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.
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.