Endolaryngeal microsurgery at the anterior glottal commissure: controversies and observations

There are a number of tenets regarding endolaryngeal microsurgical management of disease that involves and/or encroaches upon the anterior glottal commissure (AGC). They include avoidance of 1) bilateral epithelial incisions near the AGC, 2) removal of papillomatosis in the AGC, and 3) resection of bilateral keratosis with atypia or carcinoma at the AGC. During the last 6 years, 115 patients underwent microsurgical management of disease at the AGC: carcinoma in 20 (T1 in 15 and T2 in 5), keratosis in 41, papillomatosis in 20, and polypoid corditis (Reinke's edema) in 34. No patients with polypoid corditis developed a synechia or web. All cancers were successfully resected en bloc; 1 of the 20 patients developed a microscopic local failure that was successfully re-resected endoscopically. Eleven of the 20 cancers required excision of part of the supraglottis to establish adequate exposure for the glottic cancer resection. Eight of 15 patients with bilateral keratosis underwent staged resections. Fourteen of 15 patients with bilateral papillomatosis required staged resections. Twelve of the total 115 patients presented with a web secondary to prior microsurgery, and 3 developed a new, clinically insignificant web. The complications of management of disease in or near the AGC described by other authors were not noted in this series. This success was primarily the result of improved exposure in the AGC, which was achieved by use of larger and better-designed laryngoscopes and by resection of supraglottic tissue as necessary. Positioning these prototype laryngoscopes was facilitated by the use of elevated-vector suspension and external counterpressure.