Overview
Definition:
Total laryngectomy is the complete surgical removal of the larynx, including the vocal cords, epiglottis, and surrounding structures, resulting in a permanent separation of the airway from the pharynx and esophagus
This procedure is primarily performed for advanced laryngeal cancer, but also for severe laryngeal trauma or debilitating conditions unresponsive to other treatments.
Epidemiology:
Laryngeal cancer accounts for approximately 2-5% of all malignancies and a significant proportion of head and neck cancers
Incidence varies geographically, with higher rates in regions with high smoking and alcohol consumption
Total laryngectomy is typically reserved for T3 and T4 stage tumors, or recurrent disease after radiation therapy.
Clinical Significance:
Total laryngectomy profoundly impacts a patient's life, affecting speech, swallowing, breathing, and quality of life
Comprehensive perioperative care is crucial to minimize morbidity, optimize recovery, and facilitate rehabilitation, including voice restoration and safe swallowing
Effective management is a key learning objective for surgical residents preparing for DNB and NEET SS exams.
Indications
Oncological Indications:
Advanced stage laryngeal carcinoma (T3, T4) involving multiple subsites or cartilage invasion
Recurrent laryngeal cancer after radiotherapy
Salvage surgery for persistent or progressive disease
Tumors unsuitable for organ-sparing organ preservation protocols.
Non Oncological Indications:
Severe, irreversible laryngeal trauma
Debilitating conditions like chronic severe aspiration due to neurological dysfunction or previous surgery
Advanced chondronecrosis of the larynx
Severe radiation-induced necrosis of the larynx.
Relative Contraindications:
Distant metastases
Significant comorbidities precluding major surgery
Uncontrolled active infection
Patient's inability or unwillingness to participate in rehabilitation.
Preoperative Preparation
Patient Assessment:
Thorough evaluation of general health status, cardiac and pulmonary function
Nutritional assessment and optimization
Detailed assessment of swallowing and nutritional intake
Assessment of social support systems and patient's understanding of the procedure and its implications.
Nutritional Support:
Preoperative counseling on nutritional needs
Placement of a feeding tube (nasogastric or percutaneous endoscopic gastrostomy) if significant dysphagia is present
High-protein, high-calorie diet
Vitamin and mineral supplementation.
Airway Assessment:
Evaluation for any pre-existing airway compromise
Pulmonary function tests may be indicated
Smoking cessation counseling and encouragement is paramount at least 4-6 weeks prior to surgery.
Psychological Support:
Preoperative counseling by the surgical team, speech-language pathologist (SLP), and potentially a patient support group representative
Addressing concerns about voice, swallowing, and body image
Explanation of rehabilitation options, including alaryngeal speech methods.
Surgical Procedure
Anesthesia Considerations:
General anesthesia with careful airway management
Invasive monitoring (arterial line, central venous catheter) may be indicated in patients with significant comorbidities
Awake fiberoptic intubation may be required in cases of severe airway compromise prior to induction.
Technique Overview:
The larynx is removed with adequate margins
The pharynx is closed, and a pharyngocutaneous fistula is created for feeding access if a feeding tube is not pre-placed
A tracheostoma is fashioned in the anterior neck for breathing
The thyroid gland may be removed with the larynx (total laryngectomy with thyroidectomy) or preserved if oncologically safe.
Reconstruction Options:
Primary pharyngeal closure is standard
In select cases, pharyngeal reconstruction with flaps (e.g., Pectoralis major myocutaneous flap, radial forearm free flap) may be considered for large pharyngeal defects or to improve swallowing outcomes
Creation of a tracheoesophageal puncture (TEP) for voice prosthesis insertion is often performed during the same procedure.
Postoperative Care
Airway Management:
Close monitoring of the tracheostoma for patency and secretions
Frequent suctioning of tracheobronchial secretions
Humidification of inspired air to prevent crusting
Monitoring for signs of respiratory distress or airway obstruction
Chest physiotherapy and incentive spirometry are crucial.
Wound Care:
Dressing changes to the tracheostoma and neck incision
Monitoring for signs of infection, dehiscence, or hematoma
Management of drains if placed
Vigilant observation for pharyngocutaneous fistula, which is a common complication.
Nutritional Support:
Initiation of oral feeding once pharyngeal integrity is confirmed and the patient can safely swallow, typically after 7-10 days postoperatively and once the risk of fistula is low
Initially, pureed or soft diet, advanced as tolerated
If a TEP is present, clear liquids may be initiated cautiously
Continued use of feeding tube if oral intake is insufficient.
Pain Management:
Adequate analgesia is essential, often multimodal, combining opioids, NSAIDs, and adjuvant analgesics
Patient-controlled analgesia (PCA) may be beneficial in the immediate postoperative period
Regular assessment of pain score and effective management.
Voice Rehabilitation:
Early consultation with an SLP
Introduction to various alaryngeal speech methods: esophageal speech, tracheoesophageal voice prosthesis (TEP), and electrolarynx
Patient education on stoma care and humidification
SLP involvement is critical for successful rehabilitation.
Complications
Early Complications:
Pharyngocutaneous fistula (most common)
Wound infection
Hematoma/Seroma
Pneumonia
Tracheostoma stenosis or granuloma
Dysphagia
Airway obstruction.
Late Complications:
Tracheostoma related issues (stenosis, granuloma, persistent leakage)
Esophageal stricture
Pharyngeal stenosis
Chronic aspiration
Psychological distress and body image issues
Social isolation
Difficulty with alaryngeal speech.
Prevention Strategies:
Meticulous surgical technique with tension-free pharyngeal closure
Adequate wound drainage
Prophylactic antibiotics judiciously used
Early mobilization and pulmonary toilet
Aggressive suctioning and humidification
Prompt recognition and management of fistulas
Preoperative nutritional optimization
Comprehensive postoperative rehabilitation program including SLP involvement.
Key Points
Exam Focus:
Identify the primary indications for total laryngectomy
Understand the key steps in preoperative preparation, especially nutritional and airway assessment
Differentiate between various alaryngeal speech methods and their indications
Recognize common early and late postoperative complications and their management.
Clinical Pearls:
Emphasize the multidisciplinary approach involving surgeons, anesthesiologists, SLPs, dietitians, and nurses for optimal outcomes
Proactive stoma care and humidification are paramount to prevent airway complications
Early speech and swallowing rehabilitation is crucial for functional recovery and patient satisfaction.
Common Mistakes:
Inadequate preoperative assessment of nutritional status and airway
Failure to involve SLP early in the perioperative process
Underestimation of the psychological impact of laryngectomy
Inadequate management of tracheobronchial secretions and humidification
Delayed recognition and management of pharyngocutaneous fistulas.