Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Supraglottic Carcinoma The history of supraglottic laryngectomies starts off in 1883 with Bill Roth, pictured here, who performed the first laryngectomy. This was a very morbid procedure at the time, and many of his patients died on the operating room table. Since then, Trotter was one of the first to excise an epiglottic cancer via lateral pharyngotomy. It was Alonso from South America in the 1950s who was the first to describe the first supraglottic laryngectomy, but it wasn’t until the 60s that Dr. Ogura standardized the technique and showed its efficacy in treating this disease. In the 1970s, Bocca was the first to report a large series of supraglottic laryngectomies in his results. Moving on to the epidemiology — glottic laryngeal cancers comprise approximately one to five percent of malignancies. There are roughly 11,000 new cases in the U.S. each year, 67% of them being glottic,31% being supraglottic, and 2% being subglottic. Supraglottic carcinoma has the worse prognosis in that when presenting, they have more advanced disease with cervical lymph node metastasis, the reason being glottic cancers usually affect voice and are picked up earlier on. Laryngeal embryology is very important with regard to supraglottic carcinoma. The supraglottic larynx develops from branchial arches III and IV, while the glottis and subglottis derive from different branchial arches V and VI. The larynx starts to develop at 25 days of gestation, and is formed by the eighth week. Laryngeal movement is noted by the third month of gestation and continues to descend even after birth. Laryngeal anatomy. The supraglottis is typically defined as from the tip of the epiglottis to the ventricular fold. It has extensive lymphatics that feed the neck bilaterally. This is very important because 25% to 50% of supraglottic cancers already have nodal metastasis with 20% to 35% being bilateral and occult disease occurring anywhere from 20% to 38%. The glottis is described as being from the ventricular fold and extending 1cm inferior to the vocal cords. Tumors occur frequently here but have limited lymphatic supply. They are slow growing, in predictable patterns and are usually found very early. Due to this, nodal metastasis is much less. It is roughly less than 10% and occult metastasis is around 15%. Coming on down to the subglottis, it starts 1cm inferior to the vocal cord and inferior border of the cricoid. These tumors are often silent and extend via the cricoid so they involve the paratracheal and cervical lymphatics. Prognosis is poor because of advanced disease at the time of diagnosis. Supraglottic anatomy is very important with regards to our management strategies. Subsites of the supraglottis include the epiglottis, the arytenoids, and the false vocal cords. There are two important spaces that we have to focus on in the supraglottis. Pictured here on your left is the pre-epiglottic space. It is limited by the epiglottis, the thyrohyoid membrane, the hyoid epiglottic ligament, and the thyroepiglottic ligament. Moving on, at this pre-epiglottic space, tumors often spread into the space and can spread out laterally to involve the paraglottic spaces, which is pictured here on your right. The paraglottic space is anteriorly bound by the thyroid cartilage, inferiorly by the conus elasticus, and posteriorly by the quadrangular membrane. Tumors in this area can spread out laterally and go down inferiorly to become considered transglottic. Endoscopy is often not adequate enough to evaluate these tumors, and these tumors can be missed. That’s why imaging is important with regards to these paraglottic space tumors. Throughout my presentation, you are going to be seeing images that show both examples of this pre-epiglottic space tumor involvement and paraglottic space tumor involvement. The pathology of the supraglottis has multiple types of tumors. The majority, over 90%, is squamous cell in origin with varying differentiation. The next most common is verrucous carcinoma, pictured here to your right, which are usually superficial spreading. The remaining mixture of supraglottic pathology includes adenocarcinomas, sarcomas, and metastatic lesions. So what are the risk factors? As with all head and neck malignancies, smoking and alcohol play a very important role. It is interesting to note that less than five percent of laryngeal cancer patients have no smoking history. Other factors include radiation, reflux, laryngoceles, and juvenile papillomas. The staging of supraglottic cancer is based on the American Joint Committee on Cancer. It uses the T and M classification. At presentation, the majority of supraglottic cancers are staged 3 and 4. So they are advanced in disease. In the staging of tumors, it is important to note the boundaries. T1 lesions are tumors limited to one subsite of the supraglottis, and it is also important to note that there