• Home
  • Articles
  • Total Laryngectomy - Indications, Contraindications, Surgical steps and Complications

Total Laryngectomy - Indications, Contraindications, Surgical steps and Complications

on | Last revised on 8th Jun 2018

Categories:

Total laryngectomy is a surgical procedure in which the entire larynx is removed by resecting the trachea and bringing out the lower stump as a respiratory opening in the anterior part of the neck (permanent tracheostomy) and thereby closing off the air passages to the mouth and nose. The patient permanently loses his/her natural voice as well as the sensation of smell.

Total laryngectomy is mostly done for malignancies involving the larynx. With the advent of improved surgical techniques, better post op rehabilitation and infection control, the focus has shifted to more conservative approaches which aim at both anatomical as well as functional preservation of the larynx.

The concept of organ preservation churned up a myriad of surgical as well as non-surgical (Chemo-radiotherapy) therapeutic interventions. Despite all this total laryngectomy still has a definite role in the management of advanced laryngeal malignancies.

Evolution of total laryngectomy procedure

The British surgeon Patrick Watson in 1866 has been credited in some articles of literature as being the first to perform a total laryngectomy. However scrutiny of the medical records of the time clarifies that Dr Watson only performed a tracheotomy for a patient with congenital syphilis and then for purposes of teaching and demonstration did a total laryngectomy post mortem.

The first in-vivo total laryngectomy was performed by Billroth in Vienna on 31st December, 1873. It was a case of malignant growth in larynx. Patient survived the procedure and went on to live for another 7 months. Although he developed significant pharyngocutaneous fistula he had resumed an oral diet and was even fitted with an artificial larynx, created by Gussenbauer.

In Italy, Enrico Bottini performed a total laryngectomy in 1875, followed a few years later by Azio Caselli in Reggio Emilia and Francesco Durante in Rome. The results from these initial cases showed that the intra op and immediate post op complications elevated the mortality to about 50%.

In 1880 it was Gluck, along with his pupil Sorenson, who described a new method of performing the surgery. A similar approach was proposed at about the same time by Durante. They all agreed that there was a need to separate the respiratory tract as completely as possible from the digestive tract. Gluck initially proposed a two staged procedure where the trachea is separated first and the larynx removed 2 weeks later. It was Sorenson in 1890 who finally came up with a single staged surgery, total laryngectomy as we know it today.   

American surgeon George Washington Crile recognised the importance of the lymphatic system and distant metastasis. He advocated routine radical neck dissection with total laryngectomy in cases of malignancies. Martin and Ogura later standardized the steps involved in total laryngectomy with neck dissection.

In 1912 Francesco Durante’s student Gerardo Ferreri, who later became Director of Otology and Rhinolaryngology at Regia University in Rome, was the first otorhinolaryngologist to perform a total laryngectomy.

