Introduction
The most common location of laryngeal cancer is the glottis, followed by the supraglottis, with the least common site being the subglottis. The American Cancer Society estimates that more than 14,000 new cases of laryngeal cancer will occur in the United States in 2016, resulting in about 3620 deaths. It occurs more frequently in males. Tobacco (cigarette smoking) is the primary risk factor for laryngeal cancer, and the incidence is falling about 2% to 3% per year because fewer people are smoking. Other causes include alcohol, human papilloma virus (HPV), and environmental factors, such as exposure to asbestos. The most common histologic type is squamous cell carcinoma and the prognosis depends upon the stage at the time of diagnosis. Treatment has changed over the past 25 years to include conservation laryngeal surgery—for example, endoscopic techniques such as transoral laser microsurgery, transoral robotic surgery, and organ preservation protocols. Total laryngectomy is employed primarily in patients with advanced laryngeal cancer, in cases of failed organ preservation treatment, and in those who cannot undergo conservation laryngeal surgery due to medical comorbidities. Depending on the stage of a tumor, patients may require adjuvant (chemo) radiation therapy. Total laryngectomy has a significant psychologic impact related to changes in voice, swallowing, and olfaction, in addition to living with a permanent stoma.
Key Operative Learning Points
- 1.
Accurate tumor staging is paramount for successful treatment.
- 2.
Unilateral or bilateral neck dissections may be indicated, depending on the staging of the neck and the location and extent of the tumor.
- 3.
Control of the airway is of utmost importance. Some patients may require a preoperative tracheostomy for airway obstruction. If this is not required, intubation can generally be performed by direct laryngoscopy or flexible fiberoptic intubation.
- 4.
Mapping of the tumor is required to plan the surgical approach so that the cancer is removed with appropriate margins.
- 5.
Cover the edges of the tracheostoma by approximating skin to tracheal cartilage with half vertical mattress suture.
- 6.
Identify the hypoglossal nerves bilaterally to avoid inadvertent injury to the nerves.
- 7.
A watertight pharyngeal closure is required to prevent a pharyngocutaneous fistula.
- 8.
If a tracheoesophageal puncture (TEP) is performed, a pharyngeal constrictor myotomy is necessary to prevent spastic speech.
- 9.
Flap reconstruction is not a contraindication to primary TEP, provided that the party wall is not separated.
Preoperative Period
History
- 1.
History of present illness
- a.
Hoarseness is one of the most common presenting symptoms.
- b.
Patients may also complain of pain in the throat, odynophagia, dysphagia, otalgia, and weight loss.
- c.
If previously treated, the patient may have a recurrence of his or her initial presenting symptoms.
- a.
- 2.
Past medical history
- a.
Prior treatment with conservation laryngeal surgery, radiation therapy, or organ preservation protocol
- b.
Medical illness: Severe chronic obstructive pulmonary disease (COPD), cardiac disease, history of deep vein thrombosis (DVT)
- c.
Past surgical history
- d.
Family history of cancer of the head and neck
- e.
Social history: Tobacco use, alcohol abuse, environmental exposure to asbestos, marijuana use
- f.
Medications: Antiplatelet drugs, Warfarin
- g.
Allergies
- a.
Physical Examination
- 1.
Voice quality
- 2.
Dyspnea, stridor
- 3.
Laryngeal examination with a mirror or a flexible fiberoptic laryngoscope. The latter is especially helpful, as it can be used as an educational tool and to follow a patient’s progress. The location of the tumor and the mobility of the vocal cords are documented, as well as the presence or absence of aspiration and pooling of secretions.
- 4.
Complete examination of the head and neck for second primaries
- 5.
Neck: Presence of lymph node metastases; involvement of overlying skin of the anterior neck by tumor
- 6.
Nutritional status; cachexia
Imaging
- 1.
Computed tomography (CT) scan of the neck with contrast in selected cases to determine the extent of the tumor, including involvement of the pre-epiglottic space, thyroid cartilage, and lymph node metastasis
- 2.
Chest x-ray (CXR) or CT to evaluate for lung metastases: Some may obtain a positron emission tomography–computed tomography (PET-CT) scan to evaluate for distant metastases and the extent of the primary tumor and the presence of lymph node metastasis.
Indications
- 1.
Relative indications:
- a.
Whether T3 laryngeal cancer should be treated by total laryngectomy or by chemoradiation is a matter of debate.
- b.
Patients unfit for chemoradiation therapy
- c.
Life-threatening aspiration due to neurologic disease
- d.
