Larynx or voice box cancer strikes approximately 10,000 Americans each year. About two-thirds of these cancers affect the vocal cords themselves while the remaining 1/3 affects other parts of the larynx. Signs and symtoms of layrynx cancer include hoarseness, persistent sore throat, ear pain and with later stages difficulty breathing and swallowing. The majority of tumors of the vocal cords are caught in their earlier stages lending themselves to conservation larynx surgery (where only a part of the voice box is removed allowing the patient to retain their voice and swallow) and/or chemotherapy and radiation treatment. Cancers affecting other parts of the larynx tend to be diagnosed in somewhat later stages, but again are often amenable to conservative surgery and/or chemotherapy and radiation. However, patients that present with advanced larynx cancer (usually where the tumor has eroded to the outside of the larynx directly), and those who fail radiation and/or chemotherapy often require a laryngectomy or removal of the entire larynx.
This procedure, while often difficult for a patient psychologically still remains the gold standard for treatment of larynx cancer and often the best chance these patients have for cure. Recent advances in voice rehabilitation after laryngectomy with Tracheo-esophageal puncture (TEP) have given patients an excellent chance at retaining a very acceptable and understandable voice after treatment (for more information about TEP click here). After the procedure the patient will have the remaining portion of the breathing tube sewn to the skin of the neck forming a stoma. The patient will breathe through this hole and not the mouth.
When a patient undergoes laryngectomy they will often undergo simultaneous removal of the lymph nodes of one or both sides of the neck (for more information on neck dissection click here). The incision for the laryngectomy itself usually extends most of the way from the ear to near the clavicle to the other ear. While this is large, it tends to heal well and does not result in significant discomfort. In fact as in neck dissection, most patients will have a rather numb neck for several weeks to months after the procedure.
Most often after a laryngectomy you will have to remain in the hospital for 1 to 2 weeks during which time you will have to receive your nutrition through a tube in your nose to allow your new feeding tube to heal. At some point you may have a swallowing study to confirm that there are no leaks in your incisions. Once a patient passes a swallowing study he or she is typically allowed to eat by mouth. After a laryngectomy a patient will also have several drains that will be kept in place for several days to ensure that no fluid collects in the neck.
Complications of having a laryngectomy can occur and include risk of bleeding an infection, risk of tumor recurrence, problems with swallowing, narrowing of the breathing stoma and abnormal connection between the newly formed swallowing tube and the skin (called a pharyngocutaneous fistula). This final complication is much more common in patients that have poor nutritional status, are actively smoking or have had radiation therapy.
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Once the larynx itself
is removed, the portion of the feeding tube attached to it (the
pharynx) is closed and the remaining portion of the windpipe is sewn to
the skin to form a stoma (see schematic on left). The patient will have
a temporary feeding tube either through the stoma connecting to the
esophagus or in the nose, to allow the incisions to heal. The patient
is then typically kept in the hospital from 5 to 10 days (stays are on
longer side if you have had previous radiation therapy) and are fed
through the tube during that time. The patient will have several drains
in the neck and these will be monitored for evidence of leakage of the
newly recreated feeding tube. If there is no evidence of this at 5-10
days the patient will either have special x-ray to test for a leak or
will be given a slow feeding trial. If the patient passes this test,
they are usualy discharged on this day or the following day. While in
the hospital, the patient will also receive training from the nursing
staff about how to care for their new stoma. This usually involves
suctioning and keeping the area around it clean. If a primary TEP is
performed this is typically put in a couple of weeks after surgery
after sufficient healing has occurred.
Laryngectomies are procedures
performed commonly by head and neck specialists but are not without
risk of complications. The most common complication is leakage of the
closure of the pharynx (fistula), this tends to occur in about 20% of
non radiated patients and up to 50% of irradiated patients. Patients
also at high risk of this are those with poor nutritional status, those
with thyroid problems and those who are continuing to smoke. Most of
the time these are small leaks and can be controlled with packing and
continued feeding through the nasal tube or the tube put through the
stoma. Occasionally the leak is larger and requires a second operation
to close it. Other risks of laryngectomy include bleeding into the
neck, infection (patients are given several days of antibiotics to
lessen this risk), collapse of the lung, damage to the thyroid gland,
damage to other major blood vessels with very rare possibility of
stroke or death. There is always a chance that the tumor can reoccur
in the residual windpipe, although this risk is typically low. Over
time there is a chance that the stoma may become narrow making it
difficult to breathe or use the speaking prosthesis. This would require
an additional operation to widen the hole.
Often patients that
now have laryngectomies have been previously irradiated and will
require no additional therapy. Patients in which laryngectomy is being
used as the initial mode of treatment often will need to receive post
operative radiation therapy to maximize chance of cure. If you have
more questions about laryngectomy or you or a loved one has symptoms of
larynx cancer please give us a call.
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