Clinical Indicators: Laryngectomy

1. History (all required)
   1. Symptoms–describe patient complaints of voice change, difficulty swallowing and/or breathing, hemoptysis, unexplained weight loss, throat pain or “lump in throat,” and approximate date of onset.
   2. Amount and duration of smoking and alcohol use.
   3. Describe any previous treatment for complaint.
2.  Physical Examination (all required)
   1. Complete head and neck exam including description of larynx, pharynx, and neck.
   2. Assessment of size, extent and location of tumor and any neck nodes.
   3. TMN staging of laryngeal tumor.
3. Tests
   1. Chest X-Ray.
   2. Barium swallow.
   3. Pulmonary function test.
   4. Tumor biopsy confirming malignancy.
   5. CT scan neck.
   6. Panendoscopy (can be done at time of definitive surgery).
   7. Appropriate LFT’s.
   8. Fine needle aspiration.
   9. Preoperative speech and language evaluation, if possible.

Postoperative Observations

1. Chest X-ray in recovery room.
2. Bleeding–Describe amount and location.
3. Elevated temperature–notify surgeon if greater than 102° F.
4. Breathing–if noisy or obstructed even after cleaning tracheostomy tube, notify surgeon.
5. Nerve function observe for weakness of lower lip (VII), shoulder (XI), palate (X), tongue (XII), arm and wrist (brachial plexus).
6. Wound infection–observe for progressive swelling, redness and pain in surgical area or signs of pharyngeal fistulae.
7. Wound suction drainage. Observe amount of drainage every shift or failure of drain to function.
8. Urine output–if less than 1 ml/kg/hr.
9. Abnormal lab values.

Outcome Review

1. One Month
   1. Wound–Is wound healing satisfactory?
   2. Stoma–Is laryngostoma adequate size? Is there frequent crusting? Is there bleeding or granulation?
   3. Postoperative management–Has additional treatment (management of cancer or rehabilitation) been initiated based on pathology report or preoperative plan?
   4. Cancer registry–Has the patient been entered?
   5. Speech rehabilitation–Is the patient enrolled in speech rehabilitation? Has the patient developed intelligible speech? If not, is additional training appropriate?
   6. Frequent scheduled appointments with head and neck oncologic surgeon for a minimum of five years.
2. Beyond One Year
   1. Speech rehabilitation–Has patient developed intelligible speech? If not, is additional training appropriate?
   2. Aspiration–Is there evidence of chronic aspiration? Is additional treatment required?
   3. Control of malignancy–Has there been any evidence of recurrence? Has follow-up been provided by surgeon and to the tumor registry?

Associated ICD-10 Diagnostic Codes (Representative, but not all-inclusive codes)

• C78.39 Secondary malignant neoplasm of other respiratory organs
• C78.30 Secondary malignant neoplasm of unspecified respiratory organ
• D14.1 Benign neoplasm of larynx
• D14.2 Benign neoplasm of trachea
• D21.0 Benign neoplasm of connective and other soft tissue of head, face and neck
• D02.0 Carcinoma in situ of larynx
• D02.1 Carcinoma in situ of trachea
• D37.01 Neoplasm of uncertain behavior of lip
• D37.02 Neoplasm of uncertain behavior of tongue
• D37.04 Neoplasm of uncertain behavior of the minor salivary glands
• D37.05 Neoplasm of uncertain behavior of pharynx
• D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity
• J38.3 Other diseases of vocal cords
• J38.2 Nodules of vocal cords
• J38.4 Edema of larynx
• J38.7 Other diseases of larynx
• J38.6 Stenosis of larynx
• J44.9 Chronic obstructive pulmonary disease, unspecified
• J95.00 Unspecified tracheostomy complication
• J95.02 Infection of tracheostomy stoma
• J95.03 Malfunction of tracheostomy stoma
• J95.01 Hemorrhage from tracheostomy stoma
• J95.04 Tracheo-esophageal fistula following tracheostomy
• J95.09 Other tracheostomy complication
• J39.8 Other specified diseases of upper respiratory tract
• J98.09 Other diseases of bronchus, not elsewhere classified
• M86.68 Other chronic osteomyelitis, other site
• M86.38 Chronic multifocal osteomyelitis, other site
• M86.48 Chronic osteomyelitis with draining sinus, other site
• M86.58 Other chronic hematogenous osteomyelitis, other site
• M86.8X8 Other osteomyelitis, other site
• Q31.1 Congenital subglottic stenosis
• Q31.3 Laryngocele
• Q31.8 Other congenital malformations of larynx
• Q32.1 Other congenital malformations of trachea
• Q32.4 Other congenital malformations of bronchus
• Q31.2 Laryngeal hypoplasia
• Q31.5 Congenital laryngomalacia
• Q31.9 Congenital malformation of larynx, unspecified
• Q32.0 Congenital tracheomalacia
• Q32.2 Congenital bronchomalacia
• Q32.3 Congenital stenosis of bronchus
• Q39.0 Atresia of esophagus without fistula
• Q39.1 Atresia of esophagus with tracheo-esophageal fistula
• Q39.2 Congenital tracheo-esophageal fistula without atresia
• Q39.3 Congenital stenosis and stricture of esophagus
• Q39.4 Esophageal web
• S12.8XXA Fracture of other parts of neck, initial encounter for closed fracture
• S12.8XXB Fracture of other parts of neck, initial encounter for open fracture
• S12.8XXD Fracture of other parts of neck, subsequent encounter with routine healing
• S12.8XXG Fracture of other parts of neck, subsequent encounter with delayed healing
• S12.8XXK Fracture of other parts of neck, subsequent encounter with nonunion
• S12.8XXS Fracture of other parts of neck, sequela

Additional Information

Assistant Surgeon — Y
Supply Charges — N
Prior Approval — N
Anesthesia Code(s) – 00320

Patient Information

Total or partial laryngectomy has been a highly successful method to remove cancer of the larynx (voice box). The choice of surgery over other forms of treatment such as radiation or chemotherapy is determined by the tumor size, although patient preference and social factors may influence that decision. If it is quite likely that there has been spread of the tumor to the neck, a lymph node
dissection may also be recommended.

Two common, but temporary, complications of laryngectomy are wound infection and fistula (an opening from the throat allowing saliva to leak out through the neck incision). Breathing or swallowing difficulties sometimes occur and require treatment. Alteration of voice is not a complication, as it always occurs with total or partial laryngectomy. Post operative rehabilitation is usually successful in helping the patient recover a voice that can be understood. After a total laryngectomy, there may be some loss of lifting strength. Some patients also experience some difficulty in straining to have a bowel movement. Alteration in the sense of smell can be expected after total laryngectomy, because the patient is no longer able to breathe through the nose. Patients with tracheostomies must avoid water sports for risk of drowning.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery.