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Total Laryngectomy

 return to: Laryngeal Surgery (Malignant Disease) Protocols

 (see also LaryngopharyngectomyTracheoesophageal Puncture; Near-field laryngectomy for aspiration; Near-Field Laryngectomy Case; Closure of neopharynx); Mediastinal tracheostomy for total laryngectomy with resection of manubrium
return to information for patients: Patient Teaching and Education Information Nursing Protocols; Laryngectomy; Tracheoesophageal Puncture
restricted access: Total Laryngectomy Home Care Teaching Video   

 # h6. GENERAL CONSIDERATIONS

    1. Indications
      1. Oncologic
        1. Advanced laryngeal squamous cell carcinoma (T3 or T4) with extensive cartilage erosion or significant spread outside the endolarynx into the base of tongue or hypopharyx.
        2. Hypopharyngeal tumors originating or extending into the postcricoid mucosa
        3. Primary tumors of the cricoid or thyroid cartilages (chondrosarcomas)
      2. Oncologic, with consideration of previous treatment, co-morbidity, and function
        1. Irradiation or chemo-radiation failures not amenable to conservation laryngeal procedures
        2. Extensive laryngeal cancer with irreversible laryngeal dysfunction
        3. Extensive laryngeal cancer in a patient unable to tolerate function-preserving surgery or irradiation
      3. Chronic aspiration from glottic incompetence not amenable to conservative treatment
      4. Chondroradionecrosis of the larynx failing medical therapy including HBO
  1. PREOPERATIVE CONSIDERATIONS
    1. Evaluation
      1. CT of larynx and neck in all but the most superficial early glottic cancers.
      2. Panendoscopy and biopsies
      3. Consult to radiation oncology
      4. PET imaging in most patients with T3N0MX, T4N0MX, and some with T2N0MX. PET imaging in most with TXN+MX.
    2. Counseling
      1. Speech pathology consultation preoperatively. Should include description of voice restoration procedures and demonstration of educational videos (ie, Life Without the Larynx see: Laryngectomy Counselling).
      2. Counseling about avoiding situations where drowning is a possibility (ie, fishing, swimming).
      3. Up to two-thirds of patients will describe altered or complete loss of smell sensation following total laryngectomy.
    3. Consent for Surgery
      1. Describe procedure: "Removal of voice box resulting in a hole in the neck, which is necessary for breathing purposes (with or without neck dissection)." Usually include potential for pectoralis major myocutaneous flap (PMC) in the event the tumor extent is found to be greater than initially determined.
      2. Describe potential complications
        1. Bleeding
        2. Infection
        3. Anesthesia-related complications
        4. Damage to adjacent structures
        5. Salivary fistula
        6. Stomal stenosis
        7. Swallowing difficulties
        8. Hypothyroidism unlikely
        9. Loss of Smell sensation
  2. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
    2. Instrumentation and Equipment
      1. Standard
        1. Major Instrument Tray 1, Otolaryngology
        2. Major Instrument Tray 2, Otolaryngology
        3. Bipolar Forceps Trays
      2. Special
        1. Tracheotomy Tray
        2. Varidyne vacuum controller
        3. Sterile anesthetic breathing circuit and tubing
        4. Rousch Laryngoflex 7 mm endotracheal tube
        5. Corpak feeding tube
    3. Medications (specific to nursing)
      1. Antibiotic ointment
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Towels from nose to umbilicus (for possible PMC flap) and shoulder to shoulder; drape endotracheal tube into surgical field
        3. Split sheet
    5. Drains and Dressings
      1. Suction drains (Jackson-Pratt ): 7 mm or 10 mm x 3
      2. With flap placement (free-flap vs. PMC flap) most common current drain system is multiple penroses (0.25 ")
    6. Special Considerations
      1. If tracheotomy is done as a separate procedure, a separate setup will be necessary (historical perspective: old philosophy was to avoid intubating past cancer to decrease risk of stomal recurrence. Therefore tracheotomy was standard part of laryngectomy to establish airway with general anesthesia. This risk for stomal recurrence is no longer felt to be relevant and intubation past tumor is common practice.)
