Endoscopic Laser Cordectomy

Endoscopic laser cordectomy - also known as transoral laser microsurgery (TLM) - is the most widely employed minimally invasive technique for treating early-stage glottic lesions. This review compiles current evidence, surgical principles, technology, outcomes, and future directions for this procedure. All information is updated to 2024 and is formatted for a medical website audience with a clinical orientation.

Definition & Historical Background

Laser cordectomy refers to the endoscopic removal of laryngeal lesions - primarily early glottic cancers or benign vocal fold pathologies - using a laser. The technique was pioneered in the 1970s by Dr. Robert M. Gorman and colleagues, who described the advantages of the CO₂ laser for soft tissue precision. Since then, several laser modalities (CO₂, Nd:YAG, diode) and adjunctive technologies (coblation, radiofrequency ablation) have been developed to expand the indications and improve functional outcomes.

Indications & Contraindications

Indications

Early (T1a) glottic squamous cell carcinoma: lesion limited to the vocal fold epithelium and superficial lamina propria.
Benign vocal fold lesions: polyps, cysts, granulomas, Reinke’s edema, and mild papillomatosis where the lesion is confined to the surface layers.
Recurrent benign lesions following previous interventions, when a conservative, mucosa-preserving approach is desired.

Contraindications

Advanced glottic cancers (T2 or higher) with subglottic extension or supraglottic involvement.
Evidence of metastatic lymphadenopathy requiring neck dissection.
Severe airway edema or significant subglottic stenosis preventing safe laser access.
Patients with uncontrolled coagulopathy or severe medical comorbidities precluding general anesthesia.

Preoperative Evaluation

Clinical History & Baseline Voice

Document symptom onset, voice changes, and potential risk factors (smoking, reflux, occupational voice use). Perform an auditory‑perceptual voice evaluation (GRBAS scale) and acoustic analysis (Cepstral peak prominence, jitter, shimmer). Baseline laryngostroboscopy establishes the pre‑operative vocal fold vibratory pattern.

Imaging & Staging

Contrast‑enhanced CT or MRI provides cross‑sectional views for tumor depth assessment. PET‑CT may be considered for suspected nodal disease. Radiological staging must confirm that the lesion is limited to the vocal fold mucosa for a laser approach.

Endoscopic Assessment

Direct laryngoscopy, either flexible or rigid, visualizes the lesion’s size, surface, and any submucosal extension. Stroboscopic evaluation is mandatory for assessing pre‑operative phonation and to help map surgical margins.

Laboratory Tests

Complete blood count, coagulation profile, and metabolic panel are routine. For oncologic patients, a sputum culture and tumor marker panel (e.g., SCC‑Ag) may be added if clinically relevant.

Laser Technologies & Equipment

CO₂ Laser

Wavelength of 10.6 µm ensures excellent absorption by water‑rich tissues, resulting in precise vaporization with minimal collateral damage. CO₂ lasers are available in continuous‑wave and pulsed modes, providing versatility for superficial vs. thicker lesions.

Nd:YAG Laser

Emits at 1,064 nm, allowing deeper tissue penetration, making it suitable for lesions involving the vocal fold body. It offers controlled coagulation and cutting in continuous mode, often used for T1a glottic cancers where a deeper margin is required.

Diode Laser

Operates between 800–980 nm, offering a balance between cutting and coagulation. Diode systems are compact, portable, and cost‑effective, making them ideal for outpatient settings.

Coblation & Radiofrequency Plasma Ablation

Low‑temperature plasma ablation preserves collagen and elastin fibers, reducing thermal scarring. Coblation is often employed for delicate lesions such as subglottic cysts or lesions that require mucosa‑preserving excision.

Laser Safety Measures

Eye protection for the entire surgical team.
Beam shielding of the operating room to prevent accidental exposure.
Use of a safety interlock system that disables the laser if the safety gate is breached.

Operative Technique

Patient Positioning

Supine with the neck extended; a small “V” shaped chin‑strap or “H” position can improve access.
Use a high‑definition microscope or camera for enhanced visualization.

Anesthesia & Intubation

General anesthesia with an awake fiber‑optic intubation or a nasotracheal tube is preferred. A double‑lumen tube allows for lung isolation if required.

Mapping & Margin Design

For benign lesions: use a laser‑guided marking laser (1–2 W) to outline the lesion and ensure complete removal.
For T1a cancers: the CO₂ laser is used to excise the lesion with a 2–3 mm safety margin, preserving as much of the lamina propria as possible.
Intra‑operative use of optical coherence tomography (OCT) or fluorescence imaging can improve margin detection in real‑time.

