Cordectomy involves removal of the entire membranous vocal fold with the vocalis muscle. The inner perichondrium of the thyroid cartilage can be included and the arytenoids cartilage can also be removed, either partially or completely.
Cordectomy via thyrotomy is the oldest surgical procedure for the treatment of early glottic carcinoma.
It remains the standard by which all other surgical treatments of small glottic cancers are measured.
Cordectomy can be performed by the following 2 methods:
Cordectomy through laryngofissure
Endoscopic laser cordectomy
In 1908, Citelli introduced the so called cordectomy externa through thyrofissure.
Chevalier Jackson described total cordectomy to treat patient with airway obstruction from bilateral vocal folds inability (1922) but the procedure was hampered by the resultant poor voice quality.
In 1932, Hoover published the results with similar approach through laryngofissure.
An important new concept was the submucosal dissection, which later became a standard. The preservation of the overlying mucosal allowed primary wound closure. Surjan further improved the concept of the submucosal approach through laryngeal fissure.
Dennis and Kashima described posterior cordectomy for the treatment of bilateral vocal folds inability in 1989.
Images depicting cordectomy can be seen below.
Diagram showing the incision line (blue dotted line) for right posterior cordectomy in cases of bilateral abductor paralysis.
Diagram showing the result of right posterior cordectomy in cases of bilateral abductor paralysis.
The vocal folds, also known as vocal cords, are located within the larynx (also colloquially known as the voice box) at the top of the trachea. They are open during inhalation and come together to close during swallowing and phonation. When closed, the vocal folds may vibrate and modulate the expelled airflow from the lungs to produce speech and singing. For more information about the relevant anatomy, see Vocal Cord and Voice Box Anatomy.
Vocal cord cordectomy is indicated in the treatment of the following:
Dysplastic lesions of the vocal cords
Vocal cord malignancies- T1 lesions
Bilateral abductor paralysis
Cordectomy is contraindicated in the following cases:
When the vocal cords’ mobility is impaired.
When the thyroid cartilage is invaded by the tumor.
When supraglottic or subglottic extension exists.
Endoscopic laser surgery is contraindicated if general anesthesia is a threat to the patient’s life, such as in the following cases:
Patient with aneurysms
But, an increased risk is justified in patients with suspected malignancy.
Endoscopic laser surgery is not possible in patients with the following conditions:
Fracture of cervical spine
Patients with short thick neck associated with marked prognathism.
Types of Cordectomy
Cordectomy can be performed by the following 2 methods depending on the indication:
Endoscopic laser cordectomy
Laryngofissure with cordectomy
A classification of laryngeal endoscopic cordectomies was first proposed by European laryngology society in 2000.The classification described 8 types of cordectomies, as follows:
Type I: Subepithelial cordectomy, which is the resection of vocal cord epithelium passing through the superficial layer of lamina propria .
Type II: Subligamental cordectomy, which is resection of epithelium, or Reinke’s space and vocal ligament.
Type III: Transmuscular cordectomy, which proceeds through vocalis muscle.
Type IV: Total cordectomy, which extends from vocal process to the anterior commissure.
Type Va: Extended cordectomy encompassing the contralateral vocal fold.
Type Vb: Extended cordectomy encompassing the arytenoids.
Type Vc: Extended cordectomy encompassing the ventricular fold.
Type Vd: Extended cordectomy encompassing the subglottis.
This classification did not propose any specific management for the lesions arising from the anterior commissure, which are being included among the indications for type Va cordectomy. To solve this problem, new cordectomy, encompassing the anterior commissure and anterior part of vocal cord, was proposed by European laryngology society working committee on nomenclature. This is classified as type VI.
Type VI is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage.
European Laryngological Society classification allows one to define and clearly distinguish the extent of excision, which facilitates making meaningful comparisons between vocal outcomes after different types of cordectomy.
Atropine is always included in premedication. Anesthesia is induced by intravenous injection of barbiturates or by application of gas mixture via a mask. Relaxation is usually achieved by a bolus of succinyl choline. A long term relaxant is preferred for cordectomy. The anesthetic usually consists of gas mixture such as halothane, nitrous oxide and oxygen.
For more information, see general anesthesia.
Various laryngoscopes, including bivalve adjustable laryngoscopes are used to expose the larynx.
Two suction devices: one is mounted on to the operating microscope and the other suction is used by the surgeon to evacuate the plume and to manipulate the tissue.
Microlaryngeal surgery instruments
Carbon dioxide laser coupled to an operating microscope
Laser safe endotracheal tubes.
The correct position is essential for the optimal introduction of laryngoscope. The patient should preferably lie horizontally flat on operating table, with neither head ring nor sand bag under the shoulders. The dental plate is put in place before the laryngoscope is introduced.