- Email: [email protected]
Supracricoid laryngectomy with CHEP: Functional results and outcome
Supracricoid laryngectomy with CHEP: Functional results and outcome ROBERTO A. LIMA, MD, EMILSON Q. FREITAS, MD, JACOB KLIGERMAN, MD, FERNANDO L. DIAS, MD, MAURO M. BARBOSA, MD, GERALDO M. SA, MD, IZABELLA C. SANTOS, MD, and TERENCE FARIAS, MD, Rio de Janeiro, Brazil
OBJECTIVES: To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy. STUDY DESIGN: A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method. RESULTS: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3. CONCLUSIONS: This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total
From Head and Neck Service, Hospital do Cancer, National Cancer Institute/INCA, Rio de Janeiro. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 26-29, 1999. Reprint requests: Roberto A. Lima, MD, Rua Real Grandeza, 139/606, Rio de Janeiro, RJ, 22281-030 - Brazil; e-mail, [email protected] Copyright © 2001 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/77/113138 doi:10.1067/mhn.2001.113138 258
laryngectomy, regarding the extent of the lesion. (Otolaryngol Head Neck Surg 2001;124:258-60.)
T
he incidence of laryngeal cancer is relatively high in Brazil, rated 9th among all cancers. Our institution is a national referral center for treatment of head and neck cancer. Moreover, oral cavity cancer and laryngeal cancer are the most common malignant tumors treated in our institution. After 1995 we decided to treat selected cases of glottic squamous cell carcinoma with supracricoid laryngectomy with cricohiodoepiglottopexy (CHEP). This technique provides a surgical alternative to the conventional partial laryngectomies and total laryngectomies and is suitable for moderately advanced laryngeal cancer resecting a large part of the larynx structures including the paraglottic space. The European Otolaryngologist–Head and Neck Surgeons have used this procedure since 1974 with good functional results and oncologic safety.1-3 In order to assess whether supracricoid laryngectomy could successfully provide a cure while preserving the voice in glottic cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with supracricoid laryngectomy with CHEP. METHODS A retrospective analysis of 27 patients with T2/T3 glottic squamous cell carcinoma has been done between 1995 through 1997. The mean age was 57 years old (range, 41 to 79). Twenty-four patients were male, and 3 were female. All patients were heavy smokers, and 17 patients had an alcohol habit. Twenty-one patients had glottic lesions; 6 patients had transglottic lesions. According to the TNM Classification of Malignant Tumours of the Union Internationale Contre le Cancer (UICC-1992) we classified 11 patients as T2N0M0, 16 patients as T3N0M0 (Table 1). All patients had their lesions studied with CT scan and direct laryngoscopy. Two patients had radiotherapy after surgery in cases of close surgical margins or cartilage invasion. The indications of CHEP included 16 cases of unilateral or anterior glottic lesions with fixed cord but with mobile arythenoid, 8 cases of T2 lesions with supraglottic invasion, and 3 cases of T2
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Table 1. Site and stage of squamous cell carcinoma lesions treated with CHEP
Glottic Transglottic
T2N0M0
T3N0M0
11 0
10 6
Table 2. Incidence of neck recurrences in N0 patients who underwent to bilateral neck dissections, unilateral neck dissection, and no neck dissection Neck recurrences
Fig 1. Three-year disease-specific actuarial survival (Kaplan-Meier).
