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BackTable / ENT / Article
Early Glottic Cancer Treatment with Transoral Laser Microsurgery
Iman Iqbal • Updated Apr 22, 2025 • 37 hits
Early glottic cancer, classified as stage 1 or 2 (T1-T2), is a form of laryngeal cancer that is characterized by limited lymphatic drainage, allowing for single-modality treatment via surgery or radiotherapy. Treatment choice depends on the tumor's location, size, and patient factors. While surgery, especially transoral laser microsurgery (TLM), is preferred for accessible tumors, radiation therapy, including Intensity-Modulated Radiation Therapy (IMRT), is increasingly used for tumors in challenging locations.
This article explores modern strategies for managing early glottic cancer, beginning with treatment selection and moving through surgical techniques, intraoperative decision-making, and post-operative care. It highlights transoral laser microsurgery (TLM) as a key approach, with insights into biopsy methods, tissue-sparing technologies like confocal laser endomicroscopy (CLE), and emerging tools such as infrared imaging.
This article features excerpts from the BackTable ENT Podcast. You can listen to the full episode below.
The BackTable ENT Brief
• Transoral laser microsurgery (TLM) is favored for tumors that are accessible and manageable, while Intensity-Modulated Radiation Therapy (IMRT) is increasingly utilized for tumors located in challenging or less accessible areas.
• TLM involves using lasers (CO2 or KTP) with a focus on minimizing vocal fold trauma while ensuring effective tumor removal. The CO2 laser is effective for direct tumor removal, while KTP lasers provide ablative treatment, often requiring piecemeal resection to ensure complete removal while preserving vocal fold function.
• During TLM, small biopsies can be taken from areas that appear clinically normal but show potential abnormalities through confocal laser endomicroscopy (CLE) to ensure accurate diagnosis and staging before treatment, minimizing thermal damage to surrounding tissues.
• While robotic surgery enhances visualization and precision, especially for supraglottic tumors, it doesn’t offer significant advantages over traditional methods for early glottic cancer. However, robotic systems can integrate with imaging technologies like CLE for more accurate tumor resection.
• New tools, such as infrared wavelength cameras, are being explored for detecting residual tumor tissue during surgery. These technologies help identify deep-seated residual cancer, ensuring complete tumor removal without interrupting the procedure, though they are still in clinical trials.
• Patients generally experience mild discomfort post-surgery, but voice rest and careful monitoring for swallowing difficulties are key, especially after extensive resections.
• Long-term survival rates for early glottic cancer are excellent, with regular surveillance using flexible laryngoscopes and stroboscopy to detect subtle changes, often requiring occasional laser ablation for residual abnormalities.
Table of Contents
(1) Transoral Laser Microsurgery vs Radiation Therapy for Early Glottic Cancer
(2) Transoral Laser Microsurgery Modalities: KTP vs CO2
(3) Technical Considerations in Transoral Laser Microsurgery
(4) Advanced Surgical Tools for Glottic Cancer Resection: Robotics & Infrared Technology
(5) Post-Op Care & Follow-Up
Transoral Laser Microsurgery vs Radiation Therapy for Early Glottic Cancer
Treatment for early glottic cancer primarily involves surgery or radiation therapy, depending on tumor characteristics and patient factors. Both approaches are highly effective in curing early glottic cancer, but the focus of decision-making is on maintaining laryngeal function. Radiation therapy has advanced significantly, with modern techniques reducing side effects like swallowing difficulties and mucositis. However, results can still vary between patients. In contrast, surgical treatment may sometimes lead to functional deficits, but these can be managed through procedures like injection laryngoplasty to restore glottic function. Ultimately, the goal is to balance oncological effectiveness with the patient's quality of life, making the decision between surgery and radiation therapy highly individualized.
[Dr. Gopi Shah]
Are you even talking about other treatment modalities at that point? We think about the early T1 cancers being also treatable with primary XRT, but we don't know it's cancer yet. How do you talk to patients about that?
[Dr. Bharat Panuganti]
If we don't have a cancer diagnosis, and if there's any doubt in my mind about whether or not moving forward with surgical treatment is the best option for the patient, then the conversation is always, let's first get a diagnosis. Let me take a look around, get a sense for the depth of the mass. If my impression in the operating room is that it's at least worth a conversation about whether or not primary radiotherapy is a better alternative, then that's what I'll do.
