Near-Total Laryngectomy Treatment & Management
- Author: Brian Kip Reilly, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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. 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%.
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. 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.
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.
Outcome and Prognosis
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.
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.
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.
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. 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.
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.
Pressman JJ. Submucosal compartmentalization of the larynx. Ann Otol Rhinol Laryngol. 1956. 65:766-1.
Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991 Jun 13. 324(24):1685-90. [Medline].
Wenig BL, Stegnjajic A, Abramson AL. Glottic reconstruction following conservation laryngeal surgery. Laryngoscope. 1989 Sep. 99(9):983-5. [Medline].
Maceri DR, Lampe HB, Makielski KH, Passamani PP, Krause CJ. Conservation laryngeal surgery. A critical analysis. Arch Otolaryngol. 1985 Jun. 111(6):361-5. [Medline].
Suits GW, Cohen JI, Everts EC. Near-total laryngectomy. Patient selection and technical considerations. Arch Otolaryngol Head Neck Surg. 1996 May. 122(5):473-5. [Medline].
DeSanto LW. Cancer of the supraglottic larynx: a review of 260 patients. Otolaryngol Head Neck Surg. 1985 Dec. 93(6):705-11. [Medline].
Akbas Y, Demireller A. Oncologic and functional results of supracricoid partial laryngectomy with cricohyoidopexy. Otolaryngol Head Neck Surg. 2005 May. 132(5):783-7. [Medline].
Ambrosch P, Kron M, Steiner W. Carbon dioxide laser microsurgery for early supraglottic carcinoma. Ann Otol Rhinol Laryngol. 1998 Aug. 107(8):680-8. [Medline].
Andrade RP, Kowalski LP, Vieira LJ, Santos CR. Survival and functional results of Pearson's near-total laryngectomy for larynx and pyriform sinus carcinoma. Head Neck. 2000 Jan. 22(1):12-6. [Medline].
Brasnu D, Laccourreye H, Dulmet E, Jaubert F. Mobility of the vocal cord and arytenoid in squamous cell carcinoma of the larynx and hypopharynx: an anatomical and clinical comparative study. Ear Nose Throat J. 1990 May. 69(5):324-30. [Medline].
Chen AY, Schrag N, Hao Y, Flanders WD, Kepner J, Stewart A, et al. Changes in treatment of advanced laryngeal cancer 1985-2001. Otolaryngol Head Neck Surg. 2006 Dec. 135(6):831-7. [Medline].
Chevalier D, Laccourreye O, Brasnu D, Laccourreye H, Piquet JJ. Cricohyoidoepiglottopexy for glottic carcinoma with fixation or impaired motion of the true vocal cord: 5-year oncologic results with 112 patients. Ann Otol Rhinol Laryngol. 1997 May. 106(5):364-9. [Medline].
DeSanto LW, Pearson BW, Olsen KD. Utility of near-total laryngectomy for supraglottic, pharyngeal, base-of-tongue, and other cancers. Ann Otol Rhinol Laryngol. 1989 Jan. 98(1 Pt 1):2-7. [Medline].
Dumich PS, Pearson BW, Weiland LH. Suitability of near-total laryngopharyngectomy in piriform carcinoma. Arch Otolaryngol. 1984 Oct. 110(10):664-9. [Medline].
Genden EM, Ferlito A, Rinaldo A, Silver CE, Fagan JJ, Suárez C, et al. Recent changes in the treatment of patients with advanced laryngeal cancer. Head Neck. 2008 Jan. 30(1):103-10. [Medline].
Herranz-González J, Gavilán J, Martínez-Vidal J, Gavilán C. Supraglottic laryngectomy: functional and oncologic results. Ann Otol Rhinol Laryngol. 1996 Jan. 105(1):18-22. [Medline].
Iro H, Waldfahrer F, Altendorf-Hofmann A, Weidenbecher M, Sauer R, Steiner W. Transoral laser surgery of supraglottic cancer: follow-up of 141 patients. Arch Otolaryngol Head Neck Surg. 1998 Nov. 124(11):1245-50. [Medline].
