Total Laryngectomy

Overview

The surgical removal of the larynx is known as a laryngectomy. The larynx is the part of your throat that contains your vocal cords, which allow you to make sound. The larynx is the tube that links your nose and mouth to your lungs. It also protects your respiratory system by keeping food and drink in your esophagus and out of your lungs. A laryngectomy will damage your ability to talk, swallow, and breathe. Following surgery, you will need to learn new ways to accomplish these three duties.

 

What is Total Laryngectomy?

The primary objective of treatment for laryngeal cancer is disease control. Secondary aims include the preservation of speech, swallowing abilities, and the avoidance of the tracheostomy. Radiotherapy, surgery, or a combination of the two has traditionally been used to treat laryngeal carcinomas. The therapy of laryngeal cancer is based on identifying the best treatment strategy for each individual patient, which is typically established by the knowledge of an interprofessional team. Several anatomic, physiologic, regional, and occupational considerations all play a role in therapy selection. The location and size of the main tumor, as well as the health of the nearby lymph nodes, are the most essential factors determining therapy choices. Early-stage carcinomas were formerly treated with external radiation, with surgery reserved for salvage. Advanced malignancy, on the other hand, was frequently treated with a complete laryngectomy followed by postoperative radiation treatment. The emphasis for therapeutic approaches for malignant laryngeal tumors has shifted in the last decade to "organ preservation." Transoral laser microsurgery (TOLM) and transoral robotic surgery (TORS) are two treatment methods that have expanded surgical options. Total laryngectomy remains an option as first-line therapy in individuals who are not candidates for organ-preserving methods or who fail the more conservative approach. 

 

Anatomy of the neck

The larynx is located in the anterior neck and connects the inferior pharynx to the cervical trachea. There are six cartilage "rings," three of which are unpaired (thyroid, cricoid, and epiglottic) and three of which are paired (arytenoid, cuneiform, corniculate). Connective and muscle tissue surrounds each cartilage. Although the hyoid bone, which is connected to the thyroid cartilage via the thyrohyoid membrane, is not a member of the laryngeal framework, it is vital in the upper aerodigestive tract's swallowing function.  The larynx is classified into three areas based on embryologic development, each of which has multiple subsites:

• Supraglottis: This is the larynx above the apex of the ventricle. The ventricle, vestibular folds, arytenoids, aryepiglottic folds, and the epiglottis are all part of it.
• Glottis: This is made up of the voice cords as well as the anterior and posterior commissures.
• Subglottis: It runs from the glottic inferior border to the cricoid cartilage's lower border.

The surface mucosa of the larynx is made up of squamous epithelium with mucous glands interspersed. The stratified squamous epithelium lines the genuine voice chords. The internal branch of the superior laryngeal nerve supplies sensory nerves to the supraglottic larynx (nerve of Galli-Curci). The superior and recurrent laryngeal nerves feed the mucosa of the actual vocal cords with dual sensory nerve supply. The subglottic larynx, on the other hand, receives sensory input from the recurrent laryngeal nerve. Except for the recurrent laryngeal nerve, Except for the cricothyroid muscle, which is innervated by the superior laryngeal nerve's external laryngeal branch, the laryngeal intrinsic musculature is innervated by the recurrent laryngeal nerve. The blood supply to the larynx comes from branches of the superior and inferior thyroid arteries.

The supraglottic larynx contains a dense lymphatic network that drains into level II and III lymph nodes. The glottic lymphatic network is quite thin, especially near the free margin of the genuine vocal cord, which is lymphatic-free. The lymph nodes of the subglottic larynx drain into the paratracheal and deep jugular lymph nodes.

 

Why is Total Laryngectomy done?

A complete laryngectomy is recommended for individuals who have:

• Advanced laryngeal cancer or hypopharynx with thyroid or cricoid cartilage invasion and extra laryngeal soft tissue.
• Radiotherapy or chemoradiotherapy did not work;
• Extensive tumors of histologic entities that do not respond to conservative therapy.
• Soft tissue sarcomas, chondrosarcomas, melanomas, adenocarcinomas, big cell neuroendocrine tumors, and tumors of the small salivary glands are histopathological subgroups of cancers that have shown resistance to radiation.
• Severe laryngeal trauma that prevents effective organ repair.
• Patients with no voice and persistent aspiration owing to cranial nerves IX, X, and XI palsy.
• Recurrent laryngeal papillomavirus infection with an increased risk of tracheal invasion.

 

What are the Complications of Total Laryngectomy?

The existence of incurable synchronous tumors or distant metastases, a poor general state leading to a significant anesthetic risk, a tumor encasing the common or internal carotid artery, or infiltrating the deep regions of the tongue are all contraindications to surgery.