I'll stop the surgery, wake the patient up, and have them come to the clinic to have that discussion. A lot of the time, someone comes in with a diagnosis, which is nice because in that situation, we can have that entire conversation upfront. I historically have had very, very good relationships with the radiation oncologists. At UAB, what I would do is if a patient came in and there is a conversation to be had about whether or not radiation versus surgery is the better option for them, then I actually just call the radiation oncologist and they come to the clinic and we all have a conversation together.
It's really nice to compartmentalize everything, make it really nice and simple for us to be able to have a multidisciplinary conference in a clinic encounter to chat about risks, benefits, pros, cons of either approach.
[Dr. Gopi Shah]
How do you start organizing it in your mind of, "This is going to be a great surgical candidate," or "Hey, XRT is going to be better?" It sounds like you already have that in your mind.
[Dr. Bharat Panuganti]
Totally. That's a really good question. I think some of it is idiosyncratic. My perspective is probably a little bit different than another laryngologist, but I guess speaking from my own experience, the way that I think about it is I try to boil it down and make it really simple. One big thing, can I see the tumor? If someone has had multiple neck fusions and there's no opportunity for me to stick a scope in and say reliably that I have been able to expose the entirety of the larynx, then I couldn't possibly convey to the patient with any degree of confidence that I've cleared microscopic disease.
That's a really easy situation for me upfront. If someone's just not a good surgical candidate based on head and neck anatomy, that conversation about radiation treatment is had upfront. Beyond that, really the simple question is, do you think you can clear disease? It sounds like a stupid thing to say, but to really simplify it that way, I think makes the decision-making process a little bit easier.
The considerations there, is this a really sessile tumor? Not a big tumor, but a sessile tumor, a carpet of tumor that extends between or among different parts of the larynx. A stage 2 cancer can simply mean that the vocal fold can be mobile, but if there's cancer on the epiglottis, the vestibular fold, the glottis, and the subglottis, that's a really hard thing to clear surgically. It's just a larger footprint and the bigger it is, the harder it is to make certain that you've cleared margins.
Those are typically situations where I will have a conversation upfront about radiation therapy. If a tumor is really big and there's clearly impaired vocal fold mobility, again, that's another situation which I will have a conversation about radiotherapy. Now none of these are absolutes. There are situations where big tumor, vocal fold doesn't move that much, but it's just because the tumor is big and by the time you remove it, vocal fold is moving better.
A lot of the conversation is had before the surgery, but in situations where there's any doubt for me, I will tell the patient that in my belief that if we go to the operating room, I start to resect the tumor, and if I believe that to finish the resection would result in a prohibitive functional defect that would potentially be avoided with radiation therapy, then I'll stop and wake them up before any damage has been done, so to speak, because by the time you start carving into the vocal fold, whether or not you have radiation, that vocal fold's gone.
It's important to make that determination upfront, but that is a conversation I will very explicitly have with the patient is, "You have to trust me, and if I believe that it's not appropriate, then I'll stop."
[Dr. Gopi Shah]
Are there any other treatment modalities that are talked about? Is there a role for chemotherapy or immunotherapies or anything else happening from a treatment standpoint?
[Dr. Bharat Panuganti]
For early glottic cancer, no. Typically it's surgery versus radiation. Surgery has undergone evolution over the course of time. Now it's primarily transoral laser microsurgery, but ultimately, however you drop the laser in, whether it's with a robot or a microscope and an endoscope, it's primarily laser surgery.
[Dr. Gopi Shah]
Is the radiation therapy pretty much the same as it's been, or is it more focused or, as far as-- As ENTs, I think we all have that cringe with radiation because we've seen patients that have had really bad swallowing outcomes or problems with complications. Is that better?
[Dr. Bharat Panuganti]
It is. I think radiation therapy has undergone really significant evolution over the course of-- I can't give you a timeline, but certainly, in contemporary times, people have studied single vocal fold irradiation with IMRT. You can really restrict the radiation dose to the target organ, and as much as radiation oncologists have been able to historically, restrict the dose to the constrictor muscles and pharynx and carotids and all the things that we worry about in terms of postoperative radiation sequelae, they're not gone, but I think certainly compared to what it has been historically, have been mitigated to a significant degree.
