INDICATIONS OF CRICOHYOIDOEPIGLOTTOPEXY VERSUS ANTERIOR FRONTAL LARYNGECTOMY: THE ROLE OF CONTRALATERAL VOCAL FOLD SPREAD

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1 ORIGINAL ARTICLE INDICATIONS OF CRICOHYOIDOEPIGLOTTOPEXY VERSUS ANTERIOR FRONTAL LARYNGECTOMY: THE ROLE OF CONTRALATERAL VOCAL FOLD SPREAD David Bakhos, MD, Emmanuel Lescanne, MD, PhD, Patrice Beutter, MD, Sylvain Morinière, MD, PhD Department of ENT, Head and Neck Surgery, Bretonneau Hospital, 2 Boulevard Tonellé, Tours, France. bakhos_d@med.univ-tours.fr Accepted 4 April 2008 Published online 14 August 2008 in Wiley InterScience ( DOI: /hed Abstract: Background. The aim of the retrospective study was to compare the indications, the postoperative outcomes, and the survival of the supracricoid laryngectomy with cricohyoidoepiglottopexy and the anterior frontal laryngectomy. Method. Nineteen patients who underwent cricohyoidoepiglottopexy (group I) and 23 patients who underwent reconstructive anterior frontal laryngectomy (group II) from January 1992 and December 2004 have been reviewed. We have compared their respective indications and postoperative outcomes. Results. There were no differences for median time before decanulation. Median time for removal feeding tube, for first oral alimentation, and hospital stay period were significantly shorter in group II. Five-year survival was 85% (group I) and 95% (group II). Local tumor control was obtained in 83% in group I and in 87% in group II. Conclusion. Cricohyoidoepiglottopexia (CHEP) was used more often than anterior frontal laryngectomy when there was contralateral vocal fold spread but resulted in longer postoperative outcomes. VC 2008 Wiley Periodicals, Inc. Head Neck 30: , 2008 Keywords: supracricoid laryngectomy; cricohyoidoepiglottopexy; reconstructive anterior frontal laryngectomy; epiglottoplasty; glottic carcinoma Correspondence to: D. Bakhos VC 2008 Wiley Periodicals, Inc. The surgical possibilities for treating carcinomas of the glottis while maintaining arytenoid mobility are numerous and range from endoscopic cordectomy to reconstructive laryngectomy. The lastmentioned constitutes a surgical alternative to total laryngectomy. The entire range of these surgical techniques was developed by European surgeons during the second half of the twentieth century. Subsequent progress in general anesthesia, intensive care, and aseptic technique has resulted in the rapid development of these surgical techniques. Partial laryngectomy has 2 objectives: treatment of the underlying cancer and maintaining organ function. In 1959, Majer et al 1 described supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP). Later, in 1979, Tucker et al 2 developed reconstructive anterior frontal laryngectomy (RAFL) by modifying an operation previously described by Sedlacek 3 and other European authors. 4 Both these techniques allowed surgeons to construct a neolarynx so that breathing, phonation, and closing of the glottis during swallowing could be maintained. Each procedure involves the resection of different laryngeal structures but both are intended to control the local development of the cancer and are 1408 Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November 2008

2 indicated in class T1 and T2 carcinomas of the glottis with maintained arytenoid mobility. These 2 techniques have been used in our department of ENT (ear, nose, throat), Head and Neck Surgery. In this study, we analyzed the respective indications and results of these 2 techniques and compared the data we obtained to those in other published studies. To the best of our knowledge, this is the second report comparing functional outcomes and survival in these 2 surgical procedures. PATIENTS AND METHODS We performed a retrospective study on all patients operated on in our department from January 1, 1992 to December 31, They had all received surgical treatment for glottic carcinoma classified T1 or T2NxMx according to the Union Internationale Contre le Cancer (UICC) The patients in group 1 had been treated with a SCPL-CHEP procedure and the patients in group II had been treated with a RAFL procedure. Patients whose medicals