Total Laryngectomy
Gregory T. Wolf
INTRODUCTION
Total laryngectomy is one of the most life-altering surgical procedures that a head and neck surgeon performs. The resulting alterations in speech, swallowing, and quality of life are viewed by patient and physician as challenges so significant that alternative treatment approaches that attempt to preserve the function of the larynx, such as radiation therapy, combined chemoradiation, and organ-preserving extended conservation resections, are often adopted even though overall cure rates may not be as good as with total laryngectomy. Despite this, patients with advanced cancer of the larynx have some of the best overall survival rates compared to other sites of cancer of the head and neck. These rates are likely related to anatomic characteristics that affect patterns of spread and allow complete extirpation. The increasing use of organ preservation treatment approaches has relegated total laryngectomy to a strategy for secondary salvage of local cancer recurrences, which has been blamed for the decline in overall cure rates for patients with laryngeal cancer over the past two decades.
Secondary total laryngectomy after a failure of prior organ-preserving therapy is now one of the most common and most difficult procedures performed by the head and neck surgeon. The principles guiding successful surgery have not changed, but the complexities of cancer surveillance after sequential treatments, decision making, precise determination of extent of the cancer, and related tissue factors must be carefully considered in planning for a total laryngectomy. Although this chapter is devoted to describing a surgical technique that has been in use for more than a century, nuances that reflect changes in modern treatment and rehabilitation approaches are emphasized.
Advanced cancer of the larynx remains one of the most favorable types of head and neck cancer for longterm cure. The mainstay of treatment, and the standard to which all other treatment modalities are compared, is complete surgical resection. Adjuvant postoperative radiation is routinely added in many cases resulting in modest increases in survival rates. However, functional sequelae associated with a radical surgical resection that requires a total laryngectomy include permanent alterations in speech, swallowing, and respiration, which negatively impact quality of life. Because of these problems, alternatives to radical surgical excision have been popularized in an attempt to avoid permanent tracheostoma and loss of natural voice and now represent the most common standard treatment approach.
Over the last 15 to 20 years, the initial management of these patients has been changing with the development and increasing use of organ-preserving treatments such as advanced function-preserving partial laryngectomy procedures, chemotherapy and radiation protocols (induction and concurrent), and radiation therapy alone for patients who previously might have been considered for total laryngectomy. In every instance, except for neoadjuvant chemotherapy combined with radiation, direct randomized comparisons to radical surgical resection have not been performed.
Clearly, no single treatment approach is suitable for all advanced-stage laryngeal cancer patients. The key to a successful outcome is optimal patient selection. Proper selection is enhanced by using the varied expertise of a multidisciplinary treatment team that involves experts in head and neck surgery, radiation oncology, medical oncology, pathology, radiology, speech and swallowing experts, audiology, social services, and nutritionists.
At the University of Michigan, I have successfully pioneered treatment concepts based on selecting definitive management (radiation vs. total laryngectomy) based on the biologic (clinical) response of the primary cancer to a single cycle of induction chemotherapy. This individualized approach accepts the rationale that responding cancers are most often cured with definitive radiation, while nonresponding cancers are rarely controlled long term after radiation therapy. Surgical management is enhanced by permitting total laryngectomy to be performed prior to radiation therapy in most cases, and survival rates for these patients are exceptional.
In nearly every prior report of neoadjuvant chemotherapy, clinical complete tumor regressions are associated with improved survival compared to nonresponders. This principal was the basis for the landmark Veterans Affairs laryngeal cancer study, as patients with poor response to induction chemotherapy were treated with total laryngectomy followed by radiotherapy. I have taken these observations and tested the concept in a series of proof of principle phase II trials combined with correlative biomarker studies. In doing so, I have demonstrated, in advanced stage III and IV patients, overall 5-year survival rates in excess of 80% with laryngeal preservation in 70% of patients. Chemotherapy response appears consistently associated with aggressive tumor markers, high tumor proliferation rates, and histologically invasive growth patterns. I have achieved these long-term results without excluding patients on the basis of tumor factors such as tumor size or cartilage invasion but only selected them on the basis of their ability to tolerate chemotherapy and radiation. Despite these new treatment approaches, total laryngectomy remains an important initial therapeutic option for select patients (Table 29.1) as well as a means of secondary surgical treatment when more conservative treatment fails.
HISTORY
Typically patients with primary cancer of the glottis even of early stage present with hoarseness hopefully leading to earlier diagnosis and treatment. Symptoms of more advanced cancers may include referred otalgia, odynophagia, dysphagia, hemoptysis, or cervical lymph adenopathy. Stridor and airway compromise generally occur later when the cancer is large or bulky and obstructs the airway.