is normal vocal cord mobility. With T2 lesions, these lesions often invade mucosa of more than one adjacent subsite of the supraglottis. The tumor can extend outside the supraglottis to involve the base of tongue, vallecula, or piriform sinus. Shown here is an epiglottic lesion extending into the base of tongue. Again, with T2 lesions, normal vocal cord movement is noted. T3 lesions are limited in the larynx but have vocal cord fixation. They can also be classified as T3 if they invade the postcricoid area, as shown here; the pre-epiglottic tissue; or deep base of tongue. T4 lesions are the largest lesions. They involve thyroid cartilage and extend to the soft tissues of the neck, thyroid, and esophagus. Pictured here is a tumor that would involve the anterior commissure and is moving through the thyroid cartilage. The next staging is, as is with all head and neck cancers, similar. N1 disease is considered mets to a single ipsilateral lymph node. The lymph node is typically 3cm or less in its greatest dimension. N2 A disease is metastasis to a single ipsilateral lymph node, but they are larger than 3cm, but less than 6cm in its greatest dimension. N2 B shows multiple metastasis to the ipsilateral neck, none being more than 6cm in size. To qualify as N2 C, there must be multiple mets to bilateral neck or contralateral disease. Again, none more than 6cm in greatest dimension. In N3 disease, there are typically lymph node metastases that are greater than 6cm in greatest dimension. How do these supraglottic tumors spread? The tumor biology is very interesting in supraglottic carcinoma in that they grow with pushing margins. These pushing margins also tend to stay within the supraglottis. Again, as mentioned previously, the paraglottic space surrounds the glottis and acts as a conduit for cancer to spread between all divisions of the larynx. Also anterior vocal commissure has no anatomical barrier to spread of cancer, and they can spread from the anterior commissure directly to the thyroid cartilage. Pre-epiglottic space invasion is also facilitated by the numerous foramina of the epiglottis, which explains why we see a lot of tumors in this area. Anatomical studies in the literature are very beautiful. Several studies have shown with injection of submucosal dye that the dye spreads throughout the supraglottis and tends to stay limited to the level of the false vocal cords. Many authors attribute this to the development of the glottis from different branchial arches in the glottis and subglottis. It is heatedly contested whether this embryology really leads to the characteristics of these growing pushing tumor margins. Despite all this, we all must remember that cancer spreads and can spread through embryologic planes regardless. What has been shown with regards to regional and distant metastasis? Esposito in 2001 from Italy showed that the relative risk of metastasis is directly related to size of primary tumor. He measured the sizes of his primary tumors in his patients and noted that if less than 2cm, there was less than 20% chance of metastasis to the neck; but with larger tumors greater than this size, there was up to an 80% chance of metastasis. Meyers in 1996 gave the Ogura Memorial Lecture. During this lecture, he stated that regional metastasis was the most common site of failure, not local failure. Distant metastasis are found in five percent of laryngeal primaries with the most common site being lung. So what’s the prevalence of these nodal metastases? If a patient walks into your clinic and has supraglottic carcinoma, he or she has roughly 40% chance of having neck disease at that time; and if you do have neck disease at that time on one side, the chance of having a contralateral disease is up to 40% as well. So where does the supraglottic cancer spread? Most supraglottic tumors metastasize to levels II through IV. Patients with no evidence of cervical metastasis have a 27% chance of having occult mets missed by physical exam or radiology. Dissemination also occurs bilaterally, even if the tumor is one sided in your supraglottis, which is very important to know. Literature published in 2002 from Italy found a 37% chance of occult metastasis and when it recurred, 37% recurred on the contralateral side that was not treated with neck disease. Rinaldo in 2004, also from Italy, reviewed the literature and made recommendations that the treatment should be bilateral neck dissections, levels II through IV; and if there is extensive disease in these neck dissections, consideration should be given to performing neck dissections in levels I and V. As this chart shows, a review of the literature, just because a patient has a supraglottic cancer does not qualify them for undergoing a supraglottic laryngectomy. There are many physiological parameters that are important to consider. Only about 15% of patients with supraglottic carcinoma qualify for this procedure. Inclusion