That being said, I think with radiation, it's not as simple as the physics. Different patients will have different outcomes. It's a hard thing to predict. Some people don't respond well to radiation. Some people go through radiation and it's as if nothing ever happened. If it was an easier thing to predict, I think this conversation around what is a more appropriate treatment per patient would be a lot simpler. I think in general, the functional deficits associated with surgery are a little bit more predictable because you are directly responsible for the defect that you create.
In terms of functional rehabilitation, there are options for surgery. If primarily the problem that you have is a soft tissue deficit, there are things that we can do to overcome that, that injection laryngoplasty being my favorite option to restore some of that lost soft tissue bulk in a way that can restore glottic competency. Once you do that, especially if you have a good contralateral side, there's an opportunity for a really, really nice postoperative functional outcome.
[Dr. Gopi Shah]
That's really where the decision-making-- that's what it's about. The cure rate for an early T1, these patients are going to be cured of their cancer. It's just, what's their laryngeal function going to be afterwards.
[Dr. Bharat Panuganti]
Conversations about this, where there's true survival equipoise between two treatment modalities, it's fascinating because there's a lot of considerations. It's not just about the surgeon. It's not just about the radiation oncologist, it's about the patient. With surgery, for example, I always tell patients that they may need laser treatments in the clinic. The way that I treat cancers is with the KTP laser. It's ultra-narrow margin surgery.
I'm not chunking out a large portion of the vocal fold because these aren't cancers generally speaking that are going to kill patients. We have license as surgeons to be a little bit more conservative. This has been proven a number of times in the data. This isn't just a theoretical talk where ultra-narrow margin and narrow margin surgery is appropriate for early vocal fold cancers because the implications of recurrence are not the same as if it was in the tongue, for example, or the oropharynx where you're worried about local or regional and distant metastasis.
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Transoral Laser Microsurgery Modalities: KTP vs CO2
Transoral Laser Microsurgery involves either cutting or ablating the tumor using lasers, with CO2 and KTP lasers being the most common options. The CO2 laser is a cutting laser that targets water chromophores, making it effective for tumor removal. In contrast, the KTP laser is an ablative laser, vaporizing the tumor and treating the base without removing it for pathological examination. The margin of resection is often less clearly defined with the KTP laser, making it difficult to quantify. Despite this challenge, the focus remains on preserving vocal fold function while treating the cancer effectively. This sometimes involves piecemeal resection, especially when visibility is limited, but large margins are avoided to reduce functional deficits.
In some cases, a CLE is used during or after ablation to map the tumor and assess peripheral mucosal margin status, improving accuracy. Though CLE technology does not yet have a real-time tissue-marking feature, advancements are being made in digital projection techniques that could allow for more precise mapping without leaving physical marks on the tissue.
[Dr. Gopi Shah]
When you say narrow or ultra-narrow margins, how many millimeters or micromillimeters are we talking about?
[Dr. Bharat Panuganti]
That's a good question. There are basically two methods to treat early vocal fold cancers. One is to cut the cancer out and one is to ablate it. If you look at the laryngeal surgeons and the TLM surgeons, transoral laser microsurgery surgeons that do early vocal fold cancers, generally speaking, they'll use one of two different kinds of lasers, the CO2 laser or the KTP laser. The CO2 laser is a non-selective laser. A cutting laser. Basically what it does is its chromophores water.
You use it to cut tumors out. With the ablative laser, the KTP laser, I'm not actually cutting a tumor out and sending a specimen to a pathologist. What I'm doing is ablating the tumor, vaporizing it, and then treating the bed with the laser itself. The margin is not exactly quantified in that situation. A lot of it is based on what the tissue looks like at its base. It's hard for me to say exactly what an adequate margin is. I don't think that there's an answer for that because it's a really hard thing to characterize.
By the time you take the cancer out, the tissue artifact and in a lot of circumstances, even with the CO2 laser, you do what are called piecemeal resection. You're cutting portions of the tumor out so that you can see the vocal fold a little bit better before you perform the rest of the resection. By the time the specimen comes out, there isn't the kind of specimen orientation with those discrete quantifiable margins that you'll see in other parts of the head and neck. That's what makes this challenging.
