Head & Neck Surgery - Otolaryngology
4th Edition

Total laryngectomy or wide-field laryngectomy includes removal of the supraglottic larynx and hyoid bone, intrinsic larynx, portions of the pharynx, the strap muscles, one or more rings of the trachea, and part or all of the thyroid gland. The resection may include neck dissection, upper mediastinal lymph node dissection, and portions of the tongue base. The actual resection of the larynx requires entrance into the pharynx, determined by the location of the primary disease. It is desirable to make an entry away from the tumor and yet have complete visualization of the disease. The resulting defect, a pharyngotomy, consists of varying amounts of pharyngeal and esophageal mucosa, constrictor muscle remnants, and tongue base. The usual closure of this defect is primary. The geometry of closure (“T,” “Y,” “I,” or horizontal suture line) is determined by the amount of residual tissue, resultant tension, and the surgeon’s experience.

The usual approach to laryngectomy separates the pharyngeal constrictor muscles at the oblique line of the thyroid cartilage (Fig. 123.1). Specifically this includes the inferior pharyngeal constrictor and cricopharyngeus muscles. The separated constrictors are used as the third or external layer in the conventional three-layer closure of the pharynx. The junction of the pharynx and esophagus has been studied by speech pathologists as the sound source for alaryngeal speech and is called the “PE” segment, the pseudoglottis, or the CP (cricopharyngeus). It is difficult to predict resultant voice or quality because of variations in anatomy, tumor extent, muscle bulk, and operative technique. Pharyngeal closure after laryngectomy is generally concerned with controlling secretions, swallowing, and prevention of fistula formation. Recently, attention has been directed to alaryngeal voice acquisition and the possibilities for maximizing the results by changing the reconstructive technique (1, 2).

When the patient is healed and able to swallow after the laryngectomy, three possibilities for speech rehabilitation exist: the artificial larynx (electrolarynx), esophageal speech, and tracheoesophageal speech.

In the general survey of the laryngectomized patient, the initial stage of disease, operative technique, use of radiation therapy, and reconstruction methods should be noted. The patient’s health, age, and physical status are assessed. Relative concerns that may reduce the success of voice restoration are pharyngeal stricture with symp-tomatic dysphagia, radiation therapy exceeding 6,500 cGy, malnutrition, diabetes, dementia, and severe chronic obstructive pulmonary disease.

The physical examination includes a careful head and neck examination with attention to stomal hygiene, patient’s dexterity, as well as overall motivation and interest in voice restoration. The patient’s inability to use and care for the prosthesis due to impaired mental status or decrease in manual dexterity due to age, arthritis, or neurologic insult/disease has been overcome with the introduction of the indwelling prosthesis. Bilateral severe sensorineural hearing loss and limited pulmonary function are also relative contraindications to TEP because the patient cannot hear the TE voice, and limited pulmonary air restricts the fluency and volume of speech, respectively (6).

The stoma should be free of a cannula if possible and at least 1.0 cm in one dimension. Microstomia makes it difficult to place the prosthesis and may compromise the airway because of the prosthesis size. If microstoma exists, the stoma should be dilated and stented with a laryngectomy tube or revised by Z-plasty. Patients who have undergone radiation therapy whose tissues appear to be at risk are better managed by the former method. However, the posterior wall of a laryngectomy tube can be fenestrated to allow the use of voice prosthesis and laryngectomy tube together.