files were incomplete or who had less than 12 months of follow-up were excluded from the study. Patients who had received adjuvant therapy (external radiation therapy or chemotherapy) were excluded from the study. Data Obtained from Patients Medical Histories. For each patient, we noted sex, age, alcohol consumption, and smoking history as well as the presence or absence of dysphonia, otalgia, laryngeal dyspnea, odynophagia, dysphagia, or a history of aspiration pneumonia. The results of the physical examination, panendoscopy of the upper airway and gastrointestinal tract, and cervical CT scan helped determine the tumor s initial localization, the mobility of the glottis, and eventual metastases. Based on these findings, the lesion was graded according to the TNM classification. Data from the patients medical histories were compared in each group by using the chi-square test. Surgical Techniques. RAFL. Tracheotomy is performed. The subhyoid muscles are separated in the midline exposing the thyroid cartilage. The perichondrium of the thyroid cartilage is incised in the midline in order to get 2 perichondrial flaps. Two vertical parallel cuts in the thyroid ala are made. Scissors are placed in the cartilage cut on the less-involved side, opening the larynx from superior to inferior. The lesion is then removed under direct vision. If involved the vocal process of the arytenoids is removed. The petiole of the epiglottis is grasped downward with the incision of the hyoepiglottic and glosso-epiglottic ligaments. The superior mucosal attachments of the epiglottis are preserved. We switch the epiglottis to cut edge of the thyroid cartilage. The inferior fixation of the epiglottis is performed by suturing the inferior edge of the cricoid. The overlying strap muscles are sutured together with minimal tension. SCPL-CHEP. It consists of resection of the whole thyroid cartilage and paraglottic space. The cricoid cartilage, the hyoid bone, and most of the epiglottis are conserved. Reconstruction consists of suturing the hyoid bone and the suprahyoid epiglottis closely together and to the cricoid cartilage. One arytenoid is spared. Postoperative Data. We collected data on early postoperative complications (hematoma, sepsis, emphysema, aspiration) and calculated the average duration of tracheotomy, the delay before oral alimentation was reintroduced, the time feeding tube had to remain in place, and the duration of hospitalization in each group, and used Student s test to compare the 2 groups. Data Concerning the Cancer. We noted when there was local, regional, or distant recurrence and calculated 5-year survival and local tumor control at 5 years with the Kaplan-Meier method. Finally, we compared the 2 groups by using the log-rank test. Peroperative Data. We noted the surgeon who performed the operation, the number of arytenoids remaining (1 or 2), and whether the cervical lymph nodes were removed. The microscopic criteria we used were: whether or not the resection margins were free of involvement, whether there was involvement of the thyroid cartilage, or whether there was lymph nodes involvement. RESULTS Patients. We enrolled 42 patients into this retrospective study. Group I consisted of 19 patients managed with SCPL-CHEP. Group II consisted of 23 patients managed with RAFL. Their average age was 59 years. Three of the 42 patients were women. The average patient age was 60.8 years Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November

3 Table 1. TNM in group I and II. SCPL-CHEP Group I (n 5 19) RAFL Group II (n 5 23) Characteristic Mean age (SD), y 60.8 (69.6) 57 (610.4) T classification, no. of patients (%) T1 63.2% (12) 56.5% (13) T1a 10.5% (2) 47.8% (11) T1b 52.7% (10) 8.7% (2) T2 36.8% (7) 43.4% (10) N classification, 90% (17) 100% (24) no. of patients (%) N0 N1 10% (2) 0 Abbreviations: SD, standard deviation; SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty. (69.6) in group I and 57 years (610.4) in group II. Only 4 patients denied alcohol abuse or smoking. Twenty patients stated they smoked, and 19 had a history of combined alcohol abuse and smoking. All patients had dysphonia, 3 patients