Laryngectomy is the removal of the larynx. In a total laryngectomy, the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings) with the separation of the airway from the mouth, nose and esophagus. In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods (surgeries through the mouth, radiation and/or chemotherapy). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Less invasive partial laryngectomies, including tracheal shaves and feminization laryngoplasty may also be performed on transgender women and other female or non-binary identified individuals to feminize the larynx and/or voice. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery. People who are laryngectomized are vocal amputees.
History The first total laryngectomy was performed in 1873 by Theodor Billroth. The patient was a thirty-six-year-old man with a subglottic squamous cell carcinoma. On November 27, 1873, Billroth performed a partial laryngectomy. Subsequent laryngoscopic examination in mid-December 1873 found tumor recurrence. On December 31, 1873, Billroth performed the first total laryngectomy. The patient was discharged four months later after he learned to use the artificial larynx, which enabled him to speak despite the removal of his vocal cords. Unfortunately, the patient developed a recurrence of the lesion, accompanied by metastatic nodes, and passed away a year following the surgery. Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866, but this patient's larynx was only excised after death. The first artificial larynx was constructed by Johann Nepomuk Czermak in 1869. Vincenz Czerny developed an artificial larynx which he tested in dogs in 1870. Following the pioneering efforts of Billroth, the practice of total laryngectomy gained momentum among surgeons. The early attempts at this procedure, including the second ever performed by Bernhard Heine in 1874 and subsequent operations by Hermann Maas and others, often resulted in the patient's death due to complications or recurrence of disease within months. It wasn't until Enrico Bottini in Italy achieved the first long-term survival of a laryngectomy patient that the potential for lasting success was realized. The period also saw notable failures and challenges, including the tragic case of Crown Prince Frederick of Germany (the future Frederick III). Misdiagnosed initially in 1887 by Morell Mackenzie as benign, Frederick's condition was later identified as cancerous, leading to his death after a tracheostomy. This case highlighted the controversies and difficulties in diagnosing and treating laryngeal cancer, which persisted into the early 20th century. Advancements in direct laryngoscopy and suspension laryngoscopy, credited to Killian and Lynch respectively, improved the evaluation and surgical management of the larynx. Despite significant challenges such as wound infection, anesthesia, and shock, pioneers like George Washington Crile—which performed the first laryngectomy in U.S. in 1892—made significant contributions to reducing operative mortality and advancing techniques in neck surgery and the management of metastatic disease.
Incidence and prevalence According to the GLOBOCAN, 2,018 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer, there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer. In 2019, it is estimated that there will be 12,410 new laryngeal cancer cases in the United States, (3.0 per 100,000). The number of new cases decreases every year at a rate of 2.4%, and this is believed to be related to decreased cigarette smoking in the general population. The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate due to the development of less invasive techniques. A study using the National Inpatient Sample found that there were 8,288 total laryngectomy cases performed in the US between 1998 and 2008, and that hospitals performing total laryngectomy decreased by 12.3 per year. As of 2013, one reference estimates that there are 50,000 to 60,000 laryngectomees in the US.
Identification To determine the severity/spread of the laryngeal cancer and the level of vocal fold function, indirect laryngoscopies using mirrors, endoscopies (rigid or flexible) and/or stroboscopies may be performed. Other methods of visualization using CT scans, MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the glottis) can cause an individual's voice to sound hoarse. Examinations are used to determine the tumor classification (TNM classification) and the stage (1–4) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. Radiation and/or chemotherapy may also be used.
The airways and ventilation after laryngectomy
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