Preparing for Total Laryngectomy

Laryngectomy is a long treatment that can last anywhere from five to twelve hours. The procedure is carried out under general anesthesia. That is, you will be unconscious and will not experience any discomfort during the process. Prior to your operation, your healthcare team will conduct a series of tests to examine your health. You'll also meet with consultants such as speech therapists and swallowing specialists to help you prepare for life following laryngectomy. The patient is put on the operating table while being administered general endotracheal anesthesia through an orotracheal catheter. If difficult intubation is expected owing to airway impairment, a preoperative tracheotomy with local anesthetic and vasoconstrictor preparation will be required.

Measures for preparation include:

• Regular blood testing and blood work
• Physical examination
• After surgery, you will get smoking cessation counseling as well as nutritional counseling to help you eat a balanced diet.
• Fasting the night before surgery while temporarily discontinuing some drugs such as aspirin, ibuprofen, and blood thinners

Inform your doctor if you are allergic to any drugs, such as antibiotics, anesthetics, or pain relievers.

 

What are the Procedures for Total Laryngectomy?

The whole larynx, including the pre-laryngeal strap muscles and lymph nodes in the jugular chain, is removed during a conventional total laryngectomy treatment (levels II, III, and IV). The Gluck - Sorenson U-shaped incision is the most often utilized skin incision for complete laryngectomy. The incision begins at the apex of the mastoid, continues on the anterior border of the sternocleidomastoid muscle up to 1 to 2 cm above the top margin of the sternal notch, and is repeated on the other side. The tracheal stoma would be incorporated in the skin incision if a tracheotomy was performed prior to this treatment. The flap should be elevated in the subplatysmal plane, directly over the anterior and external jugular veins. As a result, the anterior and external jugular veins, which should stay linked to the underlying tissues, provide vascularisation of the flap. To get access from the hyoid to the suprasternal notch, the upper and lower skin flaps are lifted.

Mobilization of the larynx begins superiorly by disconnecting the muscles linked to the hyoid bone's top side. The superior thyroid artery and its superior laryngeal branch are isolated by dissection. These are labeled, dissected, and ligated (identification and ligation of these vessels will minimize hemorrhage during mobilization of the larynx). Deep jugular lymph nodes at levels II, III, and IV are dissected and propelled toward the specimen after the sternocleidomastoid muscle is pulled laterally to expose the carotid sheath. The sternohyoid and sternothyroid muscles are split as low in the neck as feasible as the dissection progresses. The thyroid gland is removed from the trachea after the inferior thyroid artery is split and ligated. Finally, two clamps are used to split the thyroid isthmus. The cervical trachea is exposed once the isthmus is divided. Electrocautery is used to separate the inferior constrictor muscle from the posterior margin of the thyroid cartilage on both sides.

An incision is created in the anterior tracheal wall at a level determined by the tumor's lower extent. The trachea is split obliquely, leaving a short anterior wall and a lengthy posterior wall to bevel superior lateral tracheal walls and increase the tracheostomy. Interrupted nylon sutures are used to secure the distal trachea to the skin margins of the permanent tracheostomy. Sharp dissection is used to separate the proximal trachea and larynx from the cervical esophagus.

Finally, depending on the tumor's location, entrance into the pharynx is accomplished either the vallecula or the posterior cricoid area. After entering the pharynx, the mucosal incision is continued along the laryngeal periphery until the opening is big enough to allow the entry of a retractor into the pharynx. The larynx is then removed by the division of its mucosa attachments under direct eyesight. A tracheoesophageal puncture (TEP) is conducted if it is scheduled. The pharyngeal defect is repaired, ideally transversely. With great attention, a running Connell inverting suture (true or modified) with 3-0 Vicryl is utilized to seal the pharynx defect commencing inferiorly. Suction drains are put lateral to the throat after the pharynx is closed, the platysma is closed with interrupted Vicryl sutures, and the skin is closed with interrupted nylon sutures. 

 

What are the Risks and Side Effects of Total Laryngectomy?

Bleeding, postoperative edema and airway impairment are common early consequences following complete laryngectomy. These should be closely examined, especially in the immediate postoperative period. Corticosteroids are recommended to reduce postoperative edema and airway compromise, hematoma or seroma, which should be surgically evacuated as soon as possible, wound infection due to perioperative exposure of the wound to bacteria, which could be minimized with broad-spectrum antibiotic coverage, and pharyngocutaneous fistula; total laryngectomy patients are at risk for pharyngeal suture line dehiscence with a resultant pharyngo Fistula development is affected by the strain on the pharyngeal suture line, the design of the pharyngeal closure ("T" closure or horizontal closure), prior radiation or chemoradiotherapy, the patient's nutritional state, and the existence of medical comorbidities (e.g., diabetes). The adoption of a pectoralis muscle flap to support the pharyngeal suture line may lessen the risk and severity of pharyngocutaneous fistula. Pharyngoesophageal stenosis, stoma stenosis, and hypothyroidism are late problems.

