Near-total laryngectomy: Patient selection and technical considerations

Objectives: To investigate the speech and swallowing outcomes of patients undergoing near-total laryngectomy and to determine those perioperative factors that are associated with success. Design and Setting: Retrospective analysis of a case series obtained from a hospital-based academic tertiary care center. Participants and Intervention: Records of all patients who underwent near-total laryngectomy at this institution were reviewed. Outcome Measures: Wound healing problems, quality of speech, degree of aspiration, and need for shunt revision were recorded. Results: Thirty-nine patients during a 10-year period underwent near-total laryngectomy. Good speech was obtained in 30 (76%). Severe aspiration was a complication in eight patients (21%), necessitating reversal of the shunt in four (10%). Certain technical aspects of this procedure that produce a 'hooded' myomucosal shunt were crucial to proper shunt function. Severe aspiration and poor voice outcome were most likely in patients who experienced a postoperative pharyngocutaneous fistula. These fistulas tended to occur at the junction of the pharynx and the upper end of the myomucosal shunt. When this region broke down, the hooding of the shunt was disrupted and its function impaired. Conclusions: Careful patient selection is crucial to the creation of a functional myomucosal speaking shunt after near-total laryngectomy. In patients at high risk for developing a pharyngocutaneous fistula, where irreversible aspiration through the shunt is then likely, this operation should be avoided and a total laryngectomy with tracheoesophageal puncture considered instead.