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

Conservation Laryngeal Surgery, Near-Total Laryngectomy

Brian Reilly, MD, Staff Physician, Department of Otolaryngology, McGaw Medical Center of Northwestern University
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

Updated: Jul 2, 2008

Introduction

Laryngeal cancer continues to kill nearly 4,000 people per year in the United States, despite stricter bans on smoking, increased public awareness, and improved treatment modalities. The ultimate goal of every clinician treating laryngeal canceris the extirpation of disease with the maintenance of voice functionality and swallowing. Most early glottic and supraglottic cancers can easily be treated without affecting the phonatory mechanism. This is difficult to achieve in larger transglottic lesions because the preferred surgical treatment for advanced laryngeal tumors remains total laryngectomy (TL), a surgical technique in which laryngeal speech is sacrificed.

Radiation and chemotherapy, part of the so-called organ-sparing protocols, have also resulted in effective outcomes. This article focuses on near-total laryngectomies, which aim to remove nearly all of larynx, while providing a high rate of disease control without substantial loss of function.
 
Speech is critical to a person's psychological well being. Consequently, advanced-stage laryngeal cancer creates a surgical dilemma, pitting the principles of oncologically sound resection against organ preservation. TL is an effective, albeit definitive removal of the larynx. Patients who undergo TL must also undergo voice rehabilitation with a prosthesis, electrolarynx, or esophageal speech. However, advances in partial laryngeal surgery, notably near-total, subtotal, extended partial laryngectomy, and endoscopic resection can remove the necessary cancerous tissue without overly aggressive resection of the larynx and pharynx, thereby maintaining voice. This concept of removing the cancerous tissue while aiming to maintain functionality of the phonatory mechanism is the driving force behind conservational laryngeal surgery.
 
Studies have shown that near-total laryngectomy (NTL) in select T3 and T4 laryngeal tumors provides a high rate of disease control comparable with that of the total laryngectomy. The NTL spares nontumor involved larynx, which is subsequently used for reconstruction. A patient who undergoes NTL speaks using an internal myomucosal shunt, which is lung powered. It does, however, require a tracheostomy for breathing. This article examines near-total laryngectomies and their role in the treatment of laryngeal cancer.

History of the Procedure

Billroth performed the first total laryngectomy in 1873; just 2 years later, he also performed the first hemilaryngectomy. Despite the hemilaryngectomy being a less-drastic alternative, many surgeons preferred and adopted the TL because they believed it was the most reliable manner for treating laryngeal cancer.  By the 1920s, the postoperative survival rate for TL was greater than 90%.   
 
Laryngologists, however, ultimately realized that a "one operation" concept was too aggressive, given the many nuances in disease, and that endolaryngeal surgery was more suited for some lesions. In 1980, Pearson and colleagues described an alternative to the standard TL in patients with stage T3 glottic cancers. Following pathologic examination of an excised larynx, they noted that in certain pathology specimens, the total larynx was often not involved in the disease process. As such, these researchers discovered that the uninvolved column of endolarynx could be preserved and converted into a sphincteric tube serving as a speech valve.

Since Pearson pioneered the model, the indications for NTL have been expanded to include tumors that cause unilateral vocal cord paralysis and patients undergoing or having undergone radiation therapy. Although the NTL is now an accepted alternative to TL for patients with glottic, supraglottic, base of tongue, and hypopharyngeal cancers, it is still a very limited technique.

The reasons for this may be two-fold. First, very few surgeons in the United States are comfortable performing a NTL. Second, at the same time that the NTL was introduced, Singer and Blom began popularizing tracheoesophageal puncture (TEP). TEP is a technique in which a puncture is made between the parting wall of the esophagus and the trachea, allowing a one-way valve to be inserted. This silicone prosthesis serves as a stent to prevent stenosis and aspiration but allows egress of air from the trachea to pharynx, thereby creating vibratory speech sounds. TEP is the preferred method of vocal rehabilitation when a TL is performed for oncologic soundness.
 