had otalgia, 1 patient had laryngeal dyspnea, and 5 patients had odynophagia. Initial Tumor Localization. Data on tumor localization, the mobility of the glottis, tumor extension, and TNM classification are summarized in Tables 1 and 2. Surgical and Histological Data. Three different senior surgeons performed the 42 surgical procedures, whereas 80% were performed by the same surgeon (P.B). One of the arytenoids was spared in a total of 26 patients, 10 in group I and 16 in group II. Seven functional neck dissections were performed in group I patients and lymph node invasion was noted in 4. Two patients in group II had functional neck dissections, although no lymph node invasion was observed. Postoperative Period. None of the patients died during hospitalization. Table 3 contains a summary of the immediate postoperative outcomes. There was a significant difference between group I and group II concerning the time before oral alimentation was reintroduced (12.7 days [range: 7 21] vs 8.7 days [range: 2 15], p <.001), the time feeding tube had to remain in place (21.2 days [range: 13 50] vs 8.7 days [range: 8 23], p 5.001), and length of hospital stay (22.8 days [range: 14 30] vs 17.3 days [range: 7 42], p 5.007). All these time periods were shorter in RAFL patients. In Table 2. Statistical comparison of tumor parameters between study groups. Specific tumor features Group I SCPL-CHEP No. (%) Group II RAFL No. (%) p value Anterior commissure 16 (84) 18 (78).6 Anterior 2/3 true vocal cord 7 (37) 7 (30).7 True vocal cord 11 (58) 17 (73).3 Contralateral true vocal cord 11 (58) 2 (8).001 Arytenoid 10 (53) 12 (52).98 Floor of ventricule 4 (21) 9 (39).2 Subglottis 1 (5.3) 0 (0) Abbreviations: SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty. both groups, no patients had feeding tube dependence when they were discharged home. SCPL-CHEP patients had a complication rate of 15.8% as compared with 16.7% in the RAFL patients. Aspiration pneumonia, cervical hematoma and emphysema were observed in each group. One patient in group II had local sepsis that was treated with antibiotics and local disinfection. Results Concerning the Cancer. The average follow-up was 52 months in group I and 75 months in group II. The 5-year actuarial survival was 91% in all the patients studied; it was 85% in group I patients and 95% in group II patients. There was no significant difference between the 2 groups (p 5.83). Five-year actuarial local control was obtained in 87% of all the patients studied; it was 83% in SCPL-CHEP patients and 87% in RAFL patients (Figures 1 and 2). Using the log-rank test, there was no significant difference in local control between the 2 groups (p 5.86). Local recurrence occurred in 5 patients, 2 patients in group I, and 3 patients in group II had local recurrences. Table 3. Stastical comparisons of functional parameters between study groups. Immediate postoperative outcome No. of days (6SD) by study group SCPL-CHEP RAFL p value Decanulation 6.6 (62.4) 6.1 (62).47 First oral feeding 12.7 (63.5) 8.7 (63) <.001 Tube removal 21.2 (68) 14.4 (64).001 Hospital stay 22.8 (64.4) 17.3 (67.5).007 Abbreviations: SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty; SD, standard deviation Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November 2008

4 FIGURE 1. Stastical comparaison of 5-year survival between study groups. Log-rank The 5-year survival was 85% in SCPL-CHEP group and 95% RAFL group. SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty. In 4 of these cases, the margins of the resection were insufficient. Four patients required total laryngectomy and bilateral functional neck dissections. One patient had concomitant radiationchemotherapy due to early local recurrence. Lymph node recurrence was observed in both groups and was treated with palliative chemotherapy in 1 patient and with radical neck dissection combined with external radiation therapy in another. Among the total of 7 patients who had local or regional recurrences, 5 had microscopically proven insufficient tumor removal (4 patients had a local recurrence and 1 patient had lymph node recurrence). DISCUSSION This study showed that, in our experience, patients operated on with a SCPL-CHEP had lesions extending to both vocal cords more often than patients who underwent RAFL. More RAFLs were performed for T1a lesions than SCPL-CHEP. Patients who had an RAFL had significantly faster postoperative recovery than those who had a SCPL-CHEP. Initial Tumor Work-Up. All the patients we studied had dysphonia. This is the most frequent complaint leading to the diagnosis. 