1. NEAR TOTAL LARYNGECTOMY
Dr S.Shyam Kumar

2. Anatomy of the Larynx
Supraglottis
Glottis
Subglottis

3. Classification of Laryngectomy
Conservation
Horizontal partial
Vertical partial
Total
Near total
Supracricoid/ three quarter
Narrow field
Wide field

4. Near total laryngectomy
Popularised by Bruce Pearson
Not a conservation laryngectomy
Permanent end tracheostome present
Pre-requisites
One crico-arytenoid unit with intact innervation
One arytenoid
Disease free interarytenoid area
Underlying cricoid lamina
Ipsilateral recurrent laryngeal nerve

6. End result Indications Contraindications
Myo-mucosal shunt alt to TEP buried in the neopharynx
Dynamic valve mechanism to produce voice free of any prosthesis
Separation of airway from food passage
End tracheostome
Indications
Unilateral T3/4 transglottic/glottic tumor
Unilateral T3/4 PFS tumors without involvement of PCA
Contraindications
Bilateral arytenoid disease/ interarytenoid area involvement
Extensive subglottic disease

8. Surgical procedure Gluck – Sorensen’s incision
a horizontal cervical incision at the level of the thyroid cartilage, with a separate incision for the stoma at least a fingerbreadth below
Sub-platysmal flaps
Larynx skeletonized
Division of strap muscles
Ipsilateral hemithyroidectomy
The contralateral dissection differs in that the strap muscles are preserved with their neurovascular supply; likewise, the recurrent laryngeal nerve is preserved. The greater horn of the hyoid bone is left intact.
Tracheostoma
Horizontal slit below 2nd tracheal ring

9. Divide the opposite side thyroid cartilage, cricoid ring in a vertical plane anterior to the crico-thyroid jt
Preserve the RLN of non-diseased side
Pharyngeal entry through vallecula
Hold & pull the epiglottis outwards and downwards
Again inspect the larynx for feasibility of NTL
Cut thro’ uninvolved AEF, false cord then vertically cut the cricoid
Extend the cut horizontally below cricoid of involved side
Cut vertically in the inter-arytenoid area, extend it thro’ the cricoid lamina & join with the horizontal cut

11. Tumor specimen will comprise of diseased side true, false cord, ventricle, ant comm, arytenoid, medial wall of PFS, diseased side thyroid lamina, cricoid & most of the contralateral thyroid lamina and cricoid.
Myomucosal shunt made from remaining true cord and arytenoid by tubing over 14Fr ryles tube/ foleys catheter.
If mucosa insufficient then take PFS mucosa
The remaining pharyngeal wall are approximated over the shunt which gets buried in the neopharynx but distally open to the tracheostomy.
After healing the pt can divert airflow thro’ the shunt to produce voice.

12. Complications Shunt stenosis Aspiration Pharyngeal leak
Rare treated with periodic self dilatation
Aspiration
Intractable at times may req revision to TL
Pharyngeal leak
Managed conservatively failing which surgical closure of fistula is done with PMMF/ DP flap
General – bleeding, wound infection, lung problems

13. PROS & CONS Pros Cons Oncologically sound procedure/ equal to TL
Prosthesis free voice
May not need speech therapist
Cons
Chances of aspiration
Correct pre-op assessment
Shunt dysfuntion after RT
Very few large series

14. Literature on NTL Pradhan SA et al. Asian J Surg. 2002 Jan;25(1):27-34
150 pts total. A 109 (72.7%) are alive and disease free at the last follow up ranging from 12 months to 109 months (median 38 months). Eleven pts (7.4%) had local/loco-regional recurrences and 16 pts (10.7%) had purely regional recurrences. A 135 (90%) developed communicable speech, and the speech success rate was 100% in 12 cases of ENTLP. Complications included major wound dehiscence with total shunt breakdown in 2 cases (1.3%), pharyngeal leak requiring surgical intervention in 7 cases (4.6%), significant aspiration through the shunt necessitating completion laryngectomy in 1 case (0.6%), and complete shunt stenosis in 9 cases (6%) Voice analysis showed that amongst various parameters studied for the two groups (NTL & TEP) the fundamental frequency (t = 0.000), frequency range (0.019) and maximum frequency (0.000) were better in the group that underwent a NTL resulting in a near normal voice.
The authors concluded that NTL was oncologically safe, voice conservation procedure, in advanced but lateralized lesions of the larynx and pyriform fossa

15. Cackli et al Eur Arch Otorhinolaryngol. 2005 Feb;262(2):99-102
Cackli et al Eur Arch Otorhinolaryngol Feb;262(2): Epub 2004 Mar 5
medical records of 23 male patients (mean age: 56.6, range: 35 to 72 years) who underwent near total laryngectomy. Maximal phonation times of 17 patients and fundamental frequencies of 10 patients were measured and compared with control groups consisting of sex- and age-matched normal laryngeal speakers. Pharyngocutenous fistula occurred in five cases and closed by secondary wound healing. The incidence of aspiration was 42%. Shunt stenosis wasn't observed in their cases, but loss of phonation occurred because of tumor recurrence at the neoglottal region in the 1st postoperative year of one patient. All patients were able to produce voice, and communicable speech was achieved by 19 (82.6%). Measurements of maximal phonation time indicated a significant decrease in the NTL group. The increase in fundamental frequency values of the near total laryngectomy group was also found significant in relation to the control group.

16. Kavabata NK et al, Am J Surg. 2004 Aug;188(2):111-4
retrospectively studied 15 patients with advanced laryngeal, oropharyngeal, and hypopharyngeal cancer who underwent NTL. Survival rates were calculated using the Kaplan-Meier method. The most common complication was fistula (8 of 15) followed by minor aspiration (4 of 15 patients). Eleven patients (73.5%) attained a good voice; 3 patients (19.9%) obtained a bad voice; and 1 did not achieved vocal ability. Three patients (19.9%) had local recurrence; no patients had neck recurrence; and 2 patients (13.3%) had distant metastasis. Six patients (40%) died from their disease, and 2 (13.3%) patients died from other causes. The 3-year actuarial survival rate was 81.6%.

17. Andrade RP et al, Head Neck. 2000 Jan;22(1):12-6
The patients were 40 men and two women, with a median age of 58 years. All patients had squamous cell carcinoma. There were 37 larynx and five pyriform sinus tumors. T3 stage tumor represented 85.7% of the cases. There were complications in 13 patients (28.9%). Vocal quality was considered good in 83.3% of the cases. To date, eight patients presented tumor recurrences: two local, two in the neck, and four distant. The 5-year actuarial overall survival rates were of 81.7% in larynx carcinoma and 66.6% in pyriform sinus carcinoma. The authors conluded that in selected transglottic and pyriform sinus carcinomas, NTL could be carried out with acceptable morbidity and a high potential of voice preservation and tumor control.

18. total
speech
LR Rec
complications
shunt stenosis
completion TL
pradhan etal
150
90% 27 19 9 1
cakli etal 23
82% 16 ?5
kavabata etal 15
93% 6 12 ?4
andrade RP etal 42
83.30%
4 +4 distant -