Near Total Laryngectomy (NTL) - A Complete, Easy-to-Memorise Guide

The One-Line Concept

NTL = Remove almost all of the larynx, but save ONE arytenoid + a sliver of cricoid to build a biological voice shunt. Patient breathes through a permanent stoma but speaks using lung air through the shunt.

The "Big Picture" Spectrum

Why It Was Invented

• Cummings Otolaryngology, p. 2113

Anatomy to Remember

1. Muscle (so it can act as a dynamic valve/sphincter)
2. Mucosa (to line the tube)
3. Nerve supply (so it actively contracts to prevent aspiration)

Indications

• Advanced (T3/T4) hypopharyngeal cancers (pyriform sinus - the most common hypopharyngeal site) that are lateralised
• Glottic cancers unsuitable for other conservation procedures
• Suits approximately 20% of advanced, operable pyriform sinus cancers

• Contralateral arytenoid - this is the cornerstone of the shunt
• Less than 1/3 of contralateral vocal cord involved by tumour (need enough remnant)
• Post-cricoid mucosa must be free of tumour
• Interarytenoid region must be uninvolved
• Scott-Brown's Otorhinolaryngology, p. 328-329

Contraindications

Absolute Contraindications

1. Interarytenoid involvement - makes preservation of the contralateral arytenoid oncologically unsafe
2. Post-cricoid involvement - same reason; shunt can't be made safely
3. More than 1/3 of contralateral cord involved - insufficient remnant for shunt formation

Relative Contraindication

• Prior radiotherapy (especially with oedematous tissues) - healing is compromised, shunt may fail

How the Shunt Works (The Key Concept)

BREATHING (normal):
Air → Stoma → Trachea → Lungs
(patient breathes through the neck, like total laryngectomy)

SPEAKING:
Patient covers stoma with finger
→ Air from lungs diverts UP through the shunt
→ Shunt tube vibrates → voice produced in neopharynx
→ Sphincteric muscle of shunt CLOSES after speech
→ Prevents aspiration

Surgical Steps (Simplified)

What you REMOVE:

• Entire laryngeal framework on the tumour side
• Corresponding vocal cord, arytenoid, thyroid cartilage wing
• The bulk of the larynx
• Involved pharynx (partial pharyngectomy on the diseased side)

What you KEEP (the shunt components):

1. Contralateral arytenoid (the hinge of the shunt valve)
2. Contralateral vocal cord + mucosa (lines the shunt)
3. Small portion of contralateral cricoid (the base)
4. The nerve and blood supply to these remnants (so shunt stays dynamic)

What you BUILD:

• The preserved remnant is fashioned into a myomucosal tube
• This tube runs from the trachea below → neopharynx above
• The tube is too narrow to breathe through (inadequate for airway), but large enough to shunt air for voice

Permanent tracheostomy:

• Always created, just like in total laryngectomy
• Patient will breathe through this stoma for life

Functional Outcomes

Voice

• Almost all patients achieve intelligible, lung-powered speech
• Published success rates: 74% to 100% across series
• Most common complication of voice: NTL shunt stenosis
  • Managed with dilatation using gum elastic bougies
• No prosthesis required - completely biological

Swallowing

• The sphincteric action of the innervated shunt protects the airway
• Aspiration is prevented because the remnant muscle actively contracts
• Scott-Brown's Otorhinolaryngology, p. 329

Oncological Outcomes

• In properly selected cases, locoregional control rates are comparable to total laryngectomy
• Local recurrence rate: < 7% in predominantly T3/T4 series
• Median 5-year survival: ~57%
• These figures are reassuring - NTL is not oncologically inferior to total laryngectomy when patient selection is correct
• Scott-Brown's Otorhinolaryngology, p. 330

Neck Dissection (Always Done)

• With manifest neck nodes (N1-N3): Bilateral neck dissection levels II-V
• Advanced primary, no clinically apparent nodes: Bilateral levels II-IV neck dissection

Adjuvant Therapy

• T3/T4 primary
• Close or positive cut margins
• Perineural invasion (PNI)
• Lymphovascular emboli (LVE)
• Cartilage invasion
• Multiple nodes / extracapsular spread (ECS)

Complications

Memory Anchors

• Interarytenoid involvement
• Post-cricoid involvement
• More than one-third of contralateral cord involved

Quick Comparison with Related Procedures

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 1, pp. 328-330 (NTLP section)
• Cummings Otolaryngology Head and Neck Surgery, pp. 1994, 2113 (NTL in glottic SCC and voice rehabilitation)