5 The physical examination provides valuable information on tumor extension and the mobility of the vocal cords. The study of the mobility of the vocal cords is an important consideration. The examiner needs to distinguish between vocal cord mobility and arytenoid mobility because only an immobile arytenoid constitutes a contraindication for partial laryngectomy. Millimetric CT scan slices can help the clinician evaluate the deep extension of the tumor into the thyro-epiglottic space, lateral to the paraglottic space, in front of the anterior commissure area and the thyroid cartilage 6 as well as to the cervical lymph nodes. Endoscopic palpation provides information on eventual invasion of the paraglottic space. 6 A lesion located near the superior border of the cricoid constitutes a contraindication for supracricoid laryngectomy or RAFL. We performed cervical CT scan and panendoscopy of the upper respiratory and digestive tracts in all our patients. Postoperative Period. In our study, the average duration of postoperative outcomes for both the SCPL-CHEP and RAFL procedures were comparable to results seen in the published literature 2,6 12 (Table 4). The average time before decanulation was between 6 and 6.6 days in both groups. Some authors have described longer time periods. 10,13 Lawson et al 10 removed the cannula as soon as swallowing cinema radiography showed the absence of a false passage. In our study, we found a shorter delay for oral alimentation after feeding tube was removed in the RAFL group. Because well-hospitalization duration was shorter in the RAFL group, the patients were discharged home without the feeding tube. This is probably due to the fact that the SCPL-CHEP involves a more extensive removal of the thyroid cartilage. In RAFL, the posterior thyroid cartilage and cricopharyngeal muscle are not removed. 11 However, in another report, Oysu et al 14 compared these 2 surgical procedures and found no differences for postoperative outcomes. Lawson estimates that the incidence of inhalation pneumopathies is approximately 9%. 10 It appears that there are fewer risks of false passage and inhalation pneu- FIGURE 2. Stastical comparaison of local control between study groups. Log-rank Local tumor control was obtained in 83% of the patients in SCPL-CHEP group and in 87% of the patients in RAFL group. Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November

5 Table 4. Functional parameters for supracricoid partial laryngectomy with cricohyoidoepiglottopexy and reconstructive anterior frontal laryngectomy with epiglottoplasty. Author, y No. of patients Procedure Age, y Decanulation time, d Tube removal, d Hospital stay, d Laccourreye, SCPL-CHEP Bron, SCPL-CHEP # Lallemant, SCPL-CHEP De Vincentiis, SCPL-CHEP # Our study, SCPL-CHEP Tucker, RAFL Lawson, RAFL Zanaret, RAFL # Lelièvre, RAFL Our study, RAFL Abbreviations: SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty. mopathy following RAFL than following SCPL- CHEP. 15 For this author, RAFL is more often indicated in elderly patients or when chronic obstructive pulmonary disease is present. 14,16 We did not perform these 2 surgical procedures on patients older than 75 years old. The average hospital stay reported in the literature is less than 22 days following the RAFL 10,12,13,16 and between 22 and 36 days following the SCPL-CHEP. 6 8,17 Some authors 18 perform a postoperative gastrostomy when certain criteria suggesting that normal swallowing will be delayed are present: age greater than 75 years, past history of external radiotherapy, paralysis of the hypoglossal, superior laryngeal, or recurrent nerves. The early complications of the SCPL-CHEP are infection, cervical hematoma, cervical emphysema and rupture of the pexia Laryngocele and posterior ptosis of the epiglottis are due to peroperative errors, 16 which we did not encounter. Laryngocele is due to partial resection of the roof of the ventricle. It can be avoided by verifying that the ventricle is totally intact in the surgical specimen. 