Endoscopic submucosal dissection of a neoplastic lesion in the epiglottis assisted by the use of floss traction

Laryngeal cancers are the most common malignant lesions of the head and neck, with an estimated 13,150 new laryngeal cancers per year in the USA [1]. Treatment of early-stage laryngeal tumors has evolved with, successively, open partial laryngeal surgery, suspension laryngoscopy, and CO₂ laser resection [2]. Unfavorable glottic lesions carry concerning implications for voice and swallowing depending on the extent of disease and preoperative laryngeal dysfunction (vocal fold paresis, aspiration, etc.). Endoscopic resection has been adopted by a significant part of the head-and-neck surgical oncologic community because the associated costs and length of hospital stay are lower than those associated with open partial laryngectomy, previously considered the surgical standard of care [3].

An early neoplastic lesion was found in the righthand part of the epiglottis of a 72-year-old man. The patient had a long history of smoking and reflux esophagitis. The lesion was about 1.0 × 2.0 cm in size and was assessed as a superficial raised lesion (IIa) with congestion, erosion, and a clear demarcation line ([Fig. 1]). The biopsy histopathological finding was high grade dysplasia. Computed tomography (CT) showed no evidence of metastasis. The patient was in the left decubitus position. Endoscopic submucosal dissection (ESD) was performed to remove the lesion and no adverse events occurred ([Video 1]). Because of the restricted space of the epiglottis, we adopted floss traction to expose the submucosal space during the process of dissection. The direction of floss traction was oral to caudal when we dissected the most part of the lesion ([Fig. 2]). However, we were unable to control the endoscope freely while dissecting the right side of the lesion. The remaining part of the lesion was therefore dissected by adjusting the direction of the floss traction, so that traction was from the top toward the bottom (i. e., from the patient’s right side toward his left side) ([Fig. 3]). The lesion was removed completely and the horizontal and vertical margins were negative ([Fig. 4]).

Fig. 1 Endoscopic view of the neoplastic lesion found in the righthand part of the epiglottis. The biopsy histopathological finding was high grade dysplasia.

Video 1 Endoscopic submucosal dissection of a neoplastic lesion in the epiglottis assisted by the use of floss traction.

Fig. 2 For dissection of the greater part of the lesion, the submucosal field was exposed when the direction of floss traction was oral to caudal.

Fig. 3 The remaining part of the lesion was dissected by adjusting the direction of floss traction, so that traction was from the top toward the bottom (i. e., from the patient’s right side toward his left side).

Fig. 4 Specimen of the lesion.

Floss-traction-assisted ESD has the advantages of (1) enabling curative resection, (2) providing a good surgical field of vision, (3) shortening the ESD operation time, and (4) being minimally invasive and maintaining organ integrity.

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• References

• 1 Baird BJ, Sung CK, Beadle BM. et al. Treatment of early-stage laryngeal cancer: a comparison of treatment options. Oral Oncol 2018; 87: 8-16
• 2 Karabulut B, Deveci I, Sürmeli M. et al. Comparison of functional and oncological treatment outcomes after transoral robotic surgery and open surgery for supraglottic laryngeal cancer. J Laryngol Otol 2018; 132: 832-836
• 3 Forastiere AA, Ismaila N, Lewin JS. et al. Use of larynx-preservation strategies in the treatment of laryngeal cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2018; 36: 1143-1169