A preoperative esophageal insufflation test is important in predicting the likelihood of successful secondary tracheoesophageal speech. It estimates the possibility of dysfluency from pharyngeal constrictor spasm (15, 16). The TEP crosses the upper tracheostoma and enters the esophagus inferior to the reconstituted cricopharyngeus muscle and upper esophageal sphincter. The distention of the esophagus that occurs with air ingestion results in a reflexive increase in tone in the pharyngeal constrictor muscles. This finding was described in early manometric studies of the region in normal, nonlaryngectomized patients (17). Insufflation of the esophagus in the clinical setting requires placement of a catheter through the nose into the upper esophagus. Air is introduced into the esophagus either by an external source or by adapting the tube to a special connector fixed to the tracheostoma. After air enters the esophagus and is released, voice production and connected speech are attempted, which may result in sound (i.e., ah, a low-pitched rumble, or eructation) or in a series of connected words, as in counting. The fluency of speech should be assessed carefully, observing any air trapping, which, if complete, will cause gastric filling, dis-tention, discomfort, and even vagal syncope. One of four responses is obtained after the insufflation test: fluent, sustained voice production with minimal effort indicating relaxed pharyngoesophageal muscles; a breathy, hypotonic voice indicating the absence of pharyngeal constrictor muscle tone; hypertonic voice characterized by intermittent production of effortful speech with gastric distention and posttrial burping; and spasm characterized by no production of voice even with substantial pulmonary air flow. Despite these possible responses to esophageal insufflation, no definitive guidelines exist for successful duration of speech, airflow, or desirable pressures (pharyngeal or intratracheal). Some patients may have increased pharyngeal constrictor tonicity during tracheoesophageal voicing, but no reliable data show the incidence of patients who will succeed despite equivocal catheter insufflation testing. Furthermore, dysfluency on insufflation testing may be due to causes unrelated to pharyngoesophageal spasm, including postradiation tissue edema or the presence of recurrent disease. Therefore esophageal insufflation testing may be considered a subjective evaluation of esophageal distention and should not be used as the sole method for determining the need for open-neck exploration and pharyngeal constrictor relaxation.

Pharyngoesophageal spasm, suspected with a dysfluent speech pattern on insufflation testing, may be confirmed by anesthetic block of the pharyngeal plexus. The most effective method for analysis combines radiographic assessment with a plexus block. The patient is evaluated by videofluoroscopy with a barium-coated pharynx and
esophagus; the lateral view is preferred. An at-rest view is first obtained to review the morphology of the neo-pharynx and to rule out stricture, fistula tract, or per-sistent neoplasm. Several views during voicing are taken. The pharynx is examined for the mass of constrictors, seen in the retropharyngeal radiographic plane as a bar (Fig. 123.8) (18). Note the axial length with reference to the proximity to the tongue base and its overall breadth.

The study is followed by the pharyngeal plexus block with local anesthesia (150 to 200 mg of 2% lidocaine without epinephrine). The anesthetic is injected with a 23-gauge, 1.5-inch needle placed at the level of the pre-vertebral fascia and then extracted 1 to 2 mm before injection. The neck skin is entered at the level of C2–C3 immediately parapharyngeal and medial to the carotid sheath. After 3 to 5 minutes, the patient is instructed to attempt voicing, which is nearly always effective, effortless, and fluent. The voicing dynamics are now analyzed by fluoroscopy. The typical appearance shows a reduction in the mass of the constrictor muscles, including the axial length. In effect, the pinchcock effect of the constrictors during esophageal distention is temporarily blocked by the anesthetic and is readily documented by the radiographic examination. This indicates that the use of botulinum toxin A, pharyngeal constrictor myotomy, or pharyngeal plexus neurectomy will most likely be successful in treating pharyngoesophageal spasm.

Secondary voice restoration should be delayed until 6 weeks after laryngectomy, 6 to 8 weeks after postoperative radiation therapy, or until the peristomal skin has recovered from radiation toxicity, and at least 1 month after recovery from reconstruction of a total laryngopharyngectomy or total laryngopharyngoesophagectomy defect and adjunctive therapies. Patients after reconstruction should also undergo barium swallow to evaluate the reconstructive changes and the presence of a stricture.

The diagnostic problem is to evaluate voice failures after TEP (Table 123.1). The largest percentage of patients is the group who reflexively elevate the upper esophageal sphincter pressure during esophageal distention above the threshold for voice fluency. The patients may be capable of only a few syllables, a fluent “ah” or counting up to only 5 or 6, but also may exhibit considerable effort to voice, with the characteristic appearance and results of the Valsalva maneuver. Some patients initially demonstrate the Valsalva pattern. By using breath control and internal feedback, they can reduce esophageal distention and the resultant upper esophageal sphincter tonicity.

