Which of the following methods most resembles normal speech following a total laryngectomy?

Neck Dissection and Laryngectomy

Neck dissection is commonly performed in isolation or during laryngectomy to prevent or treat any local spread of head and neck malignancy.168,169 The extent of a neck dissection operation is based on the extent to which the neck’s six lymph node levels are involved, as well as on the extent to which additional structures (spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle) are removed. Depending on the degree to which the tumor can be removed and recurrence or spread can be prevented, as well as the extent that phonation and swallowing can be preserved, various surgical options are exercised. Limited disease is sometimes managed by radiation, by laser and microsurgery, or by partial laryngectomy, thus preserving organ function. In total laryngectomy, the larynx is removed in its entirety, with the airway ending in a stoma formed by bringing the cut end of the trachea to the neck surface (with the result that the trachea now becomes independent of the esophagus.) Often a perforation between the trachea and the esophagus (tracheoesophageal puncture) is made to allow eventual placement of a voice prosthesis.170 In some cases the procedure is supplemented with microvascular free tissue transfer (free flap).

Anesthesia can be induced through a standard intravenous line, followed by large-bore intravenous and arterial lines placed after induction. A central line can usually be avoided, with systolic pressure variation of the arterial line tracing and other clinical findings to guide fluid replacement. Although nerve function monitoring is usually required during the neck dissection phase, neuromuscular blockade is acceptable at the beginning. When neuromuscular blockade is no longer desirable, opioid infusions (e.g., remifentanil) are often used to maintain adequate analgesia in conjunction with an inhaled anesthetic agent. Many clinicians prefer using a balanced technique in preference to deep inhalational anesthesia or TIVA (propofol with or without remifentanil) to avoid the troublesome hypotension. Excessive intravenous crystalloid administration should be avoided to prevent operative site edema.

In total laryngectomy cases, a tracheostomy is customarily performed near the beginning of the procedure by using a wire-reinforced ETT placed into the stoma. (Warning: accidental endobronchial intubation commonly occurs in this setting.) In some cases, the patient is turned 180 degrees from the anesthesia machine; care must be taken to ensure that nothing is disconnected in the process. Extubation in such cases is extraordinarily simple; the ETT should be removed from the stoma when extubation criteria are met. Should reintubation ever become necessary, one merely reintroduces the tracheal tube into the stoma. The patient is then simply brought to the postanesthesia care unit with an oxygen mask placed over the stoma, although when a free flap has been performed, the patient is often brought to the ICU intubated, ventilated, and sedated (depending on the surgeon’s preferences and local protocols.)

Oncologic Results of Open Partial Laryngectomy

Open partial laryngectomy comprises a heterogeneous group of procedures. Before the 1970s, partial laryngectomy primarily consisted of VPL and SGL. As SCPL–CHP and SCPL–CHEP became established in the 1970s and 1980s, data began to emerge showing the improved oncologic results of SCPL over VPL. Laccourreye compared VPL versus SCPL in T2N0 laryngeal cancers. The 10-year local control rate for VPL in 85 patients was 69.3%, compared with 94.6% for SCPL.44 A systematic review of open conservation partial laryngectomy for primary laryngeal cancer was carried out by Thomas and colleagues.45 Papers were restricted to those in the English language from 1980 onward from centers reporting more than 10 cases. Outcome measures were pooled but were also reported individually. The pooled local control rate for all the included studies was 89.8% (95% confidence interval [CI], 88.3 to 91.2) with a range of 69.3–100%. Although there are no published results specifically for T3 supraglottic cancer, one case series reported a local control rate of 85% for SCPL–CHEP for T3/T3 glottic cancer.46 In the studies in which OS was reported, the pooled OS rate was 79.7% (95% CI, 76.5 to 82.8) with a range of 46.2–100%. Similarly, where DFS was reported, the pooled DFS rate was 84.8% (95% CI, 80.6 to 88.7) with a range of 49–100%. The pooled decannulation rate was 96.3% (95% CI, 94.9 to 97.6), pooled laryngectomy rate for function 1.7% (95% CI, 1.2 to 2.2), pooled laryngectomy rate for salvage 6.0% (95% CI, 4.6 to 7.6), and pooled larynx preservation rate 90.9%. The pooled operative mortality rate was 0.7%. The heterogeneous results reflect different operations with follow-up periods ranging from 24 to 120 months. Data for SCPL were also separately analyzed, showing a pooled local control rate of 93.5% and a DFS rate of 80.5%.

