which will lift the
CHP, while transoral laser was possible in only one case. 3 mucosa and the lesion off the lamina propria. If the patch is
cases which developed only neck disease were salvaged with localized, conventional micro scissors and forceps are used
neck dissection followed by radiotherapy. 1 case that for excision. For diffuse lesions, the cord is stripped with

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the CO2 laser using a microspot at low wattage. In case laser resection. Size and surface extent should not be the
there is a microinvasive component, when saline is injected, limiting factors. Even early invasion of the pre-epiglottic
the mucosa at the site of invasion will remain tethered to space is amenable to endoscopic resection. Tumors at the
the lamina propria and will not be lifted off. In such a free border of the epiglottis or localised lesions on the edge
situation, only a limited portion of the lamina propria is of the aryepiglottic fold are easy to resect. A tumor on the
resected along with the entire leukoplakia to minimize infrahyoid epiglottis needs to be exposed adequately before
damage to the quality of voice. resection. This is achieved by first resecting the suprahyoid
If the lesion involves both vocal cords and the anterior portion of the epiglottis, transecting from one pharyngo-
commissure, the procedure may have to be staged to prevent epiglottic fold to the other. Thereafter, the infrahyoid
formation of a web. However, bilateral cord lesions with epiglottis, with the tumor, is resected along with the pre-
uninvolved anterior commissure are tackled at the same epiglottic space.
session. If a supraglottic tumor has involved the mucosa overlying
a mobile arytenoid, it is not necessary to resect the cartilage.
T1/T2 Glottic Cancer Under the magnification of the operating microscope, the
overlying mucosal tumor along with sufficient submucosal
Small midcord lesions are resected en bloc. Larger lesions
margin is very easily peeled off with the help of the laser,
are resected in segments, cutting through the tumor until
preserving the arytenoid cartilage and the soft tissues
normal supple tissue is reached. This way, as much normal
covering it. This is oncologically safe, prevents the problem
tissue as possible is preserved, to ensure good quality of
of postoperative aspiration, and is therefore a major
voice.
advantage over the open procedure.
For lesions in the anterior one-third of the cord and the
Presence of metastatic neck node can be dealt with by
anterior commissure, if the exposure is inadequate, it is best
an appropriate neck dissection either at the same sitting or
to first resect the portion of the supraglottis, viz the false
4-5 days later. Postoperative radiation therapy is only given
cord and the base of the epiglottis. This gives a good
if the resection margins are compromised or if the neck nodal
exposure of the glottis. The lesion can then be resected either
disease so demands. As in the case of glottic cancer, the
en bloc or in segments depending on the size of the tumor.
need for open partial laryngectomy for supraglottic cancer
While resecting a lesion on the anterior commissure, if it is
with freely mobile vocal cords has also significantly reduced
found that there is erosion of the thyroid cartilage, the
due to progress in microlaryngoscopic laser surgery.
procedure is either converted to an open partial laryngectomy
or a laser assisted window partial laryngectomy is performed.
Hypopharyngeal Cancers
Lesions of the anterior commissure will necessitate resection
of the anterior most portions of both vocal cords. Left to T1/T2 squamous cancers of the pyriform and the posterior
itself, it will form an anterior web. To prevent this, it is pharyngeal wall were generally treated with radiation
necessary to interpose a silicone keel between the two cords therapy, largely due to the difficulty of surgical access to
until the healing on both sides is complete. The placement these regions. Using the distending laryngopharyngoscope,
of keel is carried out endoscopically using the these lesions can now be excised transorally with the CO2
Leichtenberger needle. laser coupled to the operating microscope. In the postcricoid
Lesions involving the true cord, posteriorly, may region, such an excision is only advisable for a small lesion
necessitate resection of the vocal process of the arytenoid, confined to one wall; a circumferential excision will lead to
retaining the main body of the arytenoid cartilage. With complete stenosis of the pharynx. Like the supraglottis, the
progress in microlaryngeal laser surgery, the need for open oropharynx and the hypopharynx are highly vascular regions
vertical partial laryngectomy has been reduced significantly. and proper instrumentation is mandatory. Very large tumors
may not fit into one field and will therefore need
Supraglottic Cancer with Mobile readjustment of the scope from time to time. These lesions
Vocal Cords T1/T2/ Early T3 may at first seem formidable because of their size; however,
A distending laryngopharyngoscope is used. Only the cases if the case selection is proper (mobile vocal cords; no
with freely mobile vocal cords are selected for endoscopic cartilage erosion; no parapharyngeal soft tissue invasion;

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Marzi Mehta et al

and no ankyloglossia), it becomes progressively easier as CONCLUSION

one resects the tumor, segment by segment. In the From the point of view of oncological safety as also quality
hypopharynx, it is recommended that one proceed from the of life, transoral CO2 laser resection of early laryngeal and
proximal portion of the tumor to the distal (Cranio-caudal hypopharyneal cancer is a very useful treatment method that
direction). every H and N surgeon must endeavor to develop expertise
As mentioned in the earlier section, the arytenoid in. Presence of metastatic cervical nodes does not preclude
cartilage must be preserved whenever feasible in order to endoscopic resection of the primary. The major advantage
avoid problems of postoperative aspiration. If a pyriform over the open surgical procedure is the smooth postoperative
cancer extends on to the mucosa overlying a mobile, recovery and avoidance of tracheostomy.
functioning arytenoid, the tumor can be resected along with
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