Despite being an underused technique, NTL has a number of advantages. With the composite speaking shunt created by NTL, the voice enters the pharynx, allowing the voice to sound more natural, independent of cricopharyngeal function. In addition, phonation does not result in bloating of the stomach and aspiration of the TEP prosthesis is not a risk. Ultimately, a neoglottis that is created via conservation surgery is more maintenance free.

Problem

Select patients with advanced (T3-T4) laryngeal cancers should be considered for conservation laryngeal surgery. Patients who have piriform sinus involvement, unilateral vocal fold fixation, cartilage invasion, and irradiation failure are considered candidates for NTL. Providing absolute indications and contraindications to the NTL procedure is difficult because decisions are made based on the surgeon’s operative experience and the patient’s wishes regarding extirpation of disease. In order for the NTL surgery to be successful, the surgeon must create a shunt that functions as a neoglottis during expiration/phonation but contracts when swallowing.

Frequency

Laryngeal cancer is the second most common site for head and neck malignancy. In the United States, 11,000 new cases are reported annually. Laryngeal cancer is more common in males and has a peak incidence during the sixth and seventh decades of life.

Etiology

Alcohol and tobacco have synergistic carcinogenic properties, which directly contribute to most causes of laryngeal cancer. Most laryngeal cancers have a squamous cell histopathology. A history of juvenile human papilloma virus is an additional but very infrequently encountered risk factor.

Pathophysiology

Laryngeal cancer commences at the cellular level with mutations in the DNA, either from genetic or environmental factors. This alteration then results in a neoplasm, which initially shows evidence of dysplasia, followed by carcinoma in situ, and ultimately manifests as an invasive carcinoma.

The lymphatic drainage in the larynx is compartmentalized. Pressman showed that there are tight fibrous and cartilaginous barriers preventing unimpeded spread.1 The spread to regional lymph nodes is dictated in part by the site of origin. Glottic tumors metastasize infrequently, whereas supraglottic and subglottic tumors metastasize more commonly. Supraglottic and subglottic tumors are the least likely to cause symptoms on initial presentation, and therefore often lead to a delayed diagnosis. As such, they most frequently have distant metastases, in 10-30% of cases.

Presentation

Unfortunately, many early symptoms of laryngeal cancer are closely associated with more common benign conditions. This often leads to late recognition of a more serious problem in this region. Early symptoms of advanced laryngeal cancer include hoarseness, sore throat, and odynophagia. Later symptoms include otalgia, dysphagia, dyspnea/stridor, and weight loss.  

Indications

The treatment for laryngeal carcinoma must be made on an individualized basis. General guidelines show that most head and neck cancer surgeons do not recommend primary radiation alone in patients with either extensive T2 or T3/T4 lesions. Near-total laryngectomy (NTL) is indicated in patients with advanced (T3, T4) laryngeal cancers when the postcricoid and interarytenoid areas are free of disease and the contralateral arytenoid is salvageable. Suitability for NTL is a complex process and all patients undergoing the procedure should be consented for total laryngectomy (TL), in the event that the tumor involvement is deemed more extensive intraoperatively.
 

Relevant Anatomy

CT scanning is very helpful preoperatively to evaluate submucosal extension, pre-epiglottic space involvement, and cartilage invasion. Additional attention must be paid to the postcricoid and interarytenoid mucosa (necessary to construct the myomucosal shunt) and to the contralateral ventricle, which is approached through the thyroid lamina (the safest point of entry).

Contraindications

Patients with tumor in the interarytenoid, postcricoid region, and bilateral arytenoids are not candidates for near-total laryngectomy (NTL).

A relative contraindication is extensive subglottic spread. In addition, although the incidence of aspiration is quite low, another relative contraindication is severe respiratory dysfunction. Finally, poor general health, notably poor pulmonary and cardiac function, is a relative contraindication to NTL.