      2. Panendoscopy and/or radical neck dissection may be done in conjunction with procedure
      3. Need for flexible endotracheal tube and sterile anesthetic tubing to replace oral endotracheal intubation at time of tracheostomal maturation 
      4. If neck dissections are planned - these may be performed before laryngectomy as they will provide excellent exposure.
  3. ANESTHESIA CONSIDERATIONS
    1. General
      1. Preferable to use oral endotracheal anesthesia with conversion to anesthetic through tracheostoma via flexible endotracheal tube early in procedure rather than perform tracheotomy as separate early procedure.
    2. Specific
      1. Occasionally will need to perform local tracheotomy initially due to airway compromise or difficulty with intubation
      2. Need for sterile anesthetic tubing
      3. May be beneficial to have patient breathing spontaneously at end of procedure to preclude the need for a tracheotomy tube in fresh stoma
  4. OPERATIVE PROCEDURE - Standard Total Laryngectomy
    1. Table is turned 180° (head away from anesthesia)
    2. Shoulder roll may help extend the neck in selected cases. Use of a gel pad rather than rolled towel should be considered to avoid pressure to skin. Elevation of the back helps to decrease bleeding, drops the viscera below the diaphragm to help with ventilation, and helps with neck extension.
    3. Incision
      1. Skin incision may be made with scalpel or electrocautery (on blend of 20/20 cut/coag) well inferior to mastoid tip with a 'nearly straight line' to the trapezius. If this exposure is inadequate, vertical extensions overlying the anterior border of the trapezius may be made to extend to the mastoid tip or toward the clavicle. By avoiding the traditional incision extending directly to the mastoid tip, these vertical extensions over the trapezius are never made over the carotid.
      2. Lower border of incision will be upper aspect of tracheostoma (about 2 to 4 cm above sternal notch).
      3. Alternatively tracheostoma may come out of lower flap separate from apron incision. Should leave adequate distance (~2 cm) between these incisions to retain an adequate blood supply to the intervening skin. This practice whereby the stoma incision is separated from the incision for larynx removal is good in cases at high risk for fistula (e.g. after irradiation or chemo-radiation). A pharyngo-cutaneous fistula is more readily diverted away from the stoma through this approach.
    4. Flap elevation should be in the subplatysmal plane, immediately above anterior and external jugular veins. The skin flaps are typically carried superiorly just past the hyoid and inferiorly to the clavicles.
    5. Transect strap muscles inferiorly (hemostat dissection/monopolar cautery on cutting).
    6. Divide thyroid isthmus, oversew and dissect thyroid gland away from the trachea (may remove ipsilateral lobe along with larynx). The blood supply to the contralateral thyroid should be preserved.
    7. Trim 2 to 4 cm in half-moon shape from inferior skin flap and remove subcutaneous fat in preparation for maturing lower border of tracheostoma. With 3-0 vicryl, suture anterior tracheal wall in three to five sites to undersurface of inferior flap to begin formation of a mature tracheostoma.
    8. Clean soft tissue off anterior tracheal wall and incise between second and third rings (lower if concern for subglottic extension exists).
      1. Continue incision superolaterally to bevel lateral tracheal walls superiorly to enlarge tracheostoma.
      2. Entry into the trachea may be done with care to avoid puncturing the cuff on the endotracheal tube by the following method:
        1. Deflate the cuff of the endotracheal tube (ETT) - notify anesthesia to hold ventilations.
        2. Advance the ETT.
        3. Use a small hemostat to pucture the membranous trachea in the location where the stoma is to be placed.
        4. Use the hemostat to push the ETT posteriorly as the anterior tracheal wall is pulled anteriorly. A scalpel (15 blade, do not use 11 blade) is used to cut the anterior tracheal wall as directed by the hemostat. Re-inflate cuff on ETT. The stoma may now begin to be matured with the patient still ventilated through orotracheal intubation without a tube in the way. After the anterior wall of the tracheostoma is matured, the ETT is removed and a flexible tube is placed into the stoma and sutured to the chest.
