Treatment of laryngeal cancer often includes surgery. The surgeon can use either scalpel or laser. Laser surgery is performed using a device that generates an intense beam of light that cuts or destroys tissues.
- Removal of part of the larynx (partial laryngectomy): The surgeon takes out only the part of the larynx harboring the tumor.
- Removal of the entire larynx (total laryngectomy): The surgeon removes the whole larynx and some adjacent tissues.
- A large laryngeal untreated cancer that has eroded through cartilage and other structures.
- Laryngeal cancer that came back after previous treatment, (i.e., radiation with/without chemotherapy).
- Prevention of aspiration pneumonia resulting from prior head and neck cancer surgery at sites other the larynx (i.e,. hypopharynx, tongue base).
- Nonfunctional larynx, or inability to eat or drink because of pharyngeal or esophageal strictures.
Healing after surgery sometimes, and the length of time needed to recover varies among individuals.
Total laryngectomy is an effective and reliable operation used to remove advanced cancer of the larynx, especially when conservative approaches were unsuccessful. The defect created after the larynx is removed is generally easy to close using sutures or staples. However, when the tumor has spread beyond the larynx and also involves the pharynx or esophagus, such closure is no longer possible and more complex reconstructive options have to be used.
The purpose of reconstruction is the recreate an effective passage through which swallowing as well as esophageal or tracheoesophageal speech are possible. Surgical reconstruction increases surgical time, cost, and postsurgical risks.
When additional tissue is needed to correct the defect, the reconstructive method is affected by the size of the defect, which determines the amount of tissue needed to repair it. The tissue used is called a “flap”. Flaps can be regional (close to the defect) or distal (some distance away from the defect). The blood supply to the flap can either be kept intact (in the regional), or the artery and vein serving it need to be connected to the blood supply at the location where it is required. These types of flaps as called “free flaps”.
· Deltopectoral (DP) flap.
Pectoralis myocutaneous. This flap has been used for many years and originates from the muscle of the chest and the skin above it. Its advantages are: the excellent and reliable blood supply, availability of sufficient amount of tissue, and proximity to the neck. Its disadvantages include: its large size, the cosmetic deformity it creates by transposing it under the neck skin, and the weakness of the arm it may create.
Deltopectoral flap. Tissues for this flap are taken from deltopectoral muscles region. It is thinner and more closely fits the thin tissue of the pharynx. DP creates minimal donor site problems, but installation of the flap may need to be completed in several stages, and the amount of tissue that can be obtained maybe limited.
Radial forearm free flap. A larger more pliable flap is needed when parts the pharynx or esophagus are removed. This may require using a radial forearm which is obtained from the inside surface of the arm near the wrist. The artery and vein that serve the flap have to be sewn to an artery and vein in the neck (a microvascular anastomosis). The donor site is covered with a skin graft taken from another site. This procedure can compromise the blood supply to the hand in individuals with poor hand circulation, and this risk is evaluated prior to considering the RFFF. The first two weeks following surgery are the most vulnerable to blood supply interruption as the new blood supply may clot of. Such interruption has to be addressed promptly to prevent the flap from dying.
Taking one's pulse at the wrist is no longer possible after the surgery. It is important to notify one's medical providers about this.
The jejunal free flap. The JFF is an alternative to the RFFF. It comes as a cylinder and is especially useful when parts of the esophagus are removed. Although swallowing is generally adequate, the voice is less good as with the RFFF.
In instances where all of the pharynx, larynx, and esophagus are taken out, the stomach can be connected directly to the throat. Because of the potential for a serious infection in the mediastinum after this surgery it is generally used in the most advanced cases where no alternative for reconstruction is available.
The reconstructive options currently available allow for the treatment of more advanced cancer, with a higher likelihood of successful restoration of voicing and swallowing than has been possible in the past. The best option for the patient depends on the tumor’s extent, the risks of each reconstructive option, and the patient’s overall health. Discussion between the patients and surgeon of the risks and benefits of each option can assist in selecting the best one. Obtaining a second option can also assist in the process.
- Internist and/or family physician
- Any specialist one sees for a specific medical problem (i.e., cardiologist, pulmonologis)
- Medical oncologist
- Radiation oncologist
- Speech and language pathologist (SLP)
- Social worker or mental health counselor
Contacting a local laryngectomee club to meet other laryngectomees and find support before and after the surgery can be helpful. A list of local laryngectomee clubs in North America and throughout the world is available at the International Association of Laryngectomee website.
Getting a second opinion
When facing a new medical diagnosis that requires making a choice between several therapeutic options including surgery, it is important to get a second opinion. There may be different medical and surgical approaches and a second (or even third) opinion may be invaluable. Getting such an opinion from physicians experienced in the issues at hand is judicious. There are many situations when treatment cannot be reversed. This is why choosing the course of therapy after consulting with at least one more specialist is very important.
Gathering one's medical records and seeing another physician may take some time and effort. Generally, the delay in initiating treatment will not make the eventual treatment less effective. However, one should discuss any possible delay with the physician.
- · Throat and neck swelling
- · Local pain
- · Tiredness
- · Increased mucus production
- · Changes in physical appearance
- · Numbness, muscle stiffness and weakness
- · Tracheostomy
The degree of pain experienced after laryngecomy (or any other head and neck surgery) is very subjective, but as a general rule, the more extensive the surgery, the more likely the patient will experience pain. Certain types of reconstructive procedures, where tissue is transferred as a flap from the chest muscles, forearm, thigh, jejunum, or a stomach pull up are more likely to be associated with increased or prolonged pain.
Those who have a radical neck dissection as part of the surgery may experience additional pain. At present, most patients undergo a "modified radical neck dissection" when the spinal accessory nerve is not removed. If the spinal accessory nerve is cut or removed during surgery, the patient is more likely to have shoulder discomfort, stiffness, and long term loss of range of motion. Some of the attendant discomfort of this procedure can be prevented by exercise and physical therapy.
For individuals who experience chronic pain as a result of laryngectomy or any other head and neck surgery, evaluation by a pain management specialist is usually be very helpful.