Management of Ca larynx

1. By :
Dr. Trilok Guleria
Junior Resident,
ENT - HNS

2. Epidemiology
 2.63% of all the body cancers in India
 40- 70 years
 M:F = 10:1
 Female incidence increasing

3. Risk factors
 Smoking tobacco- implicated as the prime factor
- only 1% of laryngeal ca occur in non smokers
 Alcohol - synergistic with tobacco
 Human Papilloma Virus
 Genetic Susceptibility
 Gastroesophageal reflux

4. Risk factors
 Diets lacking green leafy vegetables, fruits & fibre
 Diets rich in salt preserved meats and dietary fats
 Occupational
Metal/plastic workers
Exposure to paint
Exposure to diesel and gasoline fumes
Exposure to asbestos
Exposure to radiation

5. Anatomy
SITE SUBSITE
Supraglottis Suprahyoid
epiglottis
Infrahyoid epiglottis
Aryepiglottic folds
( laryngeal surface )
Arytenoids
Ventricular bands
(false vocal cords)
Glottis True vocal cords+
ant and post.
Commissure
Subglottis No subsites

6. Embryology
 Supraglottic larynx derived from buccopharyngeal
primordium which develop from 3rd & 4th arch
 Glottis & subglottis are derived from tracheobronchial
primordium from 6th arch
 Different embryological derivations creates natural
barriers & restrict laryngeal compartments in early
stages cancer
 Form basis of laryngeal conservation surgery

7. Barriers to spread
 Hyoid bone
 Laryngeal cartilages
 Hyoepiglottic ligament
 Thyrohyoid membrane
 Ventricle
 Anterior commisure
 Cricothyroid membrane
 Conus elasticus
 Quadrangular membrane

8. Subtypes
 Supraglottic Cancer
 Glottic Cancer
 Subglottic Cancer
Transglottic tumors
McGravan (1961)
 Tumors crossing ventricle in vertical axis
 Usually initiate as supraglottic or glottic cancers
 Tumor can become transglottic in 4 ways :-
 Crossing ventricle directly
 Crossing at anterior commissure
 Through paraglottic space
 Spreading along arytenoid cartilage posterior to ventricle

9. Pathology
 85 - 95% Squamous Cell Carcinoma
 Variations :
 Verrucous carcinoma
 Spindle cell carcinoma
 Basaloid SCC
 Papillary SCC
 Other types of carcinoma:
 Neuroendocrine carcinoma
 Lymphepitheliomatous carcinoma
 Adenocarcinoma
 Chondrosarcomas
 Lymphomas
 Adenoid cystic (trachea more than subglottis)

10. Glottic cancer
 Spread -> tend to stay confined
vocal folds
 Anteriorly- anterior commisure
 Posteriorly- vocal process of
arytenoid
 Upward- ventricle and false cord
 Downward- Subglottic region

12. Glottic Cancer
 Hoarseness of voice is an early sign
 Even Tis may produce significant voice change
 Progressive dyspnoea & stridor
 Haemoptysis
 Referred otalgia( via vagal complex ) suggest deep
invasion
 There are no lymphatics in vocal cords and nodal
metastasis are rarely seen unless the disease spreads
beyond the region of membranous cords.
 Good Prognosis : Early presentation and late spread, it
has good prognosis.

13. Supraglottic cancer
 Majority of lesion are seen on
epiglottis, false cord followed by
aryepiglottic fold, in that order
 May spread locally and invade the
adjoining areas (vallecula, base of
tongue and pyriform fossa)
 Preepiglottic space involvement
through foramen in infrahyoid
epiglottis.
 Paraglottic space involvement
through mucosa of the ventricle.

14. Supraglottic Cancer
 Nodal metastases occur early(T1- 20%,T2-35%,T3-50%,T4-65%)
 Upper and middle jugular nodes are often involved
 Symptoms: Often silent,
 Hoarseness is a late symptom
 Foreign body sensation
 Lump in throat / throat pain
 Muffled voice
 Dysphagia
 Referred pain in ear
 Stridor
 Swelling neck
 Bad Prognosis : Due to early spread and late presentation.

15. Supraglottic Ca

16. Subglottic Cancer
 Rare( 1 - 2%)
 Spread: superficially/submucosally to the opposite side or
downwards to the trachea
 May invade Anteriorly cricothyroid membrane, thyroid
gland and muscles of neck
 LN involvement seen in 10-34%
 Symptoms: Stridor is the earliest presentation.
 Hoarseness is a late symptom as upward spread to the vocal
cords is late.
 Hoarseness of voice indicates :
 Spread of disease to undersurface of vocal cords.
 Infiltration of thyroarytenoid muscle.
 Involvement of recurrent laryngeal nerve.

17. Diagnosis Of Laryngeal Cancer
 History :
 Symptomatology of glottic, subglottic, supraglottic is
as explained earlier
Information regarding risk factors, medication &
medical comorbidities such as cardiovascular,
pulmonary, renal disease
 Examination Of Head & Neck :
It is done to find the-
a) Extralaryngeal spread of the disease.
b) Nodal metastasis.

