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Total Laryngectomy

  • Author: Eelam Aalia Adil, MD, MBA; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Feb 29, 2016
 

Background

Laryngeal cancer is a generalized term that includes carcinoma of the supraglottic, glottic, and subglottic structures. Squamous cell carcinoma is the most common pathology, but primary laryngeal adenocarcinoma, chondrosarcoma, lymphoma, and plasmacytoma have also been described.[1, 2] The median age for diagnosis is 65 years of age.[3] According to the American Cancer Society's estimates, there will be about 13,5430 new cases of laryngeal cancer and about 3,620 people (2,890 men and 730 women) will die from laryngeal cancer in the United States in 2016.[9]

Note the radiograph below for anatomical information.

Lateral radiograph of the neck showing the differe Lateral radiograph of the neck showing the different structures of the larynx: a, vallecula; b, hyoid bone; c, epiglottis; d, pre-epiglottic space; e, ventricle (air-space between false and true cords); f, arytenoid; g, cricoid; and h, thyroid cartilage.

Laryngeal Cancer Staging

Laryngeal cancer staging is based on the subsite involved and the extent of disease. The larynx has 3 subsites, as follows:

  • Supraglottis: The supraglottis extends from the epiglottis superiorly to the true vocal folds inferiorly. This subsite includes the epiglottis, aryepiglottic folds, arytenoids, and false vocal folds.
  • Glottis: These are the true vocal folds.
  • Subglottis: This extends from the true vocal folds superiorly to the first tracheal ring inferiorly.

The American Joint Committee on Cancer (AJCC) uses the TNM classification to define laryngeal cancer, as seen in the table below.[4]

Table 1. Tumor, Node, Metastasis (TNM) Classification Description (Open Table in a new window)

Laryngeal Subsite Primary Tumor (T) Regional Lymph Nodes (N) Distant Metastasis (M)
Supraglottic T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility



T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx



T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage



T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



Glottic T1a: Tumor limited to one vocal cord



T1b: Tumor involves both vocal cords



T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility



T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage



T4a: Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



Subglottic T1: Tumor limited to the subglottis



T2: Tumor extends to vocal cord(s) with normal or impaired mobility



T3: Tumor limited to larynx with vocal cord fixation



T4a: Tumor invades cricoids or through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



 

Table 2. Table 1 Tumor, Node, Metastasis (TNM) Classification Abbreviations (Open Table in a new window)

Stage T N M
I T1 N0 M0
II T2 N0 M0
III T3



T1-3



N0



N1



M0



M0



IVA T4a



T1-3



N0-2



N2



M0



M0



IVB T4b



T1-4



N1-3



N2



M0



M0



IVC T1-4 N1-3 M1

For all tumor subsites, Tx designates tumors that cannot be assessed, T0 is used when no primary tumor exists, and Tis means carcinoma in situ.

Indications

Total laryngectomy is a surgical option for patients with advanced stage laryngeal cancer that includes 1) tumors with cartilage destruction and anterior spread outside the larynx, 2) posterior commissure or bilateral arytenoid joint involvement, 3) circumferential submucosal disease, and 4) subglottic extension with extensive invasion of the cricoid cartilage.

Surgical salvage can be considered for patients who fail radiation therapy or partial laryngectomy procedures. Total laryngectomy can also be considered in patients with extralaryngeal tumors that have invaded the larynx such as advanced thyroid and base of tongue cancers. Adenocarcinoma and other less common histologies are less radiosensitive than laryngeal squamous cell cancer, so laryngectomy should be considered over organ preservation therapy in these cases. Patients with radiation necrosis of the larynx and severe aspiration can also be offered total laryngectomy.

 
 
Contributor Information and Disclosures
Author

Eelam Aalia Adil, MD, MBA Pediatric Otolaryngologist, Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School

Eelam Aalia Adil, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Medical Association, Phi Beta Kappa, American Society of Pediatric Otolaryngology, Triological Society

Disclosure: Nothing to disclose.

Coauthor(s)

David Goldenberg, MD, FACS Chief of Otolaryngology-Head and Neck Surgery, Professor of Surgery and Oncology, Pennsylvania State University College of Medicine; Director of Head and Neck Surgery, Department of Surgery, Division of Otolaryngology-Head and Neck Oncology, Milton S Hershey Medical Center

David Goldenberg, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Thyroid Association, Israeli Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

References
  1. Rutherford K, Parsons S, Cordes S. Extramedullary plasmacytoma of the larynx in an adolescent: a case report and review of the literature. Ear Nose Throat J. 2009 Feb. 88(2):E1-7. [Medline].

  2. Desai SC, Allen C, Chernock R, Haughey B. Pathology quiz case 1. Primary diffuse large B-cell lymphoma of the larynx. Arch Otolaryngol Head Neck Surg. 2011 May. 137(5):526, 528. [Medline].

  3. SEER Cancer Statistics Review, 1975-2008. Available at http://seer.cancer.gov/csr/1975_2008.

  4. Larynx. AJCC Cancer Staging Manual. 7. New York, NY: Springer; 2010. 57-62.

  5. Total Laryngectomy. Eugene N. Myers. Operative Otolaryngology: Head and Neck Surgery. 2nd. Elsevier Health Sciences; 2008.

  6. Agrawal N, Goldenberg D. Primary and salvage total laryngectomy. Otolaryngol Clin North Am. 2008 Aug. 41(4):771-80, vii. [Medline].

  7. Wax MK, Touma BJ, Ramadan HH. Tracheostomal stenosis after laryngectomy: incidence and predisposing factors. Otolaryngol Head Neck Surg. 1995 Sep. 113(3):242-7. [Medline].

  8. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, et al. SEER Cancer Statistics Review, 1975-2012, National Cancer Institute. National Cancer Institute. Available at http://seer.cancer.gov/csr/1975_2012/. April 2015; Accessed: February 29, 2016.

  9. Laryngeal and Hypopharyngeal Cancer. American Cancer Society. Available at http://www.cancer.org/cancer/laryngealandhypopharyngealcancer/detailedguide/laryngeal-and-hypopharyngeal-cancer-key-statistics. February 17, 2016; Accessed: February 29, 2016.

 
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Lateral radiograph of the neck showing the different structures of the larynx: a, vallecula; b, hyoid bone; c, epiglottis; d, pre-epiglottic space; e, ventricle (air-space between false and true cords); f, arytenoid; g, cricoid; and h, thyroid cartilage.
Table 1. Tumor, Node, Metastasis (TNM) Classification Description
Laryngeal Subsite Primary Tumor (T) Regional Lymph Nodes (N) Distant Metastasis (M)
Supraglottic T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility



T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx



T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage



T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



Glottic T1a: Tumor limited to one vocal cord



T1b: Tumor involves both vocal cords



T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility



T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage



T4a: Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



Subglottic T1: Tumor limited to the subglottis



T2: Tumor extends to vocal cord(s) with normal or impaired mobility



T3: Tumor limited to larynx with vocal cord fixation



T4a: Tumor invades cricoids or through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx



T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures



N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension



N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension



N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension



N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension



N3: Metastasis in a lymph node, >6 cm in greatest dimension



M0: No distant metastasis



M1: Distant metastasis



Table 2. Table 1 Tumor, Node, Metastasis (TNM) Classification Abbreviations
Stage T N M
I T1 N0 M0
II T2 N0 M0
III T3



T1-3



N0



N1



M0



M0



IVA T4a



T1-3



N0-2



N2



M0



M0



IVB T4b



T1-4



N1-3



N2



M0



M0



IVC T1-4 N1-3 M1
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