If you look at some of the data, early vocal fold cancer resections with TLM have a 20% positive margin rate. That is asinine. I think that if you were to propose that or present that data to any other cancer surgeon, they'd say, "That's absolutely ridiculous." It's a function of what I think we're forced to do when we do transoral laser microsurgery is, one, with the piecemeal resections, I think it's hard to truly characterize positive margin rate, but two, if you truly want to clear presumptive margins, you're knocking out a big portion of the vocal fold and that can have bad outcomes. You don't have to do that for a patient to survive. That's where it gets a little complicated.
[Dr. Gopi Shah]
There's a lot of reliance on what the tissue looks like and being able to recognize if something looks suspicious or not.
[Dr. Bharat Panuganti]
Absolutely.
[Dr. Gopi Shah]
With the confocal laser, are you going back with that after you've done your ablation to look again?
[Dr. Bharat Panuganti]
Yes. Sometimes I'll do that. Sometimes I'll just use it up front and just map the tumor out and then resect the tumor accordingly. Sometimes I'll have doubts and I'll put the probe on at the end and I'll assess the peripheral mucosal margin status. That is a really, really nice tool that overcomes some of the limitations of small-volume histopathology.
[Dr. Gopi Shah]
Does that probe have a way to mark the tissue as you're using it?
[Dr. Bharat Panuganti]
That's a really good question. It's something that I'm actively working on. There isn't. A lot of it is based on extrapolation. I have everything recorded so I'll go back in the recording and see precisely where the probe is relative to where I'm meant to take biopsies or carve out the tumor from. It would be nice if there was something projected in real-time.
[Dr. Gopi Shah]
Yes. If you could have a little tattoo where you were stenciling out your area.
[Dr. Bharat Panuganti]
That's right.
[Dr. Gopi Shah]
That's cool. More to come then on that.
[Dr. Bharat Panuganti]
More to come. We're looking at a digital projection. Something that in real-time we can-- instead of a tattoo that's physically on the tissue, something that is digitally projected so that there's no artifact on the organ itself, but you have the ability to extrapolate what you've seen with the CLE, with what you're seeing through a microscope.
Technical Considerations in Transoral Laser Microsurgery
When preparing for TLM, key considerations include exposure, scope choice, and instruments. A universal modular glottoscope system is used to achieve true suspension by pulling the scope up against the jaw, offering better anterior excursion than traditional methods that rely on the maxilla. On the back table, essential tools include micro instruments for biopsies and the KTP laser, which is favored for ablative procedures. Though KTP laser production has ceased, alternative blue light lasers are becoming available.
Dr. Panuganti emphasizes the importance of biopsy collection during TLM to confirm whether the tissue is cancerous or dysplastic, ensuring accurate diagnosis before proceeding with treatment. In cases where the tissue appears clinically normal but shows potential signs of abnormality on the CLE, additional biopsies are taken to further assess the risk. These small biopsies, typically around five or six in number, are sent for permanent pathology as frozen sections may not provide enough reliable tissue for analysis. To facilitate this process and enhance the biopsy's accuracy, a sub-epithelial saline infusion is performed. This procedure helps lift the mass and preserve the superficial lamina propria, reducing thermal damage during laser ablation.
[Dr. Gopi Shah]
You talked about exposure, you talked about your scope of preference. Just talk to us about your setup and what's on your back table. What are the key things when you're doing this?
[Dr. Bharat Panuganti]
I think it's worth talking about the scope a little bit. If you think about the way that I'd say most ENTs in the country expose the larynx, they use a fulcrum secure like a Dedo, for example, stick the Dedo in, you put something in at the end or you have something grab the C portion of the handle and then you crank it against a table. That's tried and true. What it does is it's cantilevering against the maxilla.
You're not really maximizing exposure because the maxilla is fixed to the head. It's fixed to the cranio-maxillofacial skeleton. What I use with the universal modular glottoscope system, it pulls up against the jaw. It's true suspension, so to speak. It, instead of cranking against the maxilla, pulls up against the jaw. You're getting true anterior excursion of the scope against the larynx. What else is on the table? Micro instruments for the biopsies. KTP laser is not being serviced anymore, but it is what most laryngeal surgeons that do ablative work will use. That's the major surgical tool of mine.
