Full text of DOI:10.1097/00005537-200202000-00031

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Near-Total Laryngectomy in Advanced
Laryngeal and Pyriform Cancers
Sultan A. Pradhan, FRCS, MS, FACS, FCPS; Anil K. D’Cruz, MS, DNB;
Prathamesh S. Pai, MS, DNB, DORL; Azeem Mohiyuddin, MS
Objective: To demonstrate the oncologic and
physiological safety of near-total laryngectomy
(NTL), its success in voice conservation, and its ver-
satility for use in extensive resections that necessitate
pharyngoplasty, and even in post-radiation recur-
rences. Study: In this study of 137 cases of NTL for
cancer of the larynx (45 cases) and pyriform (92 cas-
es), 86.9% were stage T3/T4 and 60.6% were N؉. A total
of 8.8% had extended pharyngeal resections necessi-
tating patch pharyngoplasty (ENTLP). In 10.9% cases,
NTL was used as salvage of post-radiation failures.
Concurrent neck dissection was performed in 99
cases. Results: A total of 70.1% was alive and disease-
free at the last follow-up ranging from 12 months to
104 months (median, 35 mo). A total of 7.3% had local/
locoregional recurrences and 11.7% had purely re-
gional recurrences. The local control rate for post-
radiation salvage with NTL was 93.3%. A total of 88.6%
developed communicable speech, and the speech suc-
cess rate was 100% in 12 cases of ENTLP. Complica-
tions included major wound dehiscence with total
shunt breakdown in 2 cases (1.5%), pharyngeal leak
requiring surgical intervention in 7 cases (3.6%), sig-
nificant aspiration through the shunt necessitating
completion laryngectomy in 1 case (0.7%), and com-
plete shunt stenosis in 9 cases (6.6%). Conclusion: The
study shows that NTL is an oncologically safe voice
conservation procedure in advanced, lateralized la-
ryngeal and pyriform cancers treated not only per
primum, but also in carefully selected post-radiation
failures. It has a high success rate of speech develop-
ment even in those cases requiring extensive pharyn-
geal resections. Major complications were acceptably
low. Key Words: Near-total laryngectomy, pyriform,
larynx, cancer.
ration. A wide range of these procedures has been de-
scribed.1–3 All of these procedures require the preserva-
tion of at least one functioning arytenoid and an intact
cricoid ring. This limits their use to relatively early can-
cers. In more advanced cancers in which there is subglot-
tic spread requiring resection of the cricoid cartilage, a
near-total laryngectomy can be performed as a voice-
conserving procedure. Because a segment of the cricoid
ring is resected, a permanent tracheostomy becomes man-
datory, and nasal respiration is sacrificed. However,
speech is possible through the formation of an innervated
myomucosal shunt constructed from the remnant unin-
volved mucosa between the trachea and the pharynx (Fig.
1). Thus, near-total laryngectomy is a procedure that
bridges the gap between the conventional voice conserva-
tion procedures that preserve both nasal respiration and
speech and a total laryngectomy in which both these func-
tions are sacrificed.
The procedure is feasible in advanced but lateralized
cancers of the larynx and pyriform fossa in which the
interarytenoid and retro-arytenoid regions are normal
(Fig. 2). A radical excision is possible on the side of the
lesion, which includes even a segment of the ipsilateral
cricoid cartilage to allow for an adequate lower clearance.
Normal supple tissues on the contralateral side are pre-
served to form a voice shunt between the trachea and the
pharynx. The biological shunt thus formed from the pa-
tient’s own tissues is maintenance-free and has several
advantages, vis-a`-vis speech rehabilitation, over the more
widely practiced tracheo-esophageal puncture and
prosthesis.
