Laryngectomy: The silent unknowns and challenges of surgical treatment

Laryngeal cancer accounts for 1% of all new cancers diagnosed in the United States, with 12,290 new cases identified in 2009. More than 90% of laryngeal cancers are classified as squamous cell carcinoma (SCCA). This type of laryngeal cancer manifests 
most often in men in the sixth to seventh decade of life. Although the male to female ratio is approximately 4:1, the incidence of SCCA in females is on the rise because of the increased percentage of women using tobacco. African American men are at higher risk for SCCA than white men (10.3 per 100,000 men compared to 6.1 per 100,000 men, respectively).¹


Squamous cell carcinoma of the larynx is difficult to treat and manage. Health care professionals should be knowledgeable about the unique challenges faced by patients with laryngeal carcinoma in order to provide effective care. In particular, PAs must understand and document the unique anatomic alterations caused by surgical resection. Patients who undergo laryngectomy and their families require increased patience and support while adjusting to the lifestyle changes that result from this procedure.


ETIOLOGY


Tobacco is the number one risk factor for laryngeal carcinoma. Seventy-five percent of patients with head and neck cancer have a tobacco history. When tobacco use is combined with alcohol use, the risk for SCCA increases by more than 50%. The more cigarettes a person smokes, the higher his or her risk for squamous cell carcinoma becomes. Insufficient nutrition, poor dental hygiene, and exposure to carcinogens (asbestos and mustard gas) also increase the risk of laryngeal carcinoma.¹ Current research shows a distinct link between the human papillomavirus (HPV) and SCCA. Recent studies of HPV 16 have indicated that HPV-positive tumors respond more favorably to treatment than HPV-negative tumors. Therefore, HPV 16 is a strong prognostic marker of improved survival in these patients.²


ANATOMY 


Although the main function of the larynx is to enable phonation, it also serves as the divider between the respiratory and digestive tracts. It assists with protecting the airway from food and liquid bolus during swallowing. The larynx can be divided into three levels: the supraglottis, the glottis, and the subglottis. The glottis is made up of the true vocal folds. The supraglottis is the area from the tip of the epiglottis to the ventricles or the undersurface of the false cords. The subglottis extends inferiorly from about 1 cm below the vocal folds to the cricoid cartilage. Approximately 60% of laryngeal tumors are glottic with 35% and 1% being supraglottic and subglottic, respectively.¹


While laryngeal tumors spread via the local lymphatic system, supraglottic tumors tend to spread bilaterally to cervical lymph nodes in zones II and III because of the rich lymphatic drainage system. Glottic SCCA can invade deep tissue; however, since the larynx itself has a limited lymphatic supply, less than 8% of patients with T1 and T2 tumors present with adenopathy. As a glottic tumor increases in size, the risk of lymphatic spread increases by 20% to 40%. Subglottic tumors normally spread superiorly to the glottis to the surrounding structures and sometimes to the paratracheal lymphatics.³


SYMPTOMS


Hoarseness is the most common symptom of laryngeal carcinoma. Patients with voice changes that persist for more than 
3 weeks should be referred to an ears, nose, and throat (ENT) specialist. Other symptoms of SCCA include odynophagia, dysphagia, dyspnea, stridor, and hemoptysis. Any patient with unilateral ear pain of unknown etiology should undergo an ENT evaluation, as this pain may be referred from a tumor or could be a symptom caused by SCCA. Aspiration is common with laryngeal tumors as a result of changes on the vocal cords and should be evaluated with a modified barium swallow and a referral to a speech therapist.


DIAGNOSIS


Patients who have symptoms should be examined by an ENT head and neck surgeon. In the ENT office, flexible laryngoscopy is used to visualize the larynx and determine whether it is normal or contains cancerous lesions (Figure 1). Careful examination of the neck is also done to evaluate for cervical adenopathy. Direct laryngoscopy and surgical biopsy are then scheduled to determine a diagnosis and pathology. A complete diagnostic workup for staging includes CT of the neck with contrast (unless contraindicated), chest radiography, CT of the chest, and positron emission tomography (PET) to evaluate for metastatic lesions. Other testing may be required for patients with multiple medical problems. Laryngeal cancer is then classified into one of a number of stages based on factors such as symptoms or tumor locations. These stages are detailed online at http://www.cancer.gov/cancertopics/pdq/treatment/laryngeal/patient/page2.


TREATMENT


Treatment for laryngeal carcinoma is multidisciplinary and involves radiation oncologists, medical oncologists, and surgeons. This team of health care providers evaluates each patient's age, medical condition, tumor stage, and personal preferences. Using these factors, the team creates an individual treatment plan.


Nonsurgical options Early-stage laryngeal carcinoma is usually managed with radiation. Cure rates for patients with early-stage cancer who undergo radiation are 80% to 85% and up to 90% when chemotherapy is administered simultaneously.⁴ Some patients may be selected to undergo a partial laryngectomy. Patients with advanced disease are generally treated with a combination of radiation, chemotherapy, and surgery. To preserve the larynx, radiation and chemotherapy are usually attempted before surgery. However, this treatment option has multiple side effects and creates a higher risk of postoperative complications caused by the negative effects radiation may have on healing.


