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The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of post-operative results. We chose to keep the word "cordectomy" even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke's space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination.

Background: A number of different surgical methods are described in the literature to enlarge the glottic gap in patients with bilateral recurrent nerve paralysis with an excessively small glottic gap. The latest method is the posterior chordectomy described by Dennis and Kashima., Patients and Methods: Twenty-three patients with bilateral recurrent nerve paralysis were treated between 1993 and 1997. In the first 5 patients, a muscular triangle as described by Dennis and Kashima from the posterior part of the muscular portion of the vocal fold was resected. Later on, the surgical procedure was extended by additional resection of muscular tissue from the anterior two-thirds of the vocal fold. Preoperative and postoperative data were carefully assessed in a prospective setting. Subjective data such as limitation of physical exertion and ability to communicate were documented. There was objective documentation by spirometry and phoniatric-logopedic assessment of voice quality parameters. Generally, it takes a number of months until the final permanent state is reached. The minimum follow-up was therefore at least 6 months with a mean of 16 months., Results: The follow-up of the 23 patients showed that the surgical technique as originally described by Dennis and Kashima does not always improve breathing sufficiently in the long run. A repeat chordectomy was required in three out of five patients with this technique. The modified technique with additional muscle resection of the anterior two-thirds of the vocal fold resulted in the desired long-term enlargement of the glottic gap in 16 out of 18 patients. Spirometric controls showed a significant improvement of respiration. However, some voice quality parameters showed a significant reduction as expected. Despite this, the overall communication ability was described as only slightly reduced by the patients themselves., Conclusions: By the modified posterior laser chordectomy, the glottic gap is widened on a long term, though less than after an arytenoidectomy. The compromise between reduction of voice quality and dyspnoea is better than after arytenoidectomy. The preservation of the laryngeal sphincter is important in that it prevents the latent aspirations that are occasionally observed and achieves a certain adduction of the vocal folds with phonation. The surgical procedure is technically simple, may be repeated, and never needs a tracheostomy.

Light microscopy of vocal cord mucosa in patients with Reinke's edema revealed highly ramified fissured spaces in the subepithelial tissue that were generally lined with flat cells. The ultrastructure of the parietal cells resembled fibroblasts whose cytoplasmic extensions overlapped in two to three layers in some places. Cell contacts were not observed. Neither electron microscopy nor immunohistochemical testing with antibody against laminin demonstrated a basal membrane. It was possible to distinguish between light and dark cells in the specimens examined. The cytoplasm of the light cells contained intermediate filaments, mitochondria, lysosomes, coated vesicles, caveolae and broad cisternae of rough endoplasmic reticulum. The dark cells were more numerous and typically exhibited a well-developed endoplasmic reticulum and free ribosomes. The parietal cells showed no immunoreaction against human vascular endothelial cells. Immunohistochemical demonstration of mesenchymal intermediate filaments using antibody against vimentin yielded a positive reaction for some of the cells in the walls of the crevices and subepithelial tissue. It was also possible to demonstrate a few cells with monoclonal antibody against macrophages (KiM6). These findings contradict the concept of lymphatic distension in cases of Reinke's edema. Since the parietal cells seen resembled synoviocytes in their structure and immunohistochemical reactions, findings indicate that the hollow spaces of Reinke's edema develop like neobursae from mechanical strain.

Findings of the presence of lymphatics in the subepithelial connective tissue layer of the true vocal cord range from the statement that lymphatics are absent to the observation that a dense lymphatic network exists. This is undoubtedly a result of the different methods of examination. The entire extent of a lymphatic system can be shown by either an enzyme histochemical demonstration of the 5'-nucleotidase activity in the lymphatics, or electron microscopy, which is more elaborate. These two methods are used to describe a subepithelial lymphatic network of varying density in 80 human vocal folds, which--contrary a frequent assumption--is not interrupted in the area of the free margin of the true vocal cord. Under the squamous epithelium, the density of the lymphatic system, which is very high in the arytenoid region, decreases continuously toward the anterior portion of the true vocal cord. It is exactly in the region in which the lymphatic system is the sparsest that almost all cancers of the true vocal cord develop. This finding is highly significant, in view of the low incidence of lymphogenous metastasis formation in T1-glottic cancers.

The first case of a papillary adenocarcinoma of the vocal cord is presented. The patient was a 63-year-old man: he was treated by a frontolateral hemilaryngectomy. The patient is alive and well with no evidence of disease 5 1/2 years later.

From July 1979 until December 1982 91 patients have been treated with 143 applications of a Coherent CO2-laser at the ENT Department of Kiel University. At the beginning the laser was applied to the majority of microsurgical indications in the larynx and pharynx. But at the end only some selected indications proved true: the treatment of papillomas, the ablation of the tonsil of the base of the tongue, the ablation of the lateral bands and of laryngeal webs. In the treatment of cancer debulking of large obstructive tumours of the larynx by laser vaporization can be used palliatively or prior to laryngectomy, obviating the need for tracheotomy. Own experiences in the treatment of 23 carcinomas of the vocal cord, considering also the literature, proved that the CO2-laser may be an alternative treatment of early glottic cancers of the middle third of the vocal cords. In the other malignant lesions of the vocal cords the laser may be an additive treatment after failure of radiotherapy and if surgical treatment is not possible.

Results of studies on the presence of lymphatic capillaries in the plica vocalis are shown, using improved methods of preparation. Immediately after laryngectomy, followed by immediate fixation of the non-pathological plicae vocalis, large lymphatic capillaries can be easily identified in the specimen. Lymphatic capillaries, which cannot be seen in conventional light microscopy, are now histochemically demonstrated with a marker of 5' nucleotidase. These histochemical results are confirmed by electron microscopy. Using a combination of both methods, a different quantity of subepithelial lymphatic capillaries can be visualised over the whole length and width of the plica vocalis. Lymphatic capillaries below the stratified squamous epithelium in the region of the anterior commissure grow gradually more numerous up to the folds of the arytenoid cartilage. Hence, in contrast to previous studies, the superficial lymphatic capillary system of the laryngeal mucosae is not separated into a supraglottic and subglottic lymphatic net of the vocal cord.

In nine cases of Reinkes edema ("polypoid chorditis") the resected mucosa is investigated by light and electron microscopy. The characteristic morphological changes of the disease are observed in the fibrous tissue of the vocal cord. The most important pathological result are extensive walled off spaces. The greater part of these are lined with a layer of mesothelial cell like fibroblasts. The slightly pathological findings at the epithelial cells are in accordance with the clinical result. Inflammatory signs morphologically can not be observed.