A variety of therapeutic approaches is currently available for the management of advanced laryngeal cancer, but only recently has attention focused on the functional outcomes of speech and swallowing as important in treatment selection. For early-stage cancer of the larynx, definitive radiotherapy or conservation laryngeal surgery results in excellent outcomes both in terms of survival and function. But for patients with advanced laryngeal carcinoma, controversy continues regarding the optimal approach to cure the cancer but preserve both speech and swallowing.
For more than a century, total laryngectomy was the gold standard for treatment of advanced larynx cancer because it was quick and safe, provided an ultimate cancer cure, resulted in near-normal swallowing, and with appropriate rehabilitation yielded intelligible speech. Mostly because of concern regarding the loss of normal voicing and the presence of a permanent stoma, new nonsurgical treatment regimens, novel surgical approaches, and contemporary, effective rehabilitative techniques have been developed. In addition to total laryngectomy, current treatment options for intermediate and advanced laryngeal carcinoma include conservation laryngeal surgeries, combined regimens of chemotherapy and radiation, and in some cases, radiation therapy or chemotherapy alone, with impressive functional results in properly selected patients.
Unfortunately, laryngeal preservation does not ensure functional preservation. Given the current advances in rehabilitation and restorative technology, sometimes complete resection of the larynx produces better functional outcomes and superior quality of life than those that spare but cripple the larynx.
Functional disability following surgery is generally proportional to the volume of the resection. This is clearly the case following conservation laryngeal surgeries such as the supracricoid partial laryngectomy that spares only the cricoid cartilage and at least one cricoarytenoid unit to avoid a permanent stoma and preserve postoperative swallowing and phonation. Rigid patient selection criteria must be followed because of the inevitable aspiration and functional debility that will unquestionably occur immediately after surgery. The speech-language pathologist plays a critical rehabilitative role. During the preoperative speech and swallowing evaluation, the SLP explains and contrasts the surgical options and prepares the patient and family with realistic expectations for postoperative outcomes. The SLP also provides the surgeon with further important information regarding patient candidacy and selection. The focus of postoperative treatment is to achieve complete and timely neoglottic closure to prevent aspiration during swallowing and to reestablish a vibratory source for phonation. Appropriate patient selection coupled with aggressive rehabilitation usually result in successful functional return.
Radiation and Chemotherapy
Radiation and combined chemoradiation protocols have been used successfully to treat selected patients with intermediate and minimally advanced tumors. However, the adverse impact of radiation may equal or exceed that associated with surgery because of the long term sequelae including fibrosis, tissue changes and altered sensory awareness. Radiation-induced fibrosis restricts laryngeal movements, can reduce tongue and jaw movements, and diminish pharyngeal wall motion when the larynx is in the radiation field. New methods of intensity-modulated radiation therapy (IMRT) have been developed to reduce the post-radiation morbidity by targeting the tumor with set radiation doses while limiting the dose to other structures. Again, the SLP plays a significant role in helping the patient through the radiation treatment while minimizing long-term effects on speech and swallowing. The goals of therapy should be to prevent or reduce the formation of fibrosis and maintain the range of motion of the oropharynx and larynx.
The administration of chemotherapy as a single therapeutic modality to cure cancer remains experimental. Early experience provides new evidence for the ability to eradicate intermediate-staged laryngeal cancer while preserving function in select patients. The studies remain investigational and care must be taken when interpreting the results as the findings may not necessarily extrapolate to other head and neck sites.
Rehabilitation After Total Laryngectomy
Successful rehabilitation after total laryngectomy continues to rely upon a knowledgeable and expert SLP. Although the artificial larynx and esophageal speech production continue to be options for alaryngeal speech production following total laryngectomy, tracheoesophageal (TE) voice restoration remains the gold standard because it results in speech production that is most similar to normal laryngeal speech. It is important to remember that there are many prosthetic choices but no single prosthesis is the best choice for every patient. Patients must be properly evaluated and selected as the complexity of our patients has significantly increased-patients are younger, the demand for success is greater, the complications are often more severe, and preoperative treatments offer greater challenges to achieving tracheoesophageal speech. Strong multidisciplinary collaboration is mandatory to ensure functional success.
In conclusion, functional restoration of head and neck cancer patients is a team effort that must include an experienced SLP. Anatomic preservation does not ensure functional success; in some cases, total laryngectomy with TE voice restoration may be preferred over anatomic laryngeal preservation.
Evidence-based comparisons of different cancer treatments and their functional outcomes must continue in order to ensure optimal quality of life for patients with head and neck cancer.