Laryngectomy, reconstruction, getting a second opinion, outcome & recovery

Types of surgery including laryngectomy 

Treatment of laryngeal cancer often includes surgery. The surgeon can use either scalpel or laser. Laser microsurgery is performed using a device that generates an intense beam of light that cuts or destroys tissues.

There are two types of surgery for removal of laryngeal cancer:

• Removal of the entire larynx (total laryngectomy): The surgeon removes the whole larynx or voice box, along with the entire pharynx. 
• Removal of part of the larynx (open partial laryngectomy): The surgeon takes out only the part of the larynx harboring the tumor.

Total Laryngectomy ( also called laryngectomie, laryngektomie, laringectomia, laryngektomii, Laringektomija, laringektomiya, and larenjektomi) is generally performed for these reasons:

• 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. 

An incision is made in the central neck, extending to both sides to perform bilateral neck dissections. The larynx and neck’s lymph nodes (if needed) and one or both lobes of the thyroid gland are removed. Frozen sections of the margins of the removed area are studied before the surgery is complete to determine if no cancer cells are left behind. A laryngostome is created by sewing the top part of the trachea directly to the skin.

Reconstruction and rehabilitation procedures might include repair of the pharynx with primary closure, or a flap. The flap is obtained from other parts of the body and include a pectoralis major flap, or fee flap recovered from the radial forearm, lateral thigh, abdominal or scapula area (see below).

A tracheoesophageal puncture might be done at the same time as the total laryngectomy to assist with speech in the post-operative time period. A gastric feeding tube is placed either through the nose, directly in the stomach or inserted through the tracheoesophageal puncture. Feeding is resumed from a few days to one or two weeks after the procedure. Small surgical drain(s) are also placed.

Because the parathyroid glands can be damaged during surgery their activity is monitored by determining calcium serum levels.

Open Partial Laryngectomy: 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 the ability to swallow. It is limited to small cancers that have recurred after prior non-surgical therapy. Transoral microsurgery is another option in these situations.

There are several types of open partial laryngectomies:

1. Laryngofissure with cordectomy: In this procedure, an incision is made in the midline of the neck, the thyroid cartilage is split vertically, and the inside of the voice box is exposed allowing the removal of vocal cord tumors. The thyroid cartilage is then sealed and the incision is closed. A temporary stent can be placed in in the voice box for a few weeks to prevent scar band formation. Sometimes a temporary tracheotomy tube is required.

2. Horizontal laryngectomy: A horizontal partial laryngectomy can be either a supraglottic hemi-laryngectomy or a supracricoid hemilaryngectomy. This can be performed with or without resection of the hyoid bone. Following 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.

 3. Vertical hemi-laryngectomy, or frontolateral vertical partial laryngectomy: The thyroid cartilage is exposed following middle neck incision. Then a vertical incision is made in the thyroid cartilage is incised vertically, and the vocal cord and arytenoid are removed. Up to 3/4 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.

4. Transoral laser microsurgery (TLM) with partial laryngectomy: The procedure is performed through the mouth using special laryngoscopes, instruments and lasers. It is an option for small recurrent cancers after non-surgical therapy. 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. Associated procedures might include a tracheotomy, feeding tube placement or a neck dissection - sometimes performed a few weeks later as a staged neck dissection.

 5. Transoral robotic-assisted partial laryngectomy: This procedure 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. This procedure is considered experimental at present. The purpose is to limit incisions and limit dissection of neck contents. 

Lymph nodes that are close or drain the cancerous site may also be taken out during either type of surgery.

Healing after surgery, and the length of time needed to recover varies among individuals.

Side neck view before and after laryngectomy

Surgical reconstruction in total laryngectomy

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 to 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 (obtained from a site close to the defect) or distal (obtained from a site some distance away from the defect). The blood supply to the flap can either be kept intact (in the regional flap), 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”. 

The types of available flaps are:

Regional flaps

           ·  Pectoralis myocutaneous (PMC) flap. 
     ·  Deltopectoral (DP) flap.

Free flaps

           ·   Radial forearm free flap (RFFF)

           ·   Jejunal free flap (JFF)

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 connected 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 to the flap as the new blood supply may be cut off because of thrombosis. Such interruption has to be addressed promptly to prevent the flap from dying.

Taking one's pulse at the wrist where the flap was obtained is no longer possible after the surgery. It is important to notify one's medical providers about this.
The donor site may feel cold, and since it has no sensation is vulnerable to trauma and frostbite. It should be protected from injury and frostbite by wearing a long shirt and a coat during winter. 

Radial forearm free flap site after surgery (left) and 2 years later 

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. 

