The management of locally advanced stage 3 and 4a cancer of the larynx and hypopharynx usually requires multidisciplinary treatment. Most head and neck surgeons would probably suggest total laryngectomy (TL) with adjuvant radiotherapy, whereas most oncologists would choose a nonsurgical treatment such as a combination of chemotherapy and radiotherapy. The choice between the two modalities is dependent upon patient factors and cancer factors. The cancer-related factors are mainly clinicoradiologic parameters such as gross cartilage invasion or deep invasion of the base of the tongue. The most important factor for any treatment protocol is a patient who is fit and gives his/her permission.
The aim of treatment should always be organ preservation or at least voice preservation if possible. In patients undergoing TL, tracheoesophageal puncture (TEP) and insertion of a voice prosthesis is the most commonly used procedure for restoration of voice. TEP is a time-tested, simple, and effective technique that results in good quality of voice in laryngectomy patients. However, TEP has a few significant limitations mainly related to maintenance, malfunction, replacement, and recurring cost. Some of the common problems are need for a regular cleaning, intraprosthesis leakage, periprosthesis leakage, overgrowth of granulation tissue, frequent replacement, spontaneous extrusion, and spastic pharyngoesophageal segment. These problems may lead to discontinuation in more than two-thirds of patients particularly after the 2nd year.
Near-total laryngectomy (NTL) is an alternative to TL in selected patients with advanced cancer of the larynx and pyriform sinus. NTL is an oncologically safe procedure and offers the advantage of a maintenancefree biologic prosthesis that obviates the need for an artificial device with its associated problems. This procedure is oncologically sound and preserves voice (not the organ), but the patient is left with a permanent tracheostoma and permanent loss of nasal breathing. The procedure was first described by Pearson et al. in 1980 under the name of “extended hemilaryngectomy.” This surgery has also been called a subtotal laryngectomy. NTL is perhaps the most accepted terminology for this procedure. This surgery exploits the phonatory ability of an innervated cricoarytenoid unit.
NTL is a surgical procedure for selected cases of locally advanced cancer of the larynx and pyriform sinus. These patients usually present with a change in the voice, pain, foreign body sensation in the throat, otalgia, dysphagia, odynophagia, breathlessness, and a mass in the neck. Patients with glottic cancer usually present at an earlier stage due to the early onset of hoarseness. Due to the paucity of lymphatic channels in the vocal cord and early detection, metastases to the cervical lymph nodes are uncommon. Cancers of the pyriform sinus and supraglottic region present in more advanced stages because of lack of symptoms in the early stage of the disease.
These regions are rich in lymphatics; therefore, metastases to the cervical lymph nodes are a common feature. Cancers of the larynx and pyriform sinus may present with shortness of breath due to either vocal cord paralysis or mass effect that may lead to obstruction of the laryngeal inlet by the sheer bulk of the cancer. Progressive dysphagia is a sign of circumferential pharyngeal involvement usually in a case of cancer of the hypopharynx. Otalgia denotes a deeply infiltrative lesion that leads to a referred pain in the ear. Aspiration of liquids is associated with vocal cord paralysis and failure of closure of the laryngeal inlet while drinking or eating. The etiology of all these cancers is usually tobacco, alcohol, and human papillomavirus or a combination of these factors.
Complete examination of the head and neck including indirect or direct laryngoscopy should be performed in all patients. Most patients require a fiberoptic examination that helps in precise tumor mapping, pictorial documentation and biopsy. Since fiberoptic examination may not be adequate in the assessment of the hypopharynx, I prefer direct rigid laryngoscopy under anesthesia. This allows me to rule out second primaries, map the lesion better and obtain an adequate biopsy. Stroboscopy is a useful procedure in evaluating early cancers of the vocal cord, which may be amenable to microlaser surgery.
A careful examination of the oral cavity and oropharynx is necessary to rule out the presence of a second primary cancer. The important things that one has to look for during indirect laryngoscopic examination are extent of disease, adequacy of the laryngeal inlet, and mobility of the vocal cords. The neck should be palpated bilaterally to detect the presence of cervical lymph node metastases. The level of the lymph nodes, number, size, mobility, and fixation to the skin or deep structures are important clinical features. Careful mapping of the cancer specifically focusing on the interarytenoid, retroarytenoid, and postcricoid regions as well as the status of the contralateral vocal cord is necessary in the planning of NTL.
Cancer of the larynx—NTL suitable for lateralized laryngeal cancers, mainly T3 or T4 cancers. It can also be used in transglottic cancer.
Cancer of the pyriform sinus—NTL is suitable for T3 and T4 lateralized cancer of the pyriform sinus.
The lesion that is suitable for partial laryngeal surgery, but the patient is not suitable for the surgery due to old age or poor pulmonary function, may be considered for NTL.
Involvement of the interarytenoid or postcricoid regions
More than one-third involvement of the contralateral cord.
Fixation of both vocal cords.
Clinical examination alone is less accurate in assessment of cartilage erosion or extralaryngeal spread, lymph node metastases, and soft tissue invasion. Computed tomography (CT) scan is one of the most trusted imaging studies used in the evaluation of cancers of the larynx and pharynx. CT scan detects cartilage erosion or invasion, soft tissue infiltration, metastases to the lymph nodes, and invasion of important organs with reasonable accuracy. Magnetic resonance imaging is more sensitive but is less specific than CT scan in detecting cartilage erosion. The role of preoperative positron emission tomography scan is not very well defined in these cancers. A biopsy confirmation is mandatory before embarking on surgery.
NTL is not an organ-preserving surgery but a voice-preserving surgery. The prerequisites for the organpreserving surgeries or partial laryngectomy procedures are an intact cricoid ring and at least one functional innervated cricoarytenoid unit. NTL is still feasible in cases where the entire cricoid ring cannot be preserved. This surgery is as radical as the TL while preserving an innervated cricoarytenoid unit for speech similar to the mechanism for a supracricoid laryngectomy. In NTL, a radical removal of the cancer along with the involved cricoid ring is performed on the predominant side. On the opposite side, the recurrent laryngeal nerve (RLN), the arytenoid, adjoining cricoid (forming the cricoarytenoid unit), and a 1 to 1.5 cm strip of the posterior wall of the trachea are preserved. This laryngotracheal remnant is sewn to create a tube to form an innervated myomucosal shunt that diverts air from the trachea to the pharynx and produces voice. Though these patients do not have nasal breathing, they are able to produce voice by occlusion of the stoma by the finger.
Gluck Sorenson’s incision (“U”-shaped incision) is normally used similar to TL.
Raise subplatysmal flap up to a level above the hyoid bone.
An appropriate neck dissection always precedes the removal of the primary tumor. For a clinically positive neck, the neck dissection removing levels II-V is advocated. For a clinically negative neck, the neck dissection removing levels II-IV is a widely accepted strategy.