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

Conservation Laryngeal Surgery, Near-Total Laryngectomy: Treatment

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

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

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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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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