Jepsen MC, Gurushanthaiah D, Roy N, Smith ME, Gray SD, Davis RK. Voice, speech, and swallowing outcomes in laser-treated laryngeal cancer. Laryngoscope. 2003 Jun. 113(6):923-8. [Medline].
Kirchner JA, Som ML. Clinical significance of fixed vocal cord. Laryngoscope. 1971 Jul. 81(7):1029-44. [Medline].
Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol. 1990 Jun. 99(6 Pt 1):421-6. [Medline].
Laccourreye O, Weinstein G, Brasnu D, Trotoux J, Laccourreye H. Vertical partial laryngectomy: a critical analysis of local recurrence. Ann Otol Rhinol Laryngol. 1991 Jan. 100(1):68-71. [Medline].
Lee NY, O'Meara W, Chan K, Della-Bianca C, Mechalakos JG, Zhung J, et al. Concurrent chemotherapy and intensity-modulated radiotherapy for locoregionally advanced laryngeal and hypopharyngeal cancers. Int J Radiat Oncol Biol Phys. 2007 Oct 1. 69(2):459-68. [Medline].
Levine PA, Debo RF, Reibel JF. Pearson near-total laryngectomy: a reproducible speaking shunt. Head Neck. 1994 Jul-Aug. 16(4):323-5. [Medline].
Lima RA, Freitas EQ, Kligerman J, Paiva FP, Dias FL, Barbosa MM, et al. Near-total laryngectomy for treatment of advanced laryngeal cancer. Am J Surg. 1997 Nov. 174(5):490-1. [Medline].
Motta G, Esposito E, Testa D, Iovine R, Motta S. CO2 laser treatment of supraglottic cancer. Head Neck. 2004 May. 26(5):442-6. [Medline].
Naudo P, Laccourreye O, Weinstein G, et al. Complications and functional outcome after supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg. 1998 Jan. 118(1):124-9. [Medline].
Pearson BW, Salassa JR, Hinnir ML. Transoral Laser Micro Resection of Advanced Laryngeal Tumors. Cummings, CW, Flint PW, et al. Otolaryngology-Head and Neck Surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005. 2326-2345.
Pradhan SA, Pai PS, Neeli SI, et al. Transoral laser surgery for early glottic cancers. Arch Otolaryngol Head Neck Surg. 2003 Jun. 129(6):623-5. [Medline].
Rademaker AW, Logemann JA, Pauloski BR, Bowman JB, Lazarus CL, Sisson GA, et al. Recovery of postoperative swallowing in patients undergoing partial laryngectomy. Head Neck. 1993 Jul-Aug. 15(4):325-34. [Medline].
Robbins KT, Michaels L. Feasibility of subtotal laryngectomy based on whole-organ examination. Arch Otolaryngol. 1985 Jun. 111(6):356-60. [Medline].
Steiner W, Ambrosch P. Endoscopic Laser Surgery of the Upper Aerodigestive Tract. New York, NY: Thieme, 2000.
Tufano RP. Organ preservation surgery for laryngeal cancer. Otolaryngol Clin North Am. 2002 Oct. 35(5):1067-80. [Medline].
Tufano RP, Weinstein GS, Laccourreye O. Conservation Laryngeal Surgery. Cummings, CW, Flint PW, et al. Otolaryngology-Head and Neck Surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005. 2346-2380.
Weinstein GS, Laccourreye O, Brasnu D, Yousem DM. The role of computed tomography and magnetic resonance imaging in planning for conservation laryngeal surgery. Neuroimaging Clin N Am. 1996 May. 6(2):497-504. [Medline].
Yu L, Syms C 3rd, Dietz W. Laryngeal compartmentalization after radiation therapy in a canine model. Otolaryngol Head Neck Surg. 2001 Oct. 125(4):385-92. [Medline].
Zhang B, Xu ZG, Tang PZ. Elective lateral neck dissection for laryngeal cancer in the clinically negative neck. J Surg Oncol. 2006 May 1. 93(6):464-7. [Medline].