Laryngectomy

A laryngectomy is a surgery to remove some or all of the voice box. Find out about laryngectomy procedures, how to prepare for them, and the risks and benefits.

A laryngectomy is the removal of some or all of the voice box, also known as a partial or total laryngectomy. The larynx, also called the voice box, has a number of functions. Its main function is to allow serve as a conduit for air to enter and leave the lungs. The larynx also works to prevent food, liquids and saliva from falling into the lungs and potentially causing pneumonia. Finally, the larynx is responsible for creating voice. This page will explain the different types of laryngectomy procedures, how to prepare for a laryngectomy, and the risks and benefits of this surgery.

Preparing for Surgery

Doctors will give their patients specific instructions regarding what to do before surgery. In general, patients should not eat or drink anything (except essential medications) any time after midnight the night before surgery. Patients should tell their doctor if they begin to feel sick before surgery.

If a patient is undergoing a laryngectomy, they should have had a discussion with a speech and swallow therapist prior to surgery to discuss speech and swallowing rehabilitation following surgery.

What to Expect

On the day of surgery, the patient will likely be asked to arrive at the hospital a few hours before the scheduled operation. During this time, nurses will check the patient in and anesthesiologists will ensure that everything is safe for general anesthesia. The surgeon will also come see the patient to review the plan and answer any last minute questions.

For all of these cases, the patient will be put completely to sleep with general anesthesia. Patients may or may not require a feeding tube to aid in eating, depending on whether a total or partial laryngectomy is performed and the extent of reconstruction required.

Total Laryngectomy

A total laryngectomy involves the complete removal of the voice box. This is done for four main reasons:

  1. To remove a  very large and invasive laryngeal cancer
  2. To remove a recurrent cancer that came back after some sort of prior treatment, such as radiation, with or without chemotherapy
  3. Severe pneumonia complications due to removal of other cancer sites, such as the tongue base or hypopharynx 
  4. Patients cannot safely eat or drink due to a nonfunctional larynx, usually related to previous radiation or chemoradiation treatment

For a total laryngectomy, the incision is placed in the central neck, extending to the sides if neck dissections to remove lymph nodes are to be performed during the same operation. As part of this surgery, sometimes one or both lobes of the thyroid gland are also removed. The surgeon might send frozen section margins (tissue around tumor) after the voice box is removed to confirm that no cancer cells are left behind. The closure will then be performed and will include creation of a laryngostome.

Laryngeal cancer - Laryngectomy

A Laryngostome

A laryngostome involves sewing the top part of the trachea directly to the surrounding neck skin. This makes the patient a permanent “neck breather” because there is no longer a connection from their mouth/nose down into their lungs, but rather, air enters directly into the trachea and lungs through the laryngostome in the neck. On the other hand, the mouth remains connected to the throat and esophagus extending down into the stomach to allow for eating.

Associated procedures might include unilateral or bilateral (both sides) neck dissections, hemi- or total thyroidectomy, or partial pharyngectomy (see total laryngopharyngectomy). Reconstruction and rehabilitation procedures might include repair of the pharynx pharyngeal opening that results from the total laryngectomy, with primary closure (placing stitches to close up the pharyngeal opening), a pectoralis major muscle flap or a free flap. In some cases, a tracheoesophageal puncture might be done at the same time as the total laryngectomy to assist with speech rehabilitation after surgery.

Tracheoesophageal Puncture (TEP)

If the patient doesn’t already have a gastric feeding tube, they will have a feeding tube placed either through the nose, directly in the stomach, or through the tracheoesophageal puncture (TEP). They will start eating anywhere from a few days to one or two weeks after the procedure, depending on the surgeon’s preference and prior treatment they might have received.

At the end of the procedure, the surgeon will likely place one or two surgical drains that rest in the surgical wound and come out through a small hole in the patient’s skin. This is to drain any blood and/or fluid that might accumulate in the space. When the time is right—one day to a few days—the drain will be removed by the surgical team. This takes only a few seconds, similar to removing a bandage and is not significantly painful.

Laryngectomy - Tracheotomy

Partial Laryngectomy

In this procedure, the entire voice box is not removed. The main goals of this procedure are to get rid of the cancer while avoiding a permanent breathing tube in the neck, preserving a suitable voice and maintaining the ability to swallow. There are a large number of different partial procedures that have been developed to successfully treat cancer involving different portions of the larynx.

Currently, a partial laryngectomy is limited utilized to small cancers that are amenable to resection in patients with uninvolved functional contralateral laryngeal structures. Transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) are two minimally invasive methods that use different technologies to access and resect these cancers through the mouth; however, partial laryngeal surgeries can also be performed through the neck via a surgical incision in some patients. Patients should speak with their doctor about the possibility of this being an option to treat their cancer. The surgeon will probably speak about the possibility of converting to a total laryngectomy, depending on what is seen during the surgery or on the frozen section analysis.

Recovery & Aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries, a patient could go home after a few hours of observation in the recovery room while others might require a stay in the hospital for one to two weeks.

Once doctors determine that a patient no longer needs in-patient level care, they will be ready for discharge. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. The discharge planning team, which includes doctors, social workers, nurses and physical therapists, along with the patient and their family, will determine the best place for the patient to go once they are ready to leave the hospital. After a total laryngectomy, there are a number of ways to speak. Some possible techniques include a tracheoesophageal puncture, esophageal speech, or an electrolarynx. To learn more, visit our speech and swallow rehabilitation page.

Risks

As with any procedure, there are risks in undergoing a laryngectomy.

  • Bleeding (including Hematoma)
    If there is severe bleeding after the procedure, the surgeon might need to quickly take the patient back to the operating room to stop the bleeding. However, some mild bleeding or small blood collections under the skin (hematomas) can be observed and managed conservatively.
  • Infection
    Infections following this surgery are quite rare. Still, as with any surgical procedure, there is always a risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Salivary Fistula
    This term is used to describe when saliva is leaking from the pharynx (throat) into the neck.  The chances of this increase if a patient has had previous treatment including radiation and/or chemotherapy due to impaired healing. 
  • Hypocalcemia
    Low calcium levels can occur postoperatively if both lobes of the thyroid are removed and all four parathyroid glands are removed or rendered nonfunctional during this process. Temporary hypocalcemia can also occur if remaining parathyroids are in a state of shock due to their blood supply being affected during surgery (temporary hypocalcemia). This is why calcium levels need to be closely monitored after some total laryngectomies (or total laryngopharyngectomies) and calcium replacement may need to be given as needed.
  • Hypothyroidism
    This can happen if both lobes of the thyroid gland are removed, if only one lobe is removed but the other lobe cannot make enough thyroid hormone, or if radiation treatment has affected the function of the thyroid gland. In any case, thyroid function can be measured with blood tests, and a once-daily pill can replace the function of the thyroid hormone.
  • Blood Clots
    Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis or DVT). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolism (PE). If such a problem occurs, patients will likely require anticoagulation (blood-thinning) medication to prevent more clots from forming and ending up in their lungs.
  • Aspiration
    This is impossible after a total laryngectomy because breathing and swallowing is completely separated. There are circumstances where liquid and saliva can leak through or around a tracheoesophageal prosthesis. However, after any sort of partial laryngectomy, this is a major consideration. Having saliva and/or food and drink fall into the lungs can lead to pneumonia.