6,17 Posterior ptosis of the epiglottis is due to an error during pexis when there is poor impaction between the hyoid and cricoid bones. In a series of 204 patients who had SCPL-CHEP, Naudo et al noted complications in 11.7% 17 Pexis rupture is a rare complication estimated to occur in 0.8% of the cases. It is caused by partial resection of the anterior arc of the cricoid cartilage, emergency recannulation or local sepsis. When it is clinically suspected, a standard X-ray of the laryngo-tracheal pathway may demonstrate a separation of a few centimeters between the hyoid bone and the cricoid cartilage. This complication requires surgical repair consisting in a new pexis that includes the first 2 tracheal rings 19 thus avoiding the need for total laryngectomy. The principal complications following the RAFL procedure described in the literature are posterior ptosis of the epiglottis that could require emergency tracheotomy, rupture of the base of the epiglottis, laryngeal stenosis and inhalation pneumopathies. 2,10,12,13 Results of the Cancer Per Se. Our results on actuarial survival and local tumor control at 5 years in the 2 groups are comparable to those seen Table 5. Oncological parameters for supracricoid partial laryngectomy with cricohyoidoepiglottopexy and reconstructive anterior frontal laryngectomy with epiglottoplasty. Author, y No. of patients Age, y T classification Procedures 5-y survival, % 5-y local control, % Laccourreye, T1T2 SCPL-CHEP Bron, # T1T2 SCPL-CHEP Lallemant, # T2 SCPL-CHEP # 84 Our study, T1T2 SCPL-CHEP Lawson, T1T2 RAFL 92 # Mallet, T1T2 RAFL Zannaret, T2 RAFL Our study, T1T2 RAFL Abbreviations: SCPL-CHEP, supracricoid partial laryngectomy with cricohyoidoepiglottopexy; RAFL, reconstructive anterior frontal laryngectomy with epiglottoplasty Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November 2008

6 in the published literature 4,7,8,10,11,13 (Table 5). Oysu et al compared SCPL-CHEP and RAFL and found similar oncological results with both treatment methods. 14 We failed to find any significant difference between these 2 cancer parameters. In contrast, Laccourreye et al, in their study on 204 patients operated on for T2 of the glottis, found better local control and 5-year survival in patients who had received an SCPL-CHEP procedure than those who had vertical laryngectomies 15 although they did not mention the proportion of patients who received an RAFL procedure. Published 5- year survival varies between 83% and 86.5% in SCPL-CHEP procedures 6,7,20 and between 82% and 98% in RAFL procedures 10,11,13 whereas local tumor control at 5 years varies between 81% and 98% following the SCPL-CHEP 6,7,16,19 and between 91% and 95% following the RAFL procedure. 11,13 Respective Indications for the 2 Interventions. When the localization of the tumor permitted either technique, the choice between the 2 was made according to the operating surgeon s personal experience. However, endoscopic carbon dioxide laser surgery has recently emerged for use in patients with early glottic carcinoma. 21 The oncological results seem similar to those achieved with open surgery. The more extensive removal of laryngeal structures during SCPL-CHEP probably explains the better local tumor control obtained. 6,22 In our study, we performed more SCPL-CHEP procedures when patients had a carcinoma which had invaded the 2 vocal cords. In addition, this technique allows the removal of a large portion of the paraglottic space, the thyroid cartilage and the inferior portion of the preglottic space. 6,15,22 The RAFL procedure permits the removal of the anterior two-thirds of the thyroid cartilage, the ventricular bands, the ventricle, and the vocal cords. 7 During the RAFL, resection is performed through the cartilage. This may explain why local recurrence has been described when the tumor infiltrates the thyroid cartilage. 