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Malignancy of the larynx: (Experimentation on Animal, Construction of Biologic Neo-Larynx and Rehabilitation of the Laryngectomee-20 Years Experience).

Research paper by P P Ghosh

Indexed on: 01 Jul '97Published on: 01 Jul '97Published in: Indian Journal of Otolaryngology and Head & Neck Surgery



Abstract

Squamous cell carcinoma is by far the commonest malignancy of the larynx and I would confine my present paper mainly to this along with the management and post-operative rehabilitation after total laryngectomy. High survival rate in majority of the cases, if diagnosed and treated early and adequately, provokes and encourages the interested laryngologist to consider not only about performing effective surgery, including on those cases where radiotherapy is inadequate or has failed, but also resorting to rehabilitative surgical procedures after total laryngectomy with or without neck dissection, offering to the laryngectomee a 'Biologic' Neo-Larynx, created from the patients own tissues, for tracheo-oesopharyngeal phonation.I am of the opinion that if a Neo-Larynx is constructed from the upper parts of the patient's own trachea and oesophagus without using any extraneous synthetic material, the patient would be happy to learn that the new voice box has been created out of his own tissues and no extraneous foreign material has been implanted and left in his body and he can effortlessly phonate 'tracheo-oesophageally' instaneously after removal of the silastic sheet from the Neoglottis five weeks after the operation without any rigorous training and the voice is better than the conventional alaryngeal 'pharyngo-oesophageal' one after total laryngectomy. Moreover, the complications associated with the prostheses viz. fungal and bacterial invasion with subsequent leakage around it and its displacement, and the tedious maintenance and replacement problems can be obviated by providing the patient with a 'biologic' Neo-Larynx of viable tissues.Therefore, my present paper will deal with the construction of Neo-Larynx after conducting experiments on animals. In the Neo-Larynx, a Neo-Epiglottis (hitherto not reported in the literature to my knowledge) and a Neo-Glottis are ingeniously constructed in order to enable the laryngectomee to phonate tracheooesophageally (c.f. pharyngoesophageally). The Neo-Glottis is transversely disposed since it offers better protection against aspiration than the vertically disposed one. The Neo-Epiglottis is constructed from the posterior tracheal wall, inferiorly based, or from the superiorly based tongue-shaped flap, raised from the full-thickness membranous posterior tracheal wall, or from the anterior tracheal wall, folded posteriorly (as in 'Duck-Bill' Neo-Larynx), for preventing aspiration through the Neo-Glottis into the tracheaobronchial tree during deglutition. In addition, a statico-dynamic sphincter or sling, reminiscent of the original primitive one, has been constructed around the Neo-Larynx, utilizing the strap muscles of the neck, in order to bring about competency of the Neo-Larynx for preventing aspiration through the Neo-Glottis. By this operation the problems of aspiration and stenosis of the Neo-Glottis have been largely solved. The Neo-Glottis is constructed in a transverse slit in the anterior oesophageal wall in a protective gutter in the anterior wall of the oesophageal lumen and the inferior lip of the slit is reinforced with a small cartilage bar in order to make it a stiff neo-vocal cord for producing stronger and better voice than pharyngo-oesophageal one which (i.e. tracheo-oesophageal one) is akin to normal voice. Presumably, the sphincter influences the voice quality by its continuously changing tension. The upper end of the trachea is closed to form a cul-de-sac and the phonetic stream is stopped here and channelised through the only available outlet i.e. the tracheooesophageal fistula (Neo-Glottis) into the oesophagus and pharynx for articulation.The latest proposed procedure is easier than the previous ones in which a biologic 'Duck-Bill' Neo-larynx is constructed from the upper parts of the trachea and oesophagus. Neo-Epiglottis and Neo-Vocal cords are incorporated in this. The Neo-Glottis is situated in the trachea anterior to the tracheo-oesophageal fistula. In this there are two additional phonatory mechanisms through which the phonetic stream passes :The two tracheal flaps, projecting into the oesophageal lumen, vibrate during phonation.Pseudoglottis at cricopharyngeus level.It is presumed that these, by producing harmonics, enrich the voice produced by the Neo-Glottis. Voice would be good with inflectional patterns and aspiration and stenosis problems would be significantly minimized.