18.  Indirect Laryngoscopy :
It is done to see the-
A) Appearance & site of lesion
B) Vocal Cord Mobility – Fixation of vocal cords indicate deeper
infiltration.
 Direct Laryngoscopy : Gold standard
It is done to see the-
a) Hidden areas of larynx
b) Extent of disease.
c) Punch biopsy/ excision biopsy
 Microlaryngoscopy:
- Laryngoscopy is done under microscope for better visualisation.
-For smaller lesions of vocal cord
- Accurate biopsy specimen can be taken

19.  Chest X Ray – Essential for co-existent lung diseases,
pulmonary metastasis and mediastinal nodes.
 X-ray STN –Extent of lesion of epiglottis ,aryepiglottic,
ventricular & vocal fold . Laryngeal & tracheal airway ,
preepiglottic space involvement can be seen.
 Barium swallow – recommended in advanced laryngeal
cancer – to find involvement of pyriform fossa , pharyngeal
wall & post cricoid area
 Esophagoscopy : Performed to exclude synchronus
primary tumor in esophagus.
 Bronchoscopy : Usually not required if chest imaging is
normal.

20.  CT Scan
To find the site & extent of the tumour, invasion of pre
epiglottic and paraglottic space, destruction of cartilage,
extralaryngeal tissue, prevertebral space, encasement of
carotid and lymph node involvement.
 MRI
Superior to CT in evaluation of cartilage erosion
 PET/CT
Residual
Recurrent

21.  Supravital staining and biopsy:
Toluidine blue is applied to the laryngeal lesion and
then washed and examined. CIS and superficial
carcinomas take up dye while leukoplakia does not and
thus helping in selecting the area for biopsy
 Videostroboscopy
– useful in CIS lesion of vocal cord
- deeper invasion into basement membrane
produce distortion of mucosal wave
- loss of synchrony between vocal cords

22.  Optical coherence tomography
Fibreoptically based
 Perform high resolution subepithelial imaging of tissue
by measuring backreflected infrared light from internal
tissue structure
Useful for diagnosis of hyperplasia, early stage
keratosis of vocal fold
Allow visualization of epithelium, basement
membrane, and lamina propria of vocal cord
Ability to observe integrity of basement membrane help
in detecting early stage carcinoma of vocal cord

23. TNM STAGING
 Staging of disease is very important
 It influences the choice of therapy
 Helps in predicting the overall prognosis
 Provides confirmity amongst clinicians thereby helping
in comparing the efficacy of various forms of therapy.

24. Staging – Primary Tumour
 Tx - Primary tumor cannot be assessed.
 T0 - No evidence of primary tumor.
 Tis - Carcinoma in situ.

25. Supraglottis
 T1 - Tumor limited to one subsite of supraglottis with normal vocal cord
mobility.
 T2 - Tumor invades mucosa of more than one adjacent subsite of
supraglottis or glottis or region outside the supraglottis (e.g., mucosa of
base of tongue, vallecula, medial wall of pyriform sinus) without
fixation of the larynx.
 T3 - Tumor limited to larynx with vocal cord fixation and/or invades
postcricoid area, pre-epiglottic space, paraglottic space .
 T4a - Tumor invades through the thyroid cartilage and/or invades
tissues beyond the larynx (e.g., trachea, soft tissues of neck including
deep extrinsic muscle of the tongue, strap muscles, thyroid, or
esophagus).
 T4b - Tumor invades prevertebral space, encases carotid artery, or
invades mediastinal structures

26. Glottis
 T1 Tumor limited to the vocal cord(s)(may involve anterior or posterior
commissure) with normal mobility.
 T1a Tumor limited to one vocal cord.
 T1b Tumor involves both vocal cords.
 T2 Tumor extends to supraglottis and/or subglottis and/or with
impaired vocal cord mobility.
 T3 Tumor limited to the larynx with vocal cord fixation and/or
invasion of paraglottic space
 T4a Tumor invades through the outer cortex of the thyroid cartilage
and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of
neck including deep extrinsic muscle of the tongue, strap muscles,
thyroid, or esophagus).
 T4b Tumor invades prevertebral space, encases carotid artery, or
invades mediastinal structures

27. Subglottis
 T1: Limited to subglottis
 T2: Extends to vocal cord with normal or impaired mobility
 T3: Limited to larynx with vocal cord fixation
 T4a: Invades cricoid or thyroid cartilage, and/or invades
tissues beyond the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of the tongue, strap
muscles, thyroid, or esophagus).
 T4b: Invades prevertebral space, encases carotid artery, or
invades mediastinal structures

28. • Regional Lymph Nodes (N)
– Nx: regional LN can’t be assessed
– N0: no regional node metastasis
– N1: single ipsilateral node, ≤ 3 cm
– N2a: single ipsilateral node, > 3 cm, ≤ 6 cm
– N2b: multiple ipsilateral nodes, ≤ 6 cm
– N2c: bilateral or contralateral nodes, ≤ 6 cm
– N3: node > 6 cm
• Distant metastasis (M)
– Mx: can’t be assessed
– M0: no distant metastasis
– M1: distant metastasis