Workup

Laboratory Studies

Order routine laboratory studies, including a basic chemistry panel (BMP), liver function test (LFT), and a complete blood count (CBC) to get a health baseline and look for metastases.

Elevated alkaline phosphatase indicates possible metastases or concomitant liver disease.

Elevated calcium levels should prompt further work-up for metastases.

Imaging Studies

Obtain a CT scan of the chest to rule out pulmonary metastases or synchronous primary tumors.

Order a neck/laryngeal CT scan with contrast for evaluation of cervical metastases to determine the presence or absence of cartilage invasion.

Other Tests

Patients often have chronic obstructive pulmonary disease (COPD) because of their heavy history of smoking. Pulmonary function tests may be indicated for some patients to determine pulmonary reserve and can help predict if lungs have sufficient power for phonation via the vibratory myomucosal shut.  

Diagnostic Procedures

Endoscopy should be performed prior to any type of laryngectomy to rule out synchronous primary cancers and to evaluate the primary laryngeal lesion and its appropriateness for surgery.

Histologic Findings

  • Greater than 93% of laryngeal tumors have a squamous cell histopathology.
  • Verrucous carcinomas are present in 2-4% of cases.
  • Adenocarcinomas and sarcomas occur in approximately 1% of cases, respectively.
  • The use of intraoperative frozen sections determines how extensive the resection must be to ensure complete excision of the lesion.

Staging

Laryngeal cancers are staged both clinically and radiographically prior to surgery. CT scans of the larynx with fine cuts, CT scans of the neck with and without contrast, and CT scans of the chest are obtained to characterize local spread and metastatic disease. Staging is generally performed as part of the endoscopy of stage T3 and T4 lesions.

Treatment

Medical Therapy

Since the Department of Veterans Affairs Laryngeal Cancer Study Group came out with their groundbreaking study in 1991, demonstrating that induction chemotherapy with radiation can have comparable survival rates to laryngectomy, nonsurgical management of laryngeal carcinoma has been on the rise.2 Currently, the percentage of advanced-stage patients treated with combined-modality chemoradiotherapy with radiotherapy (RT) has increased from 8.3% to 20.8%. RT alone has decreased from 38.9% to 23%. 

Radiotherapy technique

Postoperative radiation is implemented when a positive margin, multiple lymph node involvement, perineural invasion, and evidence of vascular spread are found. Radiation therapy usually begins approximately 4 weeks after near-total laryngectomy (NTL), giving time for the surgical site to heal. Intensity-modulated radiotherapy (IMRT) combined with concurrent chemotherapy shows promise in locoregional control of advanced laryngeal and hypopharyngeal carcinomas. 
 
IMRT uses computer modulation software to calculate and then deliver high doses of radiation to targeted tissues while minimizing the radiation delivered to nearby critical normal tissues. This technology is well suited for head-and-neck cancer because the tumor is often in proximity to critical normal tissues, such as the esophagus, spinal cord, internal jugular vein, and carotid artery. The most significant effects of radiation therapy include laryngeal necrosis, necrotizing fasciitis, and a carotid rupture. Most often patients develop mucositis, xerostomia, and pharyngoesophageal stricture.

Surgical Therapy

NTL aims to remove all local tumor tissue but spare contralateral glottic, subglottic, and arytenoids tissue for the purposes of preservation of tissue for reconstruction. Ultimately, the goal is to make a speaking shunt.

Patients with T3 and T4 laryngeal carcinomas should undergo selective neck dissections depending on tumor location. The choice between unilateral and bilateral neck dissection should be made based on whether the tumor crosses the midline.

Preoperative Details

Anesthesia should be made aware of office flexible laryngoscopy findings so as to plan for possible awake intubation. Occasionally, an awake tracheotomy needs to be performed. Preoperative preparation includes a metastatic evaluation, preoperative medical clearance, and perioperative antibiotic coverage.

Intraoperative Details

For a complete discussion of all of the surgical approaches to NTL and conservation laryngeal surgery, one is referred to a surgical atlas.

