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Laryngectomy

The larynx, also called the voice box, has a number of functions. Its main function is a conduit for air to enter your lungs. Also, the larynx works to prevent food, liquids and saliva from falling into your lungs and causing pneumonia. Finally, the larynx is responsible for creating voice.

The larynx is part of the throat. It is located below the oropharynx and in front of the hypopharynx.

The anatomy of the voice box can get complicated for people (including doctors) who don’t deal with this area all the time. It is located in the middle of the neck, partly protected by the thyroid cartilage (which you can feel in your neck as the Adam’s Apple).

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From a cancer perspective, the larynx is divided into three subsites: the supraglottis, glottis and subglottis. Cancer of the larynx starts in one of these subsites, but it can grow into another subsite.

  • Supraglottis: This part of the voice box is above the vocal cords. Subsites of the supraglottis  include the epiglottis above the hyoid bone, the epiglottis below the hyoid bone, the aryepiglottic folds, the arytenoids and the false vocal cords (also called the ventricular folds).
  • Glottis: This part of the voice box is hidden behind the thyroid cartilage. It is responsible for producing your voice. It is made up of the true vocal cords. The anterior commisure refers to the location in the front of the larynx where the vocal cords meet.
  • Subglottis: This part of the voice box extends from the bottom of the vocal cords to one centimeter below where it joins with the trachea (or windpipe).

A laryngectomy is the removal of some or all of the voice box—partial versus total laryngectomy. There are a number of types of laryngectomies (see below).

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

If you are undergoing a laryngectomy, you should have had a discussion with a speech and swallow therapist prior to surgery.

What to expect

For all of these cases, you will be put completely to sleep with general anesthesia. You might or might not require a tracheotomy and/or feeding tube, depending on the extent of the laryngectomy and reconstruction.

Total laryngectomy:
This involves removal of the entire voice box. This is done for four main reasons:

  1. A large larynx cancer that has not been previously treated and has eroded through cartilage and other structures.
  2. A recurrent cancer that came back after some sort of prior treatment, such as radiation with or without chemotherapy.
  3. Cancer resection of another site—such as the entire tongue base, or the hypopharynx—would lead to major aspiration pneumonia complications if the primary tumor was removed but the larynx was left in place.
  4. In cases in which there is no cancer, but the larynx is not performing its main function as a result of prior treatment for cancer. A laryngectomy might be performed for patients who cannot safely eat or drink. For example, if food and liquids fall into the lungs because of a non-functional larynx, patients might have their larynx removed in order to eat. Also, if the pharynx or esophagus is closed off as a result of prior treatment and the patient is unable to eat or drink, a laryngectomy (with pharyngectomy and subsequent reconstruction) might allow a patient to eat again.

For a total laryngectomy, the incision is placed in the central neck, extending quite far to the side in order to perform neck dissections on both sides. This will allow exposure to remove the voice box along with the lymph nodes in the neck, if required. As part of this surgery, one or both lobes of your thyroid gland will be removed. Your surgeon might send frozen section margins after the voice box is removed to confirm no cancer cells are left behind. The closure will then be performed and will include creation of a laryngostome. A laryngostome involves sewing the top part of the trachea directly to the skin. This makes you a “neck breather” because there is no longer a connection from your mouth/nose down into your lungs. However, your mouth does remain connected to your throat and esophagus down into your stomach to allow you to eat.

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Associated procedures might include bilateral (both sides) neck dissections, hemi- or total thyroidectomy or partial or total pharyngectomy (see total laryngopharyngectomy). Reconstruction and rehabilitation procedures might include repair of the pharynx with primary closure, a pectoralis major muscle flap or a free flap.

In some cases, a tracheoesophageal puncture might be done at the same time as the total laryngectomy to assist with speech in the post-operative time period.

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If you don’t already have a gastric feeding tube, you will have a feeding tube placed either through the nose, directly in the stomach or inserted through the tracheoesophageal puncture. You will start eating anywhere from a few days to one or two weeks after the procedure, depending on your surgeon’s preference and prior treatment you might have received.

At the end of the procedure, your surgeon will likely place a small drain coming out of your skin. This is to drain any blood and/or fluid that might accumulate in the space that is created by removing the larynx as well as any fat and lymph nodes from the neck dissection. When the time is right—one day to a few days—the drain will be removed by your surgical team. This takes only a few seconds, and you can think of it as removing a bandage. There will be a little discomfort, but it will go by quickly.

It is important to immediately check your calcium level post-operatively, because the blood supply to the parathyroid glands could become compromised after this surgery. By saving one half of the thyroid gland, it should protect two of the parathyroid glands.

After the larynx is removed, there are a number of ways to speak. Some possible techniques include a tracheoesophageal puncture, shown above, and esophageal speech or an electrolarynx, shown below.

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See voice rehabilitation after laryngectomy to learn more about options to speak after your voice box has been removed.

  • Total laryngopharyngectomy: This is the removal of the entire larynx, or voice box, along with the entire pharynx. See below for more information.
  • Open partial laryngectomy: In this procedure, your entire voice box is not removed. The main goals of this procedure are to get rid of the cancer while avoiding a permanent breathing tube in the neck, preserving a suitable voice and maintaining your ability to swallow.