29. AJCC Stage Groupings
Stage 0
 Tis, N0, M0
Stage I
 T1, N0, M0
Stage II
 T2, N0, M0
Stage III
 T3, N0, M0
 T1, N1, M0
 T2, N1, M0
 T3, N1, M0
Stage IVA
•T4a, N0, M0
•T4a, N1, M0
•T1, N2, M0
•T2, N2, M0
•T3, N2, M0
•T4a, N2, M0
Stage IVB
•T4b, any N, M0
•Any T, N3, M0
Stage IVC
•Any T, any N, M1

31. Carcinoma in situ
 Is replacement of the full depth of epithelium by
malignant cells, without those transgressing the
basement epithelium
 Tis should be regarded as part of the continuum of
early laryngeal cancer and managed as T1 carcinoma
 High possibilities of recurrent disease suggests holding
back use of radiotherapy for those lesions where
resection would lead to significant functional defcit
and use of surgical technique wherever possible
 Successful management also requires implementation of
tobacco & alcohol cessation strategies, treatment of LPR
when present and vigilant follow up

33. T1 Glottic ca
Mid cord
• RT
• Endoscopic laser
resection
• Laryngofissure
and cordectomy
Ant commissure/
Cord + AC
• Frontal
/frontolateral
laryngectomy
• Endoscopic laser
resection
• RT
Posterior cord
• Endoscopic laser
resection
• Laryngofissure &
cordectomy
• RT

34. T1 Glottic Carcinoma
Mid – cord
Radiation therapy - Offer best quality of voice
Treatment of choice in professional voice users
Surgery :- Young patients
Veruccous cancer
Pt desire short treatment time
Willing to have some voice compromise
Transoral endoscopic CO2 laser cordectomy - TOC
- > 90% cure rates
Laryngofissure & Cordectomy - Rarely used now
- Only done when endoscopic exposure is poor

35. (Anterior commissure lesion /Cord lesion extending to ant
commissure )
 Vertical Partial laryngectomy – Frontal/ frontolateral
- Std accepted surgical treatment
- > 90% cure rates
- Hospitalisation, temporary tracheostomy & NG tube feeding
 Transoral endoscopic CO2 laser resection
- Day-care procedure
- Higher recurrence due to unsatisfactory exposure of this region
Radiation therapy
- Also have higher failure rate
– Difficulty in delivery of adequate dose to this region
- Undetected cartilage erosion- lack of inner perichondrium
T1 Glottic ca

36. T1 Glottic ca
(Cord lesion extending posteriorly vocal process of
arytenoid )
 Transoral endoscopic CO2 laser resection
- Surgical treatment of choice
 Laryngofissure & Cordectomy
 Radiation therapy
-Like ant comm. lesion post placed cord lesion also have higher failure
rate

37. Mid cord glotto
-supraglotic
• RT
• Endoscopic laser
resection
• VPL/SCPL-CHEP
Anterior glotto
supraglottic
• SCPL-CHEP
• Endoscopic laser
resection
• RT
Posterior glotto
supraglottic
• Endoscopic laser
resection
• Extended
hemilaryngectomy
• SCPL-CHEP
• RT
Glotto
subglottic
• VPL/SCPL-CHEP
• Endoscopic laser
resection
• RT
T2 Glottic carcinoma (freely mobile cords)

38. T2 Glottic carcinoma (freely mobile cords)
 Surgery is TOC
 Vertical Partial laryngectomy – Frontal/ frontolateral /Extended
hemilaryngectomy
- better quality of voice than SCPL with CHEP
- better tolerated by frail & COPD patients
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy
- offer superior cure rates with T2 glottic cancer
- poor quality of voice than VPL
- post operative aspiration problems
- best to reserve this procedure for very fit pts

39.  Transoral endoscopic CO2 laser resection
- best only in experienced hands
- satisfactory endoscopic exposure is most important
- well tolerated by elderly & frail pts
 Radiation therapy
- preferred only in mid cord lesion with extention to supraglottis
- good voice results

40. • VPL(hemilarynx)
• SCPL-CHEP
• Chemo RT
• RT
Lateralised lesion
• SCPL-CHEP
• VPL(fronto lateral)
• CRT
• RT
Lesion across ant
commissure
T2 Glottic carcinoma (impaired cord mobility)

41. T2 Glottic carcinoma (impaired cord mobility)
Open partial laryngectomy is treatment of choice
 VPL ( Hemilaryngectomy ) - lateralised lesion
(Frontolateral ) – lesion across ant comm.
– safer in elderly individuals
 SCPL-CHEP – reserve for very fit pts
 Chemo radiation – TOC - unfit/unwilling for surgery
Neoadjuvant CT +RT in responders
 Radiation alone – reserve for
- unfit/unwilling for surgery
- unlikely to able tolerate chemoradiation

42. T3 glottic ca
(cord fixed arytenoid mobile)
• SCPL-CHEP
• Concurrent CTRT
Performance
status good
• VPL
• Neoadjuvant CTRT
• RT
Performance
status poor

43. T3 glottic ca
(Fixed hemilarynx)
• Concurrent CTRT
• Near total laryngectomy(lat disease)
• Total laryngectomy
Performance
status good
• Total laryngectomy
• Neo adjuvant CT RT
Performance
status poor

