Laryngeal Surgery: Information & Laryngeal Surgeons

So-called functional laryngeal surgery is used

• to improve the voice in cases of hoarseness, such as when it is caused by vocal cord paralysis,
• to alter the voice in cases of transsexuality.

Another type of functional laryngeal surgery is the enlargement of the larynx to treat shortness of breath caused by bilateral vocal cord paralysis. Here, a distinction must be made between temporary and permanent paralysis of the vocal cord nerves.

In the case of temporary vocal cord paralysis, a special suturing technique can be used to shift one vocal cord to the side. This creates space in the larynx. The Lichtenberger procedure, for example, is used in this case. If function of the vocal cord nerves returns, the sutures are removed after about one year during a minor laryngeal surgery.

If there is no improvement, another endoscopic laryngeal surgery should be performed after about one year. In this procedure, the surgeon removes a portion of the laryngeal cartilages (lateral fixation with arytenoidectomy).

If a permanent injury is confirmed, this surgical technique is recommended even without a waiting period.

Malignant tumors in the larynx are also called laryngeal carcinoma. It occurs most frequently in men aged 50 and older. Most of those affected are smokers.

Laryngeal carcinoma is most commonly recognized by hoarseness, as the vocal folds are often affected. Therefore, tumors on the vocal folds are usually detected early and can be successfully treated. For this reason, any hoarseness lasting longer than 6 weeks should be evaluated by an ENT specialist using laryngoscopy.

If the tumor is located above or below the vocal cords and does not reach them, it can grow unnoticed for a longer period of time. It sometimes only becomes apparent through

• shortness of breath due to laryngeal obstruction or
• swelling in the neck if the cancer has spread to the cervical lymph nodes

.

If laryngeal cancer is suspected, an endoscopy of the upper respiratory and digestive tracts (panendoscopy) is absolutely necessary. When a tumor is present in the larynx, additional tumors are found elsewhere in approximately 10 percent of cases. During panendoscopy, tissue samples are taken from the tumor and sent for histological examination.

During laryngoscopy, the patient lies on their back and is placed on artificial ventilation via a special endotracheal tube. The physician uses a microscope to better assess the fine structures of the larynx. Using microinstruments, the physician takes a tissue sample.

With this laryngoscopic surgical technique, a laser can also be connected to the microscope to perform laser surgery.

Several surgical options are available for treating tumors in the larynx. Among the surgical procedures that preserve a functional portion of the larynx, a distinction is made between

• the removal of part of the vocal cord or
• the entire vocal cord (decortication of the vocal fold, also known as vocal fold stripping, and chordectomy) as well as
• the various types of partial laryngectomy.

Endoscopic Laryngeal Surgery from the Inside for Laryngeal Cancer

For many patients, laryngeal surgery can be performed “from the inside,” i.e., endoscopically through the mouth and throat without any externally visible incisions. Either fine instruments or lasers are used for this purpose.

The laser has the major advantage of immediately coagulating the severed tissue as it cuts, thereby reducing bleeding. This provides a clearer view during surgery, leading to greater precision and better preservation of the remaining tissue.

The use of the laser can sometimes avoid so-called “major” external surgery involving complex reconstruction of the surgical defect through tissue grafting. As a result, the frequency of total laryngectomies has decreased in recent years. Compared to the past, it is now more often possible to preserve the larynx despite extensive tumor growth.

In addition, laser surgery can usually be performed again if the tumor recurs. The microscopically controlled removal of the tumor helps prevent the removal of too much healthy tissue.

When a laser is not used, extremely fine scissors and forceps are employed. The surgeon inserts them through the open mouth until they reach the larynx. Using these microinstruments under the surgical microscope, a particularly minimally invasive laryngectomy can be performed.

External Laryngectomy

The tumor is not always fully visible endoscopically. Consequently, safe removal of the tumor “from the inside” cannot be guaranteed. In such cases, laryngeal surgery must be performed “from the outside.”

This means that an incision through the skin of the neck and opening of the laryngeal skeleton are necessary. In cases where the tumor has spread extensively, laryngeal surgery that preserves the structures essential for laryngeal function is no longer possible. In such cases, the entire larynx must be removed—a procedure known as a total laryngectomy.

Overview of the various methods of laryngeal surgery

The following is a detailed description of the various methods of laryngeal surgery for laryngeal tumors:

Decortication of the vocal fold/vocal fold stripping

The surgeon removes the mucosa of the vocal fold endoscopically while preserving the vocal cord muscle. This procedure is used for precancerous lesions or carcinomas with very localized growth.

