Laryngectomy (laryngectomy) is a surgical therapeutic procedure in otolaryngology in which the human larynx (larynx; ancient Greek λάρυγξ lárynx “throat”) is removed. The reason for laryngectomy in most cases is advanced laryngeal carcinoma (cancer of the larynx) or hypopharyngeal carcinoma (cancer of the pharynx). A laryngectomy is performed when the tumor is already too large for radiation or chemotherapy or has spread to neighboring organs. A distinction is made between a partial laryngectomy (synonyms: partial aryngectomy; partial laryngectomy) and a total laryngectomy. A hemilaryngectomy (surgical removal of one half of the larynx) is performed when the diagnosis is strictly unilateral. Partial laryngectomy, in turn, is divided into “transverse” and “perpendicular” partial laryngectomy:
- In transverse (supraglottic) partial laryngectomy, the vocal fold plane is preserved and, therefore, voice production is virtually normal. However, swallowing is somewhat more difficult.
- In vertical (supracricoid) partial aryngectomy, swallowing causes few problems, but voice quality is significantly impaired, with dysphonia (hoarseness) to near voice loss (aphonia).
In total laryngectomy, the complete larynx including epiglottis and vocal folds is removed. As a rule, a so-called neck dissection, i.e. removal of all lymph nodes of the neck, is also performed at the same time. In a radical neck dissection, the sternocleidomastoid muscle, the accessorius nerve and the internal jugular vein are removed in addition to the cervical lymph nodes. Laryngeal carcinoma is operated on if the tumor is resectable, that is, an R0 resection (removal of the tumor in healthy tissue; no tumor tissue is detectable in the resection margin on histopathology) can be performed with appropriate safety margins. The resection margins should be completely visible in healthy tissue in an intraoperative frozen section. Note: Tracheostomy (tracheotomy) prior to laryngectomy should be avoided as much as possible.
Indications
Glottic carcinoma (vocal fold carcinoma).
- T1 and T2 carcinomas: transoral laser surgical resection (surgical removal through the mouth) or primary radiation therapy (radiation therapy alone)
- Stage pT3 pNx: vertical frontolateral partial resection of the larynx according to Leroux-Robert (in rare cases transoral) possibly also laryngectomy (laryngectomy) alternatively organ-preserving concept (radiochemotherapy, RCTX) in patients who refuse surgical therapyRadiation therapy can be omitted if:
- Resection in the area of the mucosa (mucous membrane) and the parts of the tumor not surrounded by cartilage with > 5 mm of tissue in sano and
- Unilateral or bilateral neck dissection (engl. “neck preparation”) with detection of > 10 unaffected lymph nodes in each case.
Supraglottic carcinoma (malignant (malignant) tumor above the glottis (vocal fold apparatus)).
- T1 and T2 carcinomas: transoral laser surgical resection.
- T3 and esp. T3 carcinomas: vertical frontolateral partial resection (surgical partial removal) of the larynx according to Leroux-Robert or external classical partial resection according to Alonso
- T3 to T4a carcinomas for which partial resection is no longer possible: laryngectomy (safety margin 5 mm)Radiotherapy may be omitted if:
- Resection in the area of the mucosa and the tumor portions not surrounded by cartilage with > 5 mm of tissue in sano (“in healthy”) and
- Unilateral or bilateral neck dissection (see note below) with evidence of > 10 unaffected lymph nodes in each case.
- Hemilaryngectomy (surgical removal of one half of the larynx) with strictly unilateral findings.
- Horizontal supraglottic partial resection for involvement of the epiglottis (epiglottis).
- Laryngectomy with neck dissection en bloc for extensive findings with metastases (daughter tumors); additional percutaneous postradiation (radiation therapy from outside the body).
Notice:
- For supraglottic tumors, bilateral elective neck dissection is reasonable.
- In the presence of cT4a carcinoma, laryngectomy is prognostically superior to primary radio(chemo)therapy.
Subglottic carcinoma (malignant (malignant) tumor below the glottis (vocal fold apparatus)).
- T1 and T2 carcinomas: partial hypopharyngectomy (hypopharynx: lowest part of the pharynx (throat) from the upper edge of the epiglottis (epiglottis) to the upper esophageal (esophageal) mouth or an imaginary line at the level of the annular cartilage of the larynx).
- Laryngectomy with hypopharyngeal partial resection with radiotherapy (radiotherapy, radiatio) for advanced tumors.
- For inoperable tumors: tumor reduction by laser and radiotherapy (radiotherapy, radiatio) or radio-chemotherapy possible.
Hypopharyngeal carcinoma (“throat cancer“) with involvement of the larynx.