 

How long will a Total Laryngectomy take to recover?

The majority of laryngectomy patients spend the first several days in the critical care unit (ICU). Your blood pressure, heart rate, respiration, and other vital indicators will be continuously monitored by your doctors. Following surgery, you will receive oxygen through your stoma. While your throat heals, you will be unable to eat via your mouth. Nutrition will be provided through a feeding tube that travels from your nose to your stomach or is put directly into your stomach. Your neck will swell and be unpleasant. As needed, you will be given pain medicine.

When your health improves, you will be transferred to a standard hospital room. After surgery, you should expect to be in the hospital for around 10 days. During this period, you will continue to recover and relearn how to swallow. Then start learning how to communicate without using your larynx. Your doctor and nurses will encourage you to walk around to prevent blood clots, lower your risk of pneumonia, and help you adjust to your stoma and new breathing techniques. Getting out of bed and moving about is critical for rehabilitation. Physical treatment, as well as speech and language therapy, may be provided.

 

Stoma care

Learning how to care for your stoma is an important aspect of your rehabilitation following a laryngectomy. The stoma hole may transfer germs and viruses into your body, potentially resulting in illness. This sort of issue can be avoided with proper treatment. You should wipe the stoma's margins using gauze, mild soap, and water. Remove crusting and extra mucus with care. This is something that a saltwater spray can assist with. Crusting can obstruct airflow to the lungs. Your healthcare professional should provide you specific instructions as well as advice on what to do in the event of an emergency. Coughing might help discharge mucus from your stoma. If you are unable to cough vigorously, you may need to suction the stoma out manually. Your healthcare practitioner may show you how to suction correctly to avoid infection.

Humid air aids in the prevention of stoma crusting. Make use of a humidifier in your house, particularly in your bedroom at night. For a limited time, your doctor may advise you to wear a special mask that distributes humidified air directly to your stoma. This is more likely when a stoma is just installed. The mask will be unnecessary after the skin surrounding your stoma "matures," or grows used to the dry air.

 

Rehabilitation of speech

It might be difficult to communicate following a laryngectomy. You can't create the same noises without your larynx. Anyone who has had this type of surgery can learn to communicate. There are several strategies for communicating:

• Nonverbal communication

Gestures, facial expressions, and image boards are examples of nonverbal communication, as is mouthing words without using your voice. Nonverbal communication can also include handwriting or typing on a computer. At some point during the physical healing process, every laryngectomy patient must employ nonverbal communication.

• Speech from the esophagus

Some individuals learn "esophageal speech." A person utilizes air from the mouth and traps it in the throat and upper esophagus to produce this type of speaking. Vibrations are produced by the controlled release of air, and speech may be conducted utilizing the mouth, tongue, and lips. Esophageal speaking is tough to master, yet it is effective.

• Electrolarynx

This sort of speech can be utilized as soon as three to five days after surgery. You put the gadget against your neck or use a mouth adaptor. When you speak, it improves your speech. The generated voice will seem automated and robotic, but it is simple to learn and utilize. It can be an excellent short-term option for some people as well as a long-term answer for others.

• TEP speech

The surgically induced tracheoesophageal puncture is used in TEP speech (TEP). Through the TEP, a one-way valve is introduced. This valve permits air from the trachea to enter the esophagus but prevents esophageal material, such as food and drinks, from entering the lungs. These devices are frequently coupled to a vocal prosthesis, which aids with communication. The stoma is covered by the prosthetic.

People can learn to move air from the lungs into the esophagus by closing the hole from the outside with training, allowing the vibrations to be perceived as speech. Hands-free voice prosthesis that generates speech using variable quantities of air pressure have been developed. If you are interested, consult with your doctor to determine if a vocal prosthesis is correct for you.  

 

Conclusion 

Total laryngectomy is a well-documented ablative surgical treatment. An interprofessional healthcare team's expertise and experience will almost certainly require input from a head and neck surgeon, a pulmonologist, an oncologist, a radiologist, a radiotherapist, and a pathologist. The team must evaluate the basic characteristics of laryngeal cancer as well as the expected responses to various therapies. Speech and swallowing therapists, dietitians, psychiatrists, and specialized nursing care are all critical components of the therapy plan. Interprofessional communication is essential in the treatment of laryngeal cancer. The long-term prognosis for laryngectomy patients is encouraging. The most serious risk factor is stoma obstruction, which can cut off oxygen access to the lungs. Good education and constant treatment are essential for maintaining a great quality of life following surgery. Learning to live without a larynx can be frightening, irritating, and tough, but it is doable. Many medical institutions provide support groups for those who have had a laryngectomy.