Total laryngectomy - Indications

The indications for total laryngectomy are as described below

  1. Advanced tumors of larynx with cartilage destruction and anterior extralaryngeal spread, which often manifests initially with laryngeal dysfunction that includes vocal cord paralysis; airway obstruction; or severe aspiration. These patients are not good candidates for organ preservation, because the organ already has been damaged and will not likely function even if it can be preserved anatomically. Hence total laryngectomy is recommended in them.
  2. Tumor involvement of posterior commissure or bilateral arytenoid / cricoarytenoid joint, as is sometimes seen in advanced supraglottic tumors. 
  3. Circumferential submucosal disease with or without bilateral vocal cord paralysis.
  4. Subglottic extension with extensive invasion of the cricoid cartilage.
  5. Radiotherapy or chemoradiation failures, including those who have also had partial laryngectomy failure.
  6. Completion laryngectomy for failed conservation or extensive endoscopic surgery.
  7. Hypopharyngeal tumors that originate at or spread to the postcricoid mucosa and advanced piriform sinus cancers.
  8. Massive neck metastases and thyroid tumors (usually recurrent) that invade both sides of the larynx from outside the laryngeal skeleton. 
  9. Advanced tumors of certain histologic types that are incurable by endoscopic resection, chemotherapy, or radiotherapy (e.g., adenocarcinoma, spindle cell carcinoma, soft tissue sarcomas, minor salivary gland tumors, large cell neuroendocrine tumors) and chondrosarcomas of the thyroid cartilage.
  10. Extensive pharyngeal or tongue-base resections in patients who are at high risk for aspiration problems.
  11. Radiation necrosis of the larynx, despite tumor control, that is unresponsive to adequate antibiotic and hyperbaric oxygen management (this condition can be painful and also predisposes patients to aspiration, and tumor is often found when total laryngectomy is performed).
  12. Severe irreversible aspiration, with the laryngectomy used for complete separation of the air and food passages (this indication should be rare, considering the variety of other separation or closure procedures available).
  13. Severe laryngeal trauma that doesn’t allow functional reconstruction of the organ.
  14. Laryngeal stenosis insurmountable by other types of surgery.
  15. Chronic inflammatory disease of larynx accompanied by liquefaction necrosis.
  16. Recurrent laryngeal papillomatosis with an increased risk of tracheal invasion.

Contraindications for total laryngectomy

Following are some of the contraindications for total laryngectomy

  1. The presence of incurable synchronous tumours
  2. The presence of incurable distant metastases
  3. Severe systemic general disease or poor general condition
  4. Tumour invading the profound parts of the tongue
  5. Tumour that exceeds the prevertebral fascia
  6. Tumour or metastasis that encases the common or internal carotid artery.

Investigations needed prior to surgery

Prior to making the decision for total laryngectomy the patient can be evaluated using one or more of the following:

For tumor workup:

  1. Digital X ray soft tissue neck both antero-posterior and lateral views.
  2. Videolaryngoscopy Tumour Work up
  3. Magnetic resonance imaging of neck
  4. Microlaryngeal Examination with Biopsy

For metastatic workup (distant spread of the disease)

  1. Contrast enhanced computed tomogram of Neck
  2. Ultrasonography of abdomen Metastatic Work up
  3. Thoraco-lumbar spine Radiographs
  4. Positron emission tomogram scan

To identify synchronous primary tumors (second primary tumors)

  1. Bronchoscopy
  2. Oesophagoscopy
  3. Barium swallow

Preoperative assessment

Firstly the patient’s condition must be evaluated extensively using the various modalities available and as afforded by the patient. For malignant growths a tissue diagnosis is absolutely essential. If total laryngectomy is selected as the best option for the patient – keeping in mind the above indications - the following factors need to be considered:

  • Is the patient medically fit for general anesthesia (GA) – a cardiologist must certify that the patient’s cardiac status is stable and that he may undergo surgery under GA.
  • Post total laryngectomy status puts immense stress on the respiratory system and patients with poor respiratory reserve are poor candidates for laryngectomy.
  • Patient should have adequate dexterity of hands / fingers to manage the Laryngectomy tubes.
  • Any distant foci of sepsis should be sought for and dealt with before embarking on laryngectomy. Of these, most commonly, dental caries must be treated as well as any active dermatological conditions.
  • Finally and probably most importantly the patient must be counselled to be prepared for the rigors of post total laryngectomy life.
  • A written informed or if possible a video consent should be taken prior to the surgery. The various aspects of the surgery, complications and post op rehabilitation should be discussed with the patient and relatives with emphasis on the permanent loss of voice.
  • The anaesthesia team should look for any airway difficulties and inform if tracheostomy is needed under local anesthesia (LA) - Care should be taken to site the skin incision at the intended site of tracheostomy stoma. This helps to avoid the Bipedicled Bridge of skin between the skin flap and tracheostomy site.

Surgical steps in total laryngectomy

Patient Position & Anaesthesia

The patient is positioned in supine position with neck in slight extension. This can be achieved by either placing a small sandbag beneath the shoulder or by moving the patient to the end of the table and using a head holder.

General anaesthesia is given either by intubating the patient via an endotracheal tube (ET) or via the tracheostomy (flexometallic ET tube).

The entire neck starting from the mandible down to the sternum and clavicle is painted with antiseptic - povidine iodine and then spirit. The surgical field is draped and the preferred incision is marked out.

A Ryle’s tube is inserted prior to the surgery.

Incision in Total Laryngectomy

The choice of incision mainly depends on the personal preference of the surgeon, as well as factors like whether radical neck dissection is required or not.

The most commonly followed incision for total laryngectomy is the U-shaped Gluck – Sorenson incision starting from the mastoid on one side, going along the anterior border of the sternocleidomastoid muscle, intersecting at the level of cricoid in midline (2cm above sternal notch) and extending to the mastoid on the other side, including the tracheostome in the incision.

The Gluck-Sorenson incision allows maximum access to neck dissection with the same incision. Other incisions for total laryngectomy can be found out here.

The Tracheostomy

It has been proven that the incidence of stomal recurrence after total laryngectomy increases when the tracheostomy is done prior to the laryngectomy as a separate procedure for airway obstruction. Furthermore, as the time elapsed between the tracheostomy and the laryngectomy increases the chances of stomal recurrence also increases. Keeping these facts in mind it is always desirable to fashion the tracheostomy during the laryngectomy as a single procedure whenever possible.

The site of the tracheostomy is usually at the 2nd or 3rd tracheal rings. However in case of a subglottic or tracheal involvement the site may need to be moved further down keeping in mind the principles of oncologic resection.

There are a lot of minor variations in the procedures described in literature. An attempt has been made to describe all of them here. The choice of procedure is mainly dependant on the personal preference and expertise of the surgeon.

Exposure

Firstly the incision site is injected with a vasoconstrictor usually adrenaline in 1:100000 dilution.

Using a 15 blade the skin incision is made and tissue dissected upto the subplatysmal plane.

The subplatysmal flap is raised superiorly above level of hyoid bone and inferiorly up to level of sternum and clavicular heads, so that the entire larynx is visualised. The flap should contain skin, subcutaneous fat and platysma muscle. This ensures that the vascularity of the flap is maintained. 

The deep cervical fascia is incised along the anterior border of the sternocleidomastoid muscle creating the “outer tunnels”. The anterior jugular veins need to be clamped and ligated at this point. The omohyoid muscle is identified and cut to allow good exposure.

The strap muscles are identified and cut at the level of the hyoid and the inferior end is mobilized and kept to be used at the end of the surgery to fashion the stoma. The superior end is ligated and removed with the tumour. Some authors are of the opinion that the strap muscles should always be cut as low as possible in the neck to prevent stenosis of the final stoma.

Thyroidectomy

Following above steps on both sides, the thyroid gland can be readily identified.

How the thyroid is dealt with depends on the extend of the tumour. For unilateral tumours confined to the larynx, the contralateral lobe is preserved and ipsilateral lobe may be removed. For bilateral extensive lesions invading the thyroid cartilage, those with subglottic extension more than 1 cm or those with extensive involvement of paratracheal or paralarayngeal lymphatics, a total thyroidectomy is warranted.

All attempts should be made to preserve the thyroid as much as possible to prevent post op hypothyroidism or hypoparathyroidism. 

Firstly the isthmus is identified and dissected off the trachea. It is cut between clamps and the ends ligated with heavy sutures. On the ipsilateral side the middle thyroid vein, superior and inferior thyroid pedicle are clamped, cut and ligated. The contralateral lobe is freed off its attachments to the trachea, from medial to lateral (to preserve blood supply), whilst the ipsilateral lobe is left alone and removed with the laryngectomy specimen. The superior pedicle on the side to be preserved maybe sacrificed if necessary however the inferior pedicle must be saved. If at the end of the dissection the vasculature to the parathyroid seems poor then it maybe transposed into the neck musculature.

Skeletonisation of the Larynx

After the thyroid is out of the way the neck dissection may be completed and all necessary lymph nodes along with soft tissue may be removed. A “deep tunnel” is then created by blunt dissection in the plane between the carotid sheath and the larynx. Extending this tunnel superiorly will take us to the superior laryngeal pedicle at the level of the hyoid. This is identified and clamped bilaterally.  

Once the superior laryngeal pedicle is secured, the larynx maybe mobilised. The body of the hyoid is grasped using a towel clip and the suprahyoid muscles (mylohyoid, geniohyoid, digastric sling and hyoglossus) are disinserted. Once the central part is freed the hyoid bone is held using an Alley’s forceps and the region of the greater cornu is released on both sides. Here one must be careful not to injure the hypoglossal nerve and the lingual artery. This is done by retracting the hyoid so as to expose the tip of the cornu and staying as close to the bone as possible.

Pharyngotomy

The mucosa over the epiglottis is then stripped off by blunt dissection and the epiglottis is identified and grasped using Alley’s forceps. It is important to preserve as much as mucosa as possible for pharyngeal reconstruction.

To avoid cutting through the tumour or its submucosal extension, the pharynx may be entered contralateral to the tumour. Tongue base involvement warrants a lateral pharyngotomy behind the thyroid cartilage. The extent of tumour is inspected and a safe 2 cm margin of normal looking mucosa is preserved with further cuts from below, progressing superiorly behind the thyrohyoid membrane, around the hyoid bone, and then transversely across the vallecula or tongue base.

If the tumour is confined below the level of the hyoid then the pharynx maybe entered directly through the vallecula in the antero-posterior direction. Following the hyoepiglottic ligament allows correct identification of the plane and prevents entry into the pre epiglottic space. Once the mucosa is opened the epiglottis can be identified and delivered using Alley’s forceps.

Craniocaudal Resection

The aryepiglottic fold is then cut close to the epiglottic side, thereby leaving ample pharyngeal mucosa for reconstruction. The thyroid cartilage is further angled and the attachments of the constrictor muscles are cut close to the cartilage from superior to inferior. This is continued on either side upto the apices of the pyriform sinuses.

A transverse cut through the post cricoid mucosa is then made. This incision connects the vertical incisions laterally. It is position behind the body of the cricoid lamina. Then by blunt dissection the plane between the trachea and oesophagus is identified and dissection continued upto the tracheostomy. 

Laryngotracheal Separation

Once the trachea is separated from the oesophagus the tracheal rings are cut horizontally at the desired level. The incision is carried behind in a bevelled fashion from anteroinferior to posterosuperior.

The ET tube can now be removed and a new laryngectomy or flexo metallic tube maybe inserted via the lower stump and anaesthesia delivered through it.

The lower stump must first be anchored to the skin before transecting the trachea completely.

The larynx is now totally free off all its attachments except for part of the post cricoid mucosa which is also separated. Once the specimen is out a through wash is given to the field.

Pharyngeal Closure

It is important that the specimen is given for frozen section biopsy to confirm negative margins. Then the defect in the pharynx needs to closed.

The type of closure depends on the amount of pyriform sinus mucosa available. Usually a ‘T’, vertical or horizontal closure is done. This step must be done with utmost care as a defect in the pharyngeal mucosa causes pharyngo-cutaneous fistula.

Care must be taken to ensure that the mucosal margins are inverted. Interrupted or running inverted sutures maybe used.

Once the pharynx is closed a second wash is given and any defect identified. Tissue glue maybe placed over the suture lines and allowed to set.

At this point a tracheoesophageal stoma maybe created for insertion of a TEP voice prosthesis. In cases which are not irradiated previously and the patient is counselled properly pre op, the prosthesis is kept intra op. This gives the best results.

However, previous radiation to neck increases the chance for a pharyngocutaneous fistula and the prosthesis is best delayed till complete wound closure. Some surgeons also place the primary feeding tube through the potential stoma and after wound healing replace this with the prosthesis.

If the pharyngeal mucosa is not sufficient to give adequate closure then a repair using flaps must be considered. Either a myocutaneous flap, a muscle flap, or a microvascular free flap maybe used. It is said that a remnant wall of 1.5cm width is sufficient for closure without dysphagia.  

Stoma Creation

Following pharyngeal closure a drain is kept and then the stoma is created.

Half mattress sutures with a large bite in the skin will pull the skin over the tracheal cartilage. This is done all around and the neck wound is closed in layers.

Absorbable sutures are used in the region of the stoma as removal may be difficult. The heads of the SCM may be cut to give rise to a more flat stoma and prevent stenosis. The muscle is then mobilised and secured on the prevertebral fascia between the carotid and pharyngeal closure. This potentially decreases the chance of a pharygocutaneous fistula and protects the carotids from saliva if it does occur.

Post op care

Patient is shifted immediate post op to an ICU for observation.

In our centre he/she is maintained on parenteral nutrition for the first 24 hours. Wound dressing is changed once every 24 hours. A cleaned and sterilised tube is changed each time. The drain is removed if the total collection in 24 hours is less than 20 ml for 2 consecutive days.

If patient is stable then the urine catheter is removed and the patient made ambulant the very next day of surgery.

IV antibiotics are continued for about a week post op. If there are signs of wound infection then a culture sensitivity report is warranted and targeted antibiotics are changed.

The frequency of dressing may also be increased as needed.

The viability of the flap is assessed daily and early changes noted and addressed accordingly.

The patient is advised to be NPO and not even allowed to swallow saliva till about a week. Ryle’s tube feeding maybe started after 24-48 hrs.

After 7 days the neck sutures are removed except for around the stoma.

If the closure looks healthy then the patient is asked to take sips of liquid feeds like milk/water after 1 week. If there is no leak then patient is started on oral feeds and the Ryle’s tube can be removed. If there was prior irradiation to the neck then oral feeds are delayed for about 2-3 weeks.

4 -6 weeks post op, once the wound is completely healed the patient can be sent for post op radiotherapy if required.

During the immediate post op period the acute loss of voice and getting used to stoma care may have a profound effect on the patient’s psyche. The patient is counselled during this period.

Attention should be paid to parameters like Haemoglobin count, renal function tests, urine output, nutritional status, stoma care, humidification of air and suction clearance of secretions, maintenance of saturation and corrective measures initiated at the earliest.

If a tracheo-esophageal prosthesis (TEP) is placed primarily then phonation exercises must be started early in the post op period.

Total laryngectomy - Complications

Post total laryngectomy complications can be broadly divided into two; early and late complications.

Early Complications:

Drain Failure – Non-functional drains results in collection of secretion under the flap, compromising its viability. The loss of vacuum may be due to leak in the pharynx, skin or stomal closure. It must be identified early and rectified.

Hematoma – This is a relatively rare complication of total laryngectomy. If present the patient must be taken back to the OT and clots evacuated. New drains must be inserted at this point.

Infection – If erythema and edema of the skin develops then subcutaneous infection should be suspected. The pus must be promptly drained under sterile conditions and sent for culture and sensitivity. The dead space between the neopharynx and skin flap is reduced by compressive dressing or antiseptic gauze packing. If the discharge persists then a pharyngocutaneous fistula must be suspected or a chyle fistula should be ruled out if neck dissection is carried out.

Pharyngocutaneous Fistula – Poor pre op nutritional status, advanced tumour stage, diabetes, pre op radiotherapy or chemoradiotherapy are all factors that significantly increase the chance of fistula. The fistula results from a closure defect through which saliva accumulates in the dead space between the neopharynx and skin flap.

A turbid copious drain and erythema and oedema around the wound should arouse suspicion of fistula. It can be confirmed by methylene blue given to the patient orally or by gastrograffin swallow radiography.