        5. Entry into the trachea in the course of a laryngectomy is ideally performed via incision just below a tracheal ring, thus preserving the soft tissue overlying the trachea ring which will be sutured to the skin for the stoma.  This technique leaves less (or no) exposed cartilage, allows for diminished crusting and a diminished chance of a tracheitis.
      3. One method to remove the endotracheal tube without requiring anesthetist to come to head of table to withdraw tube:
        1. After puncturing balloon of endotracheal tube in a "hand-over-hand fashion" with two large hemostats, pull tip of tube out of tracheotomy. Advance the tube inferiorly through the glottis and cut with heavy scissors, allowing the upper two-thirds remnant to retract superiorly, still attached to tape at the mouth.
        2. Inspect subglottis from below to ensure adequate margin has been obtained.
        3. Place new flexible endotracheal tube into the trachea and secure to anterior tracheal wall or chest with suture, attach to sterile anesthesia tubing, and resume ventilation through the neck.
    9. Be prepared to perform a radical or modified radical neck dissection if previously unrecognized neck disease becomes apparent after flap elevation. (see Cervical Lymphadenectomy- General Considerations)
      1. Bilateral Levels II, III, and IV neck dissections are commonly employed for advanced laryngeal SCC with clinical N0 (cN0) neck disease but suspected positive neck disease to help stage the previously untreated patient to determine the need for post-operative irradiation.
      2. If irradiation is clearly indicated postoperatively as an adjunct to laryngectomy (based on tumor characteristics as the primary site), elective neck dissection (for cN0 necks) is not necessary.
      3. If performing a salvage laryngectomy after prior treatment with chemoradiation, neck dissections are optional in the cN0 neck.
      4. Comprehensive radical or modified radical neck dissection is done for most clinically N-positive disease. Support is emerging to manage cN1 neck disease with selective dissection sparing Level V and possibly Level I if postoperative radiation is available to cover these undissected areas.
    10. Isolate the inferior pedicle of ipsilateral thyroid lobe and ligate vessels.
      1. Good practice but not essential to identify and preserve pedicled inferior parathyroid
      2. Also good practice but even less essential to identify the recurrent laryngeal nerve prior to its transection
    11. Detach constrictor muscles from the thyroid ala with cautery or scalpel blade. The mucosa of the pyriform sinus on uninvolved side may be mobilized medially with a sponge, Kitner, or Freer elevator.
    12. Dissect suprahyoid musculature off superior border of hyoid bone with monopolar dissection staying in the midline well away from the hypoglossal nerves. Grasp the midline of the hyoid with an Allis clamp.
      1. Heavy Mayo scissors dissection laterally to isolate greater cornu of hyoid bilaterally
      2. Hug corner of greater cornu to avoid hypoglossal nerve. If neck dissection is done, the hypoglossal nerves will be under direct vision.
    13. Entry into the larynx from above:
      1. Should enter larynx as far from tumor as possible: choices include the vallecula or pyriform sinus on side opposite tumor or from below; most commonly enter from the vallecula.
      2. With finger palpation of vallecula, insert Army-Navy retractor through the mouth with end of retractor now palpable through the neck immediately above hyoid.
      3. This maneuver keeps the surgeon out of the pre-epiglottic space.
      4. Cut with cautery down to the Army-Navy retractor that will now appear into the neck wound.
      5. Dissect laterally from point of entry to expose supraglottis.
      6. May place Allis clamp on epiglottis for retraction to help gain full visualization of tumor.
    14. Heavy scissors cuts (Mayo or Metzenbaum) may be made on less involved side along lateral pharyngeal wall to "open pharynx like a book."
      1. On less involved side, cuts may be made to hug arytenoids and cricoid to preserve pyriform sinus mucosa.
      2. Superior laryngeal neurovascular pedicle will be encountered with these cuts and should be ligated.
    15. With the excellent exposure now available, the involved side of the larynx is separated from posterolateral wall mucosa also with scissors cuts. This allows good visualization to obtain adequate margins.
