Laryngectomy

Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods (surgeries through the mouth, radiation and/or chemotherapy). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery. Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods (surgeries through the mouth, radiation and/or chemotherapy). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery. The first total laryngectomy was performed in 1873 by Theodor Billroth. The patient was a 36 year old man with a subglottic squamous cell carcinoma. On November 27, 1873 Billroth performed a partial laryngectomy. Subsequent laryngoscopic examination in mid-December 1873 found tumor recurrence. On December 31, 1873 Billroth performed the first total laryngectomy. The patient recovered, and an artificial larynx was manufactured for him which enabled the patient to speak despite the removal of his vocal cords. Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866,but this patient's larynx was only excised after death. The first artificial larynx was constructed by Johann Nepomuk Czermak in 1869. Vincenz Czerny developed an artificial larynx which he tested in dogs in 1870. In 2017, there were over 13,000 new laryngeal cancer cases in the United States, (3.1 per 100,000). The number of new cases decreases every year at a rate of 2.4%, and this is believed to be related to decreased cigarette smoking in the general population. The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate due to the development of less invasive techniques. Only 50,000 to 60,000 laryngectomies have been performed in the US to date. To determine the severity/spread of the laryngeal cancer and the level of vocal fold function, indirect laryngoscopies using mirrors, endoscopies (rigid or flexible) and/or stroboscopies may be performed. Other methods of visualization using CT scans, MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the glottis) can cause an individual's voice to sound hoarse. Examinations are used to determine the tumor classification (TNM classification) and the stage (1-4) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. Radiation and/or chemotherapy may also be used. The anatomy and physiology of the airways change after laryngectomy. After a total laryngectomy, the individual breathes through a stoma where the tracheostomy has created an opening in the neck. There is no longer a connection between the trachea and the mouth and nose. These individuals are termed total neck breathers. After a partial laryngectomy, the individual breathes mainly through the stoma, but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose. They are therefore termed partial neck breathers. The extent of breathing through the upper airways in these individuals varies and a tracheostomy tube is present in many of them. Ventilation and resuscitation of total and partial neck breathers is performed through the stoma. However, for these individuals, the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation. Different types of complications can follow total laryngectomy. The most frequent postoperative complication is pharyngocutaneous fistula (PCF), characterized by an abnormal opening between the pharynx and the trachea or the skin resulting in the leaking of saliva outside of the throat. This complication, which requires feeding to be completed via nasogastric tube, increases morbidity, length of hospitalization, and level of discomfort, and may delay rehabilitation. Up to 29% of persons who undergo total laryngectomy will be affected by PCF. Various factors have been associated with an increased risk of experiencing this type of complication. These factors include anaemia, hypoalbuminaemia, poor nutrition, hepatic and renal dysfunction, preoperative tracheostomy, smoking, alcohol use, older age, chronic obstructive pulmonary disease and localization and stage of cancer. However, the installation of a free-flap has been shown to significantly reduce the risks of PCF. Other complications such as wound infection, dehiscence and necrosis, bleeding, pharyngeal and stomal stenosis, and dysphagia have also been reported in fewer cases.