This dysfluent speech pattern may change over a 4- to 6-week period, but if it has not improved (and ≥15% to 25% will not change), further investigation and possible intervention are required. Voice is reassessed by the open-tract test, in which the voice prosthesis is removed and the patient tries to speak. This is successful in only a few patients, which demonstrates that the failure is the result of the unfavorable mechanics of the voice prosthesis. The device may be too long or too short. Confirmation of correct fitting length can be assessed by flexible endoscopic evaluation of the esophagus while the patient is asked to prolong phonation. If the voice retains a strained quality after assuring a proper fit, switching to a prosthesis with low-resistance characteristics and larger diameter (20F) helps reduce the resistance to airflow and results in less effort for most patients.

The patient with persistent voice failure with the open-tract test should be evaluated systematically by using video fluoroscopic examination and pharyngeal constrictor local anesthetic block. It is unusual for voice failure to occur from a morphologic abnormality of the pharynx or stricture or
the angle of the prosthesis. If the air is directed to the distal esophagus, it will regurgitate superiorly to the pharynx as the esophagus distends. If the pharynx is tubular and rigid (common with skin-flap pharyngeal reconstruction), the voice may be breathy or whisper-like. Myocutaneous flap reconstructions are characterized by decreased pitch, judged as “wet,” and can be slow to initiate because of the inertia introduced by the bulk of the flap (19, 20).

The free microvascular transfer of a segment of jejunum represents another problem. The segment of intestine is often redundant and traps air and secretions. This also is complicated by the intrinsic tonicity of the intestine, which impedes free egress of air across the grafted segment. Although a myotomy of the jejunal wall has been suggested, evidence of its efficacy remains to be documented. Although gastric transposition introduces mechanical complexity at the level of the tracheostoma, no increased risks have been described by puncture at this level into the stomach. The resultant airflow is unimpeded, and the pitch is low, with a characteristic hollow voice (21).

The TEP is readily established secondarily by using an endoscopic technique (4). A rigid esophagoscope is introduced with the patient under general anesthesia through the laryngectomized pharynx and into the upper thoracic esophagus (Fig. 123.9). Mucosal irregularity, stricture, or ulceration at the level of the cervical esophagus should be noted. At the tracheostoma, the esophagoscope is rotated 180 degrees from introduction, with the longer side of the bevel now opposed to the posterior trachea. A window on this surface facilitates the puncture.

The membranous trachea is palpated through the stoma, ensuring that the esophagoscope is against the posterior trachea. Transillumination of the trachea is not usually helpful for the precise placement of the puncture. A puncture location is identified 5 mm from the superior trachea, and the window on the esophagoscope is aligned with this point. A 14-gauge needle is curved and introduced through the wall of the trachea, corresponding with the endoscope window. Direct vision through the esophagoscope allows direction of the needle into the lumen of the endoscope. Puncture of the posterior esophageal wall and its possible sequelae are prevented by the posterior wall of the esophagoscope.

With the needle in place, a 16-gauge intravenous catheter is threaded through the needle until the catheter is retrieved at the mouth. The needle is withdrawn, and with the catheter in place as a guide, the puncture is dilated carefully with a small hemostat. The catheter is attached to a urethral catheter (14F), filiform, or other gradually tapered device. With continuous traction at the mouth, the intravenous catheter/dilating catheter is pulled retrograde through the esophagus and hypopharynx, “trailing” the esophagoscope into the oral cavity. At this point, the intravenous catheter is released, and it must be ensured that no significant bleeding is present; then the esophagoscope is reinserted. The integrity of the anterior esophageal wall at the site of the puncture is examined, and, with the tip of the endoscope, the dilating catheter is directed into the distal esophagus. A suture is placed at the lateral tracheostoma to tie the dilating catheter in place.

The patient may be released on an ambulatory basis and permitted to resume a normal diet. Neither analgesics nor antibiotics are used. The patient can use an electrolarynx or limited esophageal voice. The stoma requires increased hygiene, and increased tracheal secretions are expected. In some cases, a temporary laryngectomy may be inserted for better stoma maintenance. The prosthesis is usually fitted in 2 days.

