After a laryngectomy, patients breathe through a stoma in their neck.
This life-altering surgery, performed to treat advanced laryngeal cancer, removes all or part of the voice box, fundamentally altering speech, swallowing, and smell. The procedure is a last-resort treatment when organ-preserving therapies fail.
While laryngectomy is a critical intervention, its use is declining. A U.S. study found the number of hospitals performing total laryngectomies decreased by an average of 12.3 per year between 1998 and 2008. This trend is attributed to advancements in less invasive treatments, such as radiation therapy and chemotherapy, which can often cure the cancer without removing the larynx.
A Historical Perspective on a Life-Altering Procedure
The first total laryngectomy was performed by Theodor Billroth in 1873 on a 36-year-old man with cancer of the epiglottis. Although the patient learned to speak using an artificial larynx and was discharged four months later, the cancer recurred, and he died about a year later. Despite this initial tragic outcome, Billroth’s pioneering work demonstrated the procedure’s feasibility.
Earlier attempts at laryngectomy, such as one by Patrick Watson in Edinburgh in 1866, were performed post-mortem. The first successful artificial larynx was developed by Johann Nepomuk Czermak in 1869. The late 19th century saw high mortality rates from the procedure due to infection and shock. However, the achievement of long-term survival by Enrico Bottini in Italy proved that patients could live with the results of the surgery.
The history of laryngectomy highlights medical challenges, including a famous misdiagnosis case involving the German Crown Prince Friedrich III in 1887. This case showed the diagnostic and therapeutic difficulties that persisted into the 20th century.
Laryngectomy Removes the Voice Box for Advanced Throat Cancer
- Laryngectomy is major surgery to remove the voice box, primarily for advanced throat cancer.
- It is now performed less often due to advances in radiation and chemotherapy that can save the voice box.
- After surgery, patients must learn new ways to speak and adapt to breathing through a neck opening.
Clinical Evaluation Determines If Surgery Is Necessary
Today, laryngectomy is typically reserved for patients with advanced laryngeal cancer where organ-preserving treatments have failed or are unlikely to succeed. The decision is based on a thorough clinical evaluation. This includes direct laryngoscopy, where a doctor examines the larynx with a mirror or a flexible endoscope, to assess tumor size and location.
Imaging studies like CT, MRI, and PET scans determine the cancer's stage and extent. The TNM staging system is used, where T1-T3 tumors are generally smaller and may be treatable with partial laryngectomy, while larger T4 tumors often require a total laryngectomy, removing the entire voice box and separating the airway from the mouth and nose.
Less invasive partial laryngectomies are also performed for non-cancerous reasons, such as for transgender women or transfeminine non-binary individuals seeking a more feminine-sounding voice through procedures like vocal fold reduction or feminization laryngoplasty.
Post-Surgical Physiology and Rehabilitation
A total laryngectomy results in profound anatomical and physiological changes. Patients breathe exclusively through a permanent opening in their neck called a stoma. This severs the connection between the upper airway (nose and mouth) and the lower airway (trachea and lungs), affecting speech, smell, and taste.
Loss of natural voice is the primary functional consequence. However, several methods for voice restoration exist. The most common is tracheoesophageal puncture (TEP), a small surgical opening created between the trachea and esophagus. A one-way valve placed in this opening allows exhaled air to be directed into the esophagus, causing the pharyngeal tissues to vibrate and produce sound.
This method generally yields the most natural-sounding voice. Other options include an electrolarynx, an external device held against the neck that creates a mechanical sound, and esophageal speech, a more difficult technique that involves swallowing air and releasing it to form words.
Swallowing is also affected. While the risk of food or liquid entering the lungs (aspiration) is eliminated because the airway is separated, patients may experience difficulty swallowing solid foods.
The sense of smell and taste is diminished because inhaled air no longer passes over the olfactory receptors in the nose. A rehabilitation technique called the nasal airflow inducing maneuver (NAIM), or “polite yawning,” can help restore some olfactory function by creating negative pressure in the nasal cavity.
Symptoms That Require Immediate Medical Consultation
Laryngectomy is a major procedure with specific risks and considerations.
Post-operative symptoms that warrant immediate medical consultation include signs of infection, such as fever, increased redness, swelling, or pus around the stoma or neck incision; difficulty breathing; or the development of a pharyngocutaneous fistula, where saliva leaks from the throat to the neck skin.
Current Trends and Patient Outcomes
Laryngeal cancer affects many people globally, with an estimated 177,422 new cases and 94,771 deaths worldwide in 2018, accounting for about 1% of all cancer cases and deaths. In the U.S., around 12,410 new cases were expected in 2019, a number decreasing by approximately 2.4% annually, a trend linked to the decline in smoking rates.
Correspondingly, the number of laryngectomies performed in the U.S. has been falling more rapidly than the incidence of the disease itself, reflecting the success of organ-preservation strategies.
Despite the decline in procedures, an estimated 50,000 to 60,000 people in the U.S. are living with a laryngectomy. The quality of life for these patients varies.
Studies suggest that patients who undergo partial laryngectomy generally have a better quality of life than those who have a total laryngectomy. Recipients of total laryngectomy are at a higher risk of experiencing depression, anxiety, and a reduced quality of life related to social and physical functioning.
Global Healthcare System Impact and Future Directions
| Type of Laryngectomy | Anatomical Changes | Primary Functional Impact |
|---|---|---|
| Total Laryngectomy | Complete removal of the larynx; permanent stoma; airway separated from esophagus. | Loss of natural voice; permanent change in breathing; significant loss of smell/taste. |
| Partial Laryngectomy | Removal of part of the larynx; stoma may be temporary; some connection between airway and upper tract may remain. | Voice may be preserved but altered; swallowing may be temporarily impaired; less impact on smell/taste. |
References
- WikiPedia, Laryngectomy
- PubMed, “Trends in Laryngectomy in the United States, 1998 to 2008”.