16 For some authors, this constitutes a contraindication for the procedure. 13 The absence of a medial perichondrium at the anterior commissure facilitates spread to the cartilage. Spread to the cartilage can also occur where the collagen tracts of the paraglottic space join the medial perichondrium. 9,16,22 However, the posterior paraglottic space is poorly controlled by the RAFL. 11 These anatomic considerations help explain the procedure s limitations. Massive invasion of the anterior commissure or spread to the ventricle and ventricular bands contraindicate the RAFL 12,13,16 but not the SCPL-CHEP. Cervical CT scan using millimetric slices is a useful supplementary procedure for determining spread to the paraglottic space, the anterior commissure, and the thyroid cartilage, and can provide valuable assistance for choosing the best reconstructive laryngectomy technique to use. In our study, there were more lesions limited to a single vocal cord, which were treated with the RAFL procedure, and 96% of the patients in group II had maintained cord mobility as compared with 79% of the patients in group I. This clearly represents a selection bias in our population. In our institution, we have identified contralateral spread as important criteria to guide the choice of the surgical procedure and we think bulkier tumors with greater paraglottic disease and/or contralateral spread need the SCPL- CHEP; the RAFL is better suited to unilateral disease. A number of authors consider that the RAFL procedure is indicated in lesions that are too extensive to be treated by frontal lateral laryngectomy. 12 Indeed, Mallet 13 has observed that the introduction of the RAFL has been accompanied by a reduction in the number of frontal lateral laryngectomies. Locoregional Recurrences. The only significant criterion for local recurrence that we found in our study was the margin of resection. Indeed, 5 of the patients we studied presented a local recurrence and in 4 of them, the tumor-margins following partial laryngectomy were invaded. Chevalier et al 20 had the same findings in their study on 112 patients operated on with the SCPL-CHEP procedure. Recurrences usually occur under the neoglottis or at the arytenoid-epiglottic fold. 8 Laccourreye et al consider that exeresis should be large just as in hypopharyngeal tumors and stressed that when tumor margins are insufficient, patients require closer follow-up. 15 In our study, we closely followed the 4 patients who had insufficient tumor margins during exeresis. Local recurrences were detected with indirect laryngoscopy or careful nasofibroscopy. When the slightest doubt persisted, we performed panendoscopy with biopsy and microscopic examination. Predictive factors for lymph node recurrence described in the literature are local recurrence and insufficient resection of the tumor margins. 20 Two of our patients had lymph node recurrence and in 1, the tumor margins during partial laryngectomy were insufficient. Survival is poorer when there is Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November

7 lymph node recurrence or when the tumor margins are not free. 7 Follow-Up. Clinical follow-up may detect recurrences early and help evaluate the functional parameters of swallowing and speech. Swallowing can be evaluated by patient history and nasofibroscopic examination. A disturbance in laryngeal sensitivity can be treated with physical therapy by alternating the consistency and temperature of a bolus. 10 Collagen injections have been suggested 10 for treating permanent postoperative aspirations. CONCLUSION We failed to find any significant difference between the 2 procedures with respect to actuarial survival and local tumor control at 5 years. Nevertheless, we found that the RAFL procedure, which does not involve the thyroid ala and the constrictor muscles, allowed quicker postoperative recovery than the SCPL-CHEP procedure. In practice, the indications for these 2 procedures are different according to whether or not there is spread to the anterior commissura, the paraglottic space, and the contralateral vocal cord. When lesions are limited in the glottis, the