Disclosure Although the use of chemotherapy for advanced-stage laryngeal cancer, particularly as part of so-called organ-sparing protocols, has increased in the past decade, the mainstay of treatment remains surgery, often combined with radiation therapy. Unfortunately, most patients with advanced-stage cancer are not candidates for traditional conservational surgery in which a permanent tracheostoma is avoided; therefore, a total laryngectomy (TL) is frequently required. However, some of these cancers are suitable for near-total laryngectomy (NTL). NTL is a successful procedure for well-selected patients. After NTL, a patient speaks using an internal myomucosal shunt and requires a tracheocutaneous stoma for breathing. In the author's experience, vocal rehabilitation after NTL may be successful even when postoperative radiation therapy is administered. A description of the NTL procedure (including some suggested slight modifications) is provided, followed by some clinical results. History of the Procedure: In 1980, Pearson and colleagues described an alternative to the standard TL in patients with stage T3 glottic cancers. Since then, the indications for this technique have been expanded, and the name of the procedure has evolved to NTL. The NTL is now an accepted alternative to TL for patients with glottic, supraglottic, base of tongue, and hypopharyngeal cancers. Although quite good oncologic and physiologic results have been reported, the use of this technique outside of Pearson's experience was initially reported only in small series from non-American literature. One reason may be that at approximately the same time that the NTL was introduced, Singer and Blom began popularizing the technique of tracheoesophageal puncture (TEP), which has had a high success rate mainly because of newly developed silicone prostheses. Problem: Patients with advanced (ie, T3-T4) laryngeal cancers are not usually eligible for conservation laryngeal surgery. However, as an alternative to TL, most can be treated with NTL with the creation of a dynamic myomucosal shunt between the neopharynx and the esophagus. Frequency: In the United States, 11,000 new cases are diagnosed annually. Etiology: Most advanced laryngeal cancers can be attributed to the use of tobacco products and alcohol, usually in combination. Pathophysiology: Advanced laryngeal cancers begin as local disease, and the spread to regional lymph nodes is dictated in part by the site of origin; glottic tumors metastasize infrequently, whereas supraglottic and subglottic tumors metastasize more commonly. Distant metastases occur in 10-30% of cases. Clinical: Advanced laryngeal cancers tend to occur in middle-aged men who present with any or all of the following: hoarseness, sore throat, odynophagia (early disease) and otalgia, dysphagia, dyspnea/stridor, and weight loss (late disease).
NTL is indicated in patients with advanced (ie, T3, T4) laryngeal cancers when the postcricoid and interarytenoid areas are free of disease and the contralateral arytenoid can be saved.
Relevant Anatomy: The anatomy is similar to that which is relevant for a TL. Additional attention must be paid to the postcricoid mucosa and interarytenoid mucosa (necessary to construct the myomucosal shunt) and to the contralateral ventricle, which is approached through the thyroid lamina (the safest point of entry). Contraindications: Patients in whom the interarytenoid or postcricoid areas are involved with cancer or in whom both arytenoids are felt to be diseased are not candidates for NTL. A relative contraindication is extensive subglottic spread. While the incidence of aspiration is quite low, an additional relative contraindication is patients with severe respiratory dysfunction or patients in whom the additional 30 minutes required for surgery is undesirable. |
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Staging: Laryngeal cancers staged T3 and T4 are appropriate for NTL, and the staging is generally performed as part of the triple endoscopy. T3 lesions cause vocal cord fixation, and T4 lesions usually result in cartilage invasion.