Supracricoid Laryngectomy With Cricohyoidopexy

Supraglottic carcinomas that are not amenable to supraglottic laryngectomy because of glottic level involvement, either through the anterior commissure or the ventricle, preepiglottic space invasion; decreased cord mobility; or limited thyroid cartilage invasion will frequently be resectable with SCPL-CHP. These lesions are not rare, and in one study the incidence of spread of supraglottic carcinoma to the glottic level was between 20% and 54%.65 Glottic-level invasion should be suspected when there is either impaired cord mobility or extension of carcinoma to the ventricle.65 The oncologic success of the SCPL for supraglottic cancer can be attributed to the en bloc resection of the bilateral paraglottic spaces, the preepiglottic space, and the entire thyroid cartilage. Contraindications to the procedure include (1) subglottic extension greater than 10 mm anteriorly and 5 mm posteriorly, because of the potential for cricoid cartilage involvement; (2) arytenoid fixation; (3) massive preepiglottic space invasion with involvement of the vallecula; (4) extension to the pharyngeal wall, vallecula, base of the tongue, postcricoid region, and interarytenoid region; and (5) cricoid cartilage invasion.71

In a series of selected supraglottic carcinomas, Laccourreye and colleagues72 found there were no local recurrences in 68 patients (T1, 1; T2, 40; T3, 26; and T4, 1) with a minimum follow-up period of 18 months. Laccourreye and others159 later reported on 19 patients with gross pathologic invasion of the preepiglottic space, with a minimum follow-up period of 5 years, and noted a local control rate of 94.7% (18 of 19). Chevalier and Piquet160 reported on their series of 61 consecutive cases of supraglottic carcinoma managed with SCPL-CHP and noted a local recurrence rate of 3.3% (2 of 61). Nine case series of SCPL-CHP from around the world all demonstrate local recurrence rates less than 10% (Table 108.10). In the series from the United States, Sperry and colleagues129 reported on 17 patients who underwent primary treatment for transglottic or supraglottic cancer by SCPL-CHP, noting 5-year local control was 100%, locoregional control was 88%, larynx preservation was 100%, disease-specific survival was 86%, and overall survival was 71%. Half of these patients had nodal metastases, 18% had T2 disease, 71% were staged as T3, and 76% had advanced-stage (stage III or IV) disease.

Vertical partial laryngectomy (VPL)

VPL (or vertical hemylaryngectomy) encompasses a spectrum of procedures ranging from laryngofissure with cordectomy to extended hemi-laryngectomy. Common to all these procedures is vertical transection of thyroid cartilage and glottic resection extending into the paraglottic space (Fig. 6). In VPL, vertical incisions are made through the thyroid cartilage near the anterior commissure and just anterior to the posterior edge of the thyroid cartilage. The resulting resection includes the true vocal cord and immediate sub glottis, ventricle, false vocal cord, and arytenoepiglottic fold, and usually crosses just in front of the vocal process of the arytenoid posteriorly. This area can extend around the anterior commissure to involve the anterior one-third of the opposite vocal cord if required. When the anterior commissure is removed, the procedure is termed a frontolateral hemylaryngectomy.

It is a well-established procedure for T1 and T2 glottic cancers. Some authors believe that patients with fixation of the true vocal cord (T3) caused by direct invasion of the cancer into the thyroarytenoid muscle are still candidates for a vertical hemylaryngectomy. However, in patients with vocal cord fixation caused by cricoarytenoid joint invasion a hemilaryngectomy should not be considered. Other contraindications are involvement of the posterior commissure or the thyroid cartilage, and extension superiorly to the aryepiglottic fold.