[Dr. Gopi Shah]
When you say it's not being serviced anymore, what do you--
[Dr. Bharat Panuganti]
Boston Scientific bought it and shuttered it.
[Dr. Gopi Shah]
Oh, I didn't know that.
[Dr. Bharat Panuganti]
There's no new KTP being manufactured and Boston Scientific doesn't service the machines. You'll have to go to a third party. It doesn't mean that if a KTP machine has problems that you can't use it, but it becomes a lot more difficult. Once all the existing KTP machines die out, they will be no longer.
[Dr. Gopi Shah]
I didn't know that.
[Dr. Bharat Panuganti]
Yes. There are a couple others on the market that furnish blue light lasers. A diode blue light laser. That is the next generation of ablative laser use. For the time being, I'm a green-light believer. That's what I use. Then we'll have a series of micro-instruments, cups, right-left scissors, right-left, tiny one-millimeter, two-millimeter instruments so that I can take small-volume biopsies.
[Dr. Gopi Shah]
You do always send at least a small biopsy so that you can have a sense of whether this is dysplasia or cancer before you start ablating.
[Dr. Bharat Panuganti]
I will take numerous biopsies actually. What I mentioned with the tumor mapping with the confocal laser and microscopy is in any area where there's potential concern, if it's clinically normal, but evidence of potential aberrancy on CLE, I will take a biopsy there and send it off. Again, that's difficult because with the size of the biopsies that I'm taking, especially in a clinically normal area, I don't like to rely on frozen sections, so I send them for permanent pathology. On average, I'll take about five or six biopsies upfront.
…
Oh, tissue loss to processing is something I see in pathology reports all the time. It dissolved in the saline before it got to the lab. We do that. One of the things that I really like to do is a sub-epithelial saline infusion. I'll have this injection cannula and I use injectable saline, so preservative-free saline, and I put the needle in the sub-epithelial layer. This is something that a lot of people do, but certainly something that my fellowship mentor Steven Zeitels was very specific about conveying the importance of.
Put it directly into the sub-epithelial layer into the superficial lamina propria. What you're looking for in the course of injecting before you do any of the surgery is do you see the mass lift up? If it lifts up, what it implies is that there's some of the superficial lamina propria intact and that the mass isn't all the way through the superficial lamina propria into the underlying ligament. I do that also to create a heat sink. In the course of doing the laser ablation, the superficial lamina propria, that's sacred ground.
Anything that you can do to preserve it within the confines of what's oncologically appropriate, mitigating thermal collateral injury by infusing the saline can be potentially helpful. That's pretty much it on the back table micro-instruments. The KTP laser fiber that I use depends on the size of the mass. If it's really a sessile disease just on the surface, I'll use a small one, so 400 micrometers. If it's a bigger one, then I'll use 600 micrometers and it makes a big difference.
It doesn't sound like a lot, but it makes a big difference during the surgery. Laser is conveyed in one of two modes, either pulsed or continuous wave. Pulsed wave and there are different ways to titrate the settings, but I'm not going to get into the nuances, but basically, it shoots a little blast of the laser. Continuous wave is exactly that quasi-continuous where there isn't the break in between pulses. I'll use continuous wave in situations where there's a big exophytic tumor that I'm trying to debulk.
[Dr. Gopi Shah]
The KTP is on a handpiece or mounted to your scope?
[Dr. Bharat Panuganti]
KTP is on a handpiece. The CO2, you can do obviously connected to the scope and control with a micromanipulator.
[Dr. Gopi Shah]
Are you ever using the CO2?
[Dr. Bharat Panuganti]
In my practice, I don't.
[Dr. Gopi Shah]
When the KTP can't get serviced.
[Dr. Bharat Panuganti]
Yes, exactly.
