eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Conservation Laryngeal Surgery, Near-Total Laryngectomy: Follow-up

Author: Brian Reilly, MD, Staff Physician, Department of Otolaryngology, McGaw Medical Center of Northwestern University
Coauthor(s): Barry L Wenig, MD, MPH, FACS, Professor, Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University; Chief, Division of Otolaryngology-Head and Neck Surgery, Evanston Northwestern Healthcare
Contributor Information and Disclosures

Updated: Jul 2, 2008

Outcome and Prognosis

Voice quality

In approximately 86% of cases, voice quality following near-total laryngectomy (NTL) was deemed good; voice quality was assessed as suboptimal in less than 10% of cases.
 
Speech and swallowing

In addition, follow-up studies ranging from 6 months to 6 years show adequate pouch speech, such that patients use it as their primary mode of communication. It can be argued that quality and ease of speech exceeds that of fistula speech, allowing patients to whistle or emote.
 
Speech, swallowing, and aspiration results in patients after NTL are similar to those in patients who have had tracheoesophageal puncture (TEP) following total laryngectomy (TL). 
 
Wound healing and aspiration

Major problems associated with NTL include wound healing issues, degree of aspiration, and need for revision shunt surgery. Indeed, if aspiration is severe, reversing the shunt may be necessary.
 
Recurrence

With NTL, most recurrences occur during the first 2 years of observation. Local recurrence was noted in an average of 7% of patients. Neck recurrence was noted in approximately 11% of patients as well. Distant metastasis has been noted on average in 19% of patients, based on a meta-analysis by Suits et al.5

Future and Controversies

Over the years attempts have been made at creating tracheo-esophageal shunts, or neoglottis to allow phonation after resection of laryngeal cancer. The near-total laryngectomy (NTL) has been shown to be a sound oncologic surgery and can have many advantages over more aggressive techniques. For example, NTL  removes the tumor with clear margins and provides the patient with a lung-powered voice without the need for prosthesis. As such, NTL does not exclude the possibility of using other approaches to vocal rehabilitation, including esophageal speech, an electrolarynx, or subsequent tracheoesophageal puncture (TEP).  
 
In addition, the voice quality of patients undergoing NTL is equal, if not at times superior, to that achieved through TEP. For voice quality, the surgical outcome appears to depend in part on the surgeon’s skill and the extent of resection and subsequent reconstruction. According to DeSanto et al, the sphincteral function and size of the shunt may also play a role in acoustic quality.6
 
But NTL is not without its drawbacks. With NTL, postradiation patients have an increased risk of fistula formation. If the patient has a high likelihood of developing a pharyngocutaneous fistula (because of previous irradiation, poor nutritional status, or severe atherosclerotic disease), Suits et al argue that a total laryngectomy (TL) with TEP should be strongly considered instead.5 This is because many patients who develop fistula often go on to develop irreversible aspiration.
 
Another tradeoff of NTL is a greater risk of protracted hospital stays resulting from both the surgery and a greater risk of aspiration. Yet, because the voice is such an important human attribute, patients are often willing to have a longer recovery if it promises the possibility of voice restoration.
 
Indeed, on the whole, advances in partial laryngeal surgery, notably NTL, can in certain cases provide a more satisfying outcome for the patient while ensuring that the cancer is properly treated.  

Conclusion
 
NTL is an effective alternative to TL in carefully selected patients. Conservation laryngeal surgery aims to extirpate laryngeal malignancy, while maintaining the functional capacity to breath, swallow, and speak.  In many cases, NTL allows excellent voice function and does not exclude the possibility of other vocal rehabilitation techniques. NTL is a sound oncologic procedure for tumors, which can result in a single-stage reconstruction, without the need for prosthesis.

 


More on Conservation Laryngeal Surgery, Near-Total Laryngectomy

Overview: Conservation Laryngeal Surgery, Near-Total Laryngectomy
Workup: Conservation Laryngeal Surgery, Near-Total Laryngectomy
Treatment: Conservation Laryngeal Surgery, Near-Total Laryngectomy
Follow-up: Conservation Laryngeal Surgery, Near-Total Laryngectomy
References
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Further Reading

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Keywords

conservation laryngeal surgery, laryngeal cancer, laryngeal organ preservation surgery, near-total laryngectomy, Pearson laryngectomy, cancer surgery, near total laryngectomy, sub-total laryngectomy, laryngectomy, NTL, laryngeal cancer, neck cancer, laryngeal carcinoma, glottic cancer, glottic carcinoma, supraglottic cancer, base of tongue cancer, hypopharyngeal cancer, tongue cancer, larynx cancer, glottic tumor, laryngeal tumor, tracheoesophageal puncture, TEP

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Contributor Information and Disclosures

Author

Brian Reilly, MD, Staff Physician, Department of Otolaryngology, McGaw Medical Center of Northwestern University
Brian Reilly, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barry L Wenig, MD, MPH, FACS, Professor, Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University; Chief, Division of Otolaryngology-Head and Neck Surgery, Evanston Northwestern Healthcare
Barry L Wenig, MD, MPH, FACS is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, Association for Research in Otolaryngology, Chicago Medical Society, New York Academy of Medicine, New York Academy of Sciences, New York Head and Neck Society, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Medical Editor

M Abraham Kuriakose, MD, DDS, FRCS, Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences
M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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