Overview of Total Laryngectomy
The main goal in treating laryngeal cancer, which is cancer occurring in the voice box or larynx, is to get rid of the disease. Also, we want to protect the ability to speak and swallow, and avoid needing a tracheostomy—a surgery to make an opening in the windpipe. There are several ways to treat laryngeal cancer, including radiation therapy, chemotherapy, surgery, or a mix of these. This is usually decided by a specialized team of healthcare professionals who look at many factors like the type and location of the tumor, how well the voice box is working, and the patient’s overall health.
Removing the entire voice box, or a total laryngectomy, is commonly done when other treatments have failed, or for treating cancers that are quite advanced. However, a lot of factors, including the patient’s anatomy, lifestyle, geographical location, and occupation can influence which treatment to choose. A very important factor is the stage of the cancer, which reflects how far the cancer has spread.
Early-stage cancers (stages I and II) can typically be treated with just one type of therapy, which could be radiation therapy or surgery. If the cancer is more advanced (stages III and IV), a combination of treatments might be needed, like a mix of radiation therapy and chemotherapy, or surgery followed by radiation therapy.
In recent years, preserving the voice box has become a more prominent goal in treating laryngeal cancers. Techniques such as TOLM (Transoral Laser Microsurgery) and TORS (Transoral Robotic Surgery) offer more surgical options and may help maintain the function of the voice box. In early stage laryngeal cancers, radiation therapy is still often used as a way to preserve the voice box. Though, a total laryngectomy is always an option for patients who can’t use the voice-preserving techniques or when other treatments have failed. Infrequently, a total laryngectomy may be performed to prevent food or liquid accidentally getting into the lungs (known as chronic aspiration).
Anatomy and Physiology of Total Laryngectomy
The larynx, also known as the voice box, is situated at the front of your neck. It’s a sort of bridge that connects the lower part of your throat (pharynx) to your windpipe (trachea). It’s made up of six main parts that are formed from cartilage — a flexible substance that’s heavier than muscle, but softer than bone. There are three main parts (thyroid, cricoid, and epiglottic) and three smaller parts (arytenoid, cuneiform, corniculate). The hyoid bone, which is located above the thyroid cartilage, while not technically a part of the larynx, is essential for swallowing.
For easier study, the larynx is divided into three regions:
1. Supraglottis: This is the upper part of the larynx, located above a small cavity called the ventricle. This area includes the ventricle itself, some folds in the larynx, and the epiglottis (which acts like a lid over the windpipe when swallowing).
2. Glottis: This part contains the true vocal cords, which stretch from front to back and play a key role in producing our voice.
3. Subglottis: This lower part of the larynx extends from the bottom edge of the glottis to the lower edge of the cricoid cartilage (located near the trachea).
Inside the larynx, the surface is covered in a type of skin (squamous epithelium) and has glands that produce mucus. The true vocal cords in the glottis area have the same skin coverage.
The “feeling” in the larynx comes from branches of the superior laryngeal nerve, and other nerves assist with sensing in the vocal cords and the lower part of the larynx. The larynx also gets its blood supply from branches of the superior and inferior thyroid arteries.
The larynx’s main jobs are helping with breathing and making sound (phonation). The true and false vocal folds and the epiglottis protect the lower airways. When we inhale and exhale, these structures open wide to allow efficient air exchange. If anything unexpected touches the supraglottis or glottis during respiration, it sparks off a cough reflex which shields the lower airways.
Your vocal folds are what allows you to speak. The air you force up from your lungs makes these folds vibrate and create sound. If the folds can’t move as they should, voice changes can happen, like sounding breathy, or having hoarseness. This can happen due to benign or malignant growths on the larynx, damage to the vocal folds, or diseases.
During a complete laryngectomy (removal of the larynx), the lower airways are separated from the digestive tract, creating a new pathway for breathing and swallowing. After the procedure, breathing through the mouth or nose isn’t possible, so patients breathe through an opening at the front of the neck (stoma).
Why do People Need Total Laryngectomy
A person may require a total laryngectomy, which is the complete removal of the larynx (voice box), due to several reasons. The circumstances that could lead to needing this surgery include:
Having advanced laryngeal or hypopharyngeal cancers that have spread to nearby areas like the thyroid, cricoid cartilage (rings of cartilage around the larynx), and soft tissues outside the larynx. Advanced cancers are those in late stages which have spread beyond their original location.
If laryngeal cancer does not respond to treatments like radiotherapy or chemoradiotherapy. These treatments use high-energy radiation or a combination of drugs and radiation, respectively, for destroying cancer cells. Non-response means these treatments have failed to stop or slow the growth of the cancer cell.
Wide-ranging tumors that are not suitable for conservative treatment, which means treatments aiming to preserve organ function, so more radical solutions like the removal of the larynx are needed.