Fitting and placement of the voice prosthesis is simple. The first step in fitting is to remove the dilating catheter from the puncture that was placed in the operating room, and serially dilate the puncture by using catheters to 18F to ease placement of the measuring device, and measure the distance across the puncture (Fig. 123.10). The vocal tract
is tested before placing the prosthesis by covering the tracheostoma and introducing air with exhalation. Patients will voice easily, and most will be capable of connected speech. The second step is the actual insertion of the voice prosthesis. The prosthesis is fixed to an inserter and introduced into the puncture at an angle corresponding to the presentation of the retention collar, end on. The collar will pass with slight resistance into the esophageal lumen; when fully entered, it will unfold, and a locking sensation is detectable.

The voice prosthesis is oriented by vertical placement of the silicone strap above the tracheostoma. It is fixed to the skin with paper adhesive tape. Efforts to produce and sustain voice may now begin with the prosthesis in position. The next steps vary from patient to patient and include instruction in careful stoma occlusion for efficient airflow, proper hygiene practices and management of secretions, varying breath control and diaphragmatic pressure, diminishing injection behavior from esophageal voice, experience with prosthesis cleaning and replacement, and guidelines for emergency situations. Long-term success in voice restoration requires that the patient fully comprehend the importance of maintaining the puncture at all times and diligently observing the prosthesis for signs of failure.

The initial prosthesis design required that it be removed and cleaned daily. However, this placed a great responsibility on the patient, possibly contributing to failure and complications, particularly in those with limited dexterity. Several indwelling devices with improved retention capabilities have been introduced more recently. The physician or speech pathologist must perform placement, because the insertion and removal techniques can be traumatizing to the tissues, and special instruments are sometimes required. The prosthesis remains in place and is cleaned externally until a new prosthesis is needed. Candidiasis results in premature failure of the prosthesis (usually valve degradation with aspiration of liquids through the prosthesis) but can be managed effectively with nystatin oral suspension (22).

Patients with persistent pharyngoesophageal spasm after a successful primary or secondary TEP can be secondarily treated with a pharyngeal constrictor myotomy (Table 123.2) (14), a pharyngeal constrictor neurectomy, or botulinum toxin A injection to reduce the tonicity of the upper esophageal sphincter. The myotomy is undertaken with a dilator (36F) in place in a manner analogous to a cricopharyngeal myotomy for dysphagia in patients with an intact larynx. Complications of this procedure are few but include salivary leakage and fistula formation, hypotonic voice, and esophageal reflux.

A secondary pharyngeal constrictor neurectomy (23) is approached in a fashion similar to the pharyngeal constrictor myotomy. The pharynx is distended with a mercury-filled dilator. Surgery is performed on the opposite side of the neck if a previous radical neck dissection has occurred. The parapharyngeal tissues are dissected to the level of the prevertebral fascia. The pharynx is rotated away from the carotid sheath, exposing the posterolateral wall of the pharyngoesophagus.

A careful dissection of the fascia overlying the con-strictor muscles is done, directing the dissection superiorly to the base of the tongue, where a key landmark is en-countered, the middle pharyngeal constrictor muscle. The main branches of the pharyngeal plexus are found at the junction of the middle and inferior pharyngeal constrictor muscles, where they course before dividing and innervating the underlying constrictor muscle fibers. When the branches of the pharyngeal plexus are stimulated, a fine contraction in the constrictor muscles is produced that moves from superior to inferior. After the pharyngeal plexus is identified, which represents one to three nerve branches at this level, the fibers are electrocoagulated and divided. The procedure is performed unilaterally. The wound is then drained away from the stoma and closed. The patient may resume a normal postoperative diet, and speech rehabilitation may begin the following day.

Botulinum toxin A may be injected under electromyographic guidance or fluoroscopy into the pharyngeal constrictor muscles to correct spasm (24). Its effect usually occurs within 72 hours after injection and may require repeated injections approximately every 6 months. This method is the preferred method of choice for most patients, particularly for poor surgical candidates and for those who do not wish additional surgery.