Advanced Surgical Tools for Glottic Cancer Resection: Robotics & Infrared Technology
Dr. Panuganti notes that robotic surgery offers limited advantages in the treatment of early glottic cancers. However, he emphasizes that these systems are more beneficial for supraglottic tumors, where improved visualization can aid in precise resection. Traditional methods of exposing the larynx with a tubular endoscope can restrict the view of larger tumors, requiring frequent scope repositioning that risks trauma to both mucosa and tumor. The robot, with its ability to provide a global view and manipulate the semi-flexible endoscope, reduces the need for scope movement and minimizes the risk of trauma. Additionally, robotic systems can integrate with the CLE, allowing real-time tumor imaging and aiding in more precise resection without the need to reposition the scope.
New technologies, such as infrared wavelength cameras, are also being explored. These cameras can help detect residual tumor tissue during surgery. While currently in a clinical trial, this tool may become an essential part of ensuring complete tumor removal by identifying deep-seated residual disease without interrupting the procedure.
[Dr. Gopi Shah]
Bharat, when we were talking about doing this episode before, you mentioned robots as well, robotic surgery. Tell us a little bit about what that gives you or when you would consider using that as a tool.
[Dr. Bharat Panuganti]
I think for early glottic cancers, at least in my view, there's not really value for the robot. I think about the robot primarily for supraglottic tumors. What the robot gives you is a global view. If you think about the way that you expose a larynx with a tubular endoscope, no matter what it is, you are restricted to the confines of the tubular endoscope. You are excluding everything outside of it. For a small tumor, fine, it doesn't matter.
For a bigger tumor, if you can't see the entire tumor within the confines of the tubular endoscope, then you're having to maneuver the scope repeatedly in order to maximize your view or to see the entire footprint of the tumor. I think any situation in which you're having to do that risks traumatizing mucosa, risks traumatizing tumor, makes it really hard to differentiate between the two, makes it more likely that you miss stuff.
I had one of the robotic reps actually, before I started using the robot, come to my operating room and she counted the number of times I either moved my microscope or moved my laryngoscope in the course of the three-hour case. It was 100. That to me, was wild. I do it subconsciously, but it's really representative of how hard it is sometimes to see the inside of the larynx globally. I think the incremental value of the robotic exposure is to be able to manipulate the semi-flexible endoscope in a way that doesn't require repositioning of the scope itself.
The other possible advantage is based on what we were mentioning before, which is confocal laser and a microscopy. With the Cellvizio system, you can directly implement the imaging from the CLE, the confocal laser microscopy into the surgeon console view. I can drop the probe through the mouth, scan, put the probe down, pick up the laser adjacent to it, and start going. You can't do that with an endoscope because the way that I look with the probe is with a flexible bronchoscope so I can get all the angles.
I can't control it with a rigid scope. I have to put the bronchoscope in, take the microscope out, look, put the microscope back in, and hope that I'm ablating the right area. With the robot, because everything is integrated, it becomes a lot easier for you to integrate the information that you're getting with CLE in the course of doing the resection. Those are two of the major advantages. I think in terms of early laryngeal cancers, the benefit really at this point is restricted to supraglottic cancers, mostly because you get a better view. Hopefully in due time with the miniaturization of some of the instruments and the scopes, it'll be easier for us to use robotic instrumentation for vocal fold work.
[Dr. Gopi Shah]
You talked about with KTP, you're ablating, vaporizing the tumor. PPE for you, do you wear an N95 mask because of that?
[Dr. Bharat Panuganti]
Yes, it's a good question. I do for papilloma, so HPV disease, but for anything else, I just wear a regular mask.
[Dr. Gopi Shah]
Is there a suction cup to your scope that's evacuating those tumor vapors, I guess?
[Dr. Bharat Panuganti]
Yes, there's a suction connected to the scope and I'll have a suction adjacent to my laser too. Double power.
[Dr. Gopi Shah]
You had mentioned before about the infrared wavelength technology to help you measure depth. Do you use that at the end of the case to check, "Did I get deep enough?" When does that technology come into play or is that something that's new and upcoming?
[Dr. Bharat Panuganti]
That is only being done right now within the confines of a phase I clinical trial that we have ongoing. That is done basically throughout the case. I've only actually done it four times now. The purpose of it is not necessarily to measure the depth, but to understand if there's tumor left on the deep surface. That's being deployed. All that is is a special camera that can excite in the near-infrared wavelength. You can put that in basically whenever during the course of the resection to see if there's disease left.