44. T4 Glottic Carcinoma
(T4a resectable lesion )
 Best treated by total laryngectomy combined with neck
dissection if lymph nodes are palpable followed by post
operative RT.
 Near total laryngectomy > in well lateralised lesion
with uninvolved arytenoid region and2/3 of
contralateral cord

46. Supraglottic Carcinoma
T1-T2 Supraglottic Carcinoma
Transoral endoscopic CO2 laser resection
- treatment of choice
If endoscopic laser resection is not feasible
 Radiotherapy
-lesion at marginal zone
- T1 & small T2 lesions
- smaller lesion < 6cm –response rate – 80%
- minimal neck disease
- poor pulmonary reserve

47.  Supraglottic laryngectomy/SCPL-CHEP
- infrahyoid supraglottic cancer
- T2 lesion
- bulky nodal disease
- young patients
- fit patients; no COPD

48. T3 Supraglottic Carcinoma
Treatment options in order of preference
 Chemo – radiotherapy
 Endoscopic CO2 laser resection if the pre epiglottic space invasion is
limited
 Supraglottic partial laryngectomy (for small volume disease) and
SCPL—CHEP(if the growth is bulky or encroaching the glottis)
-in patients who are fit and have no significant chest problems.
 Near-total laryngectomy - lateralised lesion.
Total Laryngectomy as a last resort
- if none of the above is feasible

49. T4 Supraglottic Carcinoma
Total laryngectomy + post op RT
Near-total laryngectomy + post op RT ( for lateralised disease )

51. Subglottic carcinoma
T1 & T2 Subglottic carcinoma
Radiotherapy alone
-treatment of choice with preservation of voice
Surgery is reserved for failure of radiation therapy or for
patients who cannot be easily assessed for radiation therapy.
T3 & T4 Subglottic carcinoma
Total laryngectomy and post-op. RT
(radiation should also include superior mediastinum)
Radiotherapy alone
( who are unfit for surgery )

53.  Main predictor of survival in squamous cell carcinoma
is the presence, number and extracapsular spread of
lymph node metastases
 Management of neck
Depends on site of primary
T stage of primary
Clinical N stage
Choice of treatment modality for the primary

54. N0
Elective neck dissection is commonly performed for
management of node negative T2-4 supraglottic,
T3-4 glottic cancer
Elective neck irradiation

55. N+
 Comprehensive neck dissection is procedure of choice
followed by postoperative radiotherapy or
chemotherapy
 RT- Neck dissection prior to radiation or post
radiation salvage surgery for residual neck nodes

57.  Radiation therapy :Cure rates with radiation therapy
ranges from 80% -95%.
 Conventional radiotherapy consists of :
 Once daily treatment delivering 2 Gray/day.
 5 doses/week to total dose of 70 Gy over period of 7 weeks.
 Attempts to improve outcome of RT schedules focus
upon modification of radiotherapy fractionation
schedules.
 Two altered fractionation schedule:
• Hyper fractionation
• Accelerated fractionation

58. Hyper fractionation
 Delivers a higher total dose over the same 7 weeks
treatment period using multiple smaller fractions of
radiotherapy per day.
 The lower dose per fraction results in preferential sparing of
late responding tissues thus reducing the incidence of late
normal tissue effects.
Accelerated fractionation
 Delivers the same total dose over a shorter overall treatment
time
 Aimed at overcoming treatment failures caused by tumour
cell repopulation during longer courses of treatment.

59. Concurrent chemo-radiotherapy
- 66-70 Grays of radiation
-Concurrently Cisplatin 100mg/m2 is given on day
1,22, & 43
- Claims highest cure rates
-Carries high toxicity

60. Neoadjuvant chemotherapy
- 2 cycles of Cisplatin(80-120mg/m2) + 5- FU(10-
15mg/m2) given within 3 weeks interval
- Only those with > 50% tumour regression will receive
radiation therapy

62. Transoral Laser Surgery
Inclusion Criteria
 Complete endoscopic visualization of the carcinoma
 Tumor extension to the contralateral VC < 3mm
 Absence of arytenoid involvement (except vocal process)
 Subglottic extension < 5mm
 Supraglottic extension no further than lateral extension of ventricle
 Mobile vocal folds
 No cartilage involvement
 Strict correlation between recurrent lesion and 1° lesion before
radiation.

63. Advantages
 Good voice quality
 Good swallowing
 Lower complications rates
 Lower cost
 Shorter hospitalization
 Tracheostomy and NG tubes not routinely required

64. Complications
Complication rates are <5% and from most to least
common include
 Granuloma formation
 Laryngeal edema
 Laryngeal stenosis
 Chondronecrosis

65. Partial laryngectomy
Aim
 Is to perform oncological clearance of tumour with as much
preservation of normal voicing and swallowing as possible
Emphasis should be given to
 Survival is more important than voice
 Partial laryngectomies require experience and training
 Patient must have good pulmonary reserve
 More radical PL should be avoided in patients who have
been previously irradiated

