Laryngectomy is the removal of the

larynx The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is abo ...

and separation of the airway from the

mouth In animal anatomy, the mouth, also known as the oral cavity, or in Latin cavum oris, is the opening through which many animals take in food and issue vocal sounds. It is also the cavity lying at the upper end of the alimentary canal, bounded on t ...

nose A nose is a protuberance in vertebrates that houses the nostrils, or nares, which receive and expel air for respiration alongside the mouth. Behind the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air next passes th ...

and

esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the ...

. In a total laryngectomy, the entire larynx is removed (including the

vocal folds In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speech ...

hyoid bone The hyoid bone (lingual bone or tongue-bone) () is a horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage. At rest, it lies between the base of the mandible and the third cervical ver ...

epiglottis The epiglottis is a leaf-shaped flap in the throat that prevents food and water from entering the trachea and the lungs. It stays open during breathing, allowing air into the larynx. During swallowing, it closes to prevent aspiration of food int ...

thyroid The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thy ...

and

cricoid cartilage The cricoid cartilage , or simply cricoid (from the Greek ''krikoeides'' meaning "ring-shaped") or cricoid ring, is the only complete ring of cartilage around the trachea. It forms the back part of the voice box and functions as an attachment sit ...

and a few tracheal cartilage rings). In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods (surgeries through the mouth,

radiation In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium. This includes: * ''electromagnetic radiation'', such as radio waves, microwaves, infrared, vi ...

and/or

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs ( chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemother ...

). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery.

History

The first total laryngectomy was performed in 1873 by

Theodor Billroth Christian Albert Theodor Billroth (26 April 18296 February 1894) was a German surgeon and amateur musician. As a surgeon, he is generally regarded as the founding father of modern abdominal surgery. As a musician, he was a close friend and con ...

. The patient was a 36 year old man with a subglottic squamous cell carcinoma. On November 27, 1873 Billroth performed a partial laryngectomy. Subsequent laryngoscopic examination in mid-December 1873 found tumor recurrence. On December 31, 1873 Billroth performed the first total laryngectomy. The patient recovered, and an artificial larynx was manufactured for him which enabled the patient to speak despite the removal of his vocal cords. Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866, but this patient's larynx was only excised after death. The first artificial larynx was constructed by

Johann Nepomuk Czermak Johann Nepomuk Czermak (17 June 1828 – 16 September 1873) was an Austrian-German physiologist who was a native of Prague. He studied in Prague, Vienna, Breslau and Würzburg. At Breslau he was greatly influenced by the work of physiologist Ja ...

in 1869.

Vincenz Czerny Vincenz Czerny (19 November 1842 – 3 October 1916) was a German Bohemian surgeon whose main contributions were in the fields of oncological and gynecological surgery. Czerny was born in Trutnov, Bohemia, Austro-Hungarian Empire. He initially ...

developed an artificial larynx which he tested in dogs in 1870.

Incidence and prevalence

According to the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the

International Agency for Research on Cancer The International Agency for Research on Cancer (IARC; french: Centre International de Recherche sur le Cancer, CIRC) is an intergovernmental agency forming part of the World Health Organization of the United Nations. Its role is to conduct and ...

, there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer. In 2019 it is estimated that there will be 12,410 new laryngeal cancer cases in the

United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territo ...

, (3.0 per 100,000). The number of new cases decreases every year at a rate of 2.4%, and this is believed to be related to decreased cigarette smoking in the general population. The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate due to the development of less invasive techniques. A study using the National Inpatient Sample found that there were 8,288 total laryngectomy cases performed in the US between 1998 and 2008, and that hospitals performing total laryngectomy decreased by 12.3 per year. As of 2013, one reference estimates that there are 50,000 to 60,000 laryngectomees in the US.

Identification

To determine the severity/spread of the laryngeal cancer and the level of vocal fold function, indirect laryngoscopies using mirrors, endoscopies (rigid or flexible) and/or stroboscopies may be performed. Other methods of visualization using CT scans, MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the

glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), v ...

) can cause an individual's voice to sound hoarse. Examinations are used to determine the tumor classification ( TNM classification) and the stage (1-4) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. Radiation and/or

may also be used.

The airways and ventilation after laryngectomy

The anatomy and physiology of the airways change after laryngectomy. After a total laryngectomy, the individual breathes through a stoma where the tracheostomy has created an opening in the neck. There is no longer a connection between the trachea and the mouth and nose. These individuals are termed total neck breathers. After a partial laryngectomy, the individual breathes mainly through the stoma, but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose. They are therefore termed partial neck breathers. The extent of breathing through the upper airways in these individuals varies and a tracheostomy tube is present in many of them. Ventilation and resuscitation of total and partial neck breathers is performed through the stoma. However, for these individuals, the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation.