Severe COPD precluding conservation laryngeal surgery
- a.
- 2.
Absolute indications
- a.
Most T4 tumors
- b.
Invasion of the thyroid cartilage
- c.
Extension of tumor into soft tissues of the neck
- d.
Salvage laryngectomy for failed nonsurgical treatment
- e.
Chondroradionecrosis refractory to conservative management
- a.
- 3.
Contraindications
- a.
Tumors amenable to conservation laryngeal surgery, radiation, or chemoradiation
- b.
Medical comorbidities precluding general anesthesia
- c.
Patient’s refusal for total laryngectomy
- a.
Preoperative Preparation
- 1.
Endoscopy under general anesthesia for tumor mapping and biopsy and to exclude a second primary cancer
- 2.
If a biopsy was obtained at an outside institution, slides are reviewed at the treating institution to confirm the diagnosis.
- 3.
If PET-CT was not obtained previously, one may be obtained as a baseline to follow treatment results and to rule out distant metastasis.
- 4.
Patient is evaluated by medical and radiation oncology, and the case is presented at a multidisciplinary tumor board for consensus opinion
- 5.
Referrals are sent to dental oncology, nutrition, speech therapist, social worker, and patient advocate as necessary.
- 6.
Referral for spiritual and/or psychologic support if needed and patient agrees
Operative Period
Anesthesia
- 1.
General anesthesia
- 2.
The type of intubation depends on the tumor size and location and is discussed with the anesthesiologist prior to surgery: Oral endotracheal intubation (ETT), awake flexible fiberoptic ETT, local awake tracheotomy.
Positioning
- 1.
Supine with shoulder roll to extend the neck
- 2.
Arms are tucked at patient’s sides
- 3.
Bed is turned 90 or 180 degrees from the anesthesiologist to create space for the surgeons around the head of the bed
Perioperative Antibiotic Prophylaxis
The first dose should be given prior to the skin incision:
- 1.
Clindamycin 900 mg IV plus gentamicin 5 mg per kg IV × 1 dose; followed postoperatively with clindamycin 900 mg IV q 8 hours × 3 doses (particularly in penicillin allergic patients)
- 2.
Unasyn 3 gm IV q 6 hours × 4 doses
Monitoring
- 1.
Continuous monitoring of blood pressure, pulse, and oxygen
- 2.
Arterial blood gas when indicated
- 3.
Hemoglobin and hematocrit when indicated
Instruments and Equipment to Have Available
- 1.
Routine head and neck set with retractors
- 2.
Monopolar and bipolar electrocautery
- 3.
14F red rubber catheter if primary tracheoesophageal puncture is to be performed
- 4.
1% lidocaine to inject into adventitia of carotid bulb if the patient develops profound bradycardia due to manipulation of the carotid artery
Key Anatomic Landmarks
- 1.
Thyroid notch
- 2.
Cricoid cartilage
- 3.
Sternal notch
- 4.
Carotid sheath
- 5.
Esophagus
Prerequisite Skills
- 1.
Knowledge of the anatomy of the anterior neck
- 2.
Proficiency in soft tissue surgery
- 3.
Understanding appropriate oncologic resection
- 4.
Understanding intraoperative complications and how to address them
Operative Risks
- 1.
Profound bradycardia due to manipulation of the carotid artery
- 2.
Injury to the contents of the carotid sheath
- 3.
Injury to cranial nerves, particularly cranial nerve 12
- 4.
Positive surgical margins
- 5.
Inadequate pharyngeal closure with resultant pharyngocutaneous fistula
- 6.
Bleeding
Surgical Technique
- 1.
Outline an apron (U-shaped) incision that starts at the level of the greater horn of the hyoid bone bilaterally and extends inferiorly to about 2 cm above the sternal notch, to incorporate the tracheostomy incision if present. The lateral limbs of the incision are placed along the anterior border of the sternocleidomastoid muscles (SCMs). Injecting the skin incision with 1% lidocaine with 1:100,000 epinephrine for hemostasis is optional.
- 2.
Incise the platysma muscle along the above incision and raise a subplatysmal flap superiorly above the level of the hyoid bone and inferiorly to the level of the clavicles and sternal notch.
- 3.
If neck dissection is to be performed, complete the neck dissection before proceeding to the laryngectomy operative steps below.
- 4.
Using electrocautery, incise the fascia along the anterior border of the SCM.
- 5.
The SCM is retracted laterally, and the contents of the carotid sheath are identified ( Fig. 16.1 ).