66. Laryngofissure with Cordectomy
 Now replaced by CO2 laser cordectomy
 Resection of the entire cord up to the vocal process of the
arytenoid
Indications
 Mid cord lesion
 T1 lesion
 No impairment of vocal cord mobility
 No anterior commissure involvement
 Resultant mucosal defect left to heal by granulation
 Tracheostomy usually closed in a week
 Procedure is well tolerated as doesn’t cause aspiration
 Neither disturb nerve supply nor pharyngeal musculature
 Cure rate 84-98 %

67. Vertical Partial Laryngectomy
 Frontolateral laryngectomy- Extends cordectomy to take
in that part of the thyroid cartilage into which the anterior commissure
inserts
 Frontal laryngectomy- Removes this region together with part
of both cords
 Hemilaryngectomy-Removes a vertical block of larynx to
include one cord and the anterior two-thirds of the ipsilateral thyroid
cartilage.
 Extended Hemilaryngectomy- Hemilaryngectomy plus
arytenoid

68. Vertical Partial Laryngectomy

69. Vertical Partial Laryngectomy
Removal of:
 One vocal fold - from ant. commissure to vocal process
 ½ of opposite vocal fold may also be removed if involved
 Ipsilateral false vocal cord
 Ventricle
 Paraglottic space (and overlying thyroid cartilage)
 Portions of subglottic mucosa

70. Vertical Partial Laryngectomy: Contraindications
 Large T3 or any T4 lesion
 More than 1/3 rd of contralateral VC.
 Interarytenoid or cricoarytenoid joint involvement
 Bilateral arytenoid cartilage involvement or bilaterally diminished vocal
cord mobility
 Thyroid cartilage penetration
 Subglottic extension exceeding 10mm at the anterior commissure or
5mm at the vocal process of the arytenoid
 Poor pulmonary function

71. Vertical Partial Laryngectomy: Complications
Early - generally tracheostomy related
 Infection
 Aspiration and dysphonia (should not persist for > 3 weeks)
Late
 Aspiration
 Chondritis
 Laryngeal stenosis (Must rule out local recurrence)
 Severe hoarseness
 Granulation tissue (CO2 laser and keel)
 Tumor recurrence

72. Supracricoid Laryngectomy with
Cricohyoidoepiglottopexy
Removal of:
 Entire thyroid cartilage
 Bilateral true and false vocal cords
 Ventricle
 Paraglottic spaces
 Epiglottis ( lower portion )
 One arytenoid (may spare both if not involved)
- At least one arytenoid must be spared to preserve
phonation and sphincter functions

73. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction using
 Hyoid bone
 Cricoid
 Tongue
 Cricohyoidopexy is done 3 suture
of 1-0 vicryl
 Temporary tracheostomy tube
and feeding tube is required.

74. Supracricoid Laryngectomy: Contraindications
 Infiltration of both aryntenoid cartilages
 Infiltration of cricoarytenoid joint or inter-arytenoid region
 Subglottic extension >1cm below the vocal fold
 Extension to the vallecula
 Major preepiglottic space invasion
 Hyoid bone invasion
 Invasion of outer perchondrium of thyroid cartilage
 Extra-laryngeal spread

75. Supracricoid Laryngectomy: Complications
 Swallowing disorders are the most common in the short
term
 Voice quality is hoarse, rough, breathy but with acceptable
intelligibility.
 Aspiration Pneumonia is the most frequent complication
(17.5%)
 Neo-laryngeal edema

76. Supraglottic Partial Laryngectomy
Parts removed
 Epiglottis and Pre-epiglottic
space
 Hyoid bone
 Thyrohyoid membrane
 Upper half of thyroid
cartilage preserving external
perichondrium
 Supraglottic mucosa

77. Supraglottic Partial Laryngectomy
 Reconstruction is done by approximating base tongue to
lower half of thyoid cartilage
 Temporary tracheostomy is required.
 Bilateral selective lymph node dissection is carried out at
the same time
 It is important to identify and preserve internal and external
branches of superior laryngeal nerve

78. Three- quarter laryngectomy
 Operation popularised by Biller & Lawson
 Three- quarter laryngectomy combining supraglottic
laryngectomy with vertical hemilaryngectomy on the
side of the tumour
Indications
 Supraglottic cancer which involve an arytenoid &/or
vocal cord on one side only
 Tumour should be no longer than 2cm in maximum
diameter
 Should not extend in subglottis

79. Near total laryngectomy
 Described by Pearson
 Technically complex procedure to create a physiological
voice shunt based on mobile arytenoid
 No significant gains over total larygectomy
INDICATIONS:
 T3/T4 laterlised transglottic lesions with no extension to
arytenoids
 T3/T4 laterlised lesions of Pyriform Sinus with involvement
of apex and causing fixity of hemilarynx
 Interarytenoid , retroarytenoid & postcricoid region must be
free.

80. Removal of
• Strap ms
• I/L thyroid crtilage
• Thyroid lobe
• I/L cricoid cartilage ring
• Upper tracheal ring
• Preepiglottic space
• Epiglottis
• Hyoid
• I/L VC with involved C/L VC

81. Total Laryngectomy
Mainstay of treatment
for advanced laryngeal
cancer
Fistly performed by
Billroth in 1870
Curative as well as
palliative.

