Near Total Laryngectomy (NTL)

MS ENT University Exam - 20 Marks Answer

INTRODUCTION / DEFINITION

• Cummings Otolaryngology Head and Neck Surgery
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery

HISTORICAL NOTE

• First described by Pearson and colleagues (Mayo Clinic)
• Also referred to in older literature as "subtotal laryngectomy"
• Abbreviation: NTL (or NTLP = near-total laryngectomy with partial pharyngectomy)

CONCEPT AND PRINCIPLE

• A small laryngotracheal remnant (one arytenoid + cricoid strip + overlying mucosa) is preserved on the less-involved / contralateral side
• This remnant is tubularized into a conduit between the trachea and the neopharynx
• The shunt is innervated and has sphincteric (dynamic) action - protecting the airway and preventing aspiration
• On occluding the tracheostome, exhaled air is diverted through the shunt into the pharynx, producing voice
• The shunt is too narrow to serve as an airway for breathing (hence the permanent tracheostome) but sufficient for voice production

"Some surgeons have advocated the near-total laryngectomy, which is not an organ-sparing operation but rather a technique for creating a natural voice shunt." - Cummings Otolaryngology

INDICATIONS

Primary indication:

• Advanced laryngeal and hypopharyngeal cancers (T3/T4) that are unsuitable for other conservation procedures but where a small laryngeal remnant can still be safely preserved

Specific indications:

1. Glottic carcinoma - T3/T4 tumors with vocal cord fixation, unsuitable for supracricoid partial laryngectomy
2. Hypopharyngeal cancers (especially pyriform sinus) - advanced but lateralized lesions where the contralateral arytenoid and cord are free of tumor
3. Transglottic carcinomas where one side is relatively free
4. Cases where the surgeon wishes to avoid a TEP prosthesis (as a natural shunt alternative)

CONTRAINDICATIONS

SURGICAL TECHNIQUE

Preoperative preparation:

• Imaging: CT/MRI to assess extent of tumor
• Biopsy confirmation
• Neck dissection planned (unilateral or bilateral depending on nodal status)
• Counseling regarding permanent tracheostome

Steps of the procedure:

1. Position and incision: Apron flap incision; subplatysmal flaps raised
2. Neck dissection: Functional or modified radical neck dissection on the involved side; contralateral neck dissected as indicated by nodal status
3. Laryngeal exposure: Strap muscles divided; thyroid gland managed (ipsilateral thyroid lobe may be resected)
4. Assessment of the contralateral side: The contralateral arytenoid, posterior cricoarytenoid (PCA) muscle, and recurrent laryngeal nerve are carefully assessed for tumor-free status
5. Resection: The entire larynx is removed except for:
   • The contralateral arytenoid cartilage
   • A cuff of mucosa from the contralateral vocal cord/subglottis
   • A portion of the posterior cricoid cartilage on the preserved side
6. Shunt construction: The preserved remnant (arytenoid + mucosa + cricoid strip) is fashioned into a tubular conduit (myomucosal tube) connecting the superior end of the trachea to the neopharynx
7. Pharyngeal closure: The neopharynx is closed primarily around the shunt
8. Tracheostome: A permanent tracheostome is fashioned at the lower neck
9. Wound closure and drain placement

POSTOPERATIVE MANAGEMENT

• Feeding: Nasogastric tube for 7-10 days (until pharyngeal healing)
• Tracheostome care: Humidification, cleaning, suction
• Voice rehabilitation: Patient learns to occlude the tracheostome with a finger and exhale - air travels through the shunt producing voice (no prosthesis required)
• Swallowing: The sphincteric shunt protects against aspiration
• Adjuvant therapy: Radiation (± chemotherapy) for T3/T4 disease, positive margins, nodal metastases, extracapsular spread, PNI, LVI

ADVANTAGES

DISADVANTAGES / COMPLICATIONS

• Pharyngocutaneous fistula (higher in post-irradiated patients, ~50% post-RT)
• Wound infection
• Shunt stenosis / failure

• Permanent tracheostome - loss of nasal respiration
• Shunt stenosis may impair voice
• Aspiration (if shunt sphincter is compromised)

• Not suitable if adequate remnant cannot be preserved

ONCOLOGICAL OUTCOMES

• Locoregional control rates with NTL are comparable to total laryngectomy in properly selected cases
• Local recurrence rate: < 7% in predominantly T3/T4 series (Scott-Brown's series)
• Median 5-year survival: ~57% for pharyngolaryngectomy cohort (UK national data, n > 1500)

VOICE REHABILITATION AFTER NTL vs. TOTAL LARYNGECTOMY

COMPARISON: NTL vs. TOTAL LARYNGECTOMY

COMPARISON: NTL vs. SUPRACRICOID PARTIAL LARYNGECTOMY (SCPL)

SUMMARY

• Cummings Otolaryngology Head and Neck Surgery, 7th ed. - Chapters on Glottic and Laryngeal Surgery
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Hypopharyngeal Cancer chapter
• Pearson BW et al., "Near-total laryngectomy", Ann Otol Rhinol Laryngol, 1980