A 55-year-old male smoker presents with progressive hoarseness for 6 months. Laryngoscopy reveals an exophytic lesion of the right vocal cord occupying the anterior third with involvement of the anterior commissure. Pathology confirms SCC. What is the significance of anterior commissure involvement for surgical planning?

• A No clinical significance as the commissure has no lymphatics
• B It upgrades T stage to T3 due to paraglottic space involvement
• C It creates higher risk of subglottic extension and inadequate surgical margins in endoscopic laser cordectomy, and impacts the decision between transoral laser, open partial, or total laryngectomy ✓
• D It mandates prophylactic bilateral neck dissection regardless of N stage

Explanation

Anterior commissure involvement in glottic SCC is clinically significant because: (1) the petiole of epiglottis at the commissure allows subglottic extension without being obvious on laryngoscopy, (2) the anterior commissure is the thinnest point of the thyroid cartilage adjacent to Broyle's ligament (which lacks perichondrium), creating a pathway for thyroid cartilage invasion, and (3) ensuring negative anterior margins in endoscopic laser surgery is technically challenging. These factors must be weighed when choosing between transoral laser microsurgery (type IV–V cordectomy), open partial laryngectomy, or total laryngectomy with adequate margins.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.