The choice between surgery and radiotherapy as the primary treatment for carcinoma of the larynx should be made according to the likely effective control of the cancer, the general health of the patient, the relative consequences of the treatment and the informed decision of the patient. With either laryngectomy or radiotherapy, there is invariably some or total loss of normal voice and compromise of airway protection, and general function. Although patients may undergo speech rehabilitation and may swallow well after total laryngectomy, the main handicap associated with this procedure, according to quality-of-life studies, appears to be the need for a permanent stoma. Transoral laser microsurgery (TLM) is now a standard of care and transoral robotic surgery (TORS) is increasingly utilised. There is considerable geographic variation in the use of open conservational approaches which attempt to preserve as much of the larynx and its function as possible (used sparingly in the United Kingdom, but popular in Italy, Spain and South America). The goals of all partial laryngeal surgery are to control cancer and obtain a functional outcome of speech and swallowing without the need for a permanent tracheostomy. Laryngectomy techniques also have an importance in less common malignant neoplasms of the larynx (adenocarcinoma, verrucous carcinoma, fibrosarcoma, chondrosarcoma, etc.), which are invariably treated by surgery. It is apparent that the modern surgeon should not manage laryngeal cancer based on one surgical option (total laryngectomy). The repertoire must include conservative techniques and surgical voice restoration.
44.1 Types of Laryngectomy
1. Endoscopic transoral resections
a. Transoral laser microsurgery.
b. Transoral robotic surgery.
2. Vertical partial resection
b. Hemilaryngectomy (frontal, lateral and frontolateral).
3. Horizontal partial resection
b. Supraglottic laryngectomy.
4. Near-total laryngectomy
a. Supracricoid partial laryngectomy.
b. Vertical subtotal laryngectomy.
5. Total laryngectomy
44.2 Pre-Operative Management
In clinic, fibre-optic laryngoscopy should allow an inspection of the primary tumour’s site and size. Vocal cord mobility should also be assessed. The two areas which are difficult to examine by this technique are the subglottis and the laryngeal ventricle, both of which should be carefully examined at microlaryngoscopy under anaesthetic. The neck should be carefully palpated for the presence of enlarged lymph nodes.
A computed tomography (CT) or magnetic resonance imaging (MRI) scan of the larynx should be obtained prior to endoscopy and biopsy before there is distortion of the anatomy. A microlaryngoscopy should always be performed by the surgeon who is going to perform any subsequent procedure. This will allow a representative biopsy to be obtained, the tumour to be staged and the appropriate operation planned. Straight (0-degree) and angled (30- and 70-degree) rigid endoscopes should be used to carefully and systematically assess the extent of the tumour. Photographs should be taken and tumour diagrams carefully documented.
With the accumulated information, the patient’s case should be discussed in the Head & Neck MDT meeting. Close attention to the extent of the disease and the anatomical landmarks of the larynx should form the basis of dialogue regarding the patients’ suitability for a particular type of laryngectomy. This will be in conjunction with a thorough knowledge of their general condition, intercurrent disease, performance status and social (home and caregiver) circumstances. It is imperative that written confirmation of the histological diagnosis must be in the case notes before undertaking any laryngeal resection.