Cordectomy - Types, Indications, Contraindications, Procedure, and Complications

Introduction

Cordectomy is a surgical procedure used to treat laryngeal cancer. It involves the removal of part or all of the vocal cords. A cordectomy is carried out when a patient has a small tumor in the glottis. It refers to the removal of one or both vocal cords. Laryngeal cancer affects the larynx (also known as the voice box), which is responsible for speaking, breathing, and swallowing. The vocalis muscle (muscle of the larynx) and the entire membranous vocal fold are removed during a cordectomy. In addition, sometimes, the inner layer of the thyroid cartilage can also be included, and the arytenoid cartilage (cartilage present in the larynx) can be wholly or partially removed. The oldest surgical procedure for treating early glottic carcinoma is cordectomy via thyrotomy. It is still the gold standard against all other surgical treatments for small glottic cancers.

What Is the Anatomy of Vocal Cords?

The vocal folds, also known as the vocal cords, are located at the top of the trachea within the larynx (also known colloquially as the voice box). During inhalation, they open and come together to close during swallowing and phonation (while speaking or making sound). When the vocal folds close, they can vibrate and modulate the expelled airflow of the lung, resulting in speech and singing.

What Are the Indications for a Cordectomy?

Vocal cord cordectomy is used to treat the following conditions:

• Lesions of the vocal cords that are dysplastic.

• Vocal cord malignancies.

• Paralysis of the vocal cord on both sides.

What Are the Contraindications for Cordectomy?

Cordectomy is not recommended in the following circumstances:

• When the mobility of the vocal cords is compromised.

• When the tumor invades the thyroid cartilage.

• When there is a supraglottic or subglottic extension.

What Are the Types of Cordectomy?

Depending on the indication, a cordectomy can be performed in one of two ways:

• Cordectomy via Laryngofissure: This operation involves vertically splitting the thyroid cartilage in the midline to create a wide window. It is the oldest surgical procedure for treating early glottic carcinoma and is also known as median thyrotomy.

• Endoscopic Laser Cordectomy (Kashima Procedure): This is an endoscopic laser surgical procedure used to treat respiratory problems caused by vocal fold paralysis and glottic carcinoma.

What Are the Preparations Before Cordectomy?

• Patients should obtain detailed information about the procedure.

• Before the surgery, a person should be aware of all the long-term consequences, side effects, and risks of the laryngeal procedure, particularly the loss of speaking ability. In addition, a patient should be well aware that loss of speech will be proportional to the portion of the vocal cords removed.

• A patient should avoid processed foods and consume a healthy diet before surgery. In addition, follow good physical activity.

• Patients should quit smoking before the cordectomy because smoking decreases the chances of survival while increasing the side effects and recovery time.

How Is Anesthesia Given in Cordectomy?

This procedure is performed under anesthesia, and atropine is always included in the premedication. Premedication (medicines given before anesthesia) makes the anesthesia process comfortable for the patient. A bolus of succinylcholine is typically used to induce relaxation. For cordectomy, a long-term relaxant is preferred. The anesthetic is usually a gas mixture of halothane, nitrous oxide, and oxygen.

What Are the Equipment Used in Cordectomy?

• Various laryngoscopes, including flexible bivalves, are used to visualize the larynx.

• Two suction devices are used: One mounted on the operating microscope and the other operated by the surgeon to evacuate the plume (smoke or vapor) and manipulate the tissue.

• Instruments used for micro laryngeal surgery are an operating microscope and a carbon dioxide laser.

• Endotracheal tubes that are laser safe.

What Is the Patient’s Positioning During Cordectomy?

The proper positioning of the patient is essential for adequately introducing the laryngoscope. Preferably, the patient should lie flat on the operating table. Before the insertion of the laryngoscope, a dental plate is placed to keep the mouth open.

What Is the Procedure for Endoscopic Laser Cordectomy?

The procedure starts with orotracheal intubation with a laser-safe endotracheal tube. After that, the patient's eyes are covered with a pad, a head drape, and an upper teeth guard is fitted. A large laryngoscope is used to view the larynx when the patient is thoroughly relaxed and anesthetized. The patient's head is fully extended before the laryngoscope is introduced. Next, the laryngoscope is introduced between the endotracheal tube behind and the lower jaw in front. Once the laryngoscope is properly positioned, the chest holder secures the laryngoscope in position. With the help of a laryngoscope, both vocal cords can be observed along with the apex of the vocal process.

