Continuing Education Activity
The primary goal for the treatment of laryngeal cancer is the control of the disease. Preservation of speech, swallowing functions, and avoidance of the tracheostomy are secondary goals. Traditionally the treatment of laryngeal carcinomas has been radiotherapy or surgery, or a combination of both. The treatment for laryngeal cancer depends on selecting the most appropriate treatment plan for the individual patient, often determined by the expertise of an interprofessional team. Total laryngectomy is the standard of care for surgical salvage in laryngeal cancer. This activity reviews the evaluation, treatment, and the various issues related to the procedure in patients with this condition.
- Identify the indications for total laryngectomy.
- Describe the technique of total laryngectomy.
- Review the appropriate evaluation before total laryngectomy.
- Summarize interprofessional team strategies for improving care coordination and communication to advance total laryngectomy and improve outcomes.
The primary goal for the treatment of laryngeal cancer is the control of the disease. Preservation of speech, swallowing functions, and avoidance of the tracheostomy are secondary goals. Traditionally the treatment of laryngeal carcinomas has been radiotherapy or surgery, or a combination of both. The treatment for laryngeal cancer depends on selecting the most appropriate treatment plan for the individual patient, often determined by the expertise of an interprofessional team.
In selecting treatment, several anatomic, physiologic, geographic, and vocational factors play a role. The most important parameters influencing treatment selection are the location and extent of the primary tumor and the status of the regional lymph nodes.
In the past, early-stage carcinomas were treated with external radiotherapy, keeping surgery in reserve for salvage. On the other hand, advanced cancer was often treated with a total laryngectomy, followed by postoperative radiation therapy. In the last decade, the focus for therapeutic approaches for malignant laryngeal tumors has shifted to "organ preservation." Treatment modalities such as transoral laser microsurgery (TOLM) and transoral robotic surgery (TORS) have opened up new surgical possibilities. Total laryngectomy remains a therapeutic option, as first-line therapy, in patients who are not suitable for organ-preserving techniques or, in case of the more conservative measure, fail.
Anatomy and Physiology
The larynx is found in the anterior neck, connecting the inferior portion of the pharynx with the cervical trachea. There are six cartilage "rings," three are unpaired (thyroid, cricoid, epiglottic) and three paired (arytenoid, cuneiform, corniculate). Each cartilage is surrounded by connective and muscular tissue. Although the hyoid bone, attached to the thyroid cartilage through the thyrohyoid membrane, is not a part of the laryngeal framework, it plays an important role in the swallowing function of the upper aerodigestive tract. For classification purposes, based on embryologic development, the larynx is divided into three regions, of which each includes several subsites:
- Supraglottis: This comprises the larynx superior to the apex of the ventricle. It includes the ventricle, vestibular folds, arytenoids, aryepiglottic folds, and the epiglottis.
- Glottis: This comprises the vocal cords and the anterior and posterior commissure.
- Subglottis: It extends from the inferior border of the glottis to the lower border of the cricoid cartilage.
The surface mucosa of the larynx consists of squamous epithelium with interposed mucous glands. The true vocal cords are lined by stratified squamous epithelium.
The sensory nerve supply to the supraglottic larynx is provided by the internal branch of the superior laryngeal nerve (nerve of Galli-Curci). The mucosa of the true vocal cords derives dual sensory nerve supply from the superior laryngeal and recurrent laryngeal nerves. In contrast, the subglottic larynx derives its sensory supply from the recurrent laryngeal nerve. The intrinsic musculature of the larynx derives its innervation from the recurrent laryngeal nerve except for the cricothyroid muscle, which is innervated by the external laryngeal branch of the superior laryngeal nerve. The larynx derives its blood supply from branches of the superior and inferior thyroid arteries.
The supraglottic larynx has a rich lymphatic network draining into lymph nodes at levels II and III. The lymphatic network of the glottic part is very sparse, especially the free edge of the true vocal cord, which is devoid of lymphatics. Subglottic larynx drain into the paratracheal and deep jugular lymph nodes.
A total laryngectomy is indicated for patients with:
- Advanced laryngeal cancer or hypopharynx with the invasion of thyroid or cricoid cartilage and extra laryngeal soft tissue;
- Failed response to radiotherapy or chemoradiotherapy;
- Extensive tumors of histologic entities not suitable for conservative treatment;
- Histopathological subtypes of tumors that have proven resistant to radiotherapy: soft tissue sarcomas, chondrosarcomas, melanomas, adenocarcinomas, large cell neuroendocrine tumors, tumors of the minor salivary glands;
- Severe laryngeal trauma that doesn't allow functional reconstruction of the organ;
- Patients who have no voice and have chronic aspiration due to palsy of cranial nerves IX, X, and XI;
- Recurrent laryngeal papillomatosis with an increased risk of tracheal invasion.