criteria means you have to have freely mobile cords, and no cartilage invasion. Exclusion criteria includes if you have poor pulmonary function, the anterior commissure is invaded, or the tumor extends outside of the supraglottis. As to preoperative planning for these patients, we must adequately assess the extent of the primary tumor, evaluate the cervical lymphatics, and evaluate the cardiopulmonary reserve. Every patient must undergo a traditional endoscopy with biopsy to evaluate for second primaries as well as to evaluate the extensive disease. Preoperative pulmonary function is of utmost importance in supraglottic laryngectomies. There have been no objective constraints published, but it has been generally accepted that an FFE-1 of greater than 60% is determined adequate. The patient must be able to walk at least two flights of stairs and the ability to cough and ambulate cannot be overemphasized with rehabilitation of supraglottic laryngectomy patients. Preoperative imaging. CT scans are excellent to identify tumor extension outside the paraglottic space, which is often missed with direct laryngoscopy. It also helps evaluate the cervical lymphatics. Studies from UNC evaluated tumor size to predict local control after surgery. He used imaging with the one pictured above to measure tumor bonds, and he noted that if the tumor was less than 16 cc in volume, it had over an 94% control rate after surgery. The use of MRI is also very helpful to see if tumor is spreading through the various tissue planes. Pictured here above is the supraglottic tumor invading through the thyroid cartilage and pictured below is an MRI example of pre-epiglottic space iinvolvement. The MRI to the right is the tumor involving the paraglottic space involvement. Overall management. Literature has abundant reports of different management strategies for treating supraglottic cancers. It can often be very confusing and arguments can be made for treatments of any modality. Generally, single modality treatment is usually used for stage 1 to stage 2 tumors. You can either have single modality treatment with surgery or radiation therapy. Combined modality is usually noted for more advanced disease, stages 3 and 4. Combined modality includes chemotherapy and radiation therapy, or surgery and radiation therapy. To start with, we will go over single modality surgery. Single modality surgery can be divided into two branches: conservation surgery, which is referring to voice; and nonconservation, which includes total laryngectomy. The first that I plan to go over is laser excision of supraglottic cancers. Endoscopic resection of supraglottic carcinoma offers a quick, cause effective means of treating T1 or early disease. As shown by the literature review in this chart, endoscopic laser surgery is excellent for control of T1, T2 disease but fails with larger tumor sizes. Endoscopic laser excision started in the early 1930s, and Germany has really been a leader in the forefront of this. It violates principles of oncologic surgery in that sometimes the tumor has to be removed in piecemeal. Despite all this, it has showed excellent results for these early supraglottic lesions. In the realm of conservation surgeries is surgery of supraglottic laryngectomies. Supraglottic laryngectomies affords what you call a pathological exam, which basically means we have the pathologist to look at our specimens locally as well as the neck dissections and assess the characteristics of the tumor. This helps guide, if we need to give radiation therapy to our patients afterwards. It has been shown through multiple studies that supraglottic laryngectomies give local control rates comparable to that of primary radiation therapy for T1 lesions and often has been shown that slightly superior results for T2 lesions. Overall, it is just as effective as total laryngectomies for local control of supraglottic carcinoma. Next, there is the extended supraglottic laryngectomies. These were popularized by surgeons. This describes multiple extensions to the traditional supraglottic laryngectomy. These are used to remove portions of the tongue base, piriform sinus, and arytenoids. Nonconservation surgery includes a total laryngectomy. This is an excellent option for advanced disease of the supraglottic area. Swallowing is often excellent after the procedure and vocal rehabilitation with the Blomsinger T-E prosthesis offers an acceptable alternative. Radiation therapy is another form of single modality treatment for early tumors. The pros of radiation therapy is it offers excellent control of local regional disease with minimal morbidity to voice and swallowing. The disadvantages are its projected length, often taking six weeks at a time. It is a single use option because you can only radiate the neck so much. It has side effects of edema and mucositis. It has been shown that it is less ideal for advanced disease. Again, this