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Laryngectomy
For tumor of the larynx

Introduction

Cancer of the larynx (voice box) is one of the most common cancers of the upper airway. Over 10,000 new laryngeal cancers are diagnosed each year, and about 5000 people with this disease will die each year. There is a very strong association between this cancer and tobacco and/or alcohol use. Though more men have this cancer than women, women are catching up because of the increase of smoking in women.

Anatomy and Physiology

  • The largest cartilage (thyroid cartilage) of the larynx can be felt in the neck as the Adam's apple. (Figure 1) The larynx is almost cylindrical in shape and is made up of various segments of cartilage surrounded by fibrous membranes. The larynx contains the vocal cords (Figure 2), which are important for speech
Figure 1 - The anatomy of the larynx and surrounding structures. Note the tracheal cartilage of the larynx that can be felt as the Adam's apple in front of the neck. Below the larynx lies the trachea. The larynx and trachea are partially covered by the thyroid gland. © T. GravesFigure 2 - The vocal cords of the larynx as seen by a doctor using a laryngeal mirror. Note that the inside of the trachea can be seen through the open vocal cords and the opening to the esophagus can be seen lying behind the larynx. © T. Graves
  • The larynx is divided into three anatomical parts: (Figure 3)
    1. Supraglottis - the area above the vocal cords that containing the epiglottis cartilage
    2. Glottis - the area around the vocal cords
    3. Subglottis - the area below the vocal cords that contains the cricoid cartilage and continues down into the trachea (windpipe)
Figure 3 - A midline cut through the lower head and neck. Note the three portions of the larynx- glottic, containing the vocal cords; supraglottis, above the vocal cords; subglottic, below the vocal cords. © T. Graves
  • The larynx functions in:
    1. Speech, which is produced by air from the lungs rushing through the vibrating vocal cords. The vocal cords are attached to several small cartilages that are moved by small muscles of the larynx. These muscles change the distance between the vocal cords during speech
    2. Maintenance of an open airway. The larynx is the first part of the airway to the lungs and the laryngeal cartilages keep the airway open
    3. Protecting the airway during swallowing. During the swallowing of food or saliva the larynx is pulled up by the surrounding muscles, which prevents food and other matter from entering the trachea. Food is pushed into the pharynx (food pipe) behind the larynx. In addition a special cartilage called the epiglottis serves as a lid that falls over the opening into the larynx during swallowing

Pathology

  • Laryngectomy is carried out for cancer of the larynx. Cancers of the larynx are predominantly squamous cell (flat cell) in type and the location of the cancer is very important in prognosis (determining how a patient will do)
    1. Supraglottic cancers usually present in an advanced stage of the disease. This area has an abundant lymph drainage, with lymph nodes usually positive for cancer at the time of diagnosis
    2. Glottic cancers are usually noticed earlier, as even small lesions on the vocal cords can produce a change in the voice. There is not as abundant a lymph drainage for this area so cancers discovered here are earlier in stage
    • Subglottic cancers are the most rare (<1%) and may also present in a late stage
  • Staging of the cancer is extremely important before planning any treatment. The American Joint Commission on Cancer (AJCC) has developed the TNM staging used. The system is based on the degree of involvement of the tumor (T), involved lymph nodes in the region (N) and metastases (M, tumor traveling to another organ)
Primary tumor (T)
TxTumor cannot be assessed
T0No evidence of tumor
TisCarcinoma in situ (cancer of the surface layer of cells)
Supraglottis
T1Tumor limited to one portion of the supraglottis with normal vocal cord movement
T2Tumor invades more than one portion of the supraglottis or glottis and abnormal vocal cord movement
T3Tumor limited to the larynx with no movement of the vocal cords and/or invades the area behind the cricoid cartilage, medial (towards the midline) wall of the piriform sinus or in tissues before the epiglottis
T4Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx
Glottis
T1Tumor limited to the vocal cord(s) with normal movement
T2Tumor extends to the supraglottis and/or subglottis with decreased vocal cord motion
T3Tumor limited to the larynx with no movement of the vocal cords
T4Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx
Subglottis
T1Tumor limited to the subglottis
T2Tumor extends to the vocal cord(s) with normal or poor mobility
T3Tumor limited to the larynx with no movement of the vocal cords
T4Tumor invades through the cricoid or thyroid cartilage and/or extends to other tissues beyond the larynx
Regional Lymph Nodes (N)
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Metastasis in a single ipsilateral (on the same side) lymph node less than 3 cm
N2Metastasis in a single ipsilateral lymph between 3 and 6 cm; or in multiple ipsilateral lymph nodes, none more than 6 cm; or in bilateral (both sides) or contralateral (opposite side), none more than 6 cm
N3Metastasis in a lymph node greater than 6 cm Distant Metastasis (M) MX Distant metastasis cannot be assessed
M0No distant metastasis
M1Distant metastasis
Stage group and approximate survival for 5 years
Stage 0Tis, N0, M099%
Stage IT1, N0, M090-95%
Stage IIT2, N0, M080-85%
Stage III T3, N0, M060-70%
 T1, N1, M0 
 T2, N1, M0 
 T3, N1, M0 
Stage IVT4, N0, M035-50%
 T4, N1, M0 
 Any T, N2, M0 
 Any T, N3, M 
 Any T, Any M, M1 
  • Important points to note in staging:
    1. Mobility of the vocal cords is very important; fixed vocal cords indicates Stage III or IV disease
    2. Involvement of lymph nodes indicates Stage III or IV disease
    3. Involvement of cartilage around the larynx indicates Stage IV disease