Tumors that are proven-resistant to radiotherapy, including types like soft tissue sarcomas (cancer in the soft tissues like muscles and ligaments), chondrosarcomas (cancer in cartilage cells), melanomas (skin cancer), adenocarcinomas (cancer in the cells that line certain organs), large-cell neuroendocrine tumors (fast-growing, aggressive tumors), and tumors of the minor salivary glands (small glands that produce saliva).
Severe trauma (serious injury) to the larynx that makes it impossible to reconstruct and retain the functionality of the larynx.
Patients who have lost their voice and suffer from chronic (long lasting and recurring) aspiration, which is the accidental inhalation of food or drink into the windpipe due to paralysis of cranial nerves IX, X, or XI. These nerves play essential roles in swallowing, vocal cord movement and sensation.
Another condition called recurrent laryngeal papillomatosis, which is a chronic disease where benign (non-cancerous) wart-like tumors called papillomas grow in the airway, could also necessitate a total laryngectomy. This is especially true when there’s a high risk of these papillomas invading the trachea (windpipe).
When a Person Should Avoid Total Laryngectomy
In some cases, a person cannot undergo a total laryngectomy, a surgery to remove the larynx or voice box. This could be due to:
If the tumor in the larynx is too large or complicated to remove surgically (“unresectable”), or spread too far away to other parts of the body (“distant metastases”), this surgery may not be possible.
Whether the operation requires a serious level of anesthesia, which the person might not be able to withstand due to other health circumstances.
If the tumor is wrapped around either the common or internal carotid artery, the large neck arteries which supply blood to your brain, face, and neck.
And lastly, if the tumor has invaded the profound parts of the tongue. Even though technically these tumors can be removed, the operation is infrequently done since such surgery is usually only considered in extreme cases due to high risks and complications associated with it.
Equipment used for Total Laryngectomy
The doctor uses a specific set of tools designed for surgeries involving the head and neck. This not only includes a set specifically made for examining the voice box, known as a laryngoscopy set, but also a tool known as a cautery. This cautery could be either monopolar or bipolar diathermy. Another type of cautery, known as a harmonic scalpel, might also be used.
This device helps doctors to swiftly cut the tissue and seal blood vessels at the same time, reducing blood loss. If your doctor isn’t planning to do a gastrostomy (a procedure where a hole is created in your stomach for feeding), they may instead use a nasogastric tube. This is a special tube that goes in through your nose and down to your stomach.
Finally, if your doctor is planning to create an alternate path between your windpipe and your esophagus (the tube that connects your throat with your stomach) using a procedure known as tracheoesophageal puncture, they’ll need a special kit and a tracheoesophageal prosthesis. This prosthesis, or artificial device, helps to enable speech for patients who have had a part of their voice box removed.
Who is needed to perform Total Laryngectomy?
A surgical operation involves several medical professionals, all of whom play different, but crucial roles. Let’s break them down:
First off, the surgeon. This is a special kind of doctor who performs the operation. The surgeon has spent years learning how to do these procedures safely and effectively, so they’re in charge of ensuring everything goes well during the operation.
The surgical first assistant is there to assist the surgeon during the operation. They help the surgeon with tasks like holding tools, sponging or suctioning the area, and other tasks that make the surgeon’s job easier.
The anesthetist, often called an anesthesiologist, is responsible for making you unconscious during the surgery so you don’t feel any pain. They monitor and adjust the levels of anesthesia throughout the operation to keep you safe and comfortable.
The circulator or operating room nurse doesn’t actually take part in the surgery, but they’re very important. They manage the operating room environment, making sure everything is sterile and prepared. They may also help with other tasks, like passing tools to the surgeon or checking your vitals during surgery.
Finally, the surgical technologist or operating room nurse also assists the surgeon during the operation. They may help pass instruments to the surgeon or surgical first assistant, or help with other tasks during the surgery. These extremely competent individuals ensure everything in the operating room runs smoothly.
Preparing for Total Laryngectomy
Before the surgery starts, the patient is made to lie down on the operation table. To keep them comfortable and pain-free, they are given a type of anesthesia, known as general endotracheal anesthesia, which is delivered through a tube placed into their mouth and windpipe.
In some cases, where it may be hard to insert the tube due to airway issues, the doctor may choose to use a flexible, lighted tube (referred to as an awake fiberoptic intubation) or they may create a small opening in the windpipe (known as a tracheotomy). These are done using local anesthesia, which numbs the area, and medicine that shrinks blood vessels to limit bleeding.
Once the patient’s airway is secured, some surgeons may choose to do a procedure called direct laryngoscopy. This involves using a small, flexible device to look at the voice box (the larynx) and the airway. The aim of this step is to get a better view of the tumor. Knowing where the tumor is and how big it is can help the surgeon plan their initial cut during the surgery, whether it is into the pyriform (part of the throat) or the vallecula (a space at the base of the tongue).