- Hypopharyngeal carcinoma resectable and larynx strictly unilaterally infiltrated: Partial laryngo-pharyngectomy (partial removal of the larynx and removal of the pharynx).
- Hypopharyngeal carcinoma infiltrating the larynx beyond the midline: pharyngo-laryngectomy.
The surgical procedures
In the following, the detailed description of the different surgical procedures is omitted, as it is beyond the scope of this article. However, it should be mentioned that increasingly by new techniques of cannula-free tracheostoma (breathing opening in the neck) and the early use of a HME-casette (= Heat and Moisture Exchanger, heat-moisture filter), for improved pulmonary rehabilitation, the surgery has been improved in its outcome. Important to the surgical procedure is an understanding of the function of the larynx (voice box), which essentially has the function of separating the food and air passages. Thus, air inhaled through the mouth can enter the trachea (windpipe) and food also ingested through the mouth goes directly into the esophagus (food pipe). After laryngectomy, i.e. after removal of the larynx, the mouth and thus the food leads only into the esophagus (food pipe). The air is now only directed into the trachea (windpipe) through the tracheostoma. The operation is performed under general anesthesia. The duration of the operation is 2-6 hours, depending on the extent.
After the operation
- Feeding through a stomach tube or a PEG tube (percutaneous endoscopic gastrostomy: endoscopically created artificial access from the outside through the abdominal wall into the stomach, into which an elastic plastic tube can be placed) during the healing phase, which lasts approximately 10 to 14 days
- Starting at UICC stage III, adjuvant radio(chemo)therapy should follow primary surgery for laryngeal and hypopharyngeal carcinoma no later than 6 weeks after surgery [guidelines: NCCN 2018].
Potential complications
- Allergic reactions up to and including anaphylactic shock.
- Postoperative bleeding and hematoma (bruising)
- Blood may enter the respiratory tract in rare cases and extremely rarely cause respiratory problems
- Infections
- Damage to organs and structures near the surgical site (e.g., thyroid gland, esophagus)
- Nerve damage, as there are many nerves in the neck area that can be injured, especially during the often additional neck soft tissue excision. Depending on the affected nerve, different complications may occur:
- Ramus marginalis mandibulae nervi facialis (lower branch of the facial nerve): impairment of the lower lip minik (oblique position of the mouth with hanging corner of the mouth on the affected side).
- Hypoglossal nerve (XII cranial nerve): is responsible for motor innervation of the tongue (restriction of tongue movement on the affected side)
- Cervical sympathetic nerve (cervical part of the border cord of the sympathetic nerve with the cervical ganglia and associated fiber): Horner syndrome: triad associated with miosis (pupillary constriction), ptosis (drooping of the upper eyelid), and pseudoenophthalmos (apparent sunken eyeball)
- Brachial plexus (brachial plexus): paresis (paralysis) in the arm and hand on the affected side.
- Accessory nerve (XI cranial nerve): motor nerve supplying the trapezius muscle and the sternocleidomastoid muscle (movement of the arm above the horizontal is thus only possible with difficulty)
- Phrenic nerve (phrenic nerve): paralysis of the affected side (diaphragmatic protrusion with restriction of lung expansion and possible respiratory obstruction)
- Temporary or permanent soft tissue damage or scarring (e.g., narrowing of the esophagus, trachea, or pharynx)
- Skin emphysema (air into the soft tissues of the neck), so that the entire neck can swell; usually the air is absorbed by the body within a few days
- Fistula formation
- Change in the shape of the neck
- Wound healing disorders
- Breathing problems
- Dysphagia (difficulty swallowing)
Methods of voice replacement (voice rehabilitation) [requirement depends on the type of surgery (see above)].
- Electronic speech aid: an external hand-held device is used that generates vibrations and, by placing it on the neck or face, transmits these vibrations to the oral cavity. The vibrating sound thus produced is then converted into speech by tongue and lip movement.
- Ructus voice (synonym: esophageal voice): the patient learns to consciously push air into the esophagus and use it to form sounds.
- Vocal fistula, also shunt valve (prosthetic esophageal voice): usually plastic valves surgically inserted between the trachea and esophagus, which allow the breath air of the lungs (= speech air) to be used for vocalization.
The resulting voice is also known as “substitute voice”. Further notes
- The higher the number of cases for laryngectomies in a clinic, the higher the success rate. A critical threshold is a case number of six larnygectomies per year. As the number of cases increased, complications continued to decrease. Only from 28 procedures per year, the results were good.
- After an average of one year, recurrences (recurrence of the disease) occur in about 30% of patients after laryngectomy.
Laryngeal