Laryngoscope, 112:375–380, 2002
METHODS
Between July 1989 and July 1999, near-total laryngectomy
was performed on 144 patients with laryngeal/pyriform fossa
cancers. Of the 144 patients, 7 were lost to follow-up within 6
months after surgery; therefore, results are presented for the
remaining 137 patients. All the patients who were lost to
follow-up were alive and free of disease at their last visit. There
were 34 glottic, 11 supraglottic, and 92 pyriform fossa lesions. Of
the 137 patients, there were 131 men and 6 women ranging in age
from 29 years to 79 years (Table I). Most of the patients had
locally advanced disease. One hundred fourteen patients had
T3/T4 disease, whereas 83 patients had clinically positive cervical
nodal metastases (Table II). Surgery was performed per primum
INTRODUCTION
Conventional partial laryngectomy procedures for
cancer of the larynx preserve voice as well as nasal respi-
From Head and Neck Services, Tata Memorial Hospital, Parel,
Mumbai, India.
Editor’s Note: This Manuscript was accepted for publication July 17,
2001.
Send Correspondence to Sultan A. Pradhan, FRCS, MS, FACS, FCPS,
Chief, Head & Neck Services, Tata Memorial Hospital, Dr. Ernest Borges
Marg, Parel, Mumbai 400012, India. E-mail: pradhansultan@hotmail.com
Laryngoscope 112: February 2002
Pradhan et al.: Near-Total Laryngectomy
375

TABLE I.
Age and Sex Distribution.*
Sex
Age (y)
Male
Female
Total
Ͻ40
8
35
57
25
6
2
3
10
38
57
26
6
41–50
51–60
61–70
Ͼ71
1
6
Total
131
137
*Age ranging from 29–79 years.
total laryngopharyngectomy and extended near-total la-
ryngopharyngectomy, which were alluded to earlier.
Complications
Fig. 1. The concept of near-total laryngectomy. (A) Normal trachea
and esophagus. (B) Excision of the larynx and part of the upper
trachea. (C) Formation of a voice shunt between the trachea and the
pharynx.
There was one postoperative death 7 months after
salvage surgery for post-radiation recurrence. There was
major wound dehiscence resulting in pharyngeal fistula
and pneumonitis and ultimately leading to death.
Pharyngeal fistula, aspiration on swallowing, and
shunt stenosis were the main complications following
NTL (Table VI).
in 119 patients as a salvage procedure for radiotherapy failure in
15 patients and after previous laser excision in 3 patients (Table
III). Forty-one patients underwent a near-total laryngectomy
(NTL), 84 had a near-total laryngopharyngectomy (NTLP) in
which a part of the pharyngeal wall was excised but closure was
achieved primarily, and 12 patients underwent an extended near-
total laryngopharyngectomy (ENTLP) that required a myocuta-
neous flap for pharyngeal closure (Table IV). Appropriate node
dissection was carried out as judged by the extent of node involve-
ment clinically and on frozen section sampling at the time of
surgery. The majority of patients (72.3%) underwent some form of
unilateral or bilateral concurrent neck dissection (Table V). Post-
operative radiotherapy was advised in 106 patients of whom 12
patients failed to complete the scheduled dose.
Twelve patients (8.7%) developed a major pharyngeal
leak/fistula. One died as mentioned above. Four healed
spontaneously with conservative treatment. Seven re-
quired surgical intervention for closure with a flap. In the
latter, one patient had a complete breakdown of the voice
shunt as well with resultant loss of speech.
Seventeen (12.4%) patients developed minor degrees
of aspiration in the immediate postoperative period. This
was transient in nature and settled down in a few weeks
without any specific treatment.
One patient developed persistent aspiration on swal-
lowing, necessitating a completion laryngectomy. In this
patient, there was injury to the recurrent laryngeal nerve
resulting in an adynamic shunt.
Nine patients (6.6%) developed severe shunt stenosis
in which dilatation was not possible with resultant failure
to develop speech.
RESULTS
NTL is a generic term used for the procedure of
near-total laryngectomy and its extensions such as near-
TABLE II.
Stage Distribution.