Maves and Lingeman (25) and Hamaker et al. (26) were the first to introduce TEP as a primary technique at the time of laryngectomy. Patient-selection criteria are essentially the same as those for secondary TEP. If a patient is indecisive regarding primary TEP, a puncture can be performed and then allowed to close if the patient does not wish TE speech. Placing a TEP primarily requires the careful construction of the tracheostoma and a pharyngeal constrictor relaxation procedure. The surgical steps include incision (laryngectomy), followed by tracheostoma construction, TEP, unilateral pharyngeal constrictor myotomy or pharyngeal plexus neurectomy, and buttressing the tracheoesophageal party wall (26).

After laryngectomy, the stoma is constructed. The optimal tracheal diameter is ≥3 cm to prevent stenosis. The midline inferior skin flap is sewn to the midline anterior tracheal ring by using half vertical mattress sutures, which allow coverage of the cartilage. Interrupted sutures are placed at 5-mm intervals on either side of the midline, pulling the trachea laterally. This creates a straight, horizontal membranous trachea, which is sewn to the superior skin flap. If the trachea is smaller than 3.0 cm, a stomaplasty is performed (27).

The TEP is placed after the stoma is constructed and before the pharynx is closed (26). The upper tracheal rings are fixed anteriorly and inferiorly to the skin flap rather than through a concentric skin defect. After stabilizing the tracheostoma, a right-angled hemostat is placed against the membranous trachea 1 cm from the tracheal edge by way of the open pharynx (Fig. 123.11). The membranous trachea is incised transversely for 3 to 4 mm to permit the tips of the hemostat to protrude into the tracheostoma. The tracheoesophageal common wall should not be separated; if this occurs, it should be closed to prevent saliva from dissecting into this space. The tip of the hemostat is used to direct a 16F silicone Foley catheter into the esophagus to serve as a stent for the TEP and as a convenient feeding tube.

Management of the pharyngeal constrictor muscles to prevent pharyngeal spasm is the key to successful TE speech. A very reliable method for preventing spasm, if done properly, is a pharyngeal constrictor myotomy. The pharynx is rolled over a tubular structure, most often a finger or dilator, and the muscles are incised vertically in the posterior midline of the pharynx from the level of the puncture to the tongue base. The muscles are cut to the level of the submucosa. If bleeding occurs, careful use of bipolar cautery is recommended. If an inadvertent pharyngotomy is made, the mucosa is repaired at this time. If flap reconstruction of the pharynx is performed, the segment of muscle from the puncture site to the inferior flap is myotomized (26, 27).

An alternative method that can be performed to prevent pharyngeal spasm is a unilateral pharyngeal plexus neurectomy (10). The neurectomy is less traumatic to the pharyngeal wall, effectively reduces the increase in wall tension (sphincter spasm) during esophageal distention, and preserves the elasticity and vascularity of the constrictor muscles. This is performed after neck dissection while the larynx is in place (Fig. 123.12). The cornu of the thyroid cartilage and the greater cornu of the hyoid bone form a space that includes the middle pharyngeal constrictor muscle and the muscular hiatus through which the plexus fibers travel. The nerves are electrically stimulated for identification, coagulated, and divided as previously mentioned. This method also is useful when the pharynx is already closed and a myotomy was inadvertently not performed.

The party wall usually separates ∼3 to 5 mm above the site of the puncture. The party wall is buttressed by using interrupted sutures of 3-0 chromic or 4-0 vicryl, which obliterates this space. This prevents the collection of saliva in this area if a fistula develops and helps to maintain the integrity of the posterior stoma. If separation of the party wall extends below the area of the planned puncture, then the puncture is delayed, as this can lead to pocket formation with abscess and loss of the posterior tracheal wall (26, 27).