The dissection begins posteriorly (from the back) and laterally (sideways). The excision is done with a curved trajectory that matches the contour of the standard vocal fold, and the depth of the lesion determines the depth of the excision.

The telescope introduced through the laryngoscope helps examine the epiglottis' laryngeal surface, the lateral larynx wall, and the subglottic area.

What Are the Complications of Endoscopic Cordectomy?

• Anesthesia-induced circulatory and respiratory problems are examples of general complications.

• Local injuries include tooth damage, tearing, and lacerations of the palate. Laceration and hematoma of the lips or tongue can usually be avoided through the adequate insertion of the laryngoscope. These injuries are caused by laryngoscope pressure at the base of the tongue or oropharynx. Deeper lacerations are sutured immediately, and antibiotics are administered to prevent infection.

• After cordectomy, there may be laryngeal bleeding during or after the procedure. Adrenaline-soaked pledgets or deliberate coagulation are typically used to achieve hemostasis. However, massive bleeding may necessitate ligation of the superior laryngeal artery.

• Postoperative edema is uncommon, and edema can be treated with prophylactic steroids.

• Following surgery, granuloma scars and adhesions may form.

• Few types of transoral laser surgery may result in unsatisfactory phonetic outcomes, requiring an additional surgical procedure for correction.

What Are the Long-Term Observations After a Cordectomy?

• Endoscopy under general anesthesia should be performed at least every two months for the first two years after surgery, then less frequently in subsequent years.

• Voice rest for at least two weeks after surgery eliminates the need for adjunctive phono surgical treatment.

• A primary intracordal autologous fat injection at the end of the endoscopic resection for major cordectomy cases. However, the variable resorption rate of the injected fat is a potential shortcoming of this technique.

• Some authors believe phonosurgical voice rehabilitation should be performed only after a disease-free interval of at least six months to a year. A wider glottic gap usually reduces the possibility of good glottic closure in patients. After one year, these patients can be treated with appropriate phonosurgical procedures.

What Instructions Should a Patient Follow?

The most important aspect of treating laryngeal tumors endoscopically is ensuring adequate patient compliance with a strict post-operative follow-up schedule. Follow-up care includes:

• Complete voice rest.

• Coughing, throat clearing, singing, and shouting should be avoided.

• Cough suppressants and mucolytic agents should be used to treat coughing.

• Twice a day, steam inhalation is recommended.

• Antibiotic treatment with the appropriate antibiotics.

What Are the Associated Cordectomy Risks and Side Effects?

• Vocal capacity change. If a portion of the vocal cords is removed, a person may experience hoarseness or a loss of vocal range. If a total cordectomy is performed, the patient may lose the ability to make vocal sounds.

• Facial disfigurement.

• Tingling in the throat and neck.

• Difficulty swallowing or talking.

• Swelling in the mouth and throat swelling.

What Is the Recent Advancement in Cordectomy?

Assisted CO2 Laser Surgery: The transoral CO2 laser-assisted modulated cordectomies are one of the most notable advances in treating certain glottic cancers. Due to its physical properties, this is ideal for transoral laser surgery (TLS), as it converts the laser energy into heat energy, resulting in a photo thermolytic reaction. With time-limited exposure of the tissue (100 milliseconds), a pulsed CO2 laser coupled with a new-generation micromanipulator can do a more precise cut with less heat scattering and thermal damage.

Conclusion

A cordectomy is a surgery in which the surgeon removes part or all of the vocal cords, typically as part of the treatment for laryngeal cancer. This treatment is most commonly used when a patient has a small tumor of the glottis, also known as the vocal cords. A cordectomy can be performed either traditionally or using a laser instrument. Laser surgery patients often recover faster than those with an open cordectomy. Although it is a therapeutic process, it has some side effects. After the surgery, the voice quality becomes compromised in some cases. So, proper knowledge and associated side effects should be well known to the patient.