Indications

The indications for a TL have decreased as organ preservation strategies have mandated a paradigm shift. In 1991, the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that induction chemotherapy with cisplatin plus fluorouracil followed by radiation therapy allowed preservation of the larynx in 64% of patients without affecting survival when compared with TL and adjuvant radiotherapy . In 2003, Forastiere and colleagues showed that concurrent chemotherapy with cisplatin and radiotherapy resulted in higher laryngeal preservation rates, better loco-regional control rate, and similar overall survival when compared with induction chemotherapy followed by radiation and radiation therapy alone. In this study, patients who had large-volume T4 disease, defined as tumors with greater than 1 cm invasion of the base of tongue or gross cartilage invasion, were excluded.

Primary TL is indicated in advanced disease that is not amenable to partial laryngectomy, concurrent chemoradiation, or radiotherapy alone. Specifically, tumors that have penetrated through cartilage, invasion into the extralaryngeal soft tissue of the neck, and extensive involvement of the base of tongue are suitable for this procedure. Non-neoplastic indications for primary TL include laryngeal dysfunction with life-threatening aspiration or chondro-radionecrosis of the larynx. Also, pulmonary status and medical comorbidities and cognitive function may define the treatment options for a given patient.

Salvage TL is indicated for chemoradiation, radiation, or partial laryngeal surgical failures. Salvage laryngectomy was required in 16% of patients treated with concurrent chemoradiation and 31% of patients treated with radiotherapy alone . Salvage TL can be technically more difficult and carries a higher postoperative complication rate.

Patient work-up and selection

Beyond the standard history and physical examination, patients must undergo a biopsy to confirm the diagnosis of cancer. Hence, a direct laryngoscopy with biopsy should be performed to help stage the tumor accurately. Esophagoscopy, and bronchoscopy as indicated, should be performed to evaluate for extent of disease and synchronous primary lesions.

A neck CT with contrast also is required in the work-up of advanced laryngeal cancer . A primary indicator for surgery is extensive cartilage invasion. Thyroid cartilage, however, can be either ossified or chondrified, making it difficult to assess erosion by imaging. Yousem and Tufano performed a meta-analysis and reported a sensitivity of 92% and specificity of 79% with MRI of laryngeal infiltration compared with a sensitivity and specificity of 64% and 89%, respectively, with CT. The combination of CT and MRI may be the most effective strategy to evaluate patients who have laryngeal cancer . Furthermore, MRI and/or positron emission tomography (PET) may be useful to diagnose occult neck disease or recurrence .

A metastatic screen is also necessary. At the least, this includes a chest radiograph and liver function tests, although these are of uncertain value . A chest CT is more effective as a screening tool for pulmonary metastases and second primary tumors . Moreover, often an integrated PET/CT scan may be obtained to evaluate for occult neck or distant metastases, and stage the disease more accurately .

The patient must have preoperative clearance to undergo the surgical procedure. Also, the patient is required to have satisfactory performance status/manual dexterity to be able to care for the stoma and TEP prosthesis. Nutritional status and thyroid function should be assessed as well.

Patient work-up and selection

Beyond the standard history and physical examination, patients must undergo a biopsy to confirm the diagnosis of cancer. Hence, a direct laryngoscopy with biopsy should be performed to help stage the tumor accurately. Esophagoscopy, and bronchoscopy as indicated, should be performed to evaluate for extent of disease and synchronous primary lesions.

A neck CT with contrast also is required in the work-up of advanced laryngeal cancer . A primary indicator for surgery is extensive cartilage invasion. Thyroid cartilage, however, can be either ossified or chondrified, making it difficult to assess erosion by imaging. Yousem and Tufano performed a meta-analysis and reported a sensitivity of 92% and specificity of 79% with MRI of laryngeal infiltration compared with a sensitivity and specificity of 64% and 89%, respectively, with CT. The combination of CT and MRI may be the most effective strategy to evaluate patients who have laryngeal cancer . Furthermore, MRI and/or positron emission tomography (PET) may be useful to diagnose occult neck disease or recurrence .

A metastatic screen is also necessary. At the least, this includes a chest radiograph and liver function tests, although these are of uncertain value . A chest CT is more effective as a screening tool for pulmonary metastases and second primary tumors . Moreover, often an integrated PET/CT scan may be obtained to evaluate for occult neck or distant metastases, and stage the disease more accurately .

The patient must have preoperative clearance to undergo the surgical procedure. Also, the patient is required to have satisfactory performance status/manual dexterity to be able to care for the stoma and TEP prosthesis. Nutritional status and thyroid function should be assessed as well.

Surgical technique

Direct laryngoscopy is performed to determine/confirm the degree of extension of disease and verify the proposed surgical intervention. Modified apron or transverse incision is designed incorporating the existing stoma or planning the permanent stoma. This incision may be modified when performing simultaneous neck dissections.

Subplatysmal flaps are raised to the sternal notch inferiorly, hyoid cartilage superiorly, and sternocleidomastoid muscles laterally. The sternocleidomastoid muscles are exposed. The strap muscles are transected 1 cm above the clavicle and elevated from the laryngotracheal complex. The thyroid isthmus is divided; the ipsilateral thyroid gland and paratracheal lymph nodes typically are taken with the specimen, especially when there is extralaryngeal disease or subglottic spread. The contralateral thyroid lobe is freed from the trachea and mobilized laterally.

The superior boarder of the hyoid cartilage is freed by transecting the suprahyoid musculature. The greater cornu are skeletonized carefully so as not to jeopardize the hypoglossal nerve and lingual artery. The larynx is rotated, and the posterior border of the thyroid cartilage is skeletonized by separating the laryngeal constrictors. Bilateral inferior cornus and superior cornus are skeletonized. The superior laryngeal neurovascular structures are divided. The pyriform sinus mucosa is dissected away from the inner thyroid cartilage lamina if oncologically appropriate.