lesions with reduced mobility of the vocal cord. We did not perform this procedure in patients with impaired arythenoid, restrictive pulmonary function, or low performance status. Posterior commissure invasion or subglottic invasion were considered contraindications for this technique. Nineteen patients had bilateral selective lateral neck dissection,4 3 patients had unilateral selective lateral neck dissection, and 5 cases had no neck dissection. The disease-free survival was analyzed under the KaplanMeyer actuarial method. RESULTS
In all patients but 2, this technique was successful. Twenty-five patients had mild aspiration, which resolved spontaneously with the help of our speech therapists. One patient had severe aspiration and repeated pneumonia caused by reduced mobility of the remaining arythenoid and required a completion laryngectomy. One patient had a rupture of the pexy and was treated with total laryngectomy. One patient had redundant mucosa on the side of arytenoid resection and was treated with laser resection. Two patients had a fistula, which was managed successfully by clinical measures. Twenty-five patients were successfully decannulated. The mean time to decannulation was 38 days (range, 8 to 120 days), the patient with redundant mucosa needed the tracheotomy for 120 days, until we decided to use laser resection of the redundant mucosa. The mean time to nasoantral feeding tube removal was 43 days (range, 15 to 120 days). None of the patients of the neck dissection group had metastatic lymph nodes in the neck. Two patients had recurrence. One T2 undissected patient had neck metastasis managed with radical neck dissection plus radiotherapy and died of disease after 3 months (Table 2). Another patient had local recur-
Bilateral neck dissection Unilateral neck dissection None neck dissection
0/19 0/3 1/5
%
— — 20
rence treated with total laryngectomy and is alive without disease. One patient had a second cancer in the oropharynx, which was treated with palliative radiotherapy and died of disease after 6 months. The 3-year disease-free survival was 75% and 79%, respectively for T2 and T3 patients (Fig 1). DISCUSSION
In our institution most of the patients have T3 laryngeal cancer at diagnosis and, in most cases were treated with wide-field laryngectomy5 or near-total laryngectomy.6 In the end of 1995, we began to treat very selected cases of glottic T2/T3 squamous cell carcinoma with supracricoid laryngectomy and CHEP. We observed that cases of T2 glottic cancer that do not reach the arytenoid and cases of T3 glottic cancer with a mobile arytenoid could be treated with supracricoid laryngectomy while maintaining oncologic safety. Treating selected cases of T3 glottic cancer with mobile arythenoid or T2 glottic lesions with supraglottic invasion, with near-total laryngectomy seems to be a too extensive resection. The use of this technique allows the patient to keep a normal airway and swallowing while maintaining a reasonable voice. The oncologic safety of this procedure is well known and had been described in many studies.7 Moreover some studies8 show that permanent tracheotomy seems to have a major influence on quality of life. Other treatment options for moderately advanced T2/T3 squamous cell carcinoma of the glottis are radiotherapy either alone or combined with chemotherapy leaving the surgery for salvage.9-11 This is a high-cost procedure, and we are very disappointed with our own results with this program. These results are mainly
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caused by the low-performance status of our patients and discontinuance of the treatment because of patient noncompliance. Many studies in the literature showed a 40% to 64% of successful laryngeal preservation with chemoradiotherapy,10,11 using total laryngectomy as a salvage procedure. Bron et al12 showed 87% of laryngeal preservation in a group of 69 patients. Davidson et al13 showed a high rate of positive resection margin in salvage surgery for local recurrence after radiotherapy as primary treatment of T3/T4 laryngeal cancer. This parameter was the most significant variable in terms of survival prognosis. In our study, 23 (85%) patients had their larynx saved with supracricoid laryngectomy. Some published works showed the use of supracricoid laryngectomy with CHEP to treat T1b and T2 glottic lesions.7,14 Unlike these studies, 66% of our patients had a more advanced status of the disease. Two of our patients had complications needing a complete laryngectomy, however, 25 (97%) patients kept a normal airway, swallowing, and speech, results similar to others.7 Our mean time of tracheotomy and nasogastric tube was longer than other studies7,12,15 this can be explained by the low performance status of our patients. All of our T3 patients underwent selective lateral neck dissection; however, none of the patients had occult neck metastasis (Table 2). One of our T2 undissected patients had a recurrence in the neck lymph nodes. Unlike our study, other publications16,17 showed a 10% incidence of occult neck metastasis in glottic carcinoma. In these publications the overall metastatic rate for glottic carcinoma was 22.2%, with extra capsular spread in 12 (37.5%) patients. We believe our group of T3 patients was a special group with very limited lesions, without invasion of the epilarynx18 or deep infiltration of the paraglottic space. Moreover, our study had too few patients to make any conclusions about when to perform elective neck dissection in glottic lesions. The 3-year disease-free survival in our series was similar to other studies.7,12,19 CONCLUSIONS
This technique is useful in the treatment of selected cases of T2/T3 glottic cancer regarding the extent of disease. The incidence of complications seldom required a completion laryngectomy. The survival is comparable to
