Description: Either radiation, chemoradiation or surgery is commonly

employed as primary treatment of laryngeal squamous cell carcinoma.

Selected tumors can be removed endoscopically, as reviewed above. Open
procedures, which may be primary or following recurrence after irradiation,
are designed to fit tumor extent. If at least one cricoarytenoid unit (innervated
posterior cricoarytenoid muscle and working cricoarytenoid joint) is
uninvolved by tumor, the patient may be a candidate for less than a total
laryngectomy.

A vertical partial laryngectomy (VPL) involves removal of the affected

true and false vocal folds, and up to one-third of the contralateral folds
including the anterior commissure. The contralateral cricoarytenoid unit is
preserved, and reconstruction often includes a pedicled sternohyoid flap as
well as thyroid cartilage perichondrium. Exposure and anesthetic
considerations are similar to that of a total laryngectomy (discussed below)
other than the fact that a temporary tracheotomy is used in the partial
laryngectomy.

A supraglottic laryngectomy (Figs. 3-4 and 3-5) or anterior horizontal

partial laryngectomy (AHPL; Fig. 3-6) involves removal of laryngeal
structures superior to the true vocal cords. Both cricoarytenoid units remain.
The resection may include some of the base of tongue. Exposure and
anesthetic considerations are the same as for for a VPL, including the need
for a temporary tracheotomy.

Figure 3-4. The larynx is viewed from the midline, as seen by the surgeon
standing at the head of the operating table. Unless the lesion extends
posteriorly to the arytenoid, the aryepiglottic fold is transected on each side
by placing one blade of the dissecting scissors into the laryngeal ventricle or
above the false vocal cord and the other blade in the pyriform sinus. The
arytenoid on one side can be resected if the tumor extends posteriorly to
involve this structure. (Reproduced with permission from Montgomery WW:
Surgery of the Upper Respiratory System, 3rd edition. Williams & Wilkins,
Baltimore: 1996.)

Figure 3-5. The repair following supraglottic partial laryngectomy begins by

carefully approximating the margin of the mucous membrane of the pyriform
sinus to the lateral margin of the laryngeal ventricle, or to the margin of
resection above the false vocal cord. There is usually some distortion of the
true vocal cord when the repair is accomplished, as is shown on the patient’s
right side. The repair is continued anteriorly by placing multiple interrupted
3-0 chromic catgut sutures. (Reproduced with permission from Montgomery
WW: Surgery of the Upper Respiratory System, 3rd edition. Williams &
Wilkins, Baltimore: 1996.)

Figure 3-6. A: Horizontal incisions, corresponding to the mucosal incision,

are made through the thyroid lamina. B: The specimen— including true and
false vocal cords, the arytenoid, and a portion of the thyroid lamina—is
resected en bloc. (Reproduced with permission from Montgomery WW:
Surgery of the Upper Respiratory System, 3rd edition. Williams & Wilkins,
Baltimore: 1996.)

A supracricoid laryngectomy involves removal of the larynx from the top

of the cricoid ring to the hyoid bone with preservation of at least one
arytenoid. A temporary tracheostomy is required. Cuts are made above the
thyroid ala, through the cricothyroid membrane, and anterior to the arytenoid
cartilages. The epiglottis may be included in the resection if necessary,
depending upon the extent of the tumor. Blunt finger dissection anterior to
the trachea into the mediastinum is performed to allow for superior
mobilization of the trachea. A cricohyoidopexy, involving the suturing of the
cricoid ring to the hyoid bone, is then performed with three heavy sutures. If
the epiglottis has been preserved, a cricohyoidoepiglottopexy is performed.
The strap muscles are then used to reinforce the closure, and drains are
placed.

A total laryngectomy (TL) involves the resection of the entire larynx and
can be done via an incision about 8 cm long, low in the midline neck. An
apron incision is often used instead, or the low incision is extended toward a
mastoid tip to provide

exposure for a neck dissection if indicated. The thyroid gland is often

preserved, pedicled on its superior and inferior vasculature after dividing the
isthmus; but if indicated a partial thyroidectomy may be included. The thyoid
is resected with the specimen and the pharynx closed primarily. A nasogastric
tube is used for nutrition for all open laryngeal tumor surgery, unless the
surgeon opts to provide nutrition via a tracheoesphageal puncture, discussed
below. As the remaining trachea is sutured to the anterior skin in a true
tracheostoma, no tracheotomy tube or ETT is required postop unless there is
marked stomal edema or mechanical ventilaton is required, which is not
common.

If a TL is performed, a tracheoesphageal puncture (TEP) may be performed

simultaneously. This involves the creation of a tract or fistula between the
trachea and the esophagus for placement of a voicing prosthesis (a one-way
valve that allows airflow from the trachea into the pharynx for alaryngeal
speech). The voicing prosthesis may be placed at the time of the
laryngectomy or as a secondary procedure at a later date. If performed
secondarily, it is placed using the technique of rigid esophagoscopy (see
previous section). If TEP is performed at the time of laryngectomy, the valve
can be placed simultaneously. Some surgeons prefer to place a red rubber
catheter instead, which can allow the patient to be fed via this route in lieu of
a nasogastric or gastrostomy tube. After the patient is deemed fit to start oral
intake, the catheter can be exchanged secondarily for the voice prosthesis. If
a rubber catheter is used, the tube will protrude from the stoma, and care
must be taken not to dislodge it during suctioning or while removing or
replacing the laryngectomy tube if one is temporarily used during the period
of postop edema.

A TL can be extended to include part of the hypopharyx or oropharynx as

dictated by tumor extent. If flap reconstruction is necessary because of the
extent of the tumor, options include use of a pectoralis major myocutaneous
flap or a free flap, such as a radial free flap, to reconstruct less than a
circumferential defect. If a circumferential defect following resection exists
(e.g., after resection of the superior cervical esophagus and the larynx),
options for reconstruction include use of a laparascopically harvested jejunal
free flap, gastric pullup, or a tubed radial free flap reinforced with a pectoralis
major myogenous flap.

Postop care : Inpatient admission for 5–10 d; monitored bed or ICU for
tracheostomy care or following more extensive pharyngeal reconstruction; a
cuffed tracheostomy tube (and a temporary tracheotomy) will usually be
required for partial laryngectomy patients or if the patient will require postop
mechanical ventilation. A shorter tracheostomy tube following a TL will be
needed if there is significant peristomal edema or if mechanical ventilation is
required. General and drain management is similar to a neck dissection.

Usual preop diagnosis: Cancer of larynx; intractable aspiration with

resultant pneumonia unresponsive to other techniques

See preop considerations for Neck Dissection, p. 220.

Anesthetic technique: GETA. Although tracheostomy is universally

performed in TL patients, smooth emergence is still important 2° delicate
suture lines. Full muscle relaxation is essential. Moderate ↓ BP (see
Introduction, p. 178) is desirable, but may be limited by concomitant
cardiovascular disease.

See Postop Considerations for Neck Dissections