Indications and Contraindications for total laryngectomy

Total laryngectomy is a surgical procedure mostly done for malignancies involving the larynx.

In this surgery, the entire larynx (voice box) is removed by resecting the trachea and bringing out the lower stump as a respiratory opening in the anterior part of the neck (permanent tracheostomy) and thereby closing off the air passages to the mouth and nose.

The patient permanently loses his/her natural voice as well as the sensation of smell.

This article just explains the indications and contraindications of a total laryngectomy procedure. The evolution of total laryngectomy, surgical steps of laryngectomy, complications, and rehabilitation after total laryngectomy are described separately.

Indications for total laryngectomy

The indications for total laryngectomy are as described below.

1. Advanced tumors of the larynx with cartilage destruction and anterior extra laryngeal spread, which often manifests initially with laryngeal dysfunction that includes vocal cord paralysis; airway obstruction; or severe aspiration. These patients are not good candidates for organ preservation, because the organ already has been damaged and will not likely function even if it can be preserved anatomically. Hence total laryngectomy is recommended in them.
2. Tumor involvement of posterior commissure or bilateral arytenoid/cricoarytenoid joint, as is sometimes seen in advanced supraglottic tumors.
3. Circumferential submucosal disease with or without bilateral vocal cord paralysis.
4. Subglottic extension with an extensive invasion of the cricoid cartilage.
5. Radiotherapy or chemoradiation failures, including those who have also had partial laryngectomy failure.
6. Completion laryngectomy for failed conservation or extensive endoscopic surgery.
7. Hypopharyngeal tumors that originate at or spread to the postcricoid mucosa and advanced piriform sinus cancers.
8. Massive neck metastases and thyroid tumors (usually recurrent) that invade both sides of the larynx from outside the laryngeal skeleton.
9. Advanced tumors of certain histologic types that are incurable by endoscopic resection, chemotherapy, or radiotherapy (e.g., adenocarcinoma, spindle cell carcinoma, soft tissue sarcomas, minor salivary gland tumors, large cell neuroendocrine tumors) and chondrosarcomas of the thyroid cartilage.
10. Extensive pharyngeal or tongue-base resections in patients who are at high risk for aspiration problems.
11. Radiation necrosis of the larynx, despite tumor control, that is unresponsive to adequate antibiotic and hyperbaric oxygen management (this condition can be painful and also predisposes patients to aspiration, and the tumor is often found when total laryngectomy is performed).
12. Severe irreversible aspiration, with the laryngectomy used for complete separation of the air and food passages (this indication should be rare, considering the variety of other separation or closure procedures available).
13. Severe laryngeal trauma that doesn’t allow functional reconstruction of the organ.
14. Laryngeal stenosis is insurmountable by other types of surgery.
15. Chronic inflammatory disease of larynx accompanied by liquefaction necrosis.
16. Recurrent laryngeal papillomatosis with an increased risk of tracheal invasion.

Contraindications of total larngectomy

Following are some of the contraindications for total laryngectomy.

1. The presence of incurable synchronous tumors
2. The presence of incurable distant metastases
3. Severe systemic general disease or poor general condition
4. Tumour invading the profound parts of the tongue.
5. The tumor that exceeds the prevertebral fascia
6. Tumour or metastasis that encases the common or internal carotid artery.

Total laryngectomy Unedited Video

References

1. Moretti A, Croce A. Total laryngectomy: from hands of the general surgeon to the otolaryngologist. Acta otorhinolaryngologica Italica: organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 2000 Feb;20(1):16-22.
2. Mohebati A, Shah JP. Total laryngectomy. Otorhinolaryngology Clinics An International Journal. 2010 Sep 25;2(3):207-14.
3. CEACHIR O, HAINAROSIE R, ZAINEA V. Total laryngectomy–past, present, future. Maedica. 2014 Jun;9(2):210.
4. Open access Atlas of Otolaryngology, Head & Neck Operative Surgery, Total Laryngectomy, Johan Fagan
5. Head and Neck Surgery and Oncology, Jatin Shah, 3th Edition
6. Scott Brown Otorhinolaryngology, Head & Neck Surgery, 7th edition
7. Cummings Otolaryngology Head and Neck Surgery, 6th edition