How is Total Laryngectomy performed
A total laryngectomy procedure is an operation where the surgeon removes the entire larynx, including the related throat muscles, the hyoid bone, the thyroid gland on the side of the tumor, and the lymph nodes in the front of the trachea. Sometimes, the surgery may also involve removing lymph nodes in the side of the neck.
The surgeon typically starts by making a U-shaped cut on the neck (known as a Gluck-Sorenson incision). This cut goes from around the ear, down to the front of the neck, and back up to the other ear. If needed, the hole made for a previous tracheotomy will be included in this cut. The surgeon then lifts the skin to expose the area from the hyoid bone to the chest notch. This lets them clearly see the surgery area.
If any other areas need to be addressed during the surgery, like lymph nodes in the neck, this is usually done before the larynx is mobilized (detached). Care is taken to protect important nerves and muscles during this process.
The surgeon then starts to detach the larynx, beginning from the top and moving down. This involves safely cutting through and ligating (tying off) vessels and removing the muscles that are attached to the larynx. After dealing with the thyroid gland and arteries, a muscle is detached from the back of the thyroid cartilage to preserve as much throat lining as possible.
A cut is made in the front of the trachea, right under the tumor. The trachea is separated in a way that allows the surgeon to enlarge the hole where your breath will exit after surgery. The lower part of the trachea is then sewn to the skin on your chest to form the new breathing hole (stoma). The trachea and larynx are then disconnected from the esophagus.
The surgeon then makes an opening in the throat, entering through an area that varies depending on where the tumor is. A retractor is introduced to the pharynx (throat) through this opening, and the throat lining is cut around the larynx while saving a margin from the visible tumor. These procedures are important to make sure the cancer has been completely removed.
If it’s part of the plan, a puncture is made between the trachea and esophagus for voice restoration. If not, a small muscle in the throat is cut to make swallowing easier after the surgery. If the patient doesn’t already have a feeding tube, one is inserted through the nose and into the esophagus at this point.
Then, the defect in the throat is stitched up, mostly in a transverse (side-to-side) pattern, which supports healing and future swallowing. A continuous suture, a line of stitches, closes the defect. Any leaks are immediately repaired. After this, drains for any fluid build-up are placed, and the skin and muscle layers are closed.
Possible Complications of Total Laryngectomy
After having a total laryngectomy, which is a surgical procedure to remove the larynx or voice box, patients may encounter some complications shortly after their surgery. These can involve issues with bleeding, swelling, or problems with breathing. It’s highly important to keep a close eye on these symptoms after the operation is done. Patients should be taken care of on a special ward that knows how to manage the care for patients with a laryngectomy because their surgery wound, also known as a stoma, will need routine cleaning in the initial days after surgery. Appropriate signs should be put up around the patient notifying that the patient breathes through their neck and should not have any tubes put in their mouth or nose for breathing.
Sometimes after the surgery, a patient might have a collection of blood under the skin that feels hard or soft, which is known as a hematoma. This can lead to the skin becoming a purple shade; if this is noticed, it needs to be treated promptly with surgery. To reduce the chances of getting infection in the surgical wound, patients are given a wide range of antibiotics that work against oral and throat bacteria until the surgical drains are removed.
Another complication that can happen after total laryngectomy is pharyngocutaneous fistula, a condition where there is an abnormal connection between the throat and skin. This can happen if the stitches in the throat come apart. If untreated, it can become worse. Some signs of this condition include inflammation and swelling of the neck and redness of the skin. Furthermore, if the patient has drains, saliva or pus might be seen in the drain. This condition risk can be influenced by a few factors including tension on the stitches in the throat, previous treatments for cancer like radiotherapy or chemotherapy, the patient’s nourishment level, and the existence of conditions like diabetes.
Patients who have not had radiation are less likely to have this complication, with only 10% being affected. However, for patients who have had radiation treatment, the risk of leakages increases, affecting more than 30% of them. To lower the possibility and seriousness of getting a pharyngocutaneous fistula, a healthy, non-radiated flap (a section of tissue that still has its blood supply) can be used to support the stitches in the throat. This could either be a free flap, taken from a different part of the body, or a pedicled flap, a flap that is moved to the needed area while still keeping its original blood supply. This is a usual part of laryngectomy in many medical centers.
The longer-term complications could involve narrowing of the passage between the throat and esophagus, narrowing of stoma, and an underactive thyroid gland.
What Else Should I Know About Total Laryngectomy?
Surgery is the primary treatment method for advanced-stage laryngeal (throat) cancers, particularly when the voice box isn’t functioning properly. In many cases, a full removal of the voice box (total laryngectomy) is needed, especially when the cancer doesn’t respond to initial radiation therapy or comes back after treatment.
Undergoing a total laryngectomy requires significant lifestyle adjustments. For example, patients will lose their natural voice and the voice box’s function of safeguarding the lower airway. However, many people are able to live long-term with a good quality of life after this procedure, which shows that it’s possible to adapt successfully to these changes.