82. Indications
 Advanced laryngeal malignancies with extensive cartilage
destruction and extra laryneal spread
 Involvement of posterior commissure / both arytenoids
 Circumferential submucosal disease – with / without vocal fold
paralysis
 Subglottic extension to involve cricoid cartilage
 Completion procedure after failed partial laryngectomy /
irradiation
 Hypopharyngeal tumors originating / spreading to post cricoid
area
 Radiation necrosis of larynx unresponsive to antibiotics /
hyperbaric oxygen therapy
 Severe aspiration following partial / near total laryngectomy
 Massive nodal metastasis

83. Selection criteria
● Pt should be fit for general anaesthesia
● Pt should be motivated for post surgical life
● Positive biopsy
● Screening for metastasis

84. Gluck Sorenson incision
● “U” shaped
● Stoma is incorporated into the incision
● Vertical Limb situated just medial to medial border of
sternomastoid muscle
● Highest limit is the mastoid process on both sides
● Horizontal limb encircles tracheostome

85. Flap elevation
 Flap is elevated in the subplatysmal
plane and stitched out of the way
Medial border of sternomastoid
identified on each side
General investing layer of cervical
fascia is incised vertically from the
hyoid bone above, to the clavicle
below
Omohyoid muscle is divided at this
stage
This enables entry into the loose
areolar compartment of neck

86. Division of strap muscles
● Muscles are divided
close to their sternal
margins
● Division of strap
muscles exposes
thyroid gland

87. Thyroid
● Total / hemithyroidectomy
● Massive midline / bilateral tumors – Total
thyroidectomy preferred
● Unilateral laryngeal tumors – Hemithyroidectomy
is preferred

88. Suprahyoid dissection
● Hyoid bone is skeletonized
● Mylohoid, geniohyoid, digastric sling and hyoglossus
separated from hyoid from medial to lateral
● Pharynx is entered and epiglottis is delivered into the
neck

89. Skeletonization of larynx
● Posterior border of thyroid cartilage is rotated
anteriorly
● Constrictor muscles released from superior and
inferior cornu by sharp dissection

90. Larynx removal
● From above downwards
● Epiglottis is held with a forceps and pulled forwards
● Pharyngeal mucosa cut laterally with scissors on both
sides of epiglottis aiming towards the superior cornua
of thyroid cartilage
● Constrictor muscles are divided along the posterior
edge of thyroid cartilage
● Larynx separated by incising the tracheal rings
(between 1st and 2nd )

91. Pharyngeal closure
● Insert & secure
nasogastric tube
● 3-0 vicryl is used
● Continous,
interlocking
extramucosal
connel suture
● Pharyngeal closure
can be reinforced
using cervical fascia
and muscle layers
A - Closure of pharynx with detail of suturing technique
B - T-closure C - Vertical closure D - Horizontal closure.

92. Tracheostoma
 Permanent tracheostoma created with pie crust sutures
after bevelling the trachea
 Skin flap are walked medially to ensure adequate
stomal diameter by taking wider bites of skin than of
trachea with each suture
 This technique pulls skin over the tracheal edge to cover
cartilage.

93. Skin flap closure
● Skin flap is
repositioned
● Flap is sutured after
anchoring the
tracheostome
● Suction drain is placed
in the neck to prevent
hematoma formation
that could compromise
the flap

94. Complications
● Hematoma
● Skin flap infection
● Pharyngocutaneous fistula
● Flap necrosis
● Tracheal stenosis
● Oesophageal stenosis
● Hypothyroidism / Hypoparathyroidism

95. Pharyngocutaneous fistula
Introduction
 A fistula is an abnormal communication between two
epithelised surfaces.
 Pharyngocutaneous fistula is the most common non-
fatal complication following total laryngectomy.
 It creates a communication between the pharynx and
cervical skin around the surgical incision or, less
frequently, the stoma of the tracheostomy.
 The 1st total laryngectomy was carried out by Billroth
and Gussenbauer on 1870 with development a large
PCF.
 PCF significantly increase morbidity and hospital stay.

96. Etiology
 Local tissue ischemia followed by infection.
 Breakdown of the mucosal closure, resulting in salivary and
secretion leakage into surrounding soft tissue.
 Ultimately cause communication of the salivary tract with
the skin  PCF

97. Predisposing factors
 The cause of PCF is multifactorial.
 The local factors seem to play a major role.
 Nutrition
 Malnutrition is reported to be present in 35 to 50% of all
head and neck caner patients.
 BW loss more than 10% within 6 months is at a greater risk
 A postoperative Hb lower than 10 g/dL has been reported to
increase the risk of PCF.
 Preoperative radiation
 PCF higher in pre-op RT group.

98.  The PCF in peroperative RT patients:
 Appear earlier and close later
 The fistulas were significant larger than non-RT group.
 Longer healing duration
 More frequent progression to advanced muscle necrosis,
soft tissue necrosis, vascular exposure and fistula
expansion
 Often need surgical intervention earlier than
nonirradiated patients
 The extent of surgical defect (pharyngolaryngectomy),
comorbidity (CHF), and nonglottic tumor site carried an
increased risk.
 Histological infiltration of tumor’s surgical margins

99. Signs and symptoms
 The PCF will usually appear 7 to 11 days after surgery.
 First clinical sign: wound erythema with neck and facial
edema/swelling.
 Fever (38.5oC) during the first 48 post-operative hours
 Tenderness of the skin incision.
Wound amylase levels: elevated amylase levels on the
post-op days 3, 4 and 5 can be a significant predicator
of PCF.