Complications

Different types of complications can follow total laryngectomy. The most frequent postoperative complication is pharyngocutaneous

fistula A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...

(PCF), characterized by an abnormal opening between the

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its str ...

and the

trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends from the l ...

or the skin resulting in the leaking of saliva outside of the throat. This complication, which requires feeding to be completed via

nasogastric tube Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the oesophagus, and down into the stomach. Orogastric intubation is a similar process involving the insert ...

, increases morbidity, length of hospitalization, and level of discomfort, and may delay rehabilitation. Up to 29% of persons who undergo total laryngectomy will be affected by PCF. Various factors have been associated with an increased risk of experiencing this type of complication. These factors include

anaemia Anemia or anaemia ( British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, ...

, hypoalbuminaemia, poor nutrition,

hepatic The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...

and

renal The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; bloo ...

dysfunction, preoperative tracheostomy, smoking, alcohol use, older age,

chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...

and localization and stage of cancer. However, the installation of a free-flap has been shown to significantly reduce the risks of PCF. Other complications such as wound infection, dehiscence and

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dig ...

, bleeding, pharyngeal and stomal

stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture' ...

, and

dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or liq ...

have also been reported in fewer cases.

Rehabilitation

Voice restoration

Total laryngectomy results in the removal of the

, an organ essential for natural sound production. The loss of voice and of normal and efficient verbal communication is a negative consequence associated with this type of surgery and can have significant impacts on the quality of life of these individuals. Voice rehabilitation is an important component of the recovery process following the surgery. Technological and scientific advances over the years have led to the development of different techniques and devices specialized in voice restoration. The desired method of voice restoration should be selected based on each individual’s abilities, needs, and lifestyle. Factors that affect success and candidacy for any chosen voice restoration method could include: cognitive ability, individual physiology, motivation, physical ability, and pre-existing medical conditions. Pre and post-operative sessions with a speech-language pathologist (SLP) are often part of the treatment plan for people undergoing a total laryngectomy. Pre-operative sessions would likely involve counselling on the function of the

, the options for post-op voice restoration, and managing expectations for outcomes and rehabilitation. Post-operative therapy sessions with an SLP would aim to help individuals learn to vocalize and care for their new voice prosthesis as well as refine their use of speech depending on the chosen method of voice restoration.

Available methods for voice restoration: * For tracheoesophageal speech, a voice prosthesis is placed in the tracheo-oesophageal puncture (TEP) created by the surgeon. The voice prosthesis is a one-way air valve that allows air to pass from the lungs/trachea to the esophagus when the stoma is covered, where the redirected air vibrates the esophageal tissue to produce a hoarse voice. The TEP and voice prosthesis combination allows individuals post-laryngectomy to have a voice to speak, while also avoiding aspiration of saliva, food or other liquids. Tracheoesophageal speech is considered more natural sounding than esophageal speech, but voice quality differs from person to person. * For speech using an

electrolarynx An electrolarynx, sometimes referred to as a "throat back", is a medical device about the size of a small electric razor used to produce clearer speech by those people who have lost their voice box, usually due to cancer of the larynx. The most ...

, an electrolarynx is an external device that is placed against the neck and creates vibration that the speaker then articulates. The sound has been characterized as mechanical and robotic. * For esophageal speech, the speaker pushes air into the esophagus and then pushes it back up, articulating speech sounds to speak. This method is time-consuming and difficult to learn and is less frequently used by laryngectomees. * For larynx transplants, a larynx from a cadaver donor is used as a replacement. This option is the most recent and is still very rare. For individuals using tracheoesophageal or esophageal speech,

botulinum toxin Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromu ...

may be injected to improve voice quality when spasms or increased tone (hypertonicity) is present at the level of the pharyngoesophageal segment muscles. The amount of botulinum toxin administered unilaterally into two or three sites along the pharyngoesophageal segment varies from 15 to 100 units per injection. Positive voice improvements are possible after a single injection, however outcomes are variable. Dosages may need to be re-administered (individual-dependent) after a number of months, where effective results are expected to last for about 6 to 9 months.