Fistula is managed by regular antiseptic gauze packing as well as compression dressing to reduce dead space. The patient is kept NPO and not even allowed to swallow saliva. A salivary bypass procedure maybe helpful in these cases. The tract may be attempted to be sterilised from inside out by asking the patient to swallow antiseptic solution few times daily - 10 mL of 0.25% acetic acid by mouth or an antibiotic or other antiseptic preparation three to four times daily. If conservative methods fail then operative closure of the tract needs to be considered. 

An excellent option for fistula closure before complete epithelialization is a pedicled muscle flap (pectoralis, trapezius, or latissimus dorsi) slipped between the pharyngeal and skin defects. Such flaps endow excellent blood flow and antibacterial benefits to an avascular, infected bed. Control of esophageal reflux is also an important aspect of preventing and managing pharyngocutaneous fistula.

Wound Dehiscence - Wound dehiscence may accompany a tensioned skin closure, postradiation state, wound infection, fistula, or poorly designed ischemic neck flaps. Local wound care should suffice for healing by secondary intention, but if the carotid becomes persistently exposed, vascularized muscle flap coverage is advisable.

Late Complications

Stomal Stenosis - If the stoma is created as described earlier, stomal stenosis is uncommon. This approach can be used in revision as well.

In patients with small tracheas or a propensity for stenosis, women have a higher likelihood of fistula. Revision, when necessary, can be done with V-Y advancement flaps, Z-plasties, and a “fish-mouth” stomaplasty. Excision of cartilage remnants is preferable to radical excision and laryngectomy tube placement, but in some cases, prolonged use of a laryngectomy tube is required.

Pharyngoesophageal Stenosis and Stricture - When pharyngoesophageal stenosis or stricture is evident, tumor recurrence should be suspected; but once this has been ruled out by endoscopy and biopsy, outpatient dilation is usually an effective treatment. An adequate lumen (36 Fr) is necessary not only for swallowing and nutrition but also for tracheoesophageal speech production. If dilation is unsuccessful, flap reconstruction is preferable.

Hypothyroidism - Preoperative or postoperative radiotherapy plus hemithyroidectomy is usually sufficient to induce a low-thyroid state. Thyroid function tests every 1 to 2 months after completion of all treatment is indicated when supplemental thyroid medication is required.

Rehabilitation after total laryngectomy

References

  1. Moretti A, Croce A. Total laryngectomy: from hands of the general surgeon to the otolaryngologist. Acta otorhinolaryngologica Italica: organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 2000 Feb;20(1):16-22.
  2. Mohebati A, Shah JP. Total laryngectomy. Otorhinolaryngology Clinics An International Journal. 2010 Sep 25;2(3):207-14.
  3. CEACHIR O, HAINAROSIE R, ZAINEA V. Total laryngectomy–past, present, future. Maedica. 2014 Jun;9(2):210.
  4. Open access Atlas of Otolaryngology, Head & Neck Operative Surgery, Total Laryngectomy, Johan Fagan
  5. Head and Neck Surgery and Oncology, Jatin Shah, 3th Edition
  6. Scott Brown Otorhinolaryngology, Head & Neck Surgery, 7th edition
  7. Cummings Otolaryngology Head and Neck Surgery, 6th edition

Share this:

Meet the author

Dr. Nigil is an otolaryngologist (ENT) originally from Kannur, Kerala India. Currently he is working as senior resident for Department of Laryngology and Phonosurgery at Christian Medical College and Hospital Vellore, India.

He did his MBBS training from Academy of Medical Sciences, Kannur and his Masters in ENT from Stanley Medical College, India. 

He has subspecialty interests in otology, microear and microlaryngeal surgeries.

He has been an editorial board member at e4ent since 2017. Furthermore, he is a strong supporter of open access education and e-learning.

Outside of work, Dr. Nigil enjoys travel, swimming and practices martial arts.

Comments