is a chart showing early disease treated adequately with radiation therapy and more advanced disease is better suited with combined modality. In the early 1970s, surgeons were concerned about primary radiation therapies, because they felt that many patients would fail. And when failed, they would require total laryngectomies and would loss their voice as opposed to starting off with a supraglottic laryngectomy and giving them a chance at preserving voice. As the literature has shown, that has not been the case, and early cancers of the supraglottis are treated adequately with radiation therapy. Combined modality is again usually used for stage III and IV tumors. The first modality that I will talk about is chemotherapy and radiation therapy. The VA laryngeal study in the early 1980s showed that surgery and radiation therapy for stage 3 laryngeal carcinoma had no statistical increase of survival over that of the chemotherapy and radiation therapy armor. This study also showed that the chemotherapy and radiation were able to save 60% of the patient population from undergoing a total laryngectomy. Next, our modality is combining surgery and radiation therapy. Robbins in 1988 published his work from M. D. Anderson Cancer Hospital. He looked at 139 patients with primary disease and looked at control at three years. He broke up his patient population at 81 receiving radiation therapy alone and 24 receiving total laryngectomy and supraglottic laryngectomies. These surgical patients underwent postoperative radiation therapy. Local and local regional control were significantly better in the combined modality than in the radiation group alone. Overall, he showed a five-year survival rate with advanced T2, T3 lesions of 89%. So what’s the role of the neck dissection and how did that come into play in supraglottic cancers? Due to the high rate of disease and bilateral metastasis with early supraglottic carcinoma, treatment of cervical lymph nodes should be aggressive. There was a landmark article of Lutz in which he reviewed 202 of his patients. From this article, we gained the knowledge that bilateral neck dissections offered better control. Supraglottic laryngectomies were just as effective as total laryngectomies in treating this disease, and the neck unoperated contralateral side was the site where you are going to most likely fail. Overall, despite the location of the primary tumor, his recommendations were for bilateral neck dissection. This was followed up in 1994 by Dr. Weber, who showed that there is no significant increase in morbidity to performing bilateral neck dissections as opposed to performing unilateral neck dissections. Most recently, Chiu in 2004, also from Pittsburgh, showed that after reviewing 115 of supraglottic cancer patients treated at Pittsburgh with supraglottic laryngectomy and bilateral neck dissection, he compared it to the overall literature and showed that it had a decrease in cervical recurrence and increased survival. So what is the method of supraglottic laryngectomy or how do we perform it? Pictured here to your left is the specimen that is surgically removed at the time of surgery. What we do is we start by performing an apron flap. Once dissection of subplatysmal planes are developed, the strap muscles are identified and resected to expose the thyroid cartilage. The thyroid cartilage is then identified. The perichondrium of the thyroid is then elevated posteriorly and moving down inferiorly. Using an oscillating saw, the thyroid cartilage is opened, and we move into the mucosal surfaces of the larynx. Incisions are made below the level of the false cord, as pictured here and here, to expose the true vocal cords. Once the specimen is removed, as pictured here on your left, the true cord mucosa is sewn to the piriform sinus mucosa. Once this is done, the base of tongue, which is pictured here on top, is sewn to the perichondrium of the thyroid cartilage. These are sewn with nonabsorbable sutures. After this is closed, the strap muscles are reapproximaed to add extra protection. Pictured here is actual specimen that was removed, and pictured here on your right is what the surgical area would look like after your neck dissection and supraglottic laryngectomy. What are some of the surgical maneuvers to limit morbidity? You must preserve at least one of the internal branches of the superior laryngeal nerve that helps with the sensory function of the supraglottis and superior larynx; avoid injury to the arytenoids, which would help with relimiting aspiration; try to make your laryngeal cuts under direct visualization; and try to preserve the larynx and resuspend it to the hyoid. What are the possible complications of the supraglottic laryngectomy? All patients undergoing supraglottic laryngectomy experience some form of aspiration. Rehabilitation after surgery is of utmost importance and a lot of this is with the help of our speech pathologist