Vestibulectomy-Rationale, Surgical Technique and Clinical Applications

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Vestibulectomy is subtotal resection of the vestibular fold. Excision of this structure is advocated as (1) a definitive therapeutic procedure for removal of vestibular fold lesions and (2) an adjunctive diagnostic procedure when addressing vocal fold lesions. The surgical objectives are diagnostic and therapeutic when addressing vestibular fold lesions and primarily diagnostic when applied to vocal fold lesions. In the latter, superior exposure of the vocal fold, particularly of the lateral ventricle, permits direct visual and surgical access to the paraglottis and subglottis and is particularly suited to Ti and T2 glottic lesions when definitive excision can be undertaken. In T3 glottic lesions management options are expanded to permit larynx preservation procedures in lieu of the conventional laryngectomy.
Vestibulectomy allows unobstructed visual access intra-and postoperatively, particularly in cases where cordectomy has been performed. Adjunctive vestibulectomy has been useful in cases of postirradiation glottic carcinoma patients where the glottis cannot be competently visualized during follow-up examinations. Vestibulectomy is suited for inflammatory reactive lesions such as the laryngocele and saccular cysts. Voice is usually unaffected and swallowing and airway function are also preserved.
Vestibulectomy has been performed at the time of transverse cordotomy, a procedure which has been utilized in airway restoration after bilateral vocal fold paralysis. Superior exposure of the vocal fold facilitates adequate cordotomy and optimal airway enhancement.
The single complication in over 100 vestibulectomies has been postoperative superior laryngeal artery hemorrhage. This occurred in a case where vestibulectomy had been performed at the time of transverse cordotomy. The patient was returned to the operating room for hemostasis which was achieved with tamponade and laser coagulation.
Our current assessment is that vestibulectomy achieves (1) superior surgical access to the vocal fold intraoperatively, and (2) enhanced visual access postoperatively for clinical exam in 75-90% of cases particularly in patients who receive x-ray therapy and in whom reactiveswelling of the vestibular fold is not uncommon.
Revision vestibulectomy has been performed in select cases when additional enhancement of exposure and visual access to the vocal folds is needed.