Preparation of radial forearm free flap site

Preparing for surgery

Prior to surgery it is important to thoroughly discuss with the surgeon all available therapeutic and surgical options and their short and long term outcomes. Patients scheduled for surgery may be anxious and under a lot of stress. It is therefore important to have a patient advocate (such as a family member or friend) also attend the meetings with the surgeon. It is important to freely ask and discuss any concerns and request clarifications. It is necessary to repeatedly listen to explanations until they are understood. It is useful to prepare questions to ask the surgeon and write down the information obtained.

In addition to consultation with the surgeon, it is also important to see these medical providers:

• Internist and/or family physician
• Any specialist one sees for a specific medical problem (i.e., cardiologist, pulmonologis) 
• Medical oncologist
• Radiation oncologist
• Anesthetist
• Dentist
• Speech and language pathologist (SLP)
• Social worker or mental health counselor 
• Nutritionist

Pre-operative counseling sessions with the patient and family are essential in clarifying  what to expect regarding communication restoration. It is also very useful to meet other patients who have already undergone a laryngectomy. These individuals can guide the patient about future speech options, share some of their experiences and provide emotional support. 

The speech and language pathologist (SLP) plays an important role in the care of the total laryngectomy patients from initiation of pre-operative counseling through acute care, home health and outpatient services. These includes the pre-laryngectomy evaluation and education; immediate post-operative care, post-surgical home care; and post-operative outpatient care. A list of SLP that take care of laryngectomees can be found in the International Association of Laryngectomee website. 

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.

Head and neck cancers are relatively rare, so general oncologists may not have the specialized expertise and latest knowledge on treatment options compared to specialists who focus solely on these cancers. A second opinion from a head and neck cancer specialist can provide valuable insights.

Head and neck cancer specialists, who focus exclusively on these cancer types, may be aware of the latest clinical trials, new treatments, technologies or toxicities years before they are published and available to general oncologists.

Some individuals may be reluctant to ask for a referral to see another physician for a second opinion. Some may be afraid that this will be interpreted as lack of confidence in their primary physician or doubts about their competence.  However, most doctors are comfortable with patients seeking second opinions and understand the importance, especially for serious conditions like cancer where treatment decisions are complex and can have major consequences. They often encourage patients to get a second opinion for peace of mind.

The second doctor may agree with the first doctor’s diagnosis and treatment plan. Conversely, the other physician may suggest a different approach. Either way, the patient ends up with more valuable information and also with a greater sense of control. Eventually one may feel more confident about the decisions he/she makes, knowing that all options have been considered.

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.

There are numerous ways to find an expert for a second opinion. One can request a referral to another specialist from the primary doctor, a local or state medical society, a nearby hospital, or a medical school. Even though patients with cancer are often in a rush to get treated and remove the cancer as soon as possible-waiting for another opinion may be worthwhile.

A multidisciplinary team approach, where doctors from different specialties (surgery, radiation, chemotherapy) review and discuss the case together, leads to the best treatment plan tailored to the individual patient. Major cancer centers follow this protocol, but it may not happen if only seeing a single doctor.

It's common for treatment plans to be modified after getting a second opinion, sometimes in significant ways that can impact long-term outcomes and future treatment options. Around one-third of cases see a change in recommendations at multidisciplinary cancer clinics.

 

In summary, due to the complexity of head and neck cancers and the potential life-altering impact of treatment, getting a second opinion from an experienced multidisciplinary team at a major cancer center is highly advisable to ensure the optimal personalized treatment plan.

Recovery from surgery

The patient's course of recovery depends on the extent of the surgery and reconstruction. After some surgeries, it is possible to be discharged after several hours of observation in the recovery room, while other surgeries may require a hospital stay for 7 to 14 days. A longer stay may be needed because of post-operative complications.

Hospital recovery takes place in different parts of the medical center. Patients are first observed in the recovery room, than they are moved to the intensive care unit, and lastly to the regular surgical or otolaryngological ward. Each move is made when the time is right. With time the lines, tubes, catheters and drains are gradually removed, and the patient is eventually helped to get up and walk.

The post-surgical complications following laryngectomy include: local bleeding (including hematoma), wound infection, poor wound healing,  salivary fistula, low calcium levels (hypocalcemia), hypothyroidism, blood clots, and aspiration (after partial laryngectomy).

Patients are discharge from the hospital once the physician(s) determine that there is no longer a need for in-patient level care. Some patients can go home directly from the hospital with or without visiting nurses; others might need to be transferred to a rehabilitation or skilled nursing facility before going home. Selection of the best discharge location is made by the medical team that is made of physicians, social workers, nurses and physical therapists. It is made in conjunction with the patient and his/her family.

A speech and language pathologist is also involved to assisting the patient to learn about speaking options. An electrical larynx (electrolarynx) can be used to speak within a few days after the surgery. Because of neck swelling and post surgical stitches the intra-oral route of delivering vibrations with a straw-like tube is preferred.

Patients should be informed about the need for continued speech rehabilitation and communication options post-operatively. 

