Near-Total Laryngectomy Treatment & Management

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.

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.

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.

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 likely total laryngectomy is performed.

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.

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 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]

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]

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.