glottis remains mobile, and there is little spread to the paraglottic space, we preferentially use the RAFL procedure. In contrast, the SCPL-CHEP is useful for treating glottic lesions that have spread to contralateral focal fold, the paraglottic space and the ventricle. Since the SCPL-CHEP involves the complete ablation of the thyroid cartilage, it can be used when there is massive spread to the anterior commissure. Acknowledgments. Authors are indebted to Donald Schwartz, MD, for proofreading the manuscript. REFERENCES 1. Majer E, Rieder W. Technique de laryngectomie permettant de conserver la perméabilité respiratoire (la cricohyoïdo-pexie). Ann Otolaryngol Chir Cervicofac 1959;76: Tucker HM, Wood BG, Levine H, Katz R. Glottic reconstruction after near total laryngectomy. Laryngoscope 1979;89: Sedlacek K. Predni a Pateralni rekonstrukcni laryngektomie se stazenimepiglottis. Cesk Otolaryngol 1965;14: Pech A, Cannoni M, Abdul S, Zanaret M, Thomassin JM, Goubert JL. La laryngectomie frontale antérieure reconstructrice. Ann Otolaryngol Chir Cervicofac 1982; 99: Licitra L, Bernier J, Grandi C, et al. Cancer of the larynx. Crit Rev Oncol Hematol 2003;47: Laccourreye O, Muscatello L, Laccourreye L, Naudo P, Brasnu D, Weinstein G. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for early glottic carcinoma classified as T1-T2N0 invading the anterior commissure. Am J Otolaryngol 1997;18: Bron L, Brossard E, Monnier P, Pasche P. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope 2000;110: Lallemant G, Bonnin P, El-Siouf I, Bousquet J. Cricohyoepiglottopexy: long-term results in 55 patients. J Laryngol Otol 1999;113: De Vincentiis M, Minni A, Gallo A, Di Nardo A. Supracricoid partial laryngectomies: oncologic and functional results. Head Neck 1998;20: Lawson G, Jamart J, Remacle M. Improving the functional outcome of tucker s reconstructive laryngectomy. Head Neck 2001;23: Zannaret M, Giovanni A, Gras R, Bonnefille E, Robert D, Cannoni M. La laryngectomie frontale antérieure reconstructrice. Résultats à long terme dans les T2 du plan glottique. Ann Otolaryngol Chir Cervicofac 1995; 112: Lelievre G, Laccourreye O, Strunsky V, Juvanon JM, Bedbeder P, Peynegre R. Etude critique et place des laryngectomies partielles verticales reconstructrices avec épiglottoplastie selon la méthode de Tucker. A propos de 18 cas. Ann Otolaryngol Chir Cervicofac 1987;104: Mallet Y, Chevalier D, Darras D.A, Wiel E, Desaulty A. Near total laryngectomy with epiglottic reconstruction. Our experience of 65 cases. Eur Arch Otorhinolaryngol 2001;258: Oysu C, Aslan I. Cricohyoidoepiglottopexy vs near-total laryngectomy with epiglottic reconstruction in the treatment of early glottic carcinoma. Otolaryngol Head Neck Surg 2006;132: Laccourreye O, Laccourreye L, Garcia D, Gutierrez- Fonseca R, Brasnu D, Weinstein G. Vertical partial laryngectomy versus supracricoid partial laryngectomy for selected carcinomas of the true vocal cord classified as T2N0. Ann Otol Rhinol Laryngol 2000;109: Piquet JJ, Chevalier D, Darras JA, Roux X. Laryngectomie avec épiglottoplastie de Tucker. Ann Otolaryngol Chir Cervicofac 1990;107: Naudo P, Laccourreye O, Weinstein G, Jouffre V, Laccourreye H, Brasnu D. Complications and functional outcome after supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg 1998; 118: Holsinger F.C, Laccourreye O, Weinstein G, Diaz E, McWhorter A. Technical refinements in the supracricoid partial laryngectomy to optimize functional outcomes. J Am Coll Surg 2005;201: Laccourreye O, Brasnu D, Laccourreye L, Weinstein G. Ruptured pexis after supracricoid partial laryngectomy. Ann Otol Rhinol Laryngol 1997;106: Chevalier D, Laccourreye O, Brasnu D, Laccourreye H, Piquet J. Cricohyoidoepiglottopexy for glottic carcinoma with fixation or impaired motion of the true vocal cord: 5-year oncologic results with 112 patients. Ann Otol Rhinol Laryngol 1997;106: Ledda GP, Puxeddu R. Carbon dioxide laser microsurgery for early glottic carcinoma. Otolaryngol Head Neck Surg 2006;134: Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99: Cricohyoidoepiglottopexy versus Anterior Frontal Laryngectomy HEAD & NECK DOI /hed November 2008