OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

TOTAL LARYNGECTOMY Johan Fagan

Total laryngectomy is generally done for meet, unless there is tumour in the pre-
advanced cancers of the larynx and hypo- epiglottic space or vallecula or base of
pharynx, recurrence following (chemo)rad- tongue.
iation, and occasionally for intractable as-
piration and advanced thyroid cancer inva- 2. Is thyroidectomy required? Both hypo-
ding the larynx. thyroidism and hypoparathyroidism are
common sequelae of total laryngecto-
Although it is an excellent oncologic pro- my, particularly following postoperati-
cedure and secures good swallowing with- ve radiation therapy, and may be dif-
out aspiration, it has disadvantages such as ficult to manage in a developing world
having a permanent tracheostomy; that setting. Twenty-five percent of laryn-
verbal communication is dependent on gectomy patients become hypothyroid
oesophageal speech, and/or tracheoesopha- following hemithyroidectomy; and
geal fistula speech or an electrolarynx; 75% if postoperative radiation is
hyposmia; and the psychological and fi- added. However, both thyroid lobes
nancial/ employment implications. Even in may be preserved unless Level 6 nodes
the best centers, about 20% of patients do need to be resected with subglottic and
not acquire useful verbal communication. pyriform fossa carcinoma, or when
there is intraoperative or radiological
Prelaryngectomy decision making evidence of direct tumour extension to
involve the thyroid gland.
The surgeon needs to consider the follow-
ing issues before embarking on a laryngec- 3. Will a pectoralis major flap be
tomy. required? A capacious pharynx is es-
sential for good swallowing and fistula
1. What will be the tumour resection speech. Should tumour involve the
lines? As the initial incisions into the hypopharynx, especially when it ex-
pharynx are done from externally with- tends distally towards the cricopharyn-
out having the tumour in view, the sur- geus, then the expertise must be availa-
geon must carefully assess the vallecu- ble to possibly augment the pharyngeal
lae, base of tongue and the pyriform repair with a pectoralis major flap.
fossae for tumour involvement, to a- Pectoralis major muscle flaps are also
void cutting into tumour when entering frequently used to overlay the pharyn-
the pharynx. Involvement of the base geal repair with salvage laryngectomy
of tongue may also prompt the surgeon to encourage spontaneous closure of
to opt for a retrograde laryngectomy pharyngo-cutaneous fistulae when they
(commencing the laryngectomy at the occur.
tracheostomal end of the specimen). In
the absence of CT or MRI imaging, 4. Is elective neck dissection required?
one can palpate and assess tumour in- With advanced laryngeal squamous
volvement of the pre-epiglottic space cell carcinoma requiring laryngectomy,
and base of tongue under general an- elective lateral neck dissection (Levels
aesthesia by placing one index finger in 2-4), either ipsilateral (glottic carcino-
the valleculae, and the other on the skin ma) or bilateral (supraglottic, medial
of the neck just above the hyoid bone. wall of pyriform fossa, bilateral glottic
The fingers should normally virtually carcinoma) is recommended, with con-
 version to modified neck dissection Surgical anatomy
should cervical metastases be found
intraoperatively. Level 6 is included in Figures 1 & 2 illustrate all the muscles that
subglottic and pyriform fossa carcino- will be divided during laryngectomy.
ma to clear the paratracheal nodes.

5. Is the patient suitable for tracheo-

oesophageal speech? This decision is
based on assessment of cognitive func-
tion, motivation, financial ability to
pay for replacement speech prostheses,
and proximity to speech services.

6. Are there synchronous primaries or

distant metastases? Total laryngecto-
my has significant morbidity and
should only be done if panendoscopy
and CXR/CT chest exclude metastases Figure 1: Supra- and infrahyoid muscles
or 2nd primaries.