Today, open partial laryngectomies have less of an application than they did many years ago. Currently, an open partial laryngectomy is limited to small cancers that have recurred after prior non-surgical therapy. Transoral microsurgery is another option in these situations. You should speak with your doctor about the possibility of this being an option to treat your cancer. Your surgeon will probably speak to you about the possibility of converting to a total laryngectomy, depending on what is seen during the surgery or of the frozen section.

There are several types of open partial laryngectomies:

    • Laryngofissure with cordectomy: In this procedure, an incision is made in the midline of your neck, over the area of the Adam’s apple. The thyroid cartilage is split vertically, and the inside of the voice box is revealed. This gives excellent exposure to a tumor on a vocal cord, which can be removed. The thyroid cartilage is then sealed and the incision is closed. In some cases, you might have a temporary stent placed in your voice box for a few weeks to prevent a scar band from forming. You might receive a temporary tracheotomy tube.

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    • Horizontal laryngectomy: A horizontal partial laryngectomy can be either a supraglottic hemi-laryngectomy (removal of half the larynx above the vocal cords) or a supracricoid hemilaryngectomy (removal of half the larynx above the cricoid cartilage). This can be performed with or without resection of the hyoid bone. After resection, the cricoid cartilage is sewn back up to the hyoid bone or to the hyoid bone and epiglottis, depending on what remains after resection of the tumor.

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    • Vertical hemi-laryngectomy, or frontolateral vertical partial laryngectomy: In this procedure, an incision is made in the middle of your neck, exposing the thyroid cartilage. Then a vertical incision is made in the thyroid cartilage, and one entire vocal cord and arytenoid is removed. Up to 75% of the thyroid cartilage can be removed, and the resection can include a small part of the vocal cord on the other side as well. Reconstruction can be performed in various ways, including local flaps, staged procedures and/or free flaps.

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  • Transoral laser microsurgery (TLM) with partial laryngectomy: This is a partial laryngectomy performed through the mouth using special laryngoscopes, instruments and lasers. While this is most commonly used for small cancers on the vocal cords themselves, some surgeons are comfortable performing this for larger tumors of the voice box. This remains an option for small recurrent cancers after non-surgical therapy.In this procedure, you are put completely to sleep with general anesthesia. In many cases you will require a tracheotomy, but not all the time. The voice box is exposed using special instruments. A laser is used to cut out the tumor, with the aim of getting a margin of normal tissue around it. Once it is removed, your surgeon will orient the tumor and have a pathologist examine the margins under a microscope as a frozen section. If the margins are all clear, the surgery can be considered complete, as now major reconstruction is required.Associated procedures might include a tracheotomy, feeding tube placement or a neck dissection—sometimes performed a few weeks later as a staged neck dissection.
  • Transoral robotic-assisted partial laryngectomy: This procedure simply uses a robot to get exposure and to remove a tumor of the larynx through the mouth. The principles are the same as transoral laser microsurgery with the exception that the instruments are different. This procedure remains experimental in most areas, but experience is building. The purpose is to limit incisions and limit dissection of neck contents. Associated procedures might include a tracheotomy, feeding tube placement or a neck dissection—sometimes performed a few weeks later as a staged neck dissection.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries, you could go home after a few hours of observation in the recovery room. Others might require a stay in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

See voice rehabilitation after laryngectomy to learn more about options to speak after your voice box has been removed.

Risks

As with any procedure, there are risks in undergoing a laryngectomy:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Infection: Total laryngectomy is often done with both sided neck dissections, therefore, in theory, joining saliva and mucous with the sterile neck contents. Interestingly, infections of the neck are quite rare. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Salivary fistula: This term is used to describe when saliva is leaking from the pharynx into the neck. The chances of this increase if you have had previous treatment including radiation and/or chemotherapy. This is because wound healing might be impaired in these cases. Typical treatment for this is to place a drain to divert the saliva away from critical structures in the neck and later to place packing into that diverted tract and let the body heal on its own. In some cases, an additional surgical procedure might be required to close the leak (such as a pectoralis major muscle flap).
  • Hypocalcemia: Low calcium levels can occur post-operatively if all four parathyroid glands are either removed and not re-implanted (permanent hypocalcemia) or put into a state of shock by affecting their blood supply (temporary hypocalcemia). This is why calcium levels need to be closely monitored after a total laryngectomy (or total laryngopharyngectomy) and calcium replacement needs to be given as needed.
  • Hypothyroidism: This can happen if both lobes of the thyroid gland are removed, if only one lobe is removed but the other lobe cannot make enough thyroid hormone to keep up with the body’s needs or regardless of how much thyroid is removed, but radiation treatment has affected the function of the thyroid gland. In any case, thyroid function can be measured with blood tests, and a once-daily pill can replace the function of the thyroid hormone.
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood-thinning) medication to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might cause another complication, such as bleeding, especially immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.
  • Aspiration: This is impossible after a total laryngectomy because the trachea is sewn to the skin of the neck, so there is no connection between the mouth and the lungs to allow for aspiration. However, after any sort of partial laryngectomy, this is a major consideration. Having saliva and/or food and drink falling into your lungs can lead to pneumonia.