Chordectomy

The affected vocal fold is removed either endoscopically or, after temporarily splitting the thyroid cartilage, from the outside, along with the vocal cord muscle. This usually results in a voice that is easily understood but sounds hoarse.

This procedure is indicated for vocal cord carcinomas with

• free mobility of the vocal fold,
• free cricoid cartilage, and
• a free anterior portion of the vocal folds

. Here, too, the laser should be the preferred method.

Partial Laryngectomy

There are many forms of partial laryngectomy. Each type of resection has its own specific advantages and disadvantages. Essentially, however, a distinction can be made between horizontal and vertical partial resections.

This type of procedure is necessary when the tumor is too extensive to perform a chordectomy (see above). The result is good to adequate vocal function.

If the tumor is fully visible endoscopically, partial resections can also be performed using a laser. Laser procedures are generally less invasive, and the cosmetic outcome may be more favorable.

Vertical Partial Laryngectomy

Vertical partial laryngectomy is performed for unilateral tumors. During the procedure, the surgeon removes a vertical portion of the thyroid cartilage and, if necessary, the cricoid cartilage as well. Complete removal of both the vocal fold and the vestibular fold on one side is also possible.

A tracheostomy may need to be performed after laryngectomy to protect the airways. However, in most cases, this can be closed again after a few days.

Horizontal partial laryngectomy 

Horizontal partial laryngectomy is used to treat tumors located above the vocal cords. Both vocal folds and the arytenoid cartilages are preserved.

In this type of laryngeal surgery, the surgeon first makes a horizontal incision through the thyroid cartilage, roughly in the middle. The surgeon then removes the lower portion of the cartilage along with the tumor-affected tissue attached to it.

Frontolateral partial laryngectomy

This method is used for tumors that have invaded the anterior commissure. During the procedure, the surgeon removes the affected portions of the anterior commissure as well as the remaining affected vocal folds.

Total laryngectomy

If a partial resection is no longer possible due to the size of the tumor, complete removal of the larynx is necessary. A laryngectomy is also often necessary following the recurrence of laryngeal cancer (recurrence) after a partial resection or primary radiation therapy.

In this type of surgery, the airway and esophagus are completely separated from one another. As a result, the patient becomes what is known as a “neck breather,” since a permanent “tracheostomy” (tracheal incision) is required.

It is possible to learn to speak again even after complete removal of the larynx. Several options are available for this.

In esophageal speech, or “burp speech,” air is forced into the upper esophagus and then released in a controlled manner back into the throat. The vibration of the mucous membrane in the lower throat produces a sound that enables speech. However, mastering this speech technique requires several months of training. The major advantage is that the patient can speak without relying on assistive devices.

Alternatively, a surgically created shunt between the trachea and the pharynx can help. A silicone voice prosthesis, such as a Provox prosthesis or a Blom-Singer prosthesis, is inserted into this shunt. In this way, most patients can speak again fairly quickly.

However, they often rely on assistive devices, such as certain valves on the tracheostomy site, or must close the tracheostomy opening with one hand in order to speak. Furthermore, the prostheses require regular care and must be replaced from time to time. Otherwise, they gradually lose their function due to material fatigue or contamination.

A third option for voice rehabilitation is the use of a so-called electronic larynx. It uses an electronic speech aid to generate an audible vibration (known as the primary sound), which is pressed against the neck. The vibrations are thereby transmitted to the floor of the mouth or the throat.

By modulating the sound through changes in the position of the tongue and throat, the patient is able to speak in this way.

The chances of recovery are best when the tumor is detected early and treated appropriately.

In many cases, laryngeal cancer affects the vocal cords. Therefore, hoarseness is an early warning sign. The prognosis for most laryngeal carcinomas is therefore better than, for example, that of pharyngeal cancer, which can often grow unnoticed for a long time.

Nearly 90% of all patients can be cured if

• the laryngeal carcinoma is confined to only one vocal cord and
• it is detected in the early stages and treated correctly.

This percentage drops to < 50% in the case of a large, advanced laryngeal cancer.

After endoscopic laryngeal surgery, a follow-up examination is recommended in some cases approximately 6 to 8 weeks later. It is performed under general anesthesia and is used to take tissue samples. This allows doctors to check whether a tumor has formed again.

In addition, regular follow-up care by an ENT specialist is absolutely essential.