Anaesthesia

Intubation: The operation is done under

general anaesthesia. The ENT surgeon
must be present to assist with a possibly
difficult intubation. If a difficult intubation
is anticipated, then either do an awake
tracheostomy, or infiltrate skin and trachea
with local anaesthesia/vasoconstrictor, in
preparation for a possible emergency
tracheostomy.

Preoperative tracheotomy: Tracheotomy

may have been required for airway ob-
struction. It is not an independent indica- Figure 2: Middle and inferior pharyngeal
tion for postoperative radiation therapy constrictors
unless tumour was entered at the time of
tracheotomy. If a tracheostomy has already Surgical steps
been done, then ask the anaesthetist to re-
intubate through the larynx with an oro- Positioning: Extend the neck
tracheal tube once the patient has been
anaesthetised as this facilitates dissection Incisions for apron flap (Figures 3a, b)
in the lower neck and speeds up the The horizontal limb of the flap is placed
surgery. approximately 2cms above the sternal
notch. An ellipse of skin around a preexis-
Perioperative antibiotics: Commence peri- ting tracheostomy is included with the re-
operative antibiotics before putting knife to section. With a simple laryngectomy the
skin, and continue for 24 hrs. vertical incisions are placed along the ante-

2
rior borders of sternocleidomastoid mus- • Elevate the apron flap in a subplatys-
cles. For a laryngectomy with neck dissec- mal plane, remaining superficial to the
tion(s), either a wider flap overlying the external and anterior jugular veins
sternocleidomastoid muscles is made (Fig- • Dissect the flap superiorly up to ap-
ure 3a), or a narrow flap with inferolateral proximately 2cms above the body of
extensions is made (Figure 3b). The latter the hyoid bone
has the disadvantage of a trifurcation
which is more prone to wound breakdown
and exposure of the major cervical vessels.

Figure 3a: Wide apron flap to accommo-

date neck dissections

Figure 4: Elevated apron flap and inci-

sions through investing layer of cervical
along anterior borders of sternocleido-
mastoid muscles

Freeing up the larynx

• Free up one side of the larynx at a time

• Stand on the side of neck that is being
dissected
Figure 3b: Narrow apron flap for laryn- • Ligate and transect the anterior jugular
gectomy, with lateral extensions for neck veins suprasternally and above the
dissections hyoid
• Incise the investing layer of cervical
Flap elevation (Figure 4) fascia along the anterior border of the
sternocleidomastoid muscle (Figure 4)
• Cut through the superficial layer of • Retract the sternocleidomastoid muscle
investing fascia and platysma muscles. laterally
The platysma is often absent in mid- • Identify the sternohyoid and omohyoid
line. Take care not to injure the exter- muscles
nal and anterior jugular veins

3
• Transect the omohyoid muscle medial re 6). It is a broad, thin muscle, so take
to where it crosses the internal jugular special care not to injure the thyroid
vein (Figure 5) gland and its rich vasculature which is
immediately deep to muscle
• Carefully elevate and reflect the supe-
rior cut end of the sternothyroid muscle
from the thyroid gland using electro-
cautery dissection (Figure 7)

Omohyoid Omohyoid
Common carotid

Internal jugular

Sternohyoid

Figure 5: Transect omohyoid

along yellow line Sternothyroid

• Identify the dissection plane between Thyroid

carotid sheath, and larynx and thyroid

gland and open this plane with sharp
and blunt finger dissection to expose
the prevertebral fascia (Figure 6) Figure 7: Transect & elevate sterno-
thyroid to expose thyroid gland

Prevertebral
fascia

Omohyoid

Sternohyoid

Figure 6: Transect sternohyoid mus-

cle to expose sternothyroid muscle
Figure 8: Divided sternothyroid re-
• Transect the sternohyoid muscle with tracted to expose thyroid. Line indica-
electrocautery wherever convenient tes course of dissection of thyroid
(Figure 6) gland and along midline of trachea
• Identify the sternothyroid muscle and • Divide the thyroid isthmus with elec-
carefully divide it below larynx (Figu- trocautery

