Near-Total Laryngectomy: An Alternative RLN Banking Procedure

Objectives: Laryngeal transplantation may become feasible in the next several years. A functional transplant will require separate reinnervation by nerves that are activated synchronously with laryngeal adductor and abductor functions, ideally by branches of the original recurrent laryngeal nerve. This report reviews the potential to preserve these nerve branches by use of the near-total, rather than total, laryngectomy procedure. Study Design: Case series Methods: A chart review was performed of patients for whom a near-total laryngectomy (NTL) was selected with the specific purpose of preserving intrinsic laryngeal muscles innervated by their native motor nerves. Anatomic features of the tumors that make this option available were delineated. Results: Three patients underwent NTL as treatment for malignancy involving the larynx. Each patient was relatively young and expressed an interest in pursuing a laryngeal transplant at a future date if such a procedure were offered. In each case the NTL was successful at controlling the tumor, and the patient was left with aspiration-free swallow and prosthesis-free alaryngeal voice. Ultrasound examination demonstrated persistent bidirectional movement of the remaining cricoarytenoid joint. Conclusions: The NTL procedure may be the ideal method for recurrent laryngeal nerve “banking” for possible future use in laryngeal transplantation. It preserves the original laryngeal neuromuscular units for both adduction and abduction, as will be required for a functional transplant. This procedure should be considered in all younger patients that require total laryngectomy. Near-total laryngectomy can often be used in cases where total laryngectomy is planned, as in these 3 cases. Robbins and Michaels found 46 of 64 (72%) total laryngectomy specimens oncologically could have had NTL (22) or less (24).5 Dumich et al. found 13 of 20 (65%) specimens could have had a near-total approach.6 There have been several reports that demonstrate that NTL in properly selected patients offers cancer control rates comparable to total laryngectomy.7-10 While NTL is not recommended for surgical salvage of radiation failures,10 it can be used following radiation for non-oncologic indications such as aspiration (e.g., Case 3). It can also be used as a “fall-back” option if there are unexpected intraoperative findings while performing a partial laryngectomy (e.g., Case 1). Although originally described for advanced (T3-T4) tumors of the glottis, supraglottis or pyriform sinus, other indications have been described such as base of tongue extension or anterior tracheal wall involvement11 (e.g., Case 2). NTL offers the advantage of tracheopharyngeal shunt speech without the need for a prosthesis. The location of speech production in the pharynx is similar to the original larynx, not more inferior as with a TEP. The remaining, innervated laryngeal muscles may also contribute to some modulation of voice quality. Ultrasound exam of the patients in this report showed continued volitional activity of these muscles more than 5 years post-operatively. But the biggest advantage, as highlighted in this report, is that an intact neuromuscular unit is maintained and thus allows the possibility of specific motor reinnervation of a future transplant. Other partial procedures, such as supracricoid laryngectomy, also maintain at least one neuromuscular unit and can be considered good “banking” procedures. The NTL is targeted at patients who would otherwise need a TL.