Patient evaluation should include a detailed assessment of speech and swallowing function, communication needs, nutrition, health behaviors, age, comorbidities, and availability of social support for what is typically a prolonged period of treatment and rehabilitation. Critical factors in a patient’s history include those symptoms related to respiration and swallowing (particularly aspiration) that indicate impaired function. The greater the severity of symptoms, the more likely the patient will be a candidate for and benefit from total laryngectomy. Organ preservation treatment strategies using combined chemotherapy and radiation do not generally improve the speech or swallowing functions when large amounts of laryngeal tissue and framework (T4) are destroyed by the cancer since these structures are replaced with scar tissue after cancer regression. Likewise, long-term swallowing function can also be affected by fibrosis of the pharyngeal muscles and stricture formation.
Primary cancer of the supraglottis can be advanced stage at presentation since hoarseness is a late finding and cancers can be quite large without much symptomatology. Early symptoms include chronic sore throat, dysphagia, referred otalgia, or a mass in the neck. Even a small primary cancer of the supraglottis can metastasize early in the course of the disease. Age and comorbidities are important since a decision for nonsurgical organ preservation may depend upon receiving chemotherapy and elderly patients generally do not benefit from adjuvant chemotherapy. Comorbidities may limit a patient’s ability to tolerate the toxicity associated with chemotherapy. Likewise, severe comorbidities might increase anticipated surgical complications or even contraindicate total laryngectomy. The length of time the symptomatology has been present is important since it can indirectly relate to the rate of growth of the cancer. Anyone with persistent hoarseness (>6 weeks) or sore throat (>6 weeks) warrants a thorough endoscopic examination of all the mucosal surfaces within the upper aerodigestive tract, especially in those patients with a heavy smoking history or a strong family history of cancer. Since most laryngectomies are now performed following a failure of prior chemoradiation, careful review of records of drug administration, toxicities, and radiation doses and fields is helpful in planning surgery, optimizing preoperative medical status, and anticipating reconstructive needs such as replacement of the skin, free flap reconstruction, or dermal graft coverage of the great vessels. Likewise, prior information regarding initial cancer staging prior to chemoradiation should be carefully evaluated to assist in planning adequate resection of the cancer since it is still standard technique to remove all tissue at risk of harboring residual neoplasm.
The patient’s history of airway symptoms and direct visualization of the larynx will guide eventual strategy and planning for general anesthesia and tracheal intubation. This plan should be documented and discussed with the anesthesiologist preoperatively. Clear communication and decision-making issues related to obstructing cancers, distorted anatomy, anesthetic technique, and awake fiberoptic intubation versus tracheostomy are needed to avoid unnecessary patient risk. Factors such as fibrosis of the neck and trismus are equally important and can interfere with oral intubation even if an obstructing tumor is not present. After securing the airway, tumor debridement at the time of staging endoscopy and biopsy can often avoid the need for tracheostomy prior to total laryngectomy. Difficulties encountered with airway management before or after diagnostic endoscopy should be documented and may influence techniques selected for anesthesia induction at time of total laryngectomy. Preoperative thyroid function testing should be considered if prior radiation to the neck has been delivered since iatrogenic hypothyroidism can affect wound healing. Nutritional status and plans for postoperative nutritional replacement should be considered.
PHYSICAL EXAMINATION
An important principle is that no physical examination should be considered complete until all mucosal surfaces of the nasal cavity, nasopharynx, oropharynx, oral cavity, hypopharynx, and larynx have been clearly visualized. Second primary cancers have been reported in up to 20% of patients who have laryngeal cancer making a thorough examination of other sites mandatory. The examination of the head and neck must also include a detailed examination of the regional lymphatics, including palpation of the thyroid and prelaryngeal and pretracheal anatomy.
Visualization of the larynx can be performed indirectly with a handheld mirror or directly with fiberoptic laryngoscopy. Fiberoptic examination has the advantage of providing a more detailed look at the laryngeal anatomy and is probably more accurate for in-office cancer staging. Functional evaluation assessing vocal cord mobility, voice characteristics, and swallowing are facilitated by fiberoptic endoscopy. The gold standard, however, for precise tumor evaluation and staging is to combine functional evaluation with direct laryngoscopy under general anesthesia in the operating room. With large, obstructive cancers, a tracheostomy under local anesthesia in the awake patient or fiberoptic-assisted awake intubation may be necessary to safely induce general anesthesia and perform a direct laryngoscopy. In patients with large cancers where endotracheal intubation is possible, debulking the cancer may provide a sufficient airway to obviate the need for a tracheostomy, thus decreasing the potential risk of seeding of the cancer at a tracheostomy site. Despite operative direct laryngoscopy, the extent of cancer is underestimated in 30% to 40% of glottic and supraglottic cancers and close to 50% of transglottic cancers. Depth of invasion and cartilage involvement are the most difficult variables to estimate clinically. Subglottic cancer is particularly difficult to evaluate and the extent of cancer involvement is also frequently underestimated. The use of rigid telescopes (0 and 30 degrees) during direct laryngoscopy provides the best clinical evaluation of the subglottis.
