Total Laryngopharyngectomy

Hypopharyngeal cancer may present at an advanced stage, as few symptoms may be present until the cancer is advanced.

Presenting symptoms include progressive pain in the throat, dysphagia, odynophagia, dysphonia, referred otalgia, throat clearing, globus sensation, weight loss, and/or a mass in one or both necks.

Dyspnea and hoarseness may represent invasion of the larynx or the recurrent laryngeal nerve.

Dysphagia for solids and liquids implies an advanced cancer.

Risk factors include the use of tobacco and alcohol, gastroesophageal reflux, and Plummer-Vinson syndrome.

Plummer-Vinson syndrome is a rare condition generally appearing in women between the ages of 30 and 50. This syndrome consists of iron deficiency anemia, esophageal webs, dysphagia, weight loss, angular stomatitis, and atrophic glossitis.

Preoperative nutritional evaluation should be performed on patients with hypopharyngeal or cervical esophageal cancer. Prealbumin, albumin, thyroid stimulating hormone, and iron levels provide information regarding nutritional status in conjunction with complete blood counts and basic chemistry. Referral to a nutritionist or dietician may be indicated preoperatively, as well as placement of enteral feeding access. Reconstructive options must be evaluated prior to placement of feeding access, as stomach and jejunum are potential donor sites.

Evaluation of the larynx and pharynx with flexible laryngoscopy is mandatory.

Cancer may represent direct extension from the larynx or be a primary cancer of the hypopharynx.

Vocal fold motion, patency of the airway, and pooling of secretions in the hypopharynx should be noted.

Examination of the neck may reveal a mass either from regional metastasis or from direct extension of the cancer.

Stridor is suggestive of involvement of the larynx.

Poor nutritional status should be noted.

Examination of the oral cavity and oropharynx should be performed to rule out synchronous primary cancers.

Examination of the cranial nerves (hypoglossal, accessory) should be performed to evaluate extension of the cancer from the primary site or regional metastases.

Paralysis of the vocal folds can occur as a result of invasion of the paraglottic space or cricoarytenoid joint or involvement of the recurrent laryngeal nerve.

The chest wall, extremities, and abdomen should be examined to note prior surgery or chemoport placement that might affect potential reconstructive options.

Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) with contrast is used to determine the extent of the primary cancer and the presence of regional metastasis. Contrast-enhanced CT imaging is highly sensitive for evaluation of pre-epiglottic and paraglottic space involvement by laryngeal cancer. MRI is more sensitive for detecting pathologic involvement of cartilage.

Imaging of the lungs is recommended to evaluate for metastasis. CT of the chest is preferable to chest radiographs, given its higher sensitivity and specificity for detecting metastasis. Evidence of restrictive lung disease should be noted, as this may be a relative contraindication for pectoralis major flap reconstruction with a large skin paddle.

Abdominal imaging may be indicated in patients with a history of prior abdominal surgery and in whom gastric pull-up or jejunal free flap is being considered as a reconstructive option.

18-fluorodeoxyglucose positron emission tomography (PET) allows for evaluation of whole-body distant metastatic disease.

Barium swallow esophagram can evaluate esophageal involvement either from direct extension of a laryngeal or hypopharyngeal primary cancer or a second primary cancer of the esophagus. It may also be useful in evaluating possible invasion of the prevertebral fascia.

Advanced stage cancers of the hypopharynx (T3-T4)

Advanced stage laryngeal cancers with involvement of the postcricoid mucosa, posterior hypopharyngeal wall, or the pyriform sinus with extension across the midline posteriorly

Salvage surgery following primary chemoradiation in patients who fail organ preservation protocols

Significant comorbidities precluding primary surgery and reconstruction

Irresectable cancer such as encasement of the carotid artery or invasion of the prevertebral fascia

Distant metastases

Preoperative evaluation should note whether the patient may be intubated in a standard fashion or whether fiberoptic intubation is indicated. In patients with a large obstructive cancer, awake tracheostomy under local anesthesia may be the safest choice.

Pan-endoscopy should be performed to map the cancer, obtain tissue for pathologic examination and diagnosis, and to evaluate for involvement of the cervical esophagus. Tumor mapping allows for better prediction of planned cancer resection and coordination with the reconstructive surgeon.