Near-total laryngectomy.
OBJECTIVE
To demonstrate the oncological and physiological safety of near-total laryngectomy (NTL), its versatility for use following extensive resections that necessitate pharyngoplasty, in post radiation recurrences and its success in voice conservation. To highlight the importance of a "maintenance free biological shunt" for voice production in patients of advanced laryngeal and pharyngeal cancers and compare the merits of the same to an artificial shunt created with a tracheo-esophageal puncture and prosthesis.


METHODS
In this study of 150 cases of NTL for cancers of the larynx (52 cases) and the pyriform fossa (98 cases), 130 pts (86.7%) were staged T3/T4, and 90 pts (60%) were clinically node positive. Twelve pts (7.3%) had extended pharyngeal resections necessitating patch pharyngoplasty (ENTLP). In 15 pts (10%) cases, NTL was used as salvage for post radiation failures. Concurrent neck dissection was performed in 108 cases. Voice of 39 patients following NTL, and 41 patients fitted with Tracheo-Esophageal Prosthesis following total laryngectomy were analysed using a speech analyser and their acoustic characteristics studied.


RESULTS
A hundred and nine pts (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 hundred and thirty-five pts (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 prolonged period of adjustment following a TEP and prosthesis, frequent displacement, the problems of replacement and the not so infrequent loss of the prosthesis with its recurring expenditure were absent in those treated with NTL which offers a maintenance free biological shunt for good lung powered speech.


CONCLUSIONS
The study shows that NTL is an oncologically safe, voice conservation procedure, in advanced but lateralized lesions of the larynx and pyriform fossa treated not only per primum but also in carefully selected post radiation failures. It has a high success rate of speech development even, in cases requiring extensive pharyngeal resections. Speech once developed, is maintenance free, prosthesis independent and stays so for a lifetime unlike a prosthetic shunt. The fundamental frequency of the voice generated by the NTL shunt (biological shunt) is significantly better than that following a TEP (prosthetic shunt) and was found to be close to normal voice. Even the frequency variations were significantly better. This suggests that the phonation with biological shunt is better than that with the prosthetic shunt. Thus an endeavor should be made to assess every case of advanced malignancy of larynx and pyriform fossa for feasibility of near-total laryngectomy.
Pradhan
Sultan A
SA
Head and Neck Services, Tata Memorial Hospital, Parel, Mumbai, India. npradhan@vsnl.com
D'Cruz
Anil K
AK
Pai
Prathamesh S
PS
D005500:Follow-Up Studies; D006801:Humans; D007822:Laryngeal Neoplasms / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D007825:Laryngectomy / Q000379:methods*; D020127:Recovery of Function / Q000502:physiology; D012189:Retrospective Studies; D013060:Speech / Q000502:physiology; D016896:Treatment Outcome