Contraindications for surgery include the presence of incurable synchronous tumors or distant metastases, a poor general condition resulting in high anesthetic risk, a tumor that encases the common or internal carotid artery, or that invading the profound parts of the tongue.
The patient is placed on the operating table under general endotracheal anesthesia through an orotracheal tube. If difficult intubation is anticipated due to airway compromise, a preoperative tracheotomy will need to perform with local anesthesia and vasoconstrictor preparation.
A standard total laryngectomy procedure encompasses the entire larynx with its attached prelaryngeal strap muscles and the lymph nodes in the jugular chain (levels II, III, and IV). The most common skin incision used for total laryngectomy is the Gluck - Sorenson U-shaped incision. The starting point of the incision is located at the apex of the mastoid, continued on the anterior border of the sternocleidomastoid muscle up to 1 to 2 cm above the upper edge of the sternal notch, and it is continued in the same way on the opposite side. If a tracheotomy were performed before this procedure, the tracheal stoma would be included in the skin incision. Flap elevation should be in the subplatysmal plane, immediately above anterior and external jugular veins; therefore, the vascularisation of the flap is guaranteed by the anterior and external jugular veins that should remain attached to the underlying tissues. The upper and lower skin flaps are elevated to get exposure from the hyoid to the suprasternal notch.
Mobilization of the larynx begins superiorly by detaching the muscles attached to the upper surface of the hyoid bone. Dissection proceeds to isolate the superior thyroid artery and its superior laryngeal branch. These are identified, dissected, and ligated (identification and ligation of these vessels will minimize hemorrhage during mobilization of the larynx). The sternocleidomastoid muscle is retracted laterally to expose the carotid sheath, and deep jugular lymph nodes at levels II, III, and IV are dissected and mobilized toward the specimen.
As dissection proceeds, the sternohyoid and sternothyroid muscles are divided as low in the neck as possible. After having divided and ligated the inferior thyroid artery, the thyroid gland is separated from the trachea. Finally, the thyroid isthmus is divided using two clamps. Division of the isthmus exposes the cervical trachea. The inferior constrictor muscle is detached from the posterior edge of the thyroid cartilage bilaterally with the electrocautery.
An incision is made in the anterior tracheal wall at a level depending on the lower extent of the tumor. The trachea is divided obliquely, leaving a short anterior wall and a long posterior wall so as to bevel lateral tracheal walls superiorly to enlarge the tracheostomy. The distal trachea is sutured to the skin edges of the permanent tracheostomy with interrupted nylon sutures. The proximal trachea and larynx are dissected from the cervical esophagus by sharp dissection.
Finally, entry is made in the pharynx either through the vallecula or the posterior cricoid region, depending on the tumor localization. After opening the mucosa to enter the pharynx, the mucosal incision is continued along the periphery of the larynx until the opening is large enough to permit the introduction of a retractor in the pharynx. Subsequent removal of the larynx by the division of its mucosal attachments is completed under direct vision. If planned, a tracheoesophageal puncture (TEP) is performed at this time. The pharyngeal defect is closed, preferably in a transverse fashion. A running Connell inverting suture (true or modified) with 3-0 Vicryl is used to close the pharyngeal defect beginning inferiorly with meticulous attention. After the closure of the pharynx, suction drains are placed lateral to the pharynx, the platysma is closed with interrupted Vicryl sutures, and the skin is closed with interrupted nylon sutures.
Early complications after total laryngectomy include bleeding, postoperative edema, and airway compromise. These, especially in the immediate postoperative, should be carefully monitored. Administration of corticosteroids is recommended to minimize postoperative edema and airway compromise, hematoma or seroma, which should be prompt surgically evacuated, wound infection related to the perioperative exposure of the wound to bacteria, it could be minimized using a broad-spectrum antibiotic coverage and pharyngocutaneous fistula; total laryngectomy patients are at risk for pharyngeal suture line dehiscence with a resultant pharyngocutaneous fistula. The incidence of fistula formation is dependent on tension on the pharyngeal suture line, the configuration of the pharyngeal closure ("T" closure of horizontal closure), previous radiotherapy or chemoradiotherapy, nutritional status of the patient, and presence of medical comorbidity (e.g., diabetes). Support of the pharyngeal suture line with a pectoralis muscle flap is a useful measure that may reduce the risk and the severity of pharyngocutaneous fistula. Late complications include pharyngoesophageal stenosis, stoma stenosis, and hypothyroidism.
Enhancing Healthcare Team Outcomes
Total laryngectomy represents a well codified ablative surgical procedure. Expertise and knowledge from an interprofessional healthcare team will likely require input from a head and neck surgeon, a pulmonologist, an oncologist, a radiologist, a radiotherapist, and a pathologist. The team will need to consider the biological behavior of laryngeal cancer and the anticipated responses to different therapies. Additional support from speech and swallowing therapists, nutritionists, psychiatrists, along with expert nursing care, are equally important in the treatment program. Interprofessional dialogue is critical in the management of laryngeal cancer.