Many variables have been studied by various clinicians to predict those patients who will achieve successful TE speech with primary or secondary puncture. However, no consensus has been reached among these studies. We reviewed 128 patients over a 9-year period who had under-gone primary
voice restoration during laryngectomy (20). Two 4-year periods were analyzed. In the earlier group of 48 patients, 29% experienced voice failure, which was reduced to 13% by revision procedures. The more current group failed 15% of the time, with revision reducing it to 9%. This finding represents an improving trend for voice rehabilitation, with the development of improved voice prostheses, more effective patient training, and refinement of the operative techniques. Speech after laryngectomy was successful 10 to 35 days postoperatively (average, 22 days). Tracheostoma stenosis occurred in 4%, and closure of the TEP occurred in 10% of cases because of extrusion of the prosthesis, radiation therapy, or inadequate stoma hygiene (Table 123.3).

The shape of the low-pressure voice prosthesis (trapdoor valve) has introduced a problem that has affected the acceptability of this device. The tapered or obturator tip of the duckbill prosthesis gave way in the new design to a short bevel and retention collar, which complicated insertion of the prosthesis into the lumen of the esophagus. In many cases, the retention collar resides within the lumen of the puncture tract itself, producing a scarred ridge anterior to the meatus of the esophageal puncture. Stenosis of the esophageal meatus, difficult voicing, and eventual extrusion of the prosthesis may occur with closure of the fistula. Insertion can be eased by placing the prosthesis tip and the folded retention collar into half of a gelatin capsule, thus creating a rounded tip for introduction into the puncture tract. Some prostheses bypass these insertion problems by using retrograde introduction of the prosthesis via a special guidewire or catheter.

Other puncture problems include tracheal granulation tissue (treated with cautery or laser), prolapse of eso-phageal mucosa through the TEP, or leakage at the TEP and aspiration. Aspiration of the prosthesis itself has occurred in 3% to 5% of users and is prevented by careful instruction and modification of the method for patient insertion or by using the indwelling devices. The significant problem and hazard of aspiration through the TEP is usually managed by reconstructing the tracheoesophageal common wall by interposing a sternocleidomastoid muscle flap (Fig. 123.13) or, in heavily irradiated patients, placing a pectoralis major myofascial flap (20).

Two urgent conditions may result for prosthesis users and should be attended to without delay (Table 123.4). For patients who routinely change their prostheses, the inability to insert the tip of the prosthesis and collar into the lumen of the esophagus may occur, which results initially in increased voice resistance and, in some cases, complete loss of voice. The TEP tract will close from the esophagus externally, and it will be impossible after 24 to 48 hours to reenter the lumen. If this occurs, the TEP can be serially dilated with plastic catheters ranging from 10F to 18F and then stented with a flexible catheter for several hours before the voice prosthesis is replaced. If available, urethral dilators are an effective instrument for TEP dilatation. Dilatation must be performed with as little resistance as possible because it is possible to dissect into the tracheoesophageal common wall and enter the anterior mediastinum.

The second urgent condition is aspiration of the voice prosthesis. This condition usually occurs when patients attempt to replace the device in the TEP, and a cough is stimulated. The most common location for device
impaction is at the level of the upper right mainstem bronchus and carina. This usually is well tolerated, but an uncomfortable dyspnea is present. Furthermore, in the resultant anxiety, the TEP is not stented, and tracheal aspiration of saliva may occur. This complication can be prevented in most cases by providing detailed instruction in emergency techniques at the time of initial prosthesis fitting. Should aspiration of the prosthesis occur, the patient should first securely stent the puncture and then attempt to bend over as far as possible and cough out the prosthesis. Deep inhalations should be avoided because the result may be deeper penetration of the prosthesis into the airway. In the event of failure, the patient should go to an emergency medical facility as soon as possible. The size of the prosthesis prevents it from occluding the airway; patients will experience only moderate dyspnea with aspiration of the prosthesis.

The most efficient method for prosthesis retrieval is to use topical anesthesia and a rigid open or flexible bronchoscope with grasping forceps. After removing the foreign body, the TEP is stented with an 18F catheter for 24 hours before reinserting the prosthesis. The patient should avoid the changing process and should be introduced to the appropriate clinician follow-up team.

Laryngeal transplantation is currently under investigation. Animal studies have shown that canine laryngeal allografts can be physiologically reinnervated, which suggests that human larynges can be successfully innervated. However, additional research regarding the immunogenicity and function of transplanted larynges must be performed (32).