patients submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion. REFERENCES 1. Piquet JJ, Desaulty A, Decroix G. La Crico-hyoido-epiglottopexie. Technique opératoire et résultats fonctionnels. Ann Otolaryngol 1974;91:681-6. 2. Piquet J, Chevalier D. Subtotal laryngectomy with crico-hioidoepiglotto-pexy for the treatment of extended glottic carcinomas. Am J Surg 1991;162:357-61. 3. Laccourreye H, Laccourreye O, Weinstein G, et al. Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99:421-6. 4. Robbins KT, Medina JE, Wolfe GT, et al. Standardizing neck dissection terminology: official report of the academy’s committee for head and neck surgery and oncology. Arch Otolaryngol Head Neck Surg 1991;117:601-5. 5. Kligerman J, Olivatto LO, Lima RA, et al. Elective neck dissection in the treatment of t3/t4 n0 squamous cell carcinoma of the larynx. Am J Surg 1995;170:436-9. 6. Lima RA, Freitas EQ, Kligerman J, et al. Near-total laryngectomy for treatment of advanced laryngeal cancer. Am J Surg 1997;174:490-1. 7. Lefebvre J, Chevalier D. Supracricoid partial laryngectomy. Adv Otolaryngol Head Neck Surg 1998;12:1-15. 8. DeSanto LW, Olsen KD, Perry WC, et al. Quality of life after surgical treatment of cancer of the larynx. Ann Otol Rhinol Laryngol 1995;104:763-9. 9. Sandberg N, Mercke C, Turesson I. Glottic laryngeal carcinoma with fixed vocal cord treated with full-dose radiation, total laryngectomy or combined treatment. Acta Oncologica 1990;29:509-11. 10. Shirinian MH, Weber RS, Lippman SM, et al. Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancer: the M.D.Anderson Cancer Center experience. Head Neck 1994;16:39-44. 11. Wolf GT, Hong WK, Fisher SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. New Engl J Med 1991;324:1685-90. 12. Bron L, Brossard E, Monnier P, et al. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy cricohyoidopexy for glottic and supraglottic carcinoma. Laryngoscope 2000;110:627-34. 13. Davidson J, Keane T, Brown D, et al. Surgical salvage after radiotherapy for advanced laryngopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 1997;123:420-4. 14. Crampette L, Garret R, Gardiner Q, et al. Modified subtotal laryngectomy with cricohyoidoepiglottopexy-long term results in 81 patients. Head Neck 1999;21:95-103. 15. Naudo P, Laccourreye O, Weinstein G, et al. Complications and functional outcome after supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg 1998; 118:124-9. 16. Myers EN, Fagan JJ. Management of the neck in cancer of the larynx. Ann Otol Rhinol Laryngol 1999;108:828-32. 17. Johnson JT, Myers EN, Hao S, et al. Outcome of open surgical therapy for glottic carcinoma. Ann Otol Rhinol Laryngol 1993;102:752-5. 18. Lefebvre J, Buisset E, Coche-Dequeant B, et al. Epilarynx: pharynx or larynx? Head Neck 1995;17:377-81. 19. Lallemant JG, Bonnin P, El-Sioufi I, et al. Cricohyoidoepiglottopexy: long-term results in 55 patients. J Laryngol Otol 1999;113:532-7.
OBJECTIVES: To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy. STUDY DESIGN: A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method. RESULTS: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3. CONCLUSIONS: This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total
From Head and Neck Service, Hospital do Cancer, National Cancer Institute/INCA, Rio de Janeiro. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 26-29, 1999. Reprint requests: Roberto A. Lima, MD, Rua Real Grandeza, 139/606, Rio de Janeiro, RJ, 22281-030 - Brazil; e-mail, [email protected] Copyright © 2001 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/77/113138 doi:10.1067/mhn.2001.113138 258
laryngectomy, regarding the extent of the lesion. (Otolaryngol Head Neck Surg 2001;124:258-60.)
T
he incidence of laryngeal cancer is relatively high in Brazil, rated 9th among all cancers. Our institution is a national referral center for treatment of head and neck cancer. Moreover, oral cavity cancer and laryngeal cancer are the most common malignant tumors treated in our institution. After 1995 we decided to treat selected cases of glottic squamous cell carcinoma with supracricoid laryngectomy with cricohiodoepiglottopexy (CHEP). This technique provides a surgical alternative to the conventional partial laryngectomies and total laryngectomies and is suitable for moderately advanced laryngeal cancer resecting a large part of the larynx structures including the paraglottic space. The European Otolaryngologist–Head and Neck Surgeons have used this procedure since 1974 with good functional results and oncologic safety.1-3 In order to assess whether supracricoid laryngectomy could successfully provide a cure while preserving the voice in glottic cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with supracricoid laryngectomy with CHEP. METHODS A retrospective analysis of 27 patients with T2/T3 glottic squamous cell carcinoma has been done between 1995 through 1997. The mean age was 57 years old (range, 41 to 79). Twenty-four patients were male, and 3 were female. All patients were heavy smokers, and 17 patients had an alcohol habit. Twenty-one patients had glottic lesions; 6 patients had transglottic lesions. According to the TNM Classification of Malignant Tumours of the Union Internationale Contre le Cancer (UICC-1992) we classified 11 patients as T2N0M0, 16 patients as T3N0M0 (Table 1). All patients had their lesions studied with CT scan and direct laryngoscopy. Two patients had radiotherapy after surgery in cases of close surgical margins or cartilage invasion. The indications of CHEP included 16 cases of unilateral or anterior glottic lesions with fixed cord but with mobile arythenoid, 8 cases of T2 lesions with supraglottic invasion, and 3 cases of T2
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259
Table 1. Site and stage of squamous cell carcinoma lesions treated with CHEP
Glottic Transglottic
T2N0M0
T3N0M0
11 0
10 6
Table 2. Incidence of neck recurrences in N0 patients who underwent to bilateral neck dissections, unilateral neck dissection, and no neck dissection Neck recurrences
Fig 1. Three-year disease-specific actuarial survival (Kaplan-Meier).