INDICATIONS
Indications for total laryngectomy include both cancer-related factors and functional factors and are summarized in (Table 29.1). Failure of primary radiation therapy remains the most frequent indication for total laryngectomy. Failures of radiation for small (T1, T2) glottic primaries can often be managed with conservation laryngectomy techniques (endoscopic or transcervical), while supraglottic failures usually require a total laryngectomy because of wound healing problems or poor results with extended or supracricoid laryngectomy techniques. Advanced cancers with extensive destruction of the laryngeal cartilage usually result in a nonfunctional larynx after chemoradiation and such patients would benefit from primary laryngectomy. Primary cancers of the subglottis often require total laryngectomy because of invasion of the cricoid cartilage. Primary chondrosarcomas of the laryngeal framework sometimes require total laryngectomy and even invasive cancer of the thyroid or extensive cancers of the base of the tongue may require incidental total laryngectomy. Sometimes, a patient’s pulmonary or medical status may make conservation laryngectomy risky and total laryngectomy or other organ preservation approach preferable. The usual indications include:
TABLE 29.1 | |
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CONTRAINDICATIONS
If the extent of the cancer and the patient’s medical condition allow for complete resection and safe general anesthesia, there are few contraindications to total laryngectomy. The presence of distant metastases is probably the most common contraindication since it makes little sense to do a total laryngectomy without the opportunity for cure since the median life expectancy with distant metastasis is <6 months. Extension of cancer to the deep neck and adjacent critical structures is a relative contraindication. Total laryngectomy is unlikely to be curative if the cancer encases a carotid artery or has direct involvement of the deep neck muscles, mediastinal structures, cervical vertebrae, or prevertebral fascia. The presence of extensive supraclavicular lymph node
metastases, dermal metastases, or direct involvement of the skin is usually a sign of disseminated disease and relative contraindications, and alternative palliative treatment with chemoradiation might be recommended. If the primary cancer obstructs the airway or interferes with swallowing, patients can function reasonably well with a tracheostomy and an enteral feeding tube for long periods even if distant metastases are not apparent.
metastases, dermal metastases, or direct involvement of the skin is usually a sign of disseminated disease and relative contraindications, and alternative palliative treatment with chemoradiation might be recommended. If the primary cancer obstructs the airway or interferes with swallowing, patients can function reasonably well with a tracheostomy and an enteral feeding tube for long periods even if distant metastases are not apparent.
PREOPERATIVE PLANNING
Radiologic imaging is a natural complement to a complete history and examination of the head and neck. Failures after radiation therapy are typically more extensive than the gross surface representation of the cancer, and clinical assessment alone is unreliable and typically underestimates the extent of microscopic cancer. Magnetic resonance imaging (MRI) and computerized tomography (CT) both offer detailed evaluation of laryngeal anatomy that can reveal preepiglottic and paraglottic space involvement as well as submucosal and extralaryngeal extension and involved regional lymph nodes that may not be obvious on clinical examination. A high-resolution thin section CT scan is generally preferred since breath holding is necessary for MRI imaging and motion artifact can obscure many of the finer imaging details. Invasion of the thyroid cartilage (T4) and extralaryngeal spread of cancer have been proposed as contraindications for organ preservation protocols; however, successful nonsurgical management of T4 larynx cancer and those with minimal cartilage invasion has been reported. Invasion of the thyroid cartilage can be evaluated with imaging and is probably better assessed with CT rather than with MRI although each has significant limitations and direct evaluation at endoscopy is critical. The introduction of positron emission tomography (PET) scanning and combined CT registration with PET imaging has opened a new frontier for functional imaging. These newer imaging studies can detect occult disease in up to 20% of patients, although sensitivity is generally regarded as low and PET is perhaps most useful in assessing the possibility of distant metastasis and second primary cancers. Preoperative imaging of the chest is important and this is probably best accomplished with chest CT rather than a standard chest radiograph.
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