Medical therapy: Patients who are candidates for NTL also may be eligible for treatment with experimental chemoradiation protocols (so-called organ preservation trials), except when cartilage invasion exists. Some early T3 tumors also may be suitable for treatment with radiation alone. Radiation is usually delivered as adjuvant treatment to patients who undergo NTL, as described below. Radiotherapy technique Begin radiation therapy approximately 4 weeks after NTL. Treat the primary tumor site by opposed lateral ports, with the radiation dose calculated at the midplane. Also treat the inferior cervical lymph nodes. If multiple lymph nodes are involved, irradiate the upper mediastinum with an anterior port matched to the lateral fields. If no cervical adenopathy is present, use a midline bar to protect the trachea and the spinal cord in this anterior neck field. Use a 4- to 6-megaelectron volt (MeV) medical linear accelerator to deliver 2 Gy daily, 1 fraction per day, 5 fractions per week. If the surgical margins are uninvolved by tumor, administer a total dose of 50-54 Gy. If the margins are close, deliver 60 Gy; if the margins are involved, deliver 66 Gy. To minimize the chance of radiation adversely affecting shunt function, protect the shunt site by inserting a block after the delivery of 46 Gy while the remaining laryngopharynx receives at least 50-54 Gy. Surgical therapy: Several modifications of the previously described technique for NTL are indicated below. Preoperative details: Preoperative preparation is the same as for any extensive head and neck surgery and includes metastatic evaluation, preoperative anesthetic clearance, and perioperative antibiotic coverage. Pulmonary function testing may be considered in selected patients. Intraoperative details: Because this article is not intended to be an atlas, the reader is referred to the excellent monograph by Pearson and colleagues in Operative Techniques in Otolaryngology-Head and Neck Surgery. A brief summary is provided along with representative intraoperative photographs. NTL is performed through a horizontal cervical incision at the level of the thyroid cartilage, with a separate incision for the stoma at least a fingerbreadth below. Subplatysmal flaps are raised, and the cancer-bearing side of the larynx is dissected as for a routine laryngectomy, with inclusion of the delphian node, resection of the ipsilateral thyroid lobe, removal of the hyoid bone, and skeletonization of the thyroid cartilage. The contralateral dissection differs in that the strap muscles are preserved with their neurovascular supply; likewise, the recurrent laryngeal nerve is preserved. The greater horn of the hyoid bone is left intact. Ideally, the larynx is entered at the contralateral ventricle, as described by Pearson and DeSanto, because it should never be involved with cancer; however, in a departure from this method, the author commonly enters the larynx at the vallecula, provided it is free of cancer. One reason is that most practicing head and neck surgeons are familiar with the approach. Furthermore, although entering in the contralateral ventricle is safe in every instance, that approach provides a technical challenge that is usually unnecessary. Therefore, the site of entrance into the larynx can be dictated by the disease. Once the larynx is entered, perform the remaining cuts with the tumor under direct visualization. Preserve the posterior border of the contralateral thyroid cartilage to aid in maintaining the integrity of the recurrent laryngeal nerve on that side. Make a horizontal cut along the base of the tongue toward the cancer-bearing side; this significantly improves exposure. Then, make a vertical cut through the larynx on the noncancer side, preserving as much of the contralateral true vocal cord as possible, depending on the extent of the cancer. Divide the cricoid, and perform a partial cricoidectomy. Preservation of uninvolved subglottic mucosa is desirable, but nearly all of the cricoid cartilage should be removed to minimize the chance of an excessively patent shunt that leads to aspiration. Divide the interarytenoid area, and make the remaining cuts with preservation of as much piriform mucosa as possible. The most difficult aspect of the NTL is the reconstruction, specifically the formation, of the shunt. Generally, the mucosa between the pharynx and the trachea that remains at the end of the ablation (provided by preserving one arytenoid and a portion of the true vocal cord on the non–cancer-bearing side) is insufficient to ensure a patent tracheopharyngeal shunt; therefore, augmentation of this shunt with piriform mucosal flaps is necessary. The second modification of the Pearson NTL that the author has used involves this reconstructive technique of augmenting the shunt. Although the use of the ipsilateral pyriform mucosa has been described, the author has been successful using the contralateral pyriform mucosa when necessary, particularly if a pyriform cancer has been resected and the contralateral glottic/subglottic hemilarynx cannot be fashioned into an ample shunt. This provides added flexibility in using available mucosal tissue. The approach for rotating this flap into place is essentially the same as that used for ipsilateral flaps. First, the shunt is closed; this procedure can be performed over a 12F Robinson catheter to achieve an appropriately sized lumen. Then, perform routine closure of the pharynx using the technique preferred by the surgeon. A stoma is fashioned, and in a final minor modification of the NTL technique, the author routinely uses an H-flap permanent tracheostomy, as described by Fee and Ward. Postoperative details: Routinely place a feeding tube, and care for patients as if they underwent a TL. Oral feeding generally commences 7-10 days after surgery. The shunt is typically obstructed by tissue edema until approximately 6-12 weeks after surgery, when it can be used successfully. Follow-up care: Patients are monitored similar to any other head and neck cancer patient. Referral to a speech therapist is usually appropriate. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.