4
• Divide and strip the tissues overlying and reflect and preserve the superior
the cervical trachea vertically in the thyroid pedicle from the larynx (Figure
midline to avoid injuring the inferior 11)
thyroid veins • Identify and divide the superior laryn-
• Carefully reflect the thyroid lobe off geal nerve
the trachea, cricoid and inferior con-
strictor with electrocautery (Figure 9)
while inspecting for and excluding di-
rect laryngeal tumour extension to the
thyroid gland Superior
• Identify and transect the recurrent laryngeal nerve

laryngeal nerve (Figure 10) Superior

• Identify the oesophagus and tracheo- thyroid artery

oesophageal groove (Figure 10)

Inferior constrictor
muscle

Thyroid cartilage Figure 11: Identify and divide supe-

Cricothyroid rior laryngeal branch of superior
muscle
thyroid artery
Cricoid

Thyroid gland • Rotate the larynx to the contralateral

Trachea
side, and identify the posterior border
of the thyroid ala (Figure 12)

Figure 9: Thyroid gland has been

mobilised from larynx and trachea

Recurrent
laryngeal nerve

Oesophagus

Figure 10: Identify oesophagus, and

divide recurrent laryngeal nerve Figure 12: Rotate the larynx with a
• Identify and divide the superior larynx- finger placed behind the thyroid ala
geal branch of superior thyroid artery,

5
• Divide the inferior pharyngeal constric- The surgeon then crosses to the opposite
tor muscle and thyroid perichondrium side of the patient and repeats the above
with electrocautery at, or just anterior operative steps.
to the posterior border of the thyroid
ala (Figure 13) Suprahyoid dissection
• Strip the lateral wall of the pyriform
fossa off the medial aspect of the The following description applies to laryn-
thyroid ala in a subperichondrial plane geal cancer not involving the pre-epiglottic
with a swab/sponge held over a finger- space, vallecula or base of tongue. When
tip, or with a Freer’s elevator, only on tumour does involve vallecula, pre-epi-
the side of the larynx opposite to the glottic space and/or base of tongue, then
cancer (Figure 14). On the side of the the pharynx is entered via the opposite py-
cancer, this step is omitted to ensure riform fossa or a retrograde laryngectomy
adequate resection margins. is done, commencing the dissection infe-
riorly at the tracheostomy (see later)
• Identify the body of the hyoid bone
• Remember that the hypoglossal nerves
and lingual arteries lie just deep to the
greater cornua/horns of the hyoid bone
• Divide the suprahyoid muscles with
electrocautery along the superior bor-
der of the body of the hyoid bone
(Figure 15)

Suprahyoid
muscles

Pre-epiglottic
fat
Figure 13: Divided inferior pharyngeal Hyoid body
constrictor and thyroid perichondrium
Hyoid: lesser
cornua

Figure 15: Transection of suprahyoid mus-

cles from hyoid body

• Initially do not dissect lateral to the les-

ser cornua, as the hypoglossal nerves
and the lingual arteries are located deep
to the greater cornua of the hyoid bone
• Release the digastric tendon and stylo-
Figure 14: Pyriform fossa mucosa stripped hyoid ligament and muscle from the
from thyroid lamina lesser cornu of the hyoid. The hyoid

6
 then become more mobile and can be
retracted inferiorly, away from the hy-
poglossal nerves
• Rotate the hyoid bone to the contra- Lingual artery
lateral side, and identify the position of Hypoglossal
the greater cornu/horn of the hyoid nerve

bone (Figure 16)

Middle
constrictor

Hyoid: greater
cornu Figure 17: Releasing greater cornu

• Dissect along the hyoepiglottic liga-

ment and strip the vallecular mucosa
from the anterior surface of the epi-
glottis (Figure 18)

Figure 16: Identify greater cornu

• The hyoglossus and middle constrictor

muscles are next released from the
Epiglottis
greater cornu with diathermy (Figure
16) Vallecula