lesions with reduced mobility of the vocal cord. We did not perform this procedure in patients with impaired arythenoid, restrictive pulmonary function, or low performance status. Posterior commissure invasion or subglottic invasion were considered contraindications for this technique. Nineteen patients had bilateral selective lateral neck dissection,4 3 patients had unilateral selective lateral neck dissection, and 5 cases had no neck dissection. The disease-free survival was analyzed under the KaplanMeyer actuarial method. RESULTS
In all patients but 2, this technique was successful. Twenty-five patients had mild aspiration, which resolved spontaneously with the help of our speech therapists. One patient had severe aspiration and repeated pneumonia caused by reduced mobility of the remaining arythenoid and required a completion laryngectomy. One patient had a rupture of the pexy and was treated with total laryngectomy. One patient had redundant mucosa on the side of arytenoid resection and was treated with laser resection. Two patients had a fistula, which was managed successfully by clinical measures. Twenty-five patients were successfully decannulated. The mean time to decannulation was 38 days (range, 8 to 120 days), the patient with redundant mucosa needed the tracheotomy for 120 days, until we decided to use laser resection of the redundant mucosa. The mean time to nasoantral feeding tube removal was 43 days (range, 15 to 120 days). None of the patients of the neck dissection group had metastatic lymph nodes in the neck. Two patients had recurrence. One T2 undissected patient had neck metastasis managed with radical neck dissection plus radiotherapy and died of disease after 3 months (Table 2). Another patient had local recur-
Bilateral neck dissection Unilateral neck dissection None neck dissection
0/19 0/3 1/5
%
— — 20
rence treated with total laryngectomy and is alive without disease. One patient had a second cancer in the oropharynx, which was treated with palliative radiotherapy and died of disease after 6 months. The 3-year disease-free survival was 75% and 79%, respectively for T2 and T3 patients (Fig 1). DISCUSSION
In our institution most of the patients have T3 laryngeal cancer at diagnosis and, in most cases were treated with wide-field laryngectomy5 or near-total laryngectomy.6 In the end of 1995, we began to treat very selected cases of glottic T2/T3 squamous cell carcinoma with supracricoid laryngectomy and CHEP. We observed that cases of T2 glottic cancer that do not reach the arytenoid and cases of T3 glottic cancer with a mobile arytenoid could be treated with supracricoid laryngectomy while maintaining oncologic safety. Treating selected cases of T3 glottic cancer with mobile arythenoid or T2 glottic lesions with supraglottic invasion, with near-total laryngectomy seems to be a too extensive resection. The use of this technique allows the patient to keep a normal airway and swallowing while maintaining a reasonable voice. The oncologic safety of this procedure is well known and had been described in many studies.7 Moreover some studies8 show that permanent tracheotomy seems to have a major influence on quality of life. Other treatment options for moderately advanced T2/T3 squamous cell carcinoma of the glottis are radiotherapy either alone or combined with chemotherapy leaving the surgery for salvage.9-11 This is a high-cost procedure, and we are very disappointed with our own results with this program. These results are mainly
260
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LIMA et al
caused by the low-performance status of our patients and discontinuance of the treatment because of patient noncompliance. Many studies in the literature showed a 40% to 64% of successful laryngeal preservation with chemoradiotherapy,10,11 using total laryngectomy as a salvage procedure. Bron et al12 showed 87% of laryngeal preservation in a group of 69 patients. Davidson et al13 showed a high rate of positive resection margin in salvage surgery for local recurrence after radiotherapy as primary treatment of T3/T4 laryngeal cancer. This parameter was the most significant variable in terms of survival prognosis. In our study, 23 (85%) patients had their larynx saved with supracricoid laryngectomy. Some published works showed the use of supracricoid laryngectomy with CHEP to treat T1b and T2 glottic lesions.7,14 Unlike these