The most significant complication aside from local recurrence is aspiration. Patients are also at risk for all of the complications associated with TL, including fistula, neurovascular injury, and anesthetic complications.
In an effort to provide additional insight into the success of the NTL, the medical records of all patients who underwent head and neck surgical procedures at Stanford University Medical Center and its affiliated hospitals during a 14-year period were surveyed and patients who underwent either NTL or TL followed by a TEP were identified. Once these patients were identified, their charts were reviewed for numerous demographic data, including sex, age, tumor site and TNM staging, date of surgery, date of last follow-up, disease status at last follow-up, delivery of radiotherapy (preoperatively or postoperatively), pathology, status of margins, quality of voice, ease of swallowing, and incidence of aspiration. Statistical comparisons of function between NTL and TEP patients were accomplished using a paired, 2-tailed Student's t test. Voice evaluation The quality of voice was retrospectively rated no earlier than 6 months after surgery; ratings were based on a 4-point scale from 0-3.
Swallowing evaluation The ease of swallowing was evaluated using a 4-point scale from 0-3.
Evaluation of aspiration Patients were evaluated for aspiration using a 4-point scale from 0-3.
Patients with tracheoesophageal puncture The TEP group was composed of 7 men (64%) and 4 women (36%). Their mean age (± SD) was 60.4 ± 7.2 years. Included were 4 glottic cancers, 3 supraglottic cancers, and 4 hypopharyngeal/pyriform sinus cancers; 4 of the cancers were stage III, 3 were stage IV, and an additional 4 cancers were recurrences. All of the tumors were squamous cell carcinomas. Nine patients received radiotherapy. Four patients were given radiotherapy for attempted cure prior to surgery, and 5 patients were treated postoperatively. The follow-up period ranged from 12-233 months, with a mean of 67.2 ± 64.8 months. The results of the functional evaluations (ie, voice quality, ease of swallowing, degree of aspiration) were compared with those for the patients who underwent NTL. No statistically significant differences were found. Patients with near-total laryngectomy The 19 men (86.4%) and 3 women (13.6%) in the NTL group had a mean age (± SD) of 61.1 ± 9.9 years. Of the patients, 5 had glottic cancers, 9 had supraglottic cancers, 6 had hypopharyngeal/pyriform sinus cancers, and 2 had base of tongue cancers. Included were 3 stage III cancers, 15 stage IV cancers, and 4 recurrent cancers. All of these were squamous cell carcinomas. The margins were negative in 18 of 22 surgeries. Radiotherapy was given to 21 patients, with 7 undergoing surgical salvage following attempted curative radiation, and 14 patients receiving planned postoperative radiotherapy. Radiation doses ranged from 50-72 Gy. The follow-up period ranged from 4-109 months, with a mean of 26.5 ± 25.8 months. The results of the functional evaluations (eg, voice quality, ease of swallowing, degree of aspiration) were not significantly different from those for the TEP. The duration of surgery was assessed, but the variety of adjunctive procedures performed in the NTL patients prevented a meaningful comparison. However, the surgeons had the impression that the NTL takes approximately 30 minutes longer than the TL. Several specific complications were encountered in the TEP group. One patient had a stomal recurrence and was lost to follow-up. One patient had a local recurrence at the TEP site; this patient underwent resection (including a gastric pull-up), but was lost to follow-up. A third patient in the TEP group developed an unresectable 8-cm nodal recurrence, received chemotherapy, and died of his disease. A fifth patient developed an esophageal stricture. After efforts to repair the stricture, this patient developed a fistula that required 2 separate flap reconstructions before ultimately healing. Of the remaining 6 patients, one patient with a functioning TEP prefers an electrolarynx and another patient uses esophageal speech as his primary mode of communication. Complications in the NTL group included severe aspiration in 2 patients who then had their shunts taken down. In addition, 2 patients underwent completion laryngectomy, one because of a positive margin and the other because of cancer recurrence. One of the local recurrences was in a patient in whom primary radiotherapy for pyriform sinus cancer had failed. The other local recurrence was in the posterior pharyngeal wall in a patient with base of the tongue cancer. This patient's shunt was successfully preserved during salvage surgery. One NTL patient with poor vocalization through his shunt was found to have a dilated shunt appendix, and an attempted repair was unsuccessful. A second patient with poor speech ultimately underwent placement of a Blom-Singer TEP prosthesis, which he uses as his primary mode of communication. One patient with a total glossectomy and NTL developed severe aspiration. He refused a procedure to tighten his shunt and required percutaneous endoscopic gastrotomy placement. One other patient required a percutaneous endoscopic gastrotomy because of insufficient oral intake. Three additional patients underwent successful shunt revisions, in which the shunt was tightened to eliminate aspiration. Finally, one wound infection developed among the NTL patients.