With this technique overall local control and laryngeal preservation rates, between 82 and 95% have been reported for T1–T2 cases, and 5-year survival rates were greater of 90%. The local control and 5-year survival rates were lower for T3 cases, with reported local control rates between 73% and 85%. These results reflect the continuing value of the VPL in selected cases. However, currently, with the advancement of laser surgery, the role of the VPL is questionable. For most patients with lesions amenable to VPL, laser surgery provides equal local control rates, with superior voice and swallowing function and less complications. And because the relatively high recurrence rates in T3 cases, VPL was replaced by supracricoid laryngectomy for these cases in many centers.

Laryngectomy

Before 1970, laryngectomy was considered the surgical procedure of choice for the management of chronic aspiration, because it provides definitive separation of the upper digestive and respiratory tracts. Narrow-field laryngectomy (Fig. 65.1) is used, in contrast to the total laryngectomy performed for malignancy, because it preserves the hyoid, strap muscles, and as much hypopharyngeal mucosa as possible. Closure without tension and with strap muscle reinforcement minimizes the potential postoperative complications of pharyngeal stenosis and fistula.65 A staple-assisted laryngectomy technique designed specifically for treatment of aspiration may provide a technically straightforward method to decrease the postoperative fistula rate.66

Laryngectomy is also practical because of the low likelihood of recovery of most patients with chronic aspiration.67,68 However, because of the negative psychosocial aspects of laryngectomy, most patients and family members are reluctant to consent to laryngectomy for chronic aspiration. Narrow-field laryngectomy can be performed with local anesthesia. Tracheoesophageal puncture and placement of a voice prosthesis can be used for vocal rehabilitation after laryngectomy in selected patients. Because of the disadvantage of irreversibility of laryngectomy and the observation that some patients with chronic aspiration recover, other surgical procedures have been developed since the 1970s for the surgical management of chronic aspiration.

Postsurgical/Postprocedural

Total Laryngectomy: Fluoroscopic evaluation in patients after total laryngectomy demonstrates a smooth neopharynx that extends as a tube from the oropharynx to the cervical esophagus. The neopharynx may deviate toward the side of lateral neck dissection on AP views, if one was performed. The hyoid bone and laryngeal cartilage are removed and will not be evident on fluoroscopic evaluation. There is increased prevertebral soft-tissue density at the level of C4–C5 in patients after laryngectomy secondary to retracted thyropharyngeal and cricopharyngeal muscles that have been surgically detached from their usual anterior attachments.3

Partial Laryngectomy: Depending on the size and location of the tumor, partial laryngectomy can sometimes be performed. In these cases, some amount of swallowing function can be preserved depending on the postoperative anatomy. The appearance of the larynx can vary widely depending on the type of resection and reconstruction performed.3,16 Close attention to the operative report is crucial for accurate interpretation of fluoroscopic evaluation after partial laryngectomy. Evaluation for aspiration is particularly important given the risk for postoperative compromise of swallow function.

Total Laryngectomy and Swallowing

TL involves the surgical removal of the larynx and establishment of tracheal stoma on the neck skin, thus permanently separating the airway and swallowing. As a result of the division of these systems, airway protection is no longer a concern; however, swallowing efficiency is often impaired. In a 2002 report by Ward et al.,26 only 58% of patients undergoing TL and 50% of those undergoing total laryngopharyngectomy were able to enjoy a normal diet in 3 years following surgery. Maclean et al.27 surveyed 110 laryngectomees in Australia regarding swallowing function. Their data demonstrated that 71% self-reported some degree of dysphagia following TL. Swallowing complaints included food sticking in the throat daily, longer time required to swallow, and tightness in the throat daily. Social eating was reportedly avoided in 57% of those reporting dysphagia. Those patients reporting dysphagia were more likely to have depression, anxiety, and stress in comparison to those who did not report dysphagia after TL. Patients with dysphagia following TL may report an increased sense of social isolation due to the combined impact of their communication and swallowing difficulties.28 Thus, while aspiration may not be a concern after TL, dysphagia may still have significant implications.