studies, 66% of our patients had a more advanced status of the disease. Two of our patients had complications needing a complete laryngectomy, however, 25 (97%) patients kept a normal airway, swallowing, and speech, results similar to others.7 Our mean time of tracheotomy and nasogastric tube was longer than other studies7,12,15 this can be explained by the low performance status of our patients. All of our T3 patients underwent selective lateral neck dissection; however, none of the patients had occult neck metastasis (Table 2). One of our T2 undissected patients had a recurrence in the neck lymph nodes. Unlike our study, other publications16,17 showed a 10% incidence of occult neck metastasis in glottic carcinoma. In these publications the overall metastatic rate for glottic carcinoma was 22.2%, with extra capsular spread in 12 (37.5%) patients. We believe our group of T3 patients was a special group with very limited lesions, without invasion of the epilarynx18 or deep infiltration of the paraglottic space. Moreover, our study had too few patients to make any conclusions about when to perform elective neck dissection in glottic lesions. The 3-year disease-free survival in our series was similar to other studies.7,12,19 CONCLUSIONS
This technique is useful in the treatment of selected cases of T2/T3 glottic cancer regarding the extent of disease. The incidence of complications seldom required a completion laryngectomy. The survival is comparable to
patients submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion. REFERENCES 1. Piquet JJ, Desaulty A, Decroix G. La Crico-hyoido-epiglottopexie. Technique opératoire et résultats fonctionnels. Ann Otolaryngol 1974;91:681-6. 2. Piquet J, Chevalier D. Subtotal laryngectomy with crico-hioidoepiglotto-pexy for the treatment of extended glottic carcinomas. Am J Surg 1991;162:357-61. 3. Laccourreye H, Laccourreye O, Weinstein G, et al. Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99:421-6. 4. Robbins KT, Medina JE, Wolfe GT, et al. Standardizing neck dissection terminology: official report of the academy’s committee for head and neck surgery and oncology. Arch Otolaryngol Head Neck Surg 1991;117:601-5. 5. Kligerman J, Olivatto LO, Lima RA, et al. Elective neck dissection in the treatment of t3/t4 n0 squamous cell carcinoma of the larynx. Am J Surg 1995;170:436-9. 6. Lima RA, Freitas EQ, Kligerman J, et al. Near-total laryngectomy for treatment of advanced laryngeal cancer. Am J Surg 1997;174:490-1. 7. Lefebvre J, Chevalier D. Supracricoid partial laryngectomy. Adv Otolaryngol Head Neck Surg 1998;12:1-15. 8. DeSanto LW, Olsen KD, Perry WC, et al. Quality of life after surgical treatment of cancer of the larynx. Ann Otol Rhinol Laryngol 1995;104:763-9. 9. Sandberg N, Mercke C, Turesson I. Glottic laryngeal carcinoma with fixed vocal cord treated with full-dose radiation, total laryngectomy or combined treatment. Acta Oncologica 1990;29:509-11. 10. Shirinian MH, Weber RS, Lippman SM, et al. Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancer: the M.D.Anderson Cancer Center experience. Head Neck 1994;16:39-44. 11. Wolf GT, Hong WK, Fisher SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. New Engl J Med 1991;324:1685-90. 12. Bron L, Brossard E, Monnier P, et al. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy cricohyoidopexy for glottic and supraglottic carcinoma. Laryngoscope 2000;110:627-34. 13. Davidson J, Keane T, Brown D, et al. Surgical salvage after radiotherapy for advanced laryngopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 1997;123:420-4. 14. Crampette L, Garret R, Gardiner Q, et al. Modified subtotal laryngectomy with cricohyoidoepiglottopexy-long term results in 81 patients. Head Neck 1999;21:95-103. 15. Naudo P, Laccourreye O, Weinstein G, et al. Complications and functional outcome after supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg 1998; 118:124-9. 16. Myers EN, Fagan JJ. Management of the neck in cancer of the larynx. Ann Otol Rhinol Laryngol 1999;108:828-32. 17. Johnson JT, Myers EN, Hao S, et al. Outcome of open surgical therapy for glottic carcinoma. Ann Otol Rhinol Laryngol 1993;102:752-5. 18. Lefebvre J, Buisset E, Coche-Dequeant B, et al. Epilarynx: pharynx or larynx? Head Neck 1995;17:377-81. 19. Lallemant JG, Bonnin P, El-Sioufi I, et al. Cricohyoidoepiglottopexy: long-term results in 55 patients. J Laryngol Otol 1999;113:532-7.