Surgical options Total laryngectomy is a treatment option reserved for patients with larger tumors or those whose tumors did not respond to radiation and who have persistent or recurrent disease. During total laryngectomy, the larynx is removed and the lower airway and upper digestive tract are separated; in particular, the trachea and pharynx become detached (Figure 2). The trachea is brought out to the surface of the skin, and a permanent stoma is created. The pharynx is primarily closed or else a flap is used to reconstruct the area. Patients who undergo this procedure will no longer have normal speech once the larynx has been removed. Five-year survival following total laryngectomy is 74% in patients with a T2 glottic lesion and 44% in patients with a T4 lesion.¹ 


POSTOPERATIVE CHALLENGES


Misinterpreting the tracheostomy tube After undergoing laryngectomy, patients may have a tracheostomy tube or laryngectomy tube placed in their stoma to help prevent contracture and allow healing. Health care providers often mistake this implant as a tracheostomy. To avoid confusion, clinicians should make sure to carefully and accurately document the case as a "laryngectomy patient with a tracheostomy tube in the stoma." For example, if an outside facility were to treat this patient during an emergency, a clear notation of the patient's procedure and anatomy would be readily available in the case the clinic called and inquired as to the patient's history. The documentation would eliminate the potential for the patient to be confused with one who had undergone a tracheostomy. This is crucial because a patient who underwent laryngectomy can never be orally intubated. One factor that does help in gaining access to the airway is the clearly visible and accessible stoma created in these patients.


Aspiration, leakage, and dysphagia Healed laryngectomy patients are unable to aspirate, as the surgical procedure separates the trachea from the pharynx. These patients should not be sent for a swallow study unless there is a sign of a fistula. Twenty percent of patients develop a pharyngocutaneous fistula, a leakage of saliva from an incisional tract to the skin or stoma, postoperatively. Patients who had prior radiation are at higher risk for this complication. Dysphagia may manifest as a result of esophageal stenosis from radiation or surgery and should be evaluated with a swallow study.⁵


Loss of speech After laryngectomy, loss of speech is perhaps one of the most life-changing and challenging results of surgery. Fortunately, speech options are available for these patients. The most commonly known device is the electrolarynx, a battery-powered, handheld device that is placed against the throat. The machine transmits a vibration to the throat that is converted into sounds based on the words the individual forms with the lips and tongue. However, the downsides to the device are that it emits more of a mechanical sound and is difficult for many patients to use.


A transesophageal prosthesis (TEP) is another option for voice restoration (Figure 3). A TEP is a unidirectional, valved prosthesis that allows air to cross from the back of the stoma to the esophagus to enable phonation. This enables more normal-sounding speech for most patients but is more expensive than the electrolarynx. The TEP is surgically placed, and a new prosthesis must be bought and changed by a physician or speech therapist several times a year. The TEP also requires manual occlusion to obtain voicing, although several hands-free devices are now on the market.


Regular care and cleaning of the stoma and TEP are important. Health care providers should educate themselves to be able to properly evaluate a stoma. A well-healed stoma should be clean and open (Figure 4). The TEP will be visible on the posterior wall of the stoma as a plastic disc that may have a tab that extends out of the stoma and is taped to the skin. As the patient swallows or drinks, no visible sign of leakage should be present around the stoma or TEP. The stoma and TEP should be free of mucus or crusting. Most patients who undergo laryngectomy are very good at maintaining their stomas. 


Treatment challenges and effects Patients who do not have voice restoration must write all their communication. This is time-consuming for family and health care professionals alike. Patience is required in caring for these people. Social isolation may result because of the appearance of 
the stoma and aphonia, and depression is also quite common. Swimming and water activities are contraindicated 
in these patients. A change in sense of smell is another common effect of laryngectomy. Because patients who undergo the procedure become aphonic, they should be instructed to contact their local police or 911 dispatchers to ensure that any phone call from them will generate an immediate response. 


CONCLUSION


Squamous cell carcinoma of the larynx is a unique disease. Health care professionals should be familiar with the laryngectomy patient. In particular, the anatomic changes that result from surgical resection are important to understand and document. The lifestyle changes for the patient and family are enormous. Speech restoration options are available but are not normally covered by insurance. Social isolation and depression are common after surgery, and clinicians should monitor for these conditions. Support groups and information for families should be provided and encouraged. Smoking cessation for all patients using tobacco in any form should be a priority. JAAPA

Linda Diamond is a PA in the Department of Otolaryngology-Head and Neck Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania. The author has indicated no relationships to disclose relating to the content of this article.


1. American Cancer Society. Cancer Facts and Figures 2009. Atlanta, GA: American Cancer Society; 2009.


2. Ang KK, Harris J, Wheeler R, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010;363(1):24-35.


3. Kincher JA. One hundred laryngeal cancers studied by serial section. Ann Otol Rhinol Laryngol. 1969;78(4):689-709.


4. Spector JG, Sessions DG, Chao KS, et al. Stage I (T1 N0 M0) squamous cell carcinoma of the laryngeal glottis: therapeutic results and voice preservation. Head Neck. 1999;21(8):707-717.


5. Young VN, Mangus BD, Bumpous JM. Salvage laryngectomy for failed conservative treatment of laryngeal cancer. Laryngoscope. 2008;118(9):1561-1568.