Once the laryngotracheal complex is mobilized, horizontal tracheal cuts are made at a level at least 1 cm beyond the tumor. The trachea is entered, and an endotracheal tube is placed in the trachea. The anterior tracheal cuts are beveled superiorly, and the posterior wall tracheal cut is placed more cephalad. This provides a larger area for the stoma. The posterior trachea wall then is separated from the cervical esophagus.

A pharyngotomy may be made through the contralateral pyriform sinus or by means of the vallecula. Under direct visualization of the mucosal surfaces, the larynx is resected free taking care to preserve adequate uninvolved mucosa for closure. Frozen section margins should be analyzed. A cricopharyngeal myotomy is performed by sharply dividing the circumferential muscle bands up to the serosal layer.

If a TEP is planned, it is performed at this point. Primary TEP is placed through the common posterior wall, 1 cm below the posterior wall of the free end of the trachea. A temporary catheter or prosthesis is placed to stent the tract.

The pharyngeal mucosa is closed using a running inverting suture. This may be done in a T, vertical, or horizontal fashion . The closure should be tension-free. The suture line can be reinforced with a second imbricating suture line if necessary.

Sofferman and Voronetsky describe the use of a linear stapler for pharyngoesophageal closure after TL. A bougie may be placed, and a gastrointestinal TA 60 stapler is used to separate the larynx and close the pharynx.

Drains are placed in the neopharynx gutter on each side and secured. The tracheal stoma is matured by suturing the end of the trachea to the skin in an interrupted fashion with half vertical mattress sutures. The skin then is closed in layers.

Postoperatively, routine care is instituted, including wound care, stoma care, drain care, fluid management, and pain management. Nutritional status and thyroid function should be optimized.

Neck

The larynx drains into levels 2 to 4 pretracheal and paratracheal lymph nodes within the neck. Advanced laryngeal cancers have an overall 30% incidence of occult neck metastasis . Patients who have supraglottic and advanced glottic with clinically N0 neck should undergo elective treatment of the neck by either neck dissection or radiotherapy . Supraglottic tumors have a significant propensity for bilateral neck metastasis, and bilateral necks should be addressed . Patients with N1 disease who are treated with definitive chemoradiotherapy require a neck dissection for incomplete clinical response . Neck dissection arguably is required for patients with N2 or N3 disease who are treated with definitive chemoradiotherapy . For salvage surgery, the decision to perform a neck dissection should be based on CT staging of the neck, as most patients who are radiologically staged N0 are unlikely to harbor occult nodal disease .

Adjuvant radiation

Adjuvant radiotherapy may be combined with primary TL for advanced laryngeal carcinomas. The goal of adjuvant radiotherapy is to control loco-regional minimal residual disease. More specifically, postoperative radiation therapy is indicated in patients with T4 carcinoma, inadequate surgical margins, cervical lymph nodes metastasis, and extracapsular, perineural, and/or vascular spread . Nevertheless, Spector and colleagues did not demonstrate a statistically significant difference in recurrence or disease-specific survival with TL alone compared with combined TL and radiotherapy. Likewise, Cortesina and colleagues reported comparable survival in patients who underwent surgery only and combined therapy, but the latter group was comprised of patients who had more negative prognostic factors. Hence, they concluded radiotherapy was effective in controlling minimal residual disease.

Complications

Early complications after TL include bleeding/hematoma, infection, wound breakdown, and pharyngocutaneous fistula formation. In the case of bleeding, the patient should be explored in the operating room with evacuation of the clot and control of bleeding. A wound infection is managed by opening the wound and draining the infected collection, followed by packing and culture-specific antibiotics.

Pharyngocutaneous fistula is a common, troublesome complication. The incidence is generally higher after combination treatment, approximating 20% to 30% in patients treated with radiotherapy or concomitant chemoradiotherapy . Ganly and colleagues showed that chemoradiotherapy was an independent predictor of pharyngocutaneous fistula formation. In a meta-analysis, preoperative radiotherapy was associated with increased relative risk of pharyngocutaneous fistula . Furthermore, the study suggested irradiated patients had increased duration and severity of the fistula. Pharyngocutaneous fistula is treated conservatively with maintaining the patient nothing by mouth, wound packing, and antibiotics. A biopsy may be indicated to exclude persistent/recurrent cancer. If conservative management is unsuccessful after a few weeks, operative intervention with a vascularized flap is considered. If the carotid arteries are exposed, flap coverage is necessary to avoid the sometimes fatal outcomes of a carotid erosion and bleed. In fact, Withrow and colleagues claimed that prophylactic reconstruction with a vascularized flap after a salvage laryngectomy was associated with a lower fistula rate of 18% versus 50% for primary closure. Fung and colleagues , however, reported that vascularized tissue did not reduce the fistula rate in salvage laryngectomy patients, although the severity was less when compared with patients who underwent primary closure.

Late complications include stomal stenosis, pharyngoesophageal stricture/stenosis, and hypothyroidism. Stomal stenosis can be managed with a stomal button/laryngectomy tube or stomaplasty. The most effective means to treat stomal stenosis, however, is prevention with proper surgical technique during the laryngectomy. Pharyngoesophageal stenosis can be treated with dilation. In this situation, recurrence/persistence of cancer may need to be ruled out. Hypothyroidism is a relatively common occurrence, especially after combination therapy with radiation and laryngectomy . Thyroid function tests should be periodically checked postoperatively/after radiation, and thyroid replacement hormone should be initiated as needed .