colleagues who help with rehabilitating our patients. If you violate the anterior commissure, sometimes you can release the true vocal cords. If this happens, you can reapproximate them with nonabsorbable suture. At times, intractable aspiration occurs, which in some patients require conversion to a total laryngectomy. Airway obstruction has also been noted, and this has been noted with leaving a lot of the false vocal cords behind. Again, hematomas and pharyngocutaneous fistulas can occur. Overall, postoperative management focuses on the supraglottic swallow. This protects the airway from aspiration from closing the airway before swallowing, then coughing immediately after the swallow to clear any residual food on top of the vocal folds. There has also been described in the literature this supersupraglottic swallow. It’s the same as a supraglottic swallow, though it requires an extra effortful breathhold. As pictured here to the right using video stroboscopy, this is what the larynx typically looks like when we are holding our breath. Picture A is the larynx at rest. B is where the arytenoids come together. C is where the true cords come together. D is where the false cords come together. And, most important with regards to supraglottic swallow, is E and F. E is where the arytenoids start to tilt forward, and F is where the arytenoids really touch the epiglottis. By using this extra effortful breathhold, E and F are really accentuated and help patients with swallow. When supraglottic laryngectomy patients have a difficult time swallowing postoperatively, radiation therapy to the larynx can be detrimental. So, I pursued a review of the literature that tried to answer these two questions. Indications for postoperative radiation therapy after supraglottic laryngectomy were the following. After reviewing all literature, these are the lists I composed. You should give postoperative radiation therapy if you have close or positive margins; if you have cartilage invasion, perineural invasion, or vascular invasion; if you have multiple nodes greater than 2 or bilateral positive lymph nodes; extracapsular spread; and if you want to treat prophylactic treatment of residual disease. What are the complications in postoperative radiation therapy in patients who had undergone supraglottic laryngectomy? Spaulding published an article in 1989 in which he reviewed 23 patients after supraglottic laryngectomy receiving postoperative radiation therapy. He noted minimal complications and only one needing a total laryngectomy. Weems found a 17% complication rate. This was followed by Steiniger in 1997, which reviewed 17 patients, but he found a significantly higher lifelong gastrostomy dependency in upper airway obstruction. One of the best studies was done by Laccourreye from France. He found 16% severe complication rate to coincide with Steiniger’s work but found a 3.3% fatality secondary to radiation therapy. This was generally due to radiation cartilage necrosis of the larynx leading to sepsis and airway obstruction. Where’s the future of supraglottic carcinoma going? Well, Laccourreye has done amazing work in this new supracricoid laryngectomy with a criocohyoidopexy, and is having patients undergo voice-preserving procedures that would generally not qualify for supraglottic laryngectomies. These are mainly tumors involving the anterior commissure. Endoscopic laryngeal laser surgery is up and coming. It is in its infancy and as lasers get better and our experience gets better, it will be a definite adjunct to supraglottic carcinoma. Chemotherapy and laryngeal preservation studies hold a lot of promise as well. Biomarkers, such as metallic proteinases are upregulated, and this has been shown to have more aggressive tumors. One thought I had when reviewing the literature is if we can have tumor specimens and somehow test with biomarkers to see which ones are radiosensitive, this will help guide us in the future. Thus, if we can get laryngeal specimens, find out which ones are radiation sensitive, and if they are, undergo radiation therapy. If they are less radiation sensitive, undergo a supraglottic laryngectomy. This is where I think the future of supraglottic carcinoma is going. So what are the key points?
