Types of laryngectomy

1. Partial laryngectomy

A. Vertical partial laryngectomy / Hemilaryngectomy

• One side of the larynx, usually including one true vocal cord.
• May include the ipsilateral false cord, laryngeal ventricle, and a portion of thyroid cartilage.
• The other vocal cord and opposite side of larynx remain.

• Small, localized glottic cancer confined largely to one vocal cord, with adequate mobility of the opposite cord.

• Usually an open neck operation.
• The affected vertical half of the thyroid cartilage and larynx is excised with an adequate cancer margin.
• A temporary tracheostomy may be created.
• The remaining laryngeal tissues are reconstructed to form a functional airway.

• Preserves the larynx and avoids a permanent tracheostoma in appropriately selected patients.
• Speech is retained, although voice quality is usually hoarse or weak.
• Swallowing is often preserved after rehabilitation.
• Provides a surgical pathology specimen and may offer good local control for selected early tumors.

• Only suitable for carefully selected, limited disease.
• Voice is not normal and may be breathy, rough, or low volume.
• Risk of aspiration, airway narrowing, laryngeal edema, and postoperative swallowing difficulty.
• May need temporary tracheostomy and feeding tube.
• Inadequate margins or recurrence can require completion total laryngectomy.

B. Supraglottic laryngectomy

• The larynx above the true vocal cords:
  • Epiglottis
  • False vocal cords
  • Aryepiglottic folds
  • Sometimes part of the arytenoid or upper thyroid cartilage
• The true vocal cords are retained.

• Selected early to intermediate supraglottic cancers, provided the true vocal cords are mobile and the tumor does not extend significantly into the glottis.

• Performed by an open approach or, in selected cases, transoral laser/robotic surgery.
• The supraglottis is removed while retaining the vocal cords.
• Bilateral neck dissection is commonly performed because supraglottic tumors have a meaningful risk of neck-node spread.
• A temporary tracheostomy and nasogastric or gastrostomy feeding may be needed.

• Natural voice is generally retained because the true vocal cords remain.
• Breathing usually returns through the normal upper airway after healing.
• The larynx is preserved.
• Good cancer control in well-selected T1-T2 supraglottic lesions. Cummings notes high local control in selected early lesions, whereas results are less reliable for more advanced tumors. Cummings Otolaryngology Head and Neck Surgery, p. 1088.

• The epiglottis and supraglottic structures normally protect the airway during swallowing. Their removal can cause aspiration, cough during meals, and pneumonia.
• Requires adequate lung reserve, swallowing ability, cognition, and motivation for rehabilitation.
• Voice may be preserved but can sound altered.
• Not suitable if there is impaired vocal-cord mobility or substantial tumor extension below the false cords.
• Temporary or, less often, prolonged tracheostomy and feeding support may be needed.

C. Supracricoid partial laryngectomy (SCPL)

• Cricohyoidoepiglottopexy (CHEP): most of the thyroid cartilage and glottis are removed, but the epiglottis is retained.
• Cricohyoidopexy (CHP): the epiglottis is also removed.

• The cricoid cartilage.
• At least one functioning cricoarytenoid unit, meaning the arytenoid and its movement mechanism on at least one side.
• This preserved unit is essential for breathing, swallowing protection, and functional voice.

• Selected glottic or supraglottic tumors too extensive for smaller partial laryngectomies but still amenable to organ-preserving surgery.

• The diseased thyroid cartilage, vocal cords, and varying amounts of supraglottis are removed.
• The hyoid bone is sutured to the cricoid cartilage, with or without the epiglottis, creating a new functional laryngeal inlet.
• Temporary tracheostomy and feeding tube are usual.

• Can avoid total laryngectomy and permanent laryngectomy stoma in selected patients.
• Retains functional speech without a voice prosthesis.
• Can preserve oral swallowing after intensive rehabilitation.
• May treat some tumors that would otherwise require total laryngectomy.

• Technically demanding and not available in all centers.
• Recovery of safe swallowing can be prolonged.
• Aspiration, aspiration pneumonia, poor voice, prolonged tracheostomy, and stenosis can occur.
• Voice is usually low-pitched, rough, and weak.
• Requires good pulmonary function and at least one mobile cricoarytenoid unit.
• If function fails or cancer recurs, total laryngectomy may be needed.

D. Supratracheal partial laryngectomy

• Entire glottis and subglottis, thyroid cartilage, and sometimes cricoid components.
• At least one functional cricoarytenoid unit is preserved.

• Carefully selected cancers with anterior subglottic extension.

• A subtotal laryngectomy is performed.
• The trachea is suspended to the hyoid bone, with or without retained epiglottis:
  • Tracheohyoidopexy
  • Tracheohyoidoepiglottopexy

• Extends organ-preservation surgery to selected tumors with subglottic extension.
• May avoid permanent tracheostoma and preserve functional speech/swallowing.

• Very specialized, technically difficult operation.
• Higher functional burden, particularly aspiration and delayed swallowing recovery.
• Not widely performed, so outcomes depend heavily on surgeon and center experience.
• Requires excellent patient selection and rehabilitation support.

2. Total laryngectomy

• The entire larynx, including the vocal cords.
• Depending on tumor spread, surgery may also include portions of pharynx, base of tongue, thyroid gland, or neck lymph nodes. This is then called an extended total laryngectomy or laryngopharyngectomy.

• Advanced laryngeal cancer with extensive cartilage destruction, extralaryngeal spread, bilateral vocal-cord fixation, or nonfunctional larynx.
• Persistent or recurrent tumor after radiotherapy or chemoradiotherapy.
• Severe radiation-related laryngeal dysfunction in selected cases.

1. The larynx is separated from the airway and swallowing passage.
2. The trachea is brought to the skin of the lower neck, creating a permanent tracheostoma.
3. The throat is closed or reconstructed.
4. Neck dissection and reconstruction may be added when required.

• Provides the most definitive surgical cancer clearance for extensive disease.
• Eliminates aspiration through the larynx because the airway is permanently separated from the food passage.
• Swallowing often returns well if the pharynx can be closed or reconstructed adequately.
• Can be lifesaving when the larynx is severely obstructed or nonfunctional.

• Permanent neck stoma: the person breathes only through the neck, not through the nose or mouth.
• Loss of natural voice: vocal-cord speech is no longer possible.
• Air is no longer warmed, humidified, or filtered by the nose, so crusting, dry secretions, and chest irritation can occur.
• Potential complications include pharyngocutaneous fistula, wound infection, swallowing stricture, stoma narrowing, and shoulder dysfunction after neck dissection.
• Altered smell, taste, body image, communication, and social functioning can have major effects.

• Tracheoesophageal puncture with voice prosthesis: usually provides the most fluent alaryngeal speech.
• Electrolarynx
• Esophageal speech

3. Extended total laryngectomy / Laryngopharyngectomy

• Total larynx plus adjacent involved structures, such as:
  • Part or all of hypopharynx
  • Cervical esophagus
  • Base of tongue
  • Thyroid tissue
  • Soft tissues outside the larynx

• Total laryngectomy is combined with removal of involved pharyngeal structures.
• The pharynx is reconstructed using regional or free tissue flaps, such as an anterolateral thigh or jejunal free flap.

• Allows removal of locally extensive laryngeal or hypopharyngeal cancer in one operation.
• Can achieve cancer control where a standard total laryngectomy would leave disease behind.

• All lifelong consequences of total laryngectomy.
• Greater surgical complexity and complication risk.
• Higher risk of fistula, flap problems, strictures, dysphagia, and long-term feeding difficulties.
• Swallowing rehabilitation may be more difficult and some patients need dilation or nutritional support.

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