Patients with advanced laryngeal cancer have traditionally undergone TL with or without pharyngectomy. Efforts to restore lung-powered speech led to the first TEP in 1927. The procedure was simplified in 1980 by Singer and Blom, with subsequent widespread acceptance; however, the TEP requires an artificial prosthesis to maintain patency of the shunt. Because not all patients have the manual or mental dexterity to successfully use this prosthesis, careful patient selection is crucial. Other potential complications of TEP include stomal stenosis, fistula, esophageal stenosis, cellulitis, and aspiration of either oral contents or the prosthesis itself. In 1980, Pearson et al proposed an alternative procedure to TL. While this alternative procedure does not exclude the possibility of subsequent TEP, it does allow for lung-powered speech without the need for a prosthesis; however, the procedure should not be considered among the traditional partial laryngeal surgeries because the patients do require a permanent stoma. Speech is produced in a similar fashion to the TEP, in which exhaled air is directed from the stoma through a mucosalized shunt into the pharyngoesophageal segment, where vibratory sound is created. The initial reported series of 4 patients has grown to an experience of more than 100 by the authors who first reported this technique. Two theoretic criticisms have been made against the NTL procedure. The first is that shunt function is irreversibly compromised following postoperative radiotherapy. This criticism was difficult to defend in the series from the Mayo Clinic because such a small percentage of patients (15.4%) underwent postoperative radiotherapy. In a series conducted by Terris et al, 95.5% of patients received radiotherapy either before or after the NTL procedure. As indicated in the data, the NTL shunt was functional in a high percentage of these patients. The second potential criticism of the NTL procedure is the technical challenge associated with any new technique. In fact, a review of the literature revealed only 3 other authors who reported experience with the NTL, all at European institutions. This article has described 3 minor modifications of the NTL procedure; the author believes these modifications make performing the NTL easier. A significant advantage of the NTL is that it does not exclude the possibility of using other approaches to vocal rehabilitation, including esophageal speech, an electrolarynx, or subsequent TEP. Each of these alternative approaches has been used successfully at the author's institution. Finally, case selection is critical in choosing which patients are candidates for NTL. Furthermore, when an NTL is appropriate, realizing which variation of the described procedure is best is important. Therefore, entering the larynx through the vallecula is ideal for many glottic and some supraglottic and hypopharyngeal tumors, but it is not ideal in patients with base of tongue tumors. Likewise, the technical ability to perform an NTL must be weighed against oncologic and functional considerations, especially when it is difficult to ensure that complete tumor excision has been achieved (eg, recurrence of pharyngeal cancer after primary radiotherapy) or when total glossectomy is performed (thus diminishing the value of a tracheopharyngeal shunt). Conclusions NTL is an alternative to TL. In many cases, NTL allows excellent voice function and does not exclude the possibility of other vocal rehabilitation techniques. Speech, swallowing, and aspiration results in NTL patients are similar to those in patients who have had TEP following TL. NTL is a sound oncologic procedure for tumors that are causing vocal cord fixation. It can be used for most laryngeal lesions, except when either arytenoids or the postcricoid region is involved. NTL may be successful despite postoperative radiation therapy.
Conservation Laryngeal Surgery, Subtotal Laryngectomy excerpt | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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