Patient Preparation
Anesthesia
Prior to the induction of anesthesia, an airway management plan is coordinated with the anesthesiology team. In patients with bulky, airway obstructing tumors, an awake tracheotomy may need to be performed. In these cases, the tracheotomy should be performed using local anesthesia in the area of the planned laryngostoma. Once general endotracheal anesthesia is induced, the eyes should be taped shut and padded.
Positioning
The patient is laid in the supine position on the operating room table. A shoulder roll is placed to allow for gentle neck extension. The bed is rotated 180°.
Monitoring & Follow-up
Antibiotics are continued for at least 24 hours following laryngectomy. Routine postoperative care, including vital signs, intake and output monitoring, tracheostomy care, air humidification, and wound care is started for all patients following surgery. Ventilator assistance and bronchodilator therapy should also be considered in patients with co-existent chronic obstructive pulmonary disease (COPD). Labs to assess thyroid function and nutritional status should be ordered, especially in irradiated patients. Tube feeds are initiated once bowel sounds are present. Oral feeds are started after 1 week in nonirradiated patients. Postradiation patients should wait 2–3 weeks before starting oral feeds.
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Lateral radiograph of the neck showing the different structures of the larynx: a, vallecula; b, hyoid bone; c, epiglottis; d, pre-epiglottic space; e, ventricle (air-space between false and true cords); f, arytenoid; g, cricoid; and h, thyroid cartilage.
Tables
Laryngeal Subsite |
Primary Tumor (T) |
Regional Lymph Nodes (N) |
Distant Metastasis (M) |
Supraglottic |
T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures |
N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension N3: Metastasis in a lymph node, >6 cm in greatest dimension |
M0: No distant metastasis M1: Distant metastasis |
Glottic |
T1a: Tumor limited to one vocal cord T1b: Tumor involves both vocal cords T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage T4a: Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures |
N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension N3: Metastasis in a lymph node, >6 cm in greatest dimension |
M0: No distant metastasis M1: Distant metastasis |
Subglottic |
T1: Tumor limited to the subglottis T2: Tumor extends to vocal cord(s) with normal or impaired mobility T3: Tumor limited to larynx with vocal cord fixation T4a: Tumor invades cricoids or through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures |
N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension N3: Metastasis in a lymph node, >6 cm in greatest dimension |
M0: No distant metastasis M1: Distant metastasis |
Stage |
T |
N |
M |
I |
T1 |
N0 |
M0 |
II |
T2 |
N0 |
M0 |
III |
T3 T1-3 |
N0 N1 |
M0 M0 |
IVA |
T4a T1-3 |
N0-2 N2 |
M0 M0 |
IVB |
T4b T1-4 |
N1-3 N2 |
M0 M0 |
IVC |
T1-4 |
N1-3 |
M1 |