History and Examination

  • Hoarseness in an elderly patient or smoker means larynx cancer until proven otherwise
  • Risk factors include prolonged exposure to nickel, asbestos or wood dust
  • Supraglottic cancers may present with a chronic sore throat, difficulty or pain while swallowing or with a swollen lymph nodes in the neck
  • Glottic cancers usually present with a change in voice
  • Advanced cancers may present with difficulty breathing or coughing up of blood
  • A complete head and neck examination is crucial to identify the site and possible spread of the tumor
  • Speech is assessed to determine the function of the vocal cords

Tests

  • In the office a laryngoscope (a lighted instrument that looks at the larynx) may be used to identify the site of the tumor. Usually, another examination under general anesthesia is performed with a laryngoscope, to examine closely the small spaces around the larynx to identify spread and to take biopsies (samples of tissue). If there is an advanced tumor, an examination of the trachea or esophagus (tube that carries food from the mouth to the stomach and lies behind the larynx and trachea) may also be carried out at this time. Cancer at one site indicates risk of cancer at other sites of the larynx. The risk of two cancers being present is 7%
  • A chest X-ray looks for metastatic spread or a second cancer (lung cancer is high in smokers)
  • A CT scan or MRI of the larynx is used to diagnose spread of the tumor as well as involvement of cartilage, which may not be seen with a laryngoscope

Indications for Surgery

  • There is controversy as to the best treatment for cancers of the larynx
  • Carcinoma-in-situ tumors may be treated by microexcision (removal of the involved cells), laser removal or X-ray radiation with excellent results
  • Early cancers of the larynx (Stage I & II) have shown equal cure rates with either surgery or radiotherapy. Treatment of choice must be made after considering the patient's wishes to preserve voice, overall health including heart and lung condition and stage of the tumor
  • Conservative surgery (partial laryngectomy) may be performed for early laryngeal cancer. Surgery may offer a cure with excellent long term survival rates but there will be some alteration of the voice. Also, patients with poor pulmonary function may not be able to tolerate this procedure as partial laryngectomy increases the risk of aspiration of swallowed material (due to partial removal of protective mechanisms of the larynx)
  • Radiation therapy has shown equivalent survival rates as surgery for early cancer and there is minimal change in voice function. However, this treatment may takes longer and the outcome may not be known as soon as with surgery. Radiation may not be appropriate treatment in younger patients, who would have an increased risk of developing other cancers in the neck (such as thyroid cancer) because of the radiation
  • Advanced cancers (Stage III & IV) are best treated with multimodal therapy - a combination of radiation and a formal laryngectomy. Lymph node metastases in the neck may also require a neck dissection, removing all of the lymph bearing tissue in the neck
  • With a laryngectomy, the patient loses both vocal cords and will have a permanent tracheotomy (hole into the windpipe). The patients will not be able to speak and special training or equipment may be needed · Guidelines for treatment of laryngeal cancer are:
    1. Supraglottic cancers:
      • Carcinoma-in-situ: Microexcision, laser ablation or radiation Stage I or II:
      • Partial laryngectomy (supraglottic laryngectomy) or radiation Stage III or IV:
      • Multimodal therapy
    2. Glottic cancers :
      • Carcinoma-in-situ: Microexcision, laser ablation or radiation Stage I or II:
      • Partial laryngectomy (vertical - see below) or radiation Stage III or IV:
      • Multimodal therapy
    1. Subglottic cancers:
      • Multimodal therapy