    16. Final separation of the larynx is performed from below with scalpel incision of posterior tracheal wall to identify the gray line (avascular plane between esophagus and trachea).
    17. Larynx removed from patient with upward traction on the larynx permitting inspection of surgical margin, esophageal introitus, and trachea as final cuts are made.
    18. Cricopharyngeal myotomy is now often performed. One finger is placed in the esophagus and the cricopharyngeal muscle identified. A 15 blade is used to carefully feather through the cricopharyngeal muscle fibers while not entering the esophagus.
    19. Pharyngeal closure
      1. Place NG Corpak feeding tube before closure.
      2. Montgomery salivary bypass tube (10-14mm) may be used to buttress closure, especially in case of total pharyngectomy and closure with free flap. The feeding Corpak is passed through the lumen of the Montgomery tube and sutured to one side of the membranous nasal septum. The Montgomery tube can be suspended by another Corpak sutured to the other side of the nasal septum. The non-feeding Corpak should be cut at the nostril. This technique allows the Montgomery tube to remain in longer (since there are no suspensory sutures in the mouth) and be removed in the clinic (by grasping the suspensory Corpak in the oropharynx). It can be left in place as long as tolerated by the patient, even after oral diet is begun.
      3. T-shaped, vertical, or horizontal closure with 3-0 vicryl or 4-0 vicryl in running modified Connell or true Connell technique for first layer (video: Connell suture technique)
      4. Second layer of interrupted 3-0 vicryl to ensure the deeper running layer is imbricated with adjacent constrictor muscles brought over the closure.
      5. In selected cases, a third layer with interrupted 3-0 vicryl may loosely approximate adjacent musculature (strap muscles if they have been preserved through a narrow-field technique). Overly tight closure may lead to narrowing with subsequent dysphagia or failure of TEP speech, so may choose to avoid third layer. There is support in the literature to employ only one layer closure to improve TEP speech that may be compromised by a tighter closure.
    20. Tracheostoma
      1. Take bilateral "cookie bites" out of sternal head of sternocleidomastoid (SCM) to allow room for tracheostoma; may tack thyroid remnant laterally under SCM.
      2. Remove a small elliptical segment from upper skin flap above tracheostoma.
      3. Suture undersurface of upper and lower flaps (dermis, 2 to 3 mm from skin edge) to cartilage of trachea with 3-0 vicryl.
      4. Approximate skin of flaps to mucosa of trachea (covering exposed cartilage) with 4-0 chromic.
    21. Suction drains (3 or 4)
      1. Bilaterally placed active suction drains to both "gutters" (along internal jugular veins)
      2. Third drain placed horizontally just above upper aspect of tracheostoma
      3. Consider fourth drain across submental area
    22. Platysma closed with 3-0 vicryl and the skin is stapled.
  5. OPERATIVE PROCEDURE - Near Field Total Laryngectomy (click to see photos:Near-field laryngectomy for aspiration  and  Near-Field Laryngectomy Case  )
    1. Table is turned 180° (head away from anesthesia)
    2. Shoulder roll may help extend the neck in selected cases. For cases expected to last more than an hour, use of a gel pad rather than rolled towel should be considered to avoid pressure to skin. Elevation of the back helps to decrease bleeding, drops the viscera below the diaphragm to help with ventilation, and helps with neck extension.
    3. A vertical incision limits the amount of dissection, provides direct access, and preserves blood supply to the strap muscles for an added layer of closure.
    4. Through the vertical incision the strap muscled are identified and separated in the midline.
    5. The hyoid bone is identified and separated from the supra- and infra-hyoid musculature.
      1.  The exposure to remove the hyoid in a standard fashion may be limited by the constraints of the vertical incision. Therefore, the hyoid bone can be transected in the midline with the two separate segments removed separately by engaging the midportion of the segment with an Allis clamp, drawing it medially, and using scissors dissection on the bone to strip it from adjacent soft tissue.
      2. When there is concern about malignancy in the supraglottic region, a standard approach to removal of the hyoid bone in continuity with the specimen may be warranted (as in the example provided). Extensions on the incision may be needed for this exposure.
