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Hemilaryngectomy

Hemilaryngectomy is a specific type of partial laryngectomy performed to remove a cancer of the true vocal cords. The vocal cord or cords are removed along with the overlying cartilage of the voice box as shown in the figures included in this post. Decades ago, this procedure was a primary treatment option in some clinics, for medium and large vocal cord cancers that could not be removed endoscopically (through the mouth) with a laser.

Today, when laser excision is not possible due to patient preference, difficult anatomy, or inappropriate tumor characteristics, chemotherapy and radiation therapy are usually the initial treatment choice. The biggest role for hemilaryngectomy now seems to be for carefully selected tumors (in the earlier stages, T1 through large T2) that have persisted or recurred after initial treatment of radiation therapy with or without chemotherapy.

How the Procedure Works

In a hemilaryngectomy, the surgeon removes part of the thyroid cartilage, including the underlying vocal cord or cords. The extent of removal varies to best match each individual tumor size and location. In fact, the term “hemilaryngectomy” is somewhat misleading; “hemi” means “half,” but most hemilaryngectomies remove much less than half of the larynx.

A small “hemilaryngectomy” might only remove part of one side of the thyroid cartilage with the underlying soft tissue but not touch the arytenoid cartilage. On the other hand, a very extensive procedure might remove most of both sides of the thyroid cartilage, both vocal cords, and one arytenoid, leaving the patient with only one arytenoid. Many other procedures would fall on a spectrum between these two extremes.

Types of Hemilaryngectomies

The figures below represent just two “flavors” of hemilaryngectomy for illustrative purposes. Both internal soft tissue and external cartilage cuts are varied according to the exact location and size of the tumor. Today, these procedures are considered almost exclusively for tumors that persist or recur after prior treatment (radiation or radiation + chemotherapy).

“Maximal” Hemilaryngectomy (Radical Bilateral Hemilaryngectomy with arytenoidectomy)

Fronto-lateral Hemilaryngectomy (without Arytenoidectomy)

Anterior-Posterior Supraglottic / Arytenoid Mucosa Vibration Against the Epiglottis

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Hemilaryngectomy

Panoramic view (1 of 4)

Hemilaryngectomy, with standard (unmodified) epiglottic reconstruction. Panoramic view. Right true cord (left of photo) with arytenoid and anterior left true cord have been removed. The right arytenoid mucosa (left of photo) flops anteriorly because the arytenoid cartilage that would lift and stiffen this mucosa is gone on that side. Epiglottis remains in its original position, with petiole (P) opposite asymmetrical arytenoid mounds.
Interior of larynx

Interior of larynx (2 of 4)

Close up view of interior of larynx during quiet breathing. The vocal process of left arytenoid (right of photo) by “V” and the petiole of the epiglottis by “P”. The upper rim of the cricoid is labeled as well.
phonation

Phonation (3 of 4)

During phonation, the vocal process swings medially but there is nothing at the vocal cord level available to vibrate.
arytenoid and aryepiglottic fold mucosa is pressed into service

“Wolfman Jack” voice (4 of 4)

Instead, arytenoid and aryepiglottic fold mucosa is pressed into service. These tissues are seen vibrating (blurred) here in order to produce a rough “Wolfman Jack” voice quality. Compare with photo 1.

Hemilaryngectomy and Modified Epiglottic Laryngoplasty, Before and After

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laryngopharynx

Panoramic view (1 of 6)

Panorama of the laryngopharynx in a patient with post-radiation persistence of glottic cancer at the anterior commissure, prior to salvage hemilaryngectomy. Note here the still-normal anatomy: in the foreground, the epiglottis and its characteristic shape (green dotted lines), and in the background, the partially abducted vocal cords (blue dotted lines) occupying part of the glottal space.
after hemilaryngectomy with modified epiglottic laryngoplasty

Post hemilaryngectomy (2 of 6)

Same patient, after hemilaryngectomy with modified epiglottic laryngoplasty. Compare with image 1. Dotted lines indicate where the margins of the vocal cords once were. Note that, to compensate for the removed vocal cords, the epiglottis has been pulled down and folded (arrows) so that the aryepiglottic cords can more easily vibrate together as a sound source during phonation.
Pre-hemilaryngectomy

Pre-hemilaryngectomy (3 of 6)

Back to the patient’s pre-hemilaryngectomy exam, but with a closer view than image 1. The tips of the vocal processes are indicated by green dots. In the foreground, note (as in image 1) the normal shape of the epiglottis, prior to being surgically pulled down and folded.
Post-hemilaryngectomy

Post-hemilaryngectomy (4 of 6)

Back to the patient’s post-hemilaryngectomy exam, but with a closer view than image 2. The tips of the vocal processes (now exposed by the absent vocal cords) are again indicated by green dots. Compare with image 3 to see the anatomical changes created by the hemilaryngectomy and epiglottic laryngoplasty. The petiole of the epiglottis has been sutured to the cricoid cartilage, at the dotted line.
epiglottic laryngoplasty

Phonation (5 of 6)

Still post-hemilaryngectomy, during phonation. The vocal cords have been removed and can no longer be the sound source, but the modified epiglottic laryngoplasty has enabled the aryepiglottic cords and apical arytenoid mucosa (blurred due to vibration here) to serve as a substitute sound source.
phonation with the aryepiglottic cords

Closer view (6 of 6)

Closer view of phonation with the aryepiglottic cords and apical arytenoid mucosa.

Another Voice Without Vocal Cords

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Hemilaryngectomy

Hemilaryngectomy (1 of 4)

After removal of the anterior larynx (hemilaryngectomy) for cancer that recurred after radiation therapy. Though not well seen here, the vocal cords are surgically absent. The black dot seen is for orientation to the next photo. A = arytenoid; E = epiglottis.
Within the larynx

Within the larynx (2 of 4)

A view within the larynx. Note again that vocal cords are surgically absent, with only the arytenoid cartilages remaining at the level of the cords. The black dot, on the left arytenoid cartilage, orients to the prior photo. The dot is on the right vocal process.
arytenoid mounds

“Wolfman Jack” voice (3 of 4)

The patient is about to produce his rough, “Wolfman Jack” voice but the arytenoid mounds have not yet started to vibrate.
Arytenoid vibration

Arytenoid vibration (4 of 4)

Aggressive voice use brings arytenoid mounds into vibration (notice blurring). With time and practice, this kind of supraglottic voice can serve moderately well, but it is always difficult to be heard in competition with background noise.

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