Definition and Overview
A laryngectomy is a surgical procedure that entails the removal of the larynx, or the voice box. Depending on the indication, a patient may undergo total laryngectomy, wherein the entire larynx is resected, or partial laryngectomy, where only a segment is removed.
The larynx is divided into three parts, namely:
- The glottis, which corresponds to the true vocal cords
- The supraglottis, or the segment above the glottis, which begins from the epiglottis to the vocal cords. It includes the arytenoids and the false vocal folds.
- The subglottis, or the segment below the glottis, which extends from the vocal cords and ends at the first tracheal ring.
The staging of laryngeal cancer and the subsequent management is partially dependent on the segment of the larynx involved.
Who Should Undergo and Expected Results
The most common indication for performing a laryngectomy is laryngeal cancer. Approximately 13,000 patients are diagnosed with laryngeal cancer every year, but only about 3,000 patients undergo the procedure. Histopathologically, squamous cell carcinoma, a form of primary laryngeal cancer, is most commonly encountered. Other forms such as adenocarcinoma and chondrosarcoma, are less common but have also been reported. Depending on several factors, the treatment of laryngeal cancer may involve surgery, radiotherapy, or a combination of the two modalities.
A laryngectomy is a radical procedure, and is usually recommended for laryngeal cancer patients whose condition does not respond to other forms of conservative treatment and if there is already a significant damage to the larynx that prevents normal function. In particular, candidates for laryngectomy include laryngeal cancer patients who are in the advanced stages of the disease, with tumours that have destroyed the cartilage and have spread outside the larynx anteriorly.
Others that may benefit from the procedure include:
- Patients whose condition also involves both arytenoid joints and the posterior commissure
- Patients with circumferential involvement of the submucosa, as well as those with extensions in the subglottic area wherein the cricoid cartilage is invaded
- Patients with less common types of laryngeal cancer, such as adenocarcinoma, that are not as responsive to radiotherapy as compared to squamous cell cancer. In these cases, total laryngectomy may be the best option to manage the disease.
Other indications for performing a laryngectomy include severe traumatic injuries to the neck, such as those seen in gunshot wounds, and radiation necrosis of the larynx, which may occur after radiotherapy. Laryngectomy may also be considered in the management of primary tumours originating from adjacent organs, such as the thyroid gland and the tongue, which have already invaded the larynx.
Major changes are expected after a laryngectomy is performed. In patients subjected to a total laryngectomy, the nose and mouth become disconnected from the trachea and the rest of the respiratory tract. Thus, a tracheostomy is performed, wherein a hole is made in the neck and connected to the airways, through which the individual breathes. For voice replacement, a voice prosthesis may be implanted or an external device known as an electrolarynx may be used, among other methods. Rehabilitation after laryngectomy is recommended.
How is the Procedure Performed?
A laryngectomy is performed through an incision on the neck so the platysma muscle can be flapped superiorly and inferiorly. The deep cervical fascia is then incised, and the muscles are dissected bilaterally. After the identification of the carotid sheath, blunt dissection is performed between the vessels and the laryngotracheal complex. The surgery then proceeds with the release of the strap muscles, and resection of the lobe of the thyroid gland on the side of the tumour. The thyroid cartilage is then freed by lifting off the inferior constrictor muscles.
The next step is crucial, which involves the division of the trachea. This step must be performed in coordination with an anaesthesiologist. The trachea is incised between the second and third tracheal cartilages, and the tracheal stump is bevelled. The endotracheal tube is removed slowly and replaced with a Laryngoflex tube through the tracheal stump. The posterior wall of the trachea is then divided, making sure that the oesophagus is not injured.
From the oral cavity, the epiglottis is identified. The pharyngeal mucosa is then removed while preserving enough pharyngeal tissues for closure. The cricopharyngeal muscles are resected, as well. The pharynx is then sutured closed.
After irrigation and adequate hemostasis, drains and a nasogastric tube are placed. The tracheal stoma is then created, suturing the trachea to the superior and inferior skin flaps. The incision is closed. Finally, the Laryngoflex tube is replaced with a tracheostomy tube and secured in place.
Possible Risks and Complications
Aside from the expected changes to breathing and phonation, a laryngectomy may also be associated with wound complications, such as wound infection and dehiscence, as well as seroma formation. A pharyngocutaneous fistula may also develop in some patients with poor nutrition or those who have been subjected to previous radiation therapy. Complex fistulas need a regional flap for closure. Stomal stenosis is a complication that has been reported in as much as 40% of patients. Revision of the stoma may have to be performed using different stomatoplasty techniques and advancement flaps.
Ouyang D, Liu TR, Chen YF, Wang J. Modified frontolateral partial laryngectomy operation: combined muscle-pedicle hyoid bone and thyrohyoid membrane flap in laryngeal reconstruction. Cancer Biol Med.
Luna-Ortiz K, Campos-Ramos E, Villavicencio-Valencia V, Contreras-Buendía M, Pasche P, Gómez AH. Vertical partial hemilaryngectomy with reconstruction by false cord imbrication. ANZ J Surg. 2010 May. 80(5):358-63.