Further reconstructive and cosmetic procedures or treatments are generally done after discharge. This allows the patent time for recovery from the initial surgery, get the pathological results from specimens obtained during the surgery, and make any arrangements needed for the next steps.

After surgery 

Surgery's outcome

The surgery can result in all or some of the following:

•   Throat and neck swelling
•   Local pain
•   Tiredness
•   Increased mucus production
•   Changes in physical appearance
•   Numbness, muscle stiffness and weakness  
•   Tracheostomy

Most people feel weak or tired for some time after surgery, have a swollen neck, and experience pain and discomfort for the first few days. Pain medications can relieve some of these symptoms.

Surgery can alter the ability to swallow, eat, and talk. However, not all such effects are permanent, as discussed in the Eating and Swallowing page. outcome of surgery page. Those who lose their ability to talk after surgery may find it useful to communicate by writing on a notepad, writing board (such as a magic slate), cell phone, or computer. They can also utilize speech generating devices (see page 96) such as laptop, and smartphone. Prior to the surgery it may be helpful to make a recording for one's answering machine or voicemail to inform callers about one's speaking difficulties.

An electrolarynx can be used to speak within a few days after the surgery. (See methods of speaking section chapter) Because of neck swelling and post surgical stitches, the intra-oral route of delivering vibrations using a straw-like tube is preferred.

Feeding after laryngectomy

Determining if feeding after laryngectomy is possible involves considering several factors based on the provided search results:

Patient Factors

Presence of prior radiotherapy or chemo radiotherapy: Patients who have undergone prior radiation therapy or chemoradiation may have increased risk of complications, such as pharyngocutaneous fistula formation, which could delay the initiation of oral feeding. 

Surgical complexity

 In cases of total laryngopharyngectomy or complex pharyngeal reconstruction with flaps, a more conservative approach to oral feeding may be warranted due to the increased risk of complications.

 

Feeding after laryngectomy is a crucial aspect of postoperative care, and the timing of initiating oral feeding has been a subject of debate among healthcare professionals. A swallow test is typically done for all laryngectomees before they are allowed to start swallowing on their own after surgery. These are the key points regarding feeding after laryngectomy: 

Timing of Oral Feeding

Many surgeons traditionally waited 7-10 days before initiating oral feeding after total laryngectomy to allow for adequate healing and closure of the pharyngeal repair. However, several studies have demonstrated that early oral feeding, within the first 72 hours or even within 3 days after surgery, is safe and does not increase the risk of pharyngocutaneous fistula formation compared to delayed feeding.

 

Advantages of Early Oral Feeding

Early oral feeding may result in shorter hospital stays for patients and can potentially reduce the need for nasogastric tube insertion or other alternative feeding methods. Early initiation of oral feeding can improve patient satisfaction and quality of life.

 

Feeding Progression:

• A swallow test is typically done for all laryngectomy patients before they are allowed to start swallowing on their own after surgery.
• In cases of total laryngectomy without prior radiotherapy or surgical complications, oral hydration with water is typically introduced around day 7, followed by liquid diets (e.g., juice, milk) after day 7-10.
• Semi-solid foods (e.g., purees) are often started between days 10-14, and a free diet is introduced after day 15.
• The progression to more solid foods may be delayed in cases of salvage laryngectomy, prior radiotherapy, or complex pharyngeal closures.

 

Incidence of pharyngocutaneous fistula

• The incidence of pharyngocutaneous fistula, a common complication after total laryngectomy, was found to be similar between early and delayed oral feeding groups in several studies.
• One study reported a pharyngocutaneous fistula rate of 12% in both early and delayed feeding groups.

In summary, the available evidence suggests that early oral feeding after total laryngectomy, within the first 72 hours or even 3 days postoperatively, is a safe practice and does not increase the risk of complications like pharyngocutaneous fistula formation. However, the progression to more solid foods may need to be adjusted based on individual patient factors and surgical complexity.

Long term survival

The prognosis of head and neck squamous cell carcinoma depends on the cancer’s stage at diagnosis and its location. Survival rates represent the percentage of people who are alive within a certain period of time after treatment, but they should not be used to predict how cancer will affect a particular patient. Five-year overall survival in patients with stage I or stage II cancer is generally 70 - 90%. More advanced (stage III or IV) cancer and those who continue to smoke and consume alcohol have a poorer prognosis. Those with advanced laryngeal carcinoma have about 40 % five years survival.

The prognosis is better in HPV associated oropharyngeal cancers compared to non- HPV associated oropharyngeal cancers.

A tool that allows general calculation of the expected survival rates of head and neck cancer patients is available. 

In general, the frequency of follow-up is greatest in the first two to four years following diagnosis because about 80 to 90% of all recurrences occur within this period. However, follow-up beyond five years is warranted because of the risks of late complications, late recurrence, and second malignancies. This is especially important for patients with non-HPV associated oropharyngeal cancers.

Pain management after surgery

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" where 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 very helpful.