N-Stage
T-Stage
N0
N1
N2a N2b N3 N2c Nx Non Sq. Total
1
T1
1
1
T2
5
31
10
4
2
6
2
8
76
43
8
T3
11
9
16
17
9
5
3
T4
Tx
1
3
3
Non Sq
Total
1
50
23
10
33
14
3
1
137
Fig. 2. Advanced but lateralized lesion of the larynx and pyriform
fossa with cord fixity and normal inter- and retroarytenoid region.
Non Sq ϭ non-squamous.
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376
Pradhan et al.: Near-Total Laryngectomy

TABLE III.
TABLE V.
Preoperative Treatment.
Neck Dissection.
No.
Percent
No.
Percent
Nil
119
15
86.9
11.0
2.2
Nil
9
4
6.6
2.9
Radiation
Laser
Total
Sampled
Vein to vein
MND
3
25
13
25
12
49
137
18.2
9.5
137
100.0
RND
18.2
8.8
Bil. MND
MND ϩ RND
Total
35.8
100.0
Of the 15 patients who underwent NTL as a salvage
procedure for radiotherapy failure, 2 patients developed
major pharyngeal leak, ultimately leading to death in 1
and loss of voice shunt in the other.
MND ϭ modified neck dissection; RND ϭ radical neck dissection.
Control Rates
dilatation of the shunt with a regular 14 Fr esophageal
elastic boogie. This maneuver restored the patency of the
shunt, which may have gotten blocked as a result of in-
spissated secretions or minor degrees of stenosis.
Of the 137 evaluable patients, 96 (70.1%) are alive
and free of disease at the time of the last follow-up, which
ranges from 12 months to 104 months (median, 35 mo)
(Table VII). Seven patients developed local recurrence, 3
had locoregional recurrence, and 16 patients had pure
regional recurrence. Most patients with regional failure
(12 of 16) had advanced nodal disease at presentation (N2
or N3) and had undergone neck dissection for the same.
Nine patients developed distant metastasis and 4 patients
developed a new primary in the head and neck (Table
VIII). Two local, 1 locoregional, and 2 regional failures
could be salvaged successfully. Of the 4 patients who
developed second primaries, 1 was salvaged (Table IX).
Thirty-one patients died of cancer and 3 patients died of
other causes.
DISCUSSION
Near-total laryngectomy is feasible in locally ad-
vanced laryngeal cancers, even when there is subglottic
spread or involvement of the apex of the pyriform sinus as
the resection provides adequate clearance by going well
beyond the cricoid in its lowest extent (Fig. 3A, B). The
lesion, however, must be lateralized and the interaryte-
noid tissue must be supple and free of disease. The resec-
tion is radical on the side of the tumor, allowing the
contralateral, disease-free, supple tissues to be used for
the formation of a myomucosal shunt.4
Direct laryngoscopy performed preoperatively to
judge the feasibility of the procedure is of greater value
than sophisticated imaging with computerized tomogra-
phy (CT) or magnetic resonance imaging (MRI), although
it has its own limitations. At times a bulky lesion or lax
laryngeal tissues may give an impression of involvement
of the contralateral side. The exact extent of the disease
can only be judged at the time of surgery. This being so, all
surgically treated advanced laryngeal cancers should be
finally assessed at surgery for the possibility of perform-
ing an NTL. This allows many patients scheduled for total
laryngectomy to have the benefit of this voice-conserving
procedure. With such a policy in our service, approxi-
mately 20% of advanced laryngeal and pyriform sinus
cancers are now treated with a near-total laryngectomy.
The authors use a modification of the original Bruce
Pearson technique4 by making a suprahyoid transvallecu-
lar entry into the larynx and delivering and pulling the
Speech
One hundred twenty-one (88.3%) patients developed
communicable lung-powered speech (Table X), which was
graded as excellent in 104 (full sentences spoken effort-
lessly), fair in 11 (short sentences with some effort), and
poor in 6 (a breathy whisper that required considerable
effort and was associated with bouts of coughing) (Table
XI). The onset of speech after surgery varied from patient
to patient. Although an occasional patient developed
speech as early as the second postoperative week, the
majority picked up speech after the completion of radio-
therapy when the acute reaction settled down. In 17 pa-
tients, the development of speech was delayed postopera-
tively. All these patients, however, responded to simple
TABLE IV.