The assessment of dysphagia following TL requires direct visualization of the swallowing passage to ascertain the exact etiology. The videofluoroscopic swallowing study (VFSS) is the most effective method for evaluating swallowing following TL. The VFSS is preferred in this population as it allows for visualization of the UES and cervical esophagus as well as assessment of bolus flow through the neopharynx. It should be emphasized that the intent of the VFSS with laryngectomees is not to evaluate for aspiration but rather to assess for other factors such as postoperative fistulas, strictures, efficiency of bolus clearance, and pseudoepiglottis and pseudovallecula. The VFSS can also be used to assess the cervical esophagus in relation to tracheoesophageal voice prosthesis issues. With the rising incidence of salvage laryngectomy following radiation-based treatment in contrast to primary laryngectomy,29 the VFSS is increasingly used following surgery to assess healing and identifying potential complications such as pharyngocutaneous fistula. Historically, pharyngocutaneous fistula was uncommon and impacted less than 20% of patients; however, in the era of salvage surgery, rates have risen to nearly 30%.30,31 The presence of a postoperative fistula will delay initiation of oral intake. A prolonged nil per os (NPO) status may result in issues such as atrophy, fibrosis, and stricture leading to further delays in diet advancement. While pharyngocutaneous fistula has a marked impact on oral intake, it is typically a transient condition expected to resolve over time.

Disruption of typical pharyngeal physiologic function is anticipated following laryngectomy; however, unlike pharyngocutaneous fistula, these issues do not typically resolve with time. Thus, the swallowing problems associated with changes in the pharyngeal swallow apparatus are likely to persist over time and are likely to be of greater severity in patients undergoing salvage laryngectomy.32,33 One common issue impacting the efficiency of bolus clearance is related to the removal of the hyolaryngeal complex. The elevation and anterior excursion of the hyolaryngeal complex is responsible for the traction forces that pull open the UES. Thus, disruption of this force may result in decreased bolus clearance into the esophagus. Driving pressures behind the bolus are also important for pharyngeal clearance and bolus entry into the esophagus. Disruption of the pharyngeal constrictors will result in lower bolus driving pressures, thus impacting both pharyngeal stripping and UES opening. Typically, a myotomy will be performed during TL to reduce resistance at the level of the UES.34

In addition to the alteration of muscular influences leading to reduced traction of and pressure against the UES, stricture may further restrict bolus flow into the esophagus. Stricture is a common challenge after TL with incidence rates ranging from ∼19% to 39%.35,36 Strictures are particularly common in patients undergoing salvage surgery with hypopharyngeal primary tumors, closed primarily rather than with free tissue transfer, in females and in those requiring extended laryngectomy.37–39 Dilation or stretching of the region of stricture has been the primary treatment approach; however, in order to adequately manage stricture, dilation may need to be repeated multiple times.40

Manometric assessment has contributed greatly to our understanding of pressure changes following TL. Most notably, manometry has demonstrated that intrabolus pressures are consistently high following laryngectomy and that higher intrabolus pressure is associated with worse patient perceived dysphagia.40 This suggests that despite the typical practice of myotomy during laryngectomy, there remains obstruction of bolus flow at the level of the UES (see Fig. 21.3). Additionally, hypopharyngeal peak contraction is typically lower in patients following laryngectomy in comparison to controls, although not associated with increasing dysphagia severity40,41 (see Fig. 21.4).

Another possible contributor to postlaryngectomy dysphagia is the formation of a pseudoepiglottis/pseudovallecula. This is a structural byproduct of vertical closure and looks much like a normal epiglottis/vallecula on videofluoroscopy36 (see Fig. 21.5). In Davis' series, all patients with vertical closure and two-thirds of patients with T-closure had pseudoepiglottis following TL. As the pseudoepiglottis is an immobile structure, foods and liquids may build up in the pseudovallecular space, potentially backflowing into the oral or nasal passages. If warranted, laser resection may be offered to eliminate this problem.