Case Presentation: FH is a 58-year-old male referred to the Michael E. DeBakey VA Hospital ENT clinic by his PCP for a 2-month history of gradually worsening dysphagia associated with muffled voice. He denied having odynophagia, otalgia, hemoptysis, unexplained weight loss or difficulty breathing. He was otherwise healthy and had no major medical problems. Social history revealed that he smoked one pack of cigarettes a day for the past forty-years. He denied alcohol abuse or IV drug use. Physical exam reveals a physically fit appearing man with a slightly muffled voice without stridor. Head and neck examination was remarkable for an exophytic mass involving the left laryngeal surface of the epiglottis. Flexible fiberoptic examination demonstrated that the mass extended to the false vocal fold but not its free edge. The arytenoids, true vocal fold, and anterior commissure were uninvolved by the tumor. The true vocal cords were fully mobile. Palpation of the neck revealed no adenopathy or crepitus. A cranial nerve examination was normal. Preoperative chest x-ray and pulmonary function tests were normal. A CT scan of the neck showed a left exophytic epiglottic mass measuring 3.6 cm x 2.9 cm. Several lymph nodes were noted bilaterally in levels II and III. There was no thyroid cartilage erosion or extralaryngeal extension. A flexible endoscopic clinic biopsy was performed using curved forceps revealed a poorly differentiated squamous cell carcinoma. The patient was staged as a T2N2cM0 of the supraglottic larynx. The patient subsequently underwent direct laryngoscopy, and esophagoscopy in the operating room, which confirmed the supraglottic mass. He then underwent an awake tracheotomy and a supraglottic laryngectomy with bilateral neck dissections levels II-IV on the left and II-III on the right. Postoperatively, the patient did well and without complication. He was discharged on postoperative day #12 with a good voice result. The patient was managing his secretions well and practicing the supraglottic swallow. Final pathology revealed a poorly differentiated squamous cell carcinoma involving the epiglottis and part of the base of tongue. Margins were negative for malignancy. The right neck dissection had no positive nodes and the left neck dissection was positive for three out of thirty lymph nodes. He is scheduled to undergo postoperative radiation therapy. Bibliography: Bocca E, Calearo C, Vincentis ID, et al. Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-ear multicentric research. Laryngoscope 1984;94:1086-1090. Bocca E, Pignataro O, Oldini C. Supraglottic laryngectomy: 30 years of experience. Ann Otol Rhinol Laryngol 1983;92:14-18. Cabanillas R, Rodrigo JP, Llorente JL, et al. 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Head Neck 2004;26:442-446. Myers EN, Alvi A. Management of carcinoma of the supraglottic larynx: evolution, current concepts, and future trends. Laryngoscope 1996;106:559-566. Myer EN, Faga JJ. Management of the neck in cancer of the larynx. Ann Otol Rhinol Laryngol 1999;108:828-832. Mukherji SK, O’Brien SM, Gerstle RJ, et al. The ability of tumor volume to predict local control in surgically treated squamous cell carcinoma of the supraglottic larynx. Head Neck 2000;22:282-287. Ogura JH, Marks JE, Freeman RB. Results of conservation surgery for cancers of the supraglottis and pyriform sinus. Laryngoscope 1980;90:591-600. OhmaeY, Lodegmann JA, Kaiser P, et al. Effects of two breath-holding maneuvers on oropharyngeal swallow. Ann Otol Rhinol Laryngol 1996;105:123-131. Redaelli de Zinis LO, Nicholai P, Tomenzoli D, et al. The distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications. Head Neck 2002;24:913-920. Rinaldo A, Ferlito A, Robbins KT, et al. Is dissection of level V necessary in patients with T2-T4N0 supraglottic cancer? J Laryngol Otol 2004;118:175-178. Robbins KT, Davidson W, Peters L, et al. Conservation surgery for T2 and T3 carcinomas of the supraglottic larynx. Arch Otolaryngol Head Neck Surg 1988;114:421-426. Rodrigo JP, Domiguez F, Alvarez C, et al. Expression of E-cadherin in squamous cell carcinomas of the supraglottic larynx with correlations to clincopathological features. Eur J Cancer 2002;38:1059-1064. Rudert HH, Werner JA, Hoft S. Transoral carbon dioxide laser resection of supraglottic carcinoma. Ann Otol Rhinol Laryngol 1999;108:819-827. Scola B, Fernandez-vega M, Martinez T, et al. Management of cancer of the supraglottis. Otolaryngol Head Neck Surg 2001;124:195-8. Spaulding CA , Constable WC, Levine PA, et al. Partial laryngectomy and radiotherapy for supraglottic cancer: a conservative approach. Ann Otol Rhinol Larngol 1989;98:125-127. Steiniger JR, Parnes SM, Gardner GM. Morbidity of combined therapy for the treatment of supraglottic carcinoma: supraglottic laryngectomy and radiotherapy. Ann Otol Rhinol Laryngol 1997;106:151-158. Terrell JE, Fisher S, Wolf GT. Long-term quality of life after treatment of laryngeal cancer. Arch Otolaryngol Head Neck Surg 1998;124:964-71. Tu G. Upper neck (level II) dissection for N0 neck supraglottic carcinoma. Laryngoscope 1999;109:467-470. Weber PC, Johnson JT, Myers EN. Impact of bilateral neck dissections on recovery following supraglottic laryngectomy. Arch Otolaryngol Head Neck Surg 1993;119:61-64. Weinstein GS, El-Sawy MM, Ruiz C, et al. Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy. Laryngoscope 2001;111:191-199. Xie M, Sun Y, Li Y. Expression of matrix metalloproteinases in supraglottic carcinoma and its clinical implication for estimating lymph node metastases. 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