Anatomical Cadaver Study of Endolaryngeal Vascularization: Focus on the Glottis, Supraglottis, and Subglottis From the Transoral Microsurgical Point of View

Abstract

IntroductionCarbon dioxide laser coagulation during transoral laser microsurgery (TLM) for laryngeal cancer allows control of bleeding from vessels smaller than 0.5 mm. Therefore, larger arteries and veins must be carefully managed by clipping and/or monopolar cautery. The aim of this paper is to detail endolaryngeal vascular anatomy and identify areas of possible bleeding during TLM.MethodsWe performed an anatomical study on a series of 11 fresh-frozen human cadavers. After injection of a bicomponent red silicone into the innominate, left common carotid, and left subclavian arteries, 22 hemilarynges were dissected, the course of the supraglottic, glottic, and subglottic vessels were traced after microdissection of the intervening structures, and their size measured at specific landmark points where such vessels are more frequently encountered during TLM.ResultsThree vessels arising from the superior laryngeal artery were identified after its entry point at the level of the thyro-hyoid membrane: (1) the epiglottic artery (EA), documented in 100% of cases, a common trunk dividing into two main vessels (2) the postero-inferior artery (PIA), present in 100% of the specimens, running downward and dividing in a posterior (pPIA), and anterior (aPIA) branches (3) the antero-inferior artery (AIA), present in 95% of our specimens, running downward to the anterior commissure (AC). Two transverse anastomotic networks (TANs) connected the AIA and PIA, both parallel to the vocal muscle, one lateral (present in 100% of cases), and another medial (91% of specimens). Finally, a fourth vessel supplying the glottic plane was found to be the endolaryngeal paracommissural branch of the crico–thyroid artery (PCA), arising from the inferior laryngeal artery and emerging just below the AC, through the crico–thyroid membrane (reported in 100% of the specimens). This vessel anastomosed in 91% of cases with the AIA, through one or both of the TANs.ConclusionThe course of the endolaryngeal arteries, their relationships with adjacent structures, and size at specific landmark points have been herein described in order to provide surgeons with a map to guide them during the steep learning curve of transoral surgery of the larynx, with special emphasis given to TLM.

Current and potential use of fresh frozen cadaver in surgical training and anatomical education

“…A study by Perotti et al (2018) attempted to identify anatomical landmarks that are required for more precise microsurgery performance. These landmarks are not only important, but each surgery also requires a different landmark identification (Perotti et al, 2018). Researchers specifically focused on transoral microsurgery, where preventing unwanted bleeding is important.…”

“…Silicone was injected in FFC models to fill the vessels, and microdissection was performed to identify the sized location of the landmark vessels. The results organized a detailed identification with specific measurements (Perotti et al, 2018).…”

Subglottic Mucosal Flap: Endoscopic Single‐Stage Reconstruction for Anterior Glottic Stenosis

“…The ASGMF was demonstrated to be a reliable and viable tool, which may be attributed to the rich blood supply at the donor site. Perotti et al 35 documented the vascular anatomy of the larynx on a cadaver study and described two related arterial networks: the anteroinferior artery arising from the superior laryngeal artery and reaching the anterior commissure from above, and the paracommissural branch of the cricothyroid artery, arising from the inferior laryngeal artery and emerging at the anterior subglottis, through the cricothyroid membrane. These two arteries communicate by one to two anastomoses that may significantly contribute in maintaining the vitality of this flap.…”

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

“…The fact that most TLM operations are occurring at centers that perform the fewest cases has potential implications for postoperative margin rates, especially given TLM's steep learning curve. 15,16 Margin status is of primary concern in TLM. The minimally invasive endoscopic and microscopic elements allow for narrow surgical margins; however, this feature of TLM also risks a higher PMR.…”

“…Over 60% of patients were treated at facilities that perform <2 cases annually. The fact that most TLM operations are occurring at centers that perform the fewest cases has potential implications for postoperative margin rates, especially given TLM’s steep learning curve 15 , 16 . Margin status is of primary concern in TLM.…”