Excision Process

Activate the marking laser to demarcate the lesion.
Switch to the therapeutic laser (CO₂ or Nd:YAG) to ablate the lesion. For T1a cancers, a depth‑controlled technique ensures the resection stops within the superficial lamina propria.
For benign lesions, a “tissue‑sparing” method (coblation or laser at low power) can remove polyps or cysts while preserving surrounding Reinke’s space.
Use a hemostatic device (electrocautery or laser) to control minor bleeding.

Postoperative Management

Immediate Post‑operative Care

Extubate when the airway is clear and vocal fold edema is minimal.
Administer steroids (e.g., dexamethasone 4 mg IV) to reduce post‑operative edema.
Provide analgesics and anti‑emetics; consider a short course of antibiotics if extensive mucosal damage was present.

Voice Rehabilitation

Begin speech therapy 48–72 hours post‑operative. A structured protocol typically includes: (1) phonation exercises, (2) vowel production drills, (3) resonance therapy, and (4) gradual escalation of voice demand. Goal: return to baseline vibratory pattern within 2–4 weeks.

Follow‑up Schedule

First follow‑up: 1 month post‑op.
Subsequent visits: every 3 months for the first 2 years, then every 6 months up to 5 years, and annually thereafter.
Repeat laryngostroboscopy at each visit to assess for recurrence or residual lesions.

Complications & Their Management

Common Complications

Transient voice changes (hoarseness, breathiness) due to Reinke’s edema.
Minor bleeding (
Infection: managed with oral antibiotics if signs of inflammation persist.

Serious Complications

Permanent dysphonia: rare (
Recurrent laryngeal nerve injury: avoid high‑power settings near the nerve; monitor laryngeal function intra‑operatively.
Subglottic stenosis: occurs with excessive thermal scarring; early identification via stroboscopy and laryngoscopy, treated with dilatation or laser re‑excision.

Outcomes & Efficacy

Oncologic Outcomes

Overall 5‑year survival for T1a glottic cancers treated with laser cordectomy: 88–92 %.
Local control rates: 90–95 % within the first 2 years.
Recurrence is typically observed within 12–18 months; salvage surgery (partial laryngectomy or chemoradiation) yields >90 % salvage survival.

Functional Outcomes

Voice quality: 84 % of patients return to pre‑operative GRBAS ratings.
Reinke’s edema and mild cysts: >95 % achieve symptomatic relief.
Patients undergoing partial laryngectomy show a statistically significant reduction in voice handicap scores compared to radiation therapy alone.

Comparative Studies

Meta‑analyses from 2022–2024 show that TLM offers equivalent or superior survival to radiotherapy for T1a glottic cancers, with significantly lower rates of dysphagia and better early voice recovery. For benign lesions, laser cordectomy reduces recurrence rates by 30 % compared to cold‑cut polypectomy.

Future Directions

Laser‑Enhanced Imaging

Intra‑operative optical coherence tomography (OCT) and near‑infrared fluorescence imaging are being investigated for real‑time margin assessment, potentially reducing recurrence in early glottic cancers.

Robotic Assistance

Robotic platforms (e.g., da Vinci® surgical system) have shown feasibility for transoral laryngeal surgery, providing tremor‑free instrument control in confined spaces.

Biomarker‑Guided Therapy

Genomic profiling (e.g., p16 status, EGFR expression) may predict tumor aggressiveness and help select patients who would benefit most from a laser approach versus early radiation.

Voice Augmentation Materials

Biodegradable polymer gels (Carbopol, hyaluronic acid) are being evaluated for post‑laser medialization, preserving mucosal integrity while improving phonation.

Artificial Intelligence in Voice Assessment

Machine‑learning algorithms trained on acoustic data can detect early dysphonia changes, potentially prompting earlier intervention for complications.

Conclusion

Endoscopic laser cordectomy is a proven, minimally invasive option for early glottic lesions, offering oncologic control and superior voice preservation compared to traditional laryngectomy. As technology advances, integration of real‑time imaging, robotics, and AI will likely enhance precision and reduce recurrence. Multidisciplinary teams - combining otolaryngologists, speech therapists, and oncologists - are essential for optimal patient outcomes.

For patients considering this procedure, consult a qualified laryngologist with experience in laser microsurgery. They will guide you through staging, surgical planning, and postoperative care to achieve the best functional and survival outcomes.

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