Surgical procedures

  • Complete Laryngectomy
    1. The procedure is carried out under general anesthesia with neck extended
    2. An incision is made across the lower neck and may be curved up one side of the neck if lymph node removal is planned (Figure 4A)
    3. The strap muscles (the small muscles in front of the larynx and trachea) on the side of the cancer are divided to exposure the larynx (Figure 4B)
    4. The thyroid gland on the side of the cancer is divided and removed
    5. The hyoid bone above the larynx may be removed
    6. The larynx is separated from the underlying esophagus. (Figure 4C) The trachea is divided low in the neck. (Figure 4D) The endotracheal tube, which was placed at the beginning of the operation for anesthesia, is removed and a tracheotomy (opening in the trachea) tube is placed in the lower cut end of the trachea. This becomes the new permanent tracheotomy
    7. The larynx is lifted upwards to expose the back of the larynx then separated from the pharynx (upper end of the food tube) wall and removed
    8. The muscular opening in the pharynx is closed
    9. The tissues overlying the removed larynx and the skin are closed
    10. An opening is made on the skin surface for the tracheotomy tube to come out and a dressing placed over the wound (Figure 4E)
  • Partial Laryngectomies for early stage cancers. There are several types of partial laryngectomy for early cancer. Two of are described:
    1. Supraglottic laryngectomy. This procedure may be possible in a patient that has cancer confined to the supraglottis with no evidence of lymph node, vocal cord, cartilage or involvement outside the glottis
    • Reasonable lung function is necessary because of a higher incidence of aspiration of swallowed contents after this surgery
    • The operative approach is similar to a complete laryngectomy
    • The upper half of the thyroid cartilage is divided above the vocal cords
    • The larynx above the vocal cords including the epiglottis and the hyoid bone are removed
    • The glottic area may be pulled up to the base of the tongue with sutures, to offer better protection from aspiration
    • There is significant residual speech function, as both vocal cords are preserved
    1. Vertical hemilaryngectomy:
    • This procedure may be possible in a patient with early cancer confined to one vocal cord
    • In this procedure the right or left half of the larynx from the cricoid cartilage below to the epiglottis above is removed
    • Small muscles of the neck may be rotated to lie vertically for the remaining vocal cord to lie against so there will be some speech function
Figure 4A - Incision for a total laryngectomy. © T. GravesFigure 4B - The strap muscles on either side of the larynx and trachea are cut and the thyroid gland is divided. © T. Graves
Figure 4C - The larynx and trachea are separated from the esophagus (arrow). © T. GravesFigure 4D -The trachea is cut below the larynx and a tracheostomy tube placed in the cut lower end of the trachea to provide an airway. The trachea and larynx are peeled away from the underlying esophagus and pharynx. © T. Graves
Figure 4E - After removal of the larynx the wound is closed leaving an opening into the lower end of the cut trachea as an airway. © T. Graves

 

Complications

  • Fistula (channel) from the pharynx to the skin may occur when the repaired pharynx breaks down and opens out to the neck. This is particularly a problem after radiotherapy. This is usually managed by surgery where soft tissue and muscle with good blood supply is placed between the pharynx and skin to help it heal
  • Stenosis (narrowing) of the larynx or pharynx can occur and may interfere with speech therapy or tracheotomy care. This may also require further operation and repair
  • Recurrent cancer at the edge of the removed tissues (trachea and/or esophagus). This may require further removal of the tracheal margin and lower positioning of the tracheotomy or, in cases of esophageal involvement, it may require removal of the esophagus with the stomach pulled up into the neck as the new food tube
  • Infection
  • Bleeding

Postoperative Care

  • Patients are usually fed via a tube passing through the nose into the stomach for a few days to allow the operative site to heal
  • Drains kept in place after the operation may be removed on the 3rd or 4th day after surgery
  • The patient is instructed on the care of the tracheotomy
  • Speech training is discussed before surgery. An electric larynx may be given for use before formal training is done

Speech Rehabilitation

  • Speech training is extremely important for a patient after a laryngectomy to ensure a reasonable quality of life
  • Options include:
  • Esophageal speech. The patient learns to swallow air into the food tube and expel it in a controlled fashion with the lips and tongue helping to form words. About 30% of patients become fluent with this speech
  • Tracheoesophageal puncture. An artificial opening is created between the trachea and the esophagus behind. Air expelled out of the lungs is passed into the esophagus and mouth for the lips and tongue to form words. This feels more normal for patients with air coming out of the lungs. Success rates are higher with this therapy
  • Electrolarynx. The elecrolarynx us an amplifier of vibrations produced by air coming up the trachea. It then transmits these vibrations from the neck to the mouth area to form words. The speech is understandable but has a characteristic robotic nature. Most people are familiar with the electrolarynx, which is held up against the neck. There is also model that is in the mouth, which is more difficult to learn

Chemotherapy

  • Early studies have shown that chemotherapy with platinum-containing drugs may work against laryngeal cancer. Some centers have added chemotherapy into their multimodal treatment approach