100. Prevention
 Perioperative nutritional supplementation
 Pre-op enteral or parenteral alimentation.
 Restore serum protein levels.
 Blood transfusion if needed.
 Perioperative antibiotics :Coverage of aerobic and anaerobic
 Improve surgical technique
 Closure type: T or Y vs linear.
 Watertight two-layer to three-layer of mucosal closure.
 Catgut showed a higher rate of PCF than Vicryl.

101.  Nonclosure of the pharyngeal constrictor muscle :
reduce the pharyngoesophageal pressure  lower
PCF rate.
 Cricopharyngeal myotomy during total
laryngectomy for lower intraluminal pressure.
 Reconstruction with flaps
Patient with significant radiation effect or
extensive mucosal defect may be considered for flap
reconstruction rather than primary closure.
 Gastroesophageal reflux prophylaxis

102.  Early oral feeding:
Traditional standards for initiation of oral feeding: 7
days for nonirradiated patient and delayed for
irradiated patient.
Early oral feeding without NG insertion (even started as
early as 24 hours after surgery) dose not increase the
incidence of PCF.
Early oral feeding can shorten the hospital stay.
The NG tube has also been demonstrated as an
ascending pathway for intestinal flora and to cause
local trauma on the fresh suture with local tissue
damage.

103. Management of PCF
Classification of PCF:
 Small fistula, less than 0.5 cm in diameter.
 Medium fistula, 0.5 to 2.0 cm in diameter.
 Large fistula, more than 2.0 cm in diameter.
Small or medium size fistulas usually close
spontaneously with conservative treatment.

104. Conservative treatment
 Residual tumor should be excluded first.
Principles:
 Salivary diversion
 Silicone salivary bypass tube.
 Complete debridement
 Nutritional support
 Antibiotics
 Pressure dressing for flap down
 Placement of a cuffed tracheostomy tube to prevent aspiration
 Tube feeding with adequate nutrition
 Successful rate: 50% to 80%

105. Surgical repair
 Surgical intervention is reserved after failed by
conservative treatment.
 Timing: Do not operate before 40th postopeartive day.
 Control infection
 Improvement of local flaps
 Method of surgical repair (depending on size of PCF
and local condition).
 Primary closure.
 Rarely possible.
 Small fistula with minimal sounding tissue loss.
 Fibrin glue-reinforced closure.

106. Flap reconstruction:
Adjacent flaps, distant pedicle flaps, free flaps, and
combination of the above.
 Flap reconstruction should not be undertaken until
secondary healing healthy granulation tissue has
occurred.
 Adjacent flaps:
 SCM & trapzius flaps  within RT field  prone to failure.
 Deltopectoral flap: multiple stage.
 Distant pedicle flaps:
 PMMCF: effective for all types of fistula.
 Latissimus dorsi myocutaneous flaps: extensive resection and
additional bulk and skin were needed

107.  Free flaps: Radial forearm and jejunal flaps (circumferential
pharyngoesophageal defect).
 Radial forearm flap in combination with PMMF
 Double paddle myocutaneous flap.
 Due to the reliability and highly successful rate for all types
of fistulaPMMF/PMMCF remains the workhorse flap for
PCF reconstruction.

109. Methods of speech following Laryngectomy
 Esophageal speech
 Electro larynx
 TEP (Tracheo-oesophageal puncture)

111. Oesophageal speech
 Air is swallowed into cervical esophagus
 This swallowed air is expelled out causing vibrations of
pharyngeal mucosa
 These vibrations along with articulations of tongue
cause speech to occur
 The exact vibrating portion of pharynx is the pharyngo-
oesophageal segment
 The vibrating muscles and mucosa of cervical
oesophagus cause speech

112. Pharango-oesophageal segment
 This segment is made up of musculature and mucosa
of lower cervical area (C5-C7 segments).
 Vibration of this segment causes speech in patients
without larynx
 Cricopharyngeal spasm in these pts. Can lead to failure
in developing Oesophageal speech
 Cricopharyngeal myotomy may help these pts. in
developing Oesophageal speech

113. Esophageal speech - Advantages
 Patient’s hands are free
 No additional surgery / prosthesis needed. Hence no
extra cost for the pt.
 Pts. get easily adapted to esophageal voice

114. Esophageal speech - Disadvantages
 Nearly 40% of pts fail to develop esophageal speech
 Quality of voice generated is rather poor
 Patients will be able to speak only in short bursts
 Significant training is necessary
 Loudness / pitch control is difficult

115. Esophageal speech development
causes for failure
 Presence of cricopharyngeal spasm
 Presence of reflux esophagitis
 Thinning of muscle wall in that area
 Denervation of muscle in the PE segment
 Poorly motivated patient