Type of Surgery and Primary Site.
Surgical Type
Site
NTL
NTLP
ENTLP
11
Total
TABLE VI.
Major Complications.
PF
81
2
92
34
No.
Percent
GL
32
9
SG
Total
1
1
11
Large pharyngeal leaks
Persistent aspiration
Shunt dehiscence
12
1
8.8
0.7
1.5
6.6
41
84
12
137
2
PF ϭ pyriform fossa; GL ϭ glottis; SG ϭ supraglottis; NTL ϭ near-total
laryngectomy; NTLP ϭ near-total laryngopharyngectomy; ENTLP ϭ extended
near-total laryngopharyngectomy.
Complete shunt stensosis
9
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Pradhan et al.: Near-Total Laryngectomy
377

TABLE VII.
Last Follow-Up Status.
TABLE VIII.
Recurrence.
No.
Percent
No.
Percent
Alive disease free*
Alive with disease
Dead of cancer
Dead other cause
Dead cause unknown
Total
96
1
70.1
.7
Local
7
5.1
11.7
2.2
Regional
16
3
31
6
22.6
4.4
Locoregional
Distant metastasis
Second primary
Total
9
6.6
3
2.2
4
2.9
137
100.0
137
100.0
*Range 12 months–104 months; median ϭ 35 months.
epiglottis downward and forward. This not only provides
better exposure to the interior of the larynx, but also
makes the laryngeal tissues taut and defines the tumor
limits more clearly, enabling a better assessment of the
extent of the disease and of the feasibility or otherwise of
a near-total laryngectomy.5 In this study of 137 cases, 119
(86.9%) had T3/T4 disease, 8 had T2 tumors, 1 patient had
T1 disease, 8 patients had Tx tumors, and 1 patient had
non-squamous tumor. The relatively early cancers (T1 and
T2 tumors) were either recurrences after RT (11) or fol-
lowing laser surgery (3), or had disease extending beyond
the cricoid but had mobile vocal cords (3). The prime
concern should therefore be the oncologic soundness of the
procedure. The results should measure up to the gold
standard of total laryngectomy. In properly selected cases,
NTL is an oncologically sound procedure, as is seen from
the present study, which records 10 cases of local and
locoregional recurrences out of a total of 137 evaluable
cases (7.2%). This is comparable to the results of other
series with local recurrences ranging from 7% to 8.4%.6–8
The procedure allows concurrent neck dissection to
be performed at surgery. In 99 (72.3%) cases, a concurrent
cervical lymph node dissection was performed. This is
important given the fact that NTL is resorted to in ad-
vanced laryngeal and pyriform sinus cancers, in which the
incidence of cervical node metastasis is high. In the
present series, 83 cases had histologically proven neck
nodes.
Postoperative radiation has little impact on the func-
tional outcome of the shunt created for speech.6 One hun-
dred four patients were advised radiation postoperatively,
94 patients completed the radiation schedule, and among
these, 88 (93.7%) patients had no adverse effect on the
shunt whereas 6 (6.3%) patients developed shunt stenosis.
Although NTL was feasible as a salvage procedure
after prior radiotherapy, the complication rate was mar-
ginally higher in these patients. Fifteen (10.8%) cases
were taken up as salvage procedures. Thirteen (86.6%)
cases had uneventful postoperative recovery. Two patients
had a major pharyngeal leak ultimately leading to death
in 1 and loss of the voice shunt in the other. Thirteen
patients are alive and disease-free and 1 died as a result of
cancer. Pearson’s series showed a 20% recurrence among
those taken for post-radiation salvage.6 NTL can be con-
sidered as a salvage procedure after radiation therapy
failure, but caution must be exercised at case selection.
Not only should the interarytenoid and retro-arytenoid
tissues be free of disease, they should also be supple and
free of post-radiation edema.
In the evaluation of the overall safety of the proce-
dure, physiological safety is also an important consider-
ation, because a shunt is being created between the tra-
TABLE IX.
