NEAR-TOTAL LARYNGECTOMY - PATIENT SELECTION AND TECHNICAL CONSIDERATIONS

Objectives: To investigate the speech and swallowing outcomes of patie nts undergoing near-total laryngectomy and to determine those perioper ative factors that are associated with success. Design and Setting: Re trospective analysis of a case series obtained from a hospital-based a cademic tertiary care center. Participants and Intervention: Records o f all patients who underwent near-total laryngectomy at this instituti on were reviewed. Outcome Measures: Wound healing problems, quality of speech, degree of aspiration, and need for shunt revision were record ed. Results: Thirty-nine patients during a 10-year period underwent ne ar-total laryngectomy. Good speech was obtained in 30 (76%). Severe as piration was a complication in eight patients (21%), necessitating rev ersal of the shunt in four (10%). Certain technical aspects of this pr ocedure that produce a ''hooded'' myomucosal shunt were crucial to pro per 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 dow n, the hooding of the shunt was disrupted and its function impaired. C onclusions: 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, whe re irreversible aspiration through the shunt is then likely, this oper ation should be avoided and a total laryngectomy with tracheoesophagea l puncture considered instead.