PATIENT SELECTION

VPL is ideally suited for primary treatment of glottic cancers that are not likely to be satisfactorily managed with endoscopic laser excision or radiotherapy.3 These lesions typically include bulky T1 cancer of the true vocal cord (TVC) involving the anterior commissure or the vocal process of the arytenoids, cancer of the TVC with invasion of the vocalis muscle but not the thyroid cartilage, or T2 cancers that extend above or below the level of the TVC.4 It should be noted that large tumor volume correlates with the likelihood of radiation failure in early-stage vocal cord cancer.5 The procedure is also appropriate for surgical salvage of selected patients with persistent carcinoma of the vocal cord after initial treatment with radiotherapy, for early glottic cancer in patients who wish to avoid radiotherapy, and for patients with verrucous carcinoma.

The most commonly performed procedure is a vertical frontolateral partial laryngectomy (Fig. 48-1). Many surgeons now perform supracricoid partial laryngectomy (SPL) with cricohyoidoepiglottopexy to manage more extensive cancer involving both vocal cords, the anterior commissure, and the paraglottic space.6 These procedures rely on very different paradigms of reconstruction, so decisions to use one or the other technique must be made before surgery.

Cancer involving the cricoid cartilage is a contraindication to hemilaryngectomy and a relative contraindication to SPL. Recently, Laccourreye and colleagues7 reported excision of the superior aspect of the cricoid cartilage in patients with extensive subglottic extension. Therefore, the cancer should ideally not extend more than 1 cm subglottically at the anterior commissure and no more than 5 mm subglottically posteriorly. Cancer extending onto the arytenoid cartilage is theoretically resectable by SPL as long as there is a sufficient margin of resection in the posterior commissure and the contralateral arytenoid can be left intact. Cancers with vocal cord fixation or those that extend through the ventricle up onto the false vocal cord (transglottic) are not suitable for VPL. These cancers may be pathologically T4 because of proximity of the laryngeal ventricle to thyroid cartilage with resultant cartilage invasion and may spread by way of the rich lymphatic drainage into the cervical lymph nodes.8,9 Because thyroid cartilage is resected by SPL, some of these cancers may be candidates for supracricoid resection if the cricoarytenoid joint is free of involvement (see Chapter 47).7

Extended frontolateral partial laryngectomy with epiglottopexy is feasible and in the past was considered a standard procedure for larger tumors involving both vocal cords. However, this procedure results in glottic dysfunction and has largely been supplanted by SPL.

Decisions regarding resection of thyroid cartilage and methods of reconstruction after VPL remain controversial. If the thyroid ala is left in situ, a soft tissue flap, typically strap muscle, may be used to fill the void.9 Brasnu and coauthors reported the use of a false vocal cord (if uninvolved) flap for reconstruction.10 We routinely resect the ipsilateral thyroid ala to permit the adjacent soft tissue to fall into the void created by tumor resection, which results in acceptable voice postoperatively. Patients with cancer involving the anterior commissure are good candidates for VPL because the results of treatment with radiation therapy and laser surgery are poor.11

Definition/Background

Partial laryngectomy procedures are performed to treat various-sized tumors of the supraglottic larynx. These procedures spare the true vocal cords and preserve speech. This case illustrates a “horizontal” or “supraglottic” laryngectomy. During supraglottic laryngectomy, the surgeon removes the epiglottis, aryepiglottic folds, and upper third of the thyroid cartilage. In some patients, one arytenoid cartilage or a small portion of the medial wall of the piriform sinus may be removed. The hyoid bone may be resected, partially resected, or spared. A cricopharyngeal myotomy may be performed. The surgeon approximates the remaining thyroid cartilage and thyroid perichondrium to the base of the tongue, or remainder of the hyoid bone if the hyoid was not fully resected. A free margin of the piriform sinus may be pulled anteromedially creating a fold superior to the ipsilateral vocal cord (this is the neo-false cord).

The early postoperative complications of voice-sparing procedures shown during a pharyngoesophagogram are fistula formation, airway obstruction by vocal cord and subglottic edema, aspiration, and aspiration pneumonia. Other early postoperative complications include wound breakdown, abscess formation, hematoma, mediastinitis, and thoracic duct or carotid artery injury. The late complications of a voice-sparing procedure include hoarseness, aspiration, recurrent tumor, laryngeal stenosis, velopharyngeal incompetence, and failure of a flap graft.