116. Electrolarynx
 These are battery operated vibrating devices
 It is held in the submandibular region
 Muscle contraction and changes in facial muscle
tension causes rudiments of speech
 Initial training to use this equipment should begin even
before surgery

117. Electrolarynx - Types
 External /Neck
 Intraoral type

118. Electrolarynx - External / Neck
 Neck type is commonly
used
 Hypoesthesia of neck
during early phases of
post op period can cause
difficulties
 If neck type cannot be
used intraoral type is the
next preferred one

119. Intraoral artificial larynx
 Intraoral cup should form a
tight seal over the stoma.
There should not be any air
leak
 Oral tip should be placed in
the oral cavity
 Pts exhaled air rattles the
cup placed over the stoma
 Changes in exhaled
pressure can vary the
quality of sound generated

120. Electrolarynx - advantages
 Can be easily learnt
 Immediate communication is possible
 Additional surgery is avoided
 Can be used as a interim measure till the patient
masters the technique of esophageal speech or gets a
TEP inserted

121. Electrolarynx - Disadvantages
 Expensive to maintain
 Speech generated is mechanical in quality
 Difficult while speaking over telephone

122. Types of voice restoration surgeries
 Neoglottic reconstruction
 Shunt technique

123. Neoglottic procedure
 Tracheo hyoidopexy
 This can restore voice function in alaryngeal patients
 Abandoned due to increased incidence of complications
like aspiration

124. Shunt technique
 Developed by Guttmann in 1930
 Involves creation of shunt between trachea and
esophagus
 Lots of modifications of this procedure is available,
Basic aim is to divert air from trachea into the
esophagus

125. Types of shunts
 High trachea-esophageal shunt (Barton)
 Low trachea-esophageal shunt (Stafferi)
 TEP shunts (Guttmann)

126. Causes of failure of shunt procedure
 Aspiration through the fistula
 Closure of the fistula
 To avoid these problems prosthesis was introduced

127. Types of Prosthesis

128. Tracheo-esophaseal puncture
 Was first introduced by Blom and Singer in 1979
 One way silicone valve is introduced via the fistula
 This valve served as one way conduit for air into
esophagus while preventing aspiration
 This prosthesis has two flanges, one enters the
esophagus while the other rests in the trachea. It fits
into the tracheo-esophageal wound

129. Prosthesis used in TEP
 Blom-Singer prosthesis
 Panje button
 Gronningen button
 Provox prosthesis

130. Blom-Singer prosthesis
 Introduced by Blom and Singer in
1979
 Commonly used prosthesis
 This prosthesis acts as one way
valve allowing air to pass into the
esophagus and prevents aspiration
 This prosthesis is shaped like a
duck bill hence known as “Duck bill
prosthesis”
 The duck bill end should reach up
to oesophagus
 It is an indwelling prosthesis can be
left in place for 3 months
 This prosthesis is available in
varying lengths

131. Panje voice button
 Biflanged tube with one way
valve
 Can be inserted through the
fistula created for this
purpose
 It is supplied with an
introducer which makes
insertion simple
 Should be removed and
cleaned every two days
 Can be removed, cleaned
and reinserted by the
patient

132. Gronningen button
 Introduced by
Gronningen in
Netherlands in 1980
 It causes high airflow
resistance delayed speech
in some patients
 Now low air flow
resistance tubes have
been introduced

133. Provox prosthesis
 Indwelling low air
flow pressure
prosthesis
 It has extended life
time. Can last a
couple of yeas if used
properly
 Insertion is easy

134. Types of TEP
 Primary TEP – Performed during total laryngectomy
 Secondary TEP – Performed 6 weeks after surgery

135. Primary - TEP
 Hamaker first performed in 1985
 Primary TEP should be attempted where ever possible
 In this procedure puncture is performed immediately
after laryngectomy and prosthesis is inserted
 Primary tracheo-oesophageal puncture is now accepted
as the optimal method for voice rehabilitation.
 Prosthesis of sufficient length should be used

136. Secondary TEP
 Usually performed 6 weeks following laryngectomy
 This allows pt time to develop esophageal speech
 Area of fistula is identified using rigid esophagoscope
 Prosthesis can be inserted immediatly

137. Advantages of TEP
 Can be performed after laryngectomy / irradiation /
chemotherapy / neck dissection
 Fistula can be used for esophago-gastric feeding during
immediate PO period
 Easily reversible
 Speech develops faster than esophageal speech
 High success rate
 Closely resembles laryngeal speech

138. Disadvantages of TEP
 Pt should manually cover the stoma during voicing
 Good pulmonary reserve is a must
 Additional surgical procedure is needed to introduce it
 Posterior esophageal wall can be breached

139. TRACHEOSTOMAL PROBLEMS
•Patients who have undergone total laryngectomy will have a permanent
tracheostomy with the usual potential problems of increased chest
infections, crusting and stenosis.
•Surgical attention to detail when fashioning the stoma with access to
nebulization and humidification devices can reduce these. The current trend
is to use hands free occlusion for speech and moisture conservation devices
applied directly to the stoma.
Figure - Heat moisture exchange
devices.
(a) Stomvent
(b) Trachenaze Plus with shower
protector
(c) Trachenaze
(d) Provox