Primary and Salvage Total Laryngectomy

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Treatment of laryngeal cancer has evolved, and newer methods of laryngeal conservation, both surgical and nonsurgical, are the primary treatment of choice. Nevertheless, total laryngectomy is not extinct and still plays an important role in primary therapy for advanced stage laryngeal cancers and as salvage therapy for failures of organ preservation strategies.

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Indications

The indications for a TL have decreased as organ preservation strategies have mandated a paradigm shift. In 1991, the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that induction chemotherapy with cisplatin plus fluorouracil followed by radiation therapy allowed preservation of the larynx in 64% of patients without affecting survival when compared with TL and adjuvant radiotherapy [6]. In 2003, Forastiere and colleagues [7] showed that concurrent chemotherapy with

Patient work-up and selection

Beyond the standard history and physical examination, patients must undergo a biopsy to confirm the diagnosis of cancer. Hence, a direct laryngoscopy with biopsy should be performed to help stage the tumor accurately. Esophagoscopy, and bronchoscopy as indicated, should be performed to evaluate for extent of disease and synchronous primary lesions.

A neck CT with contrast also is required in the work-up of advanced laryngeal cancer [9]. A primary indicator for surgery is extensive cartilage

Surgical technique

Direct laryngoscopy is performed to determine/confirm the degree of extension of disease and verify the proposed surgical intervention. Modified apron or transverse incision is designed incorporating the existing stoma or planning the permanent stoma. This incision may be modified when performing simultaneous neck dissections.

Subplatysmal flaps are raised to the sternal notch inferiorly, hyoid cartilage superiorly, and sternocleidomastoid muscles laterally. The sternocleidomastoid muscles are

Neck

The larynx drains into levels 2 to 4 pretracheal and paratracheal lymph nodes within the neck. Advanced laryngeal cancers have an overall 30% incidence of occult neck metastasis [18]. Patients who have supraglottic and advanced glottic with clinically N0 neck should undergo elective treatment of the neck by either neck dissection or radiotherapy [19]. Supraglottic tumors have a significant propensity for bilateral neck metastasis, and bilateral necks should be addressed [20]. Patients with N1

Adjuvant radiation

Adjuvant radiotherapy may be combined with primary TL for advanced laryngeal carcinomas. The goal of adjuvant radiotherapy is to control loco-regional minimal residual disease. More specifically, postoperative radiation therapy is indicated in patients with T4 carcinoma, inadequate surgical margins, cervical lymph nodes metastasis, and extracapsular, perineural, and/or vascular spread [25], [26], [27], [28]. Nevertheless, Spector and colleagues [29] did not demonstrate a statistically

Complications

Early complications after TL include bleeding/hematoma, infection, wound breakdown, and pharyngocutaneous fistula formation. In the case of bleeding, the patient should be explored in the operating room with evacuation of the clot and control of bleeding. A wound infection is managed by opening the wound and draining the infected collection, followed by packing and culture-specific antibiotics.

Pharyngocutaneous fistula is a common, troublesome complication. The incidence is generally higher

Recurrence

In a recent study, approximately 31% of patients who underwent a TL for primary tumor or for salvage therapy had recurrence, defined as loco-regional recurrence, second primaries, or distant metastases [37]. The mean interval between TL and detection of recurrence was 11.6 months. Almost 60% of patients had loco-regional recurrence, most commonly in the neck or tracheostomal recurrence. Approximately 25% had metastatic disease, and most of the remaining patients had a second primary malignancy.

Swallowing

Intraoperatively, either a nasogastric tube or a temporary catheter is placed in the tracheoesophageal fistula. Tube feeds are begun once bowel sounds are present. Common practice is to initiate oral feeding on postoperative day 5 to 7 in nonradiated patients, and 7 to 14 postoperative days in radiated patients. There is evidence, however, that oral feeding may be commenced on postoperative days 2 to 3 without increasing the rate of a fistula [44], [45].

Dysphagia warrants a modified barium

Voice

The three methods of communication after a TL include TEP speech, esophageal speech, and artificial or mechanical larynx. Today, tracheoesophageal speech is the preferred form of voice rehabilitation after TL [47], [48]. Tracheoesophageal speech functions by forcing air through a one-way valve into a narrow pharyngoesophageal segment that vibrates to produce sound. To achieve intelligible speech and successful voice rehabilitation, patients are encouraged to work closely with the speech

Summary

TL continues to play a major role in the treatment of advanced laryngeal cancer or for recurrent/persistent disease after failed organ preservation attempts. Functional rehabilitation is available, and most patients are able to communicate effectively with tracheoesophageal speech and maintain swallowing function.

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