Salvage of Recurrences.
Type of Salvage
Salvage
Status
Wide
Excision
Recurrence
RT
1
TL
2
RND
1
RT ϩ TL
Pall Rx
Metastectomy
Total
YES
Local
1
3
2
Regional
Locoregional
Second primary
Total
1
2
1
1
1
1
1
1
1
1
7
NO
Local
4
12
2
4
Regional
1
1
14
2
Locoregional
Distant
9
9
Second primary
Total
2
3
1
3
28
32
RT ϭ radiation therapy; TL ϭ total laryngectomy; RND ϭ radical neck dissection; Pall Rx ϭ palliative
treatment.
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378
Pradhan et al.: Near-Total Laryngectomy

TABLE X.
Speech.
No.
Percent
Successful
Shunt stenosis
Shunt breakdown
Adynamic tone
NK
121
9
88.3
6.6
2
1.5
1
.7
4
2.9
Total
137
100.0
chea and the pharynx. While a minor degree of aspiration
is not infrequent, it is transient and does not lead to any
serious complications. Only one patient had to have com-
pletion laryngectomy for persistent aspiration. It was be-
cause of injury to the recurrent laryngeal nerve. To create
a dynamic myomucosal shunt, preservation of the con-
tralateral recurrent laryngeal nerve is of the utmost im-
portance. The nerve is likely to be damaged as it enters
the larynx just behind the cricothyroid joint. To prevent
injury to the nerve, the plane of division of the thyroid
cartilage, the thyrocricoid membrane, and the cricoid car-
tilage should be anterior to the cricothyroid joint. If this
caution can be exercised, aspiration can be minimized. In
fact, near-total laryngectomy is considered a safe alterna-
tive to a supraglottic laryngectomy, which is fraught with
the complication of aspiration pneumonitis in elderly in-
dividuals with compromised respiratory functions.8
As a voice conservation procedure, near-total laryn-
gectomy has a high rate of success in the development of
intelligible lung-powered speech, ranging from 79% to
90% in most series.6–8 Moreover, restoration of speech
does not require prolonged sessions with a speech pathol-
ogist. In this series, 122 (88.4%) patients developed com-
municable speech, which was graded as excellent in 105,
fair in 11, and poor in 6. The ease and fluency of speech
depends on the patency and competence of the voice
shunt.9 As outlined earlier, competence of the shunt can
be maintained by avoiding damage to the uninvolved re-
current laryngeal nerve. A shunt is created over a 14 Fr
catheter, and if required, the lumen should be augmented
with the uninvolved mucosa from the pyriform sinus, as
described by Pearson.4
The most widely used method of speech rehabilita-
tion after a total laryngectomy is the tracheo-esophageal
(TE) puncture using the TE prosthesis.10 Like near-total
laryngectomy, the TE prosthesis allows lung-powered
speech with comparable success rate. However, it has
several disadvantages. The TE prosthesis is expensive,
TABLE XI.
Speech Quality.
No.
Percent
Good
Fair
104
11
6
75.9
8.0
Fig. 3. (A) Cartilage cuts. Note the line of division of thyroid cartilage
safeguarding the contralateral recurrent laryngeal nerve. (B) NTL.
Dotted line denoting resection extending below to include a seg-
ment of the cricoid ring.
Poor
4.4
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Pradhan et al.: Near-Total Laryngectomy
379

needs to be replaced every few months, and causes tra-
cheal and pharyngeal irritation resulting in a disturbing
cough. The TE prosthesis also needs regular maintenance
and cleaning, and when replaced needs to fit the puncture
site snugly. This is often difficult for the patient or his
attendants and usually requires the help of trained per-
sonnel. This is the major drawback of the TE prosthesis,
particularly in a developing country like India where do-
miciliary care is totally lacking and patients have to travel
long distances for medical help. On the other hand, the
near-total laryngectomy provides a maintenance-free bio-
logic shunt that is permanent and once successful, stays so
for life.
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