    6. When the procedure is done for no-cancer related problems (radionecrosis/intractable aspiration), the dissection may be performed close to the thyroid cartilage to preserve overlying perichondrium.
    7. Closure is effected with a running Connell suture (true or modified) begun inferiorly. Favorable anatomy will permit closure with a single vertical suture line, but in most cases a T-closure is employed.
    8. A second layer closure incorporating constrictor muscles and straps reinforces the first closure with dead space obliterated between the two layers of closure.
    9. The final closure may be effected with 'parachute sutures' over rubber shods (see case example) with penrose drain placement.
  6. POSTOPERATIVE CARE
    1. Drains
      1. Leave 3 or 4 drains in place a minimum of three days.
      2. Begin to remove individual drains once output diminishes to 10 cc per eight-hour shift (30 cc per day).
    2. Feeding
      1. Begin oral feeding on postoperative day 7 in uncomplicated resection in the non-irradiated patient.
      2. Begin oral feeding on postoperative day 14 in irradiated patient (rule: delay by one additional day per each 1,000 cGy the time to feeding; ie, no irradiation, then postoperative day 7; 7,0000 cGy, then postoperative day 14).
    3. Discharge
      1. May discharge home the day after last drain is removed and begin feeding as outpatient.
      2. It is generally best not to discharge before postoperative day 6 in order to observe for fistula.
    4. Be aware of high incidence of hypothyroidism (60%) with total laryngectomy patients who have been irradiated.
    5. Please see Airway Monitoring protocol
    6. Patients should have their thyroid function (TSH, Free T4) checked every 6 months to 1 year following total laryngectomy, particularly in those patients having received radiation therapy prior to surgery.
  7. Complications of Laryngectomy
              Predisposing factors for complications include prior radiation, general debility, systemic disease.
                         a. Hematoma Formation: Usually within the first 24 hours. Prevented by adequate hemostasis and suction drain placement
                         b. Fistula formation (up to 30%). May occur secondary to undue tension on the closure line, diabetes, hematoma, lack of inversion of the mucosa, prior irradiation with poor wound healing, or  cancer recurrence. Small fistulas may close spontaneously, large fistulas may require closure/coverage by pectoralis flap.
                         c. Post op Hypocalcemia
                         d. Chyle leak
                         e. Stomal Strictures
                         f.  Carotid Rupture
  8. CPT CODING
    1. 31360, Laryngectomy; total, without radical neck dissection
    2. 31365, Laryngectomy; total, with radical neck dissection
  9. SUGGESTED READING
    1. Sheehan AJ, Shaw HJ. Total laryngectomy for squamous carcinoma of the glottis. J Laryngol Otol. 1979;93:461-475.
    2. Wang CP, Tseng TC, Lee RC, Chang SY. The techniques of nonmuscular closure of hypopharyngeal defect following total laryngectomy: the assessment of complication and pharyngoesophageal segment. J Laryngol Otol. 1997;111:1060-1063.
    3. Wei WI, Lau WF, Lam KH. Entering the pharynx in total laryngectomy. J Laryngol Otol. 1987;101:589-591.
    4. Ampil FL, Nathan CA, Caldito G, Lian TF, Aarstad RF, Krishnamsetty RM. Total laryngectomy and postoperative radiotherapy for T4 laryngeal cancer: a 14-year review. Am J Otolaryngol 2004 Mar-Apr;25:88.93.
    5. Garvey C.M., Panje W.R., and Hoffman H.T.:  “The ‘Parachute’ Bolster Technique for Securing Intraoral Skin Grafts”.  Ear, Nose & Throat Journal 80(10):720-723, 2001.
    6. Agrawal N, Goldenberg D. Primary and salvage total laryngectomy. Otolaryngologic clinics of North America 2008;41:771-80, vii.
    7. Hilly O, Stern S, Horowitz E, Leshno M, Feinmesser R. Is there a role for elective neck dissection with salvage laryngectomy? A decision-analysis model. Laryngoscope. 2013 Nov;123(11):2706-11.