It's a nice tool because it doesn't require that I change anything. You can actually ablate with the rigid endoscope to boot. It's a really nice handy tool. There are some problems with visualization at the level of the vocal folds that are probably beyond the scope of this conversation, but something that we're hoping to release to the wild soo
Post-Op Care & Follow-Up
After completing the resection of an early glottic tumor, patients typically experience minimal laryngeal pain. The main discomfort is usually in the floor of the mouth, especially on the right side where the scope was placed. This may include micro tears at the glossotonsillar junction and temporary neuropraxia, leading to taste changes. Most patients do not need a tracheostomy, and post-op pain is generally controlled with standard pain management.
In terms of voice rest and diet, recommendations depend on the extent of the resection. For superficial resections, patients can usually return to normal activities. However, for more extensive surgeries, particularly those involving vocal fold nodules, voice rest is strictly advised. Patients are also monitored closely for potential swallowing difficulties, with post-op evaluations to ensure glottic competence.
Long-term survival rates for early glottic cancer are excellent, with T1 tumors showing 90-95% survival. Follow-up care includes regular surveillance, typically every two months in the first year, gradually reducing in frequency over time. Flexible laryngoscopes, often paired with stroboscopy, are used for monitoring any subtle changes in vibration or tissue perturbation, while minor in-office procedures like laser ablation are occasionally required to manage any residual keratosis or dysplasia. In cases of positive surgical margins, further resection or radiation may be necessary.
[Dr. Gopi Shah]
As you're concluding the case, you've ablated the tumor, you're inspecting visually and you feel like, "Okay, this looks like ultra-narrow margins have been achieved, we're done," and as far as post-op considerations, what do you talk to your patients about what to expect? I assume they're not needing a tracheostomy because again, we're talking about early T1 small tumors.
[Dr. Bharat Panuganti]
Yes, you're right. Trachs, basically never. Really the biggest considerations post-op, the larynx usually doesn't hurt. What hurts is floor of the mouth on the right side. I always go on the right side. Scope is situated between the mandible and the side of the tongue. Not uncommon to have micro tears at the glossitantular junction. Some people will have numbness, just a neuropraxia from the scope being situated next to where the lingual nerve goes to the tongue.
Some people have a taste change for a couple of months. It's almost universally temporary, but the biggest problem that people complain about is throat pain just from the exposure, but that's the cost, unfortunately, of getting a better view.
[Dr. Gopi Shah]
Do they need to be on voice rest or have a special diet or are they just back to normal?
[Dr. Bharat Panuganti]
Diet is based on the extent of the resection. If there's any concern about having resected muscle enough where there's glottic incompetency, I will always keep those patients for a post-op day one inpatient swallow evaluation before sending them home. If it is truly a superficial resection, they go home the same day. Swallow protocol depends on extent. In terms of voice rest, I've evolved a little bit over the course of time. I used to be very adamant about keeping people on voice rest.
This isn't based in data, frankly, but what I realized is that in situations where-- If it's a de-epithelialization of the entire vocal fold, I haven't anecdotally noticed a big difference between someone being on voice rest for a few days, not being on voice rest at all. I think generally speaking, if someone's hoarse, they don't like to talk. It doesn't really make a big deal in my mind. Again, that's not a universality, but I'm generally a little bit less of a stickler when it comes to voice rest after a vocal fold tumor resection.
On the flip side, if someone has a nodule surgery or a phonomicrosurgical surgery, and I'm worried about a flap sitting, to maximize voice outcome, I am absolutely sure that they need voice rest 100% of the time.
[Dr. Gopi Shah]
Then in terms of overall survival, how do you counsel patients? How do you survey them? What is the follow-up after that?
[Dr. Bharat Panuganti]
Survival, excellent. Large population data, T2s, 80%, 85%, 90%, depending upon the study. T1s, a lot higher, 90% to 95%. I generally tell people that obviously, this is curable. I think a big part of making sure that early glottic cancer, even if it reccurs, stays early glottic cancer is surveillance. It's a big part and that's universal of course across the head and neck. I just follow the standard NCCN guidelines. The first year every two months, second year every two to four, third year every four to six, then six to eight, then every month or every year after five years.
[Dr. Gopi Shah]
Are you just doing flex scopes or do you strobe or what's your routine?
[Dr. Bharat Panuganti]
That's really just a function-- I think if there is a subtle lesion, if you notice a perturbation and vibration, it's something that can give you a hint that something exists. The other thing that I'll do is in situations where some people are just prone to redeveloping keratosis and we don't know if it's cancer or dysplasia or anything truly concerning because we're not taking biopsies, but that's the value of seeing them in clinic with a flexible scope is if we see something, history of early glottic cancer, just throw a laser in and ablate it presumptively.
It's a five-minute procedure, get them numb, no general anesthesia, and they go home about 10 minutes later. It's a really nice way for us to be able to manage disease, again, in a way that doesn't require that we whack a big part of the vocal fold and maintain treatment in a way that doesn't require that they go to the operating room.
[Dr. Gopi Shah]
Are there any features on pathology after the surgery that are red flags or that change your management at all?
[Dr. Bharat Panuganti]
I don't know if there are any features on pathology itself that would change my management. I think that if a cancer is poorly differentiated, generally speaking, in my mind, that's a bad sign and suggests perhaps that a conservation endoscopic approach may not be in their best interest. For the most part, pathology is usually confirmatory and simply corroborates what I basically know in the operating room anyhow.
[Dr. Gopi Shah]
With 20% positive margins, do you expect that as you're surveilling these patients, they're going to need that office ablation more commonly compared to other types of cancers in the head and neck?
[Dr. Bharat Panuganti]
If I get a positive margin, we're going back to the operating room 100% of the time. If I get a positive margin again, radiation. That's just my protocol because if I can't clear disease surgically after two bouts, that's an explicit sign that surgical management is not appropriate, in my mind, at least. If someone has a positive margin and we clear it the second time, I don't think that really affects whether or not they will need more in-office management. I think it's more than likely just a simple function of underappreciating disease that existed initially.
[Dr. Gopi Shah]
When you're counseling patients pre-op and talking to them about, "Okay, you're going to need to see me regularly. We're going to have to take a look and you may need to get this other procedure," how often would they potentially need to have the office ablation or does it just depend? Is there an average or not really?
[Dr. Bharat Panuganti]
I don't know that I have that information for you. I think most people don't. Some people do.
[Dr. Gopi Shah]
It's not a common thing?
[Dr. Bharat Panuganti]
It's relatively common, but I think that the majority of people that undergo a TLM approach don't usually need something regularly in the office.
[Dr. Gopi Shah]
Got it. It's not something that they need to expect to have to be done, but it's a possibility.
[Dr. Bharat Panuganti]
That's right. Absolutely.
[Dr. Gopi Shah]
In terms of equitable care, what are some of the challenges you've seen? We're talking about early glottic cancer care. Those patients who are able to see you while it's early, realizing that they have glottic cancer, they're red flags that maybe present quicker. What do you see in terms of providing equitable care or challenges to gaining--
[Dr. Bharat Panuganti]
I think in general, radiation is by far the most common treatment offered for early glottic cancer. I think part of that is just availability. The vast majority of the country geographically, there isn't someone that's doing TLM surgery. Just by virtue of what radiation is, it's simply more available. I think generally speaking, in terms of equity, I think that the average person is much more likely to have radiation as an option versus TLM.
Beyond the simple availability of laryngeal surgeons doing this kind of surgery across the country, I can't tell you exactly what the link between insurance coverage and access to care is, frankly. We did publish a study a few years ago, looking at rates of surgery versus radiation for early glottic cancer care after Medicaid expansion with the PPACA. We did find that among states that expanded access to Medicaid, there was a significant increase in the proportion of patient time versus time that we're getting surgery versus radiation for early glottic cancer.
How do we explain that exactly? It's tough for me to say, but I do believe that access to TLM is a problem, just like access to surgery across the spectrum of head and neck cancer care is also potentially problematic.
Podcast Contributors
Dr. Bharat Panuganti
Dr. Bharat Panuganit is an otolaryngologist and airway surgeon at Washington University in St. Louis, Missouri.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, November 12). Ep. 199 – Advances in Early Glottic Cancer Treatment Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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