Oral feeding

The laryngectomy surgery results in anatomical and physiological changes in the larynx and surrounding structures. Consequently,

swallowing Swallowing, sometimes called deglutition in scientific contexts, is the process in the human or animal body that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is ...

function can undergo changes as well, compromising the patient's oral feeding ability and nutrition. Patients may experience distress, frustration, and reluctance to eat out due to swallowing difficulties. Despite the high prevalence of post-operative swallowing difficulties in the first days following the laryngectomy, most patients recover swallowing function within 3 months. Laryngectomy patients do not aspirate due to the structural changes in the larynx, but they may experience difficulty swallowing solid food. They may also experience changes in appetite due to a significant loss in their senses of taste and smell. In order to prevent the development of pharyngocutaneous fistula, it is common practice to reintroduce oral feeding as of the seventh to tenth day post-surgery, although the ideal timeline remains controversial. Pharyngocutaneous fistula typically develops before the reintroduction of oral feeding, as the pH level and presence of

amylase An amylase () is an enzyme that catalyses the hydrolysis of starch (Latin ') into sugars. Amylase is present in the saliva of humans and some other mammals, where it begins the chemical process of digestion. Foods that contain large amount ...

in saliva is more harmful to tissues than other liquids or food. Whether the reintroduction of oral feeding at an earlier post-operative date decreases the risk of fistula remains unclear. However, early oral feeding (within 7 days of the operation) can be conducive to reduced length of hospital stay and earlier discharge from the hospital, entailing a decrease in costs and psychological distress.

Smell and taste rehabilitation

A total laryngectomy causes the separation of the upper air respiratory tract ( pharyn), nose, mouth) and lower air respiratory tract (lungs, lower

). Breathing is no longer done through the nose (nasal airflow), which causes a loss/decrease of the sense of smell, leading to a decrease in the sense of taste. The Nasal Airflow Inducing Manoeuvre (NAIM), also known as the "Polite Yawning" manoeuvre, was created in 2000 and is widely accepted and used by speech-language pathologists in the

Netherlands ) , anthem = ( en, "William of Nassau") , image_map = , map_caption = , subdivision_type = Sovereign state , subdivision_name = Kingdom of the Netherlands , established_title = Before independence , established_date = Spanish Neth ...

, while also becoming more widely used in Europe. This technique consists of increasing the space in the

oral cavity In animal anatomy, the mouth, also known as the oral cavity, or in Latin cavum oris, is the opening through which many animals take in food and issue vocal sounds. It is also the cavity lying at the upper end of the alimentary canal, bounded on t ...

while keeping the lips closed, simulating a yawn with a closed mouth by lowering the jaw, tongue and floor of the mouth. This causes a negative pressure in the oral cavity, leading to nasal airflow. The NAIM has been recognized as an effective rehabilitation technique to improve the sense of smell.

Quality of life

People with a partial laryngectomy are more likely to have a higher

quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...

than individuals with a total laryngectomy. People having undergone total laryngectomy have been found to be more prone to depression and anxiety, and often experience a decrease in the quality of their social life and physical health. Voice quality, swallowing and reflux are affected in both types, with the sense of smell and taste ( hyposnia/

anosmia Anosmia, also known as smell blindness, is the loss of the ability to detect one or more smells. Anosmia may be temporary or permanent. It differs from hyposmia, which is a decreased sensitivity to some or all smells. Anosmia can be due to a num ...

and

dysgeusia Dysgeusia, also known as parageusia, is a distortion of the sense of taste. Dysgeusia is also often associated with ageusia, which is the complete lack of taste, and hypogeusia, which is a decrease in taste sensitivity. An alteration in taste o ...

) also being affected in total laryngectomies (a complaint which is given very little attention by medical professionals). Partial or total laryngectomy can lead to swallowing difficulties (known as ''

''). Dysphagia can have a significant effect on some patients' quality of life following surgery. Dysphagia poses challenges in eating and social involvement, often causing patients to experience increased levels of distress. This effect holds true even after the acute phase of recovery. More than half of patients who received total laryngectomy were found to experience restrictions in their food intake, specifically in what they can eat and how they can eat it. The diet limitations imposed by dysphagia can negatively impact a patient's quality of life, as it can be perceived as a form of participation restriction. Accordingly, these perceived restrictions are more commonly experienced by dysphasic laryngectomy patients compared to non-dysphasic laryngectomy patients. Therefore, it is important to consider dysphagia in short and long-term outcomes post-laryngectomy in order for patients to uphold a higher quality of life. Often, speech-language pathologists are involved in the process of prioritizing swallowing outcomes. People receiving voice rehabilitation report best voice quality and overall quality of life when using a voice prosthesis as compared to esophageal speech or

. Furthermore, individuals going through non-surgical therapy report a higher quality of life than those having undergone a total laryngectomy. Lastly, it is much more difficult for those using

alaryngeal speech Alaryngeal speech is speech using an airstream mechanism that uses features other than the glottis to create voicing. There are three types: esophageal, buccal, and pharyngeal speech. Each of these uses an alternative method of creating phonat ...

to vary their pitch, which particularly affects the social functioning of those speaking a

tonal language Tone is the use of pitch in language to distinguish lexical or grammatical meaning – that is, to distinguish or to inflect words. All verbal languages use pitch to express emotional and other paralinguistic information and to convey emp ...

References

{{Respiratory system surgeries and other procedures Surgical oncology Surgical removal procedures Larynx surgery