Wenig et al published a detailed surgical description.3 This article describes the use of intraluminal stenting, thyroid perichondrium and cervical fascia to create a functional glottic closure and realign the endolaryngeal mucosa.

After securing the airway either via intubation or a tracheotomy, a direct laryngoscopy (DL) is done to confirm the endolaryngeal extent of the tumor. This information is important because in order to accomplish a NTL, the postcricoid and interarytenoid areas must be clear of disease and at least one of the arytenoids must be saved to create a neoglottis.

Next, a neck dissection is undertaken with a curvilinear incision in the neck crease. This incision should be made in a separate incision from the tracheotomy. After completion of the selective neck dissection, the cancer-bearing side of the larynx is dissected for a routine laryngectomy. Subplatysmal flaps are elevated and the midline raphe is identified and incised as the strap muscles are retracted laterally.

The larynx can be entered either via the cricothyroid membrane at the noninvolved aspect of the larynx, ventricle, or the vallecula. The resection and cartilaginous cuts are different, depending on whether the patient has a glottic, supraglottic, or base-of-tongue primary. Mucosal endolaryngeal cuts are made around the tumor and include the ipsilateral arytenoids. The ultimate resection may include the Delphian nodes, ipsilateral thyroid lobe, involved thyroid and cricoid cartilage, as well as any involved portions of the hyoid. Care is taken to preserve the superior laryngeal nerve and vessels as well as the recurrent laryngeal nerve on the tumor-free side of the dissection.

After en block removal of the tumor, reconstruction of the neolarynx begins. This is the most challenging aspect of the operation. A tracheopharyngeal shunt needs to be created to allow breathing but prevent aspiration during swallowing. A 2.0 polyglactin suture is placed to suspend the epiglottis, which allows postoperative inspection of the larynx. The posterior defect is repaired using the elevated thyroid perichondrium and possibly the investing cervical fascia, which is sutured to the posterior mucosa with 4.0 polyglactin suture. On the side of the endolarynx with lesser involvement, the surgeon uses thyroid perichondrium from the ipsilateral side to lengthen the remnant of the true cord. The anterior wall is reconstructed with approximation of the strap muscles and the neck is closed in a layered fashion. Intraoperative frozen sections should be sent to the pathologist if a tumor is involved near critical margins, and if positive, a more extensive and likelytotallaryngectomy is performed.

Postoperative Details

All patients require a feeding tube placed intraoperatively for postoperative feedings. A surgical ICU bed should be reserved because the patient needs close monitoring for the first 24 hours after a tracheotomy. In addition, surgical drains should be closely monitored for development of a fistula. A speech consult is typically ordered and swallow assessment can be made. Oral feeding generally commences 7-10 days after surgery. The shunt is typically obstructed by tissue edema until approximately 6-12 weeks after surgery, when it can be used successfully.

Follow-up

All patients should ideally be presented at a head and neck oncology conference. Patients are monitored similar to any other patient with head and neck cancer, usually every month for the first year after surgery, every 2 months for the second year, every 3 months for the third year, every 6 months after 4 years postsurgery and every year after 5 years postsurgery. All patients should be followed by an oncologist and head and neck surgeon for life, even after 5 years with no evidence of disease.  

Speech therapy works with the patient to improve voice intelligibility. Patients can visit eMedicine’s links on Cancer and Tumors Center and Cancer of the Mouth and Throat for more information.

Complications

Complications are associated with near-total laryngectomy (NTL). Andrade et al found complications in nearly 29% of patients, the most common of which is pharyngocutaneous fistula in 21% of the patients. Minor aspiration, not requiring intervention occurred in 19% of patients. If, despite speech therapy, persistent aspiration occurs after the NTL, the shunt may need to be revised. Patients run the risk of higher recurrence of the cancerous tissue than those undergoing total laryngectomy, with recurrence rates of 30%-40% reported in the literature by Maceri et al.4

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.

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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

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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