• Divide the soft tissue on the medial Hyoepiglot-tic

aspect of the tips of the greater cornua ligament

of the hyoid with scissors to free the Pre-epiglot-

tic fat
greater cornua of the hyoid bilaterally
(Figure 17). Hug the inner aspect of
the greater cornua to avoid the hypo-
glossal nerves. If a neck dissection has
been done, the hypoglossal nerves will Figure 18: Suprahyoid approach to valle-
already be visible culae
• Dissect transversely with diathermy
along the superior margin of the body • Enter the pharynx by incising the mu-
of the hyoid bone, and along the supe- cosa along the superior margin of the
rior margin of the pre-epiglottic space epiglottis (Figure 19)
• Identify the hyoepiglottic ligament in
the midline

7
 Laryngeal resection

• Inspect the subglottis through the tra-

cheostoma to ensure that the tracheal
tumour resection margin is adequate
• Move to the head of the operating table
• Retract the epiglottis and larynx ante-
riorly through the pharyngotomy, and
inspect the larynx and the tumour
• Commence laryngeal resection contra-
lateral to the tumour using curved scis-
sors with points located anteriorly/
upwards to avoid inadvertently resec-
ting too much pharyngeal mucosa
• Cut along the lateral border of the epi-
Figure 19: Entering vallecula glottis on the less involved side, to ex-
pose the hypopharynx
Tracheostomy • Repeat this on the side of tumour with
at least a 1cm mucosal margin around
• A tracheostomy is done at this stage to the tumour
mobilise the larynx and to facilitate the • On the less involved side, cut through
laryngeal resection the lateral wall of the pyriform fossa
• Ask the anaesthetist to preoxygenate and hug the arytenoids and cricoid to
the patient preserve pyriform sinus mucosa (Fig-
• Incise the trachea transversely between ure 20). The superior laryngeal neuro-
the 3rd/4th/5th tracheal rings or below a vascular pedicle is transected if not
preoperative tracheostomy previously addressed
• With a small trachea, incise the lateral • Repeat on the tumour side
tracheal walls in a superolateral direc-
tion to bevel and enlarge the tracheo-
stoma
• Place a few 3-0 vicryl half-mattress
sutures between the anterior wall of the
transected trachea and the skin to ap-
proximate mucosa to skin
• Puncture and deflate the cuff of the
endotracheal tube, and cut the tube in
the pharynx, and remove the distal end
of the tube through the pharyngotomy
• Insert a flexible endotracheal tube e.g.
armoured tube into the tracheostoma. Figure 20: Resect the larynx preserving
Avoid inserting the tube too deeply as maximum amount of pharyngeal mucosa
the carina is quite close to the tracheo-
stoma. Fix the tube to the chest wall or • Join the left and right pyriform inci-
drapes with a temporary suture so that sions by tunnelling below and cutting
it does not become displaced, attach the postcricoid mucosa transversely
the sterile anaesthesia tubing and resu- (Figure 21)
me ventilation
8
Figure 21: Transverse postcricoid cut Figure 23: Transect trachea and remove
larynx
• Separate the posterior wall of the lar-
ynx (cricoid, tracheal membrane) from Retrograde laryngectomy
the anterior wall of the oesophagus by
dissecting with a scalpel along the • This involves commencing the laryngeal
avascular plane between that exists be- resection inferiorly at the tracheostomy
tween oesophagus and trachea/cricoid site; it is recommended when tumour in-
(Figure 22). Take care to stop just volves the pre-epiglottic space and/or base
short of the tracheostoma. of tongue, to ensure an adequate supra-
hyoid resection margin. Some surgeons
routinely do retrograde laryngectomy
• Free the hyoid bone and the lateral
borders of the thyroid cartilage as
described above
• Incise the trachea at about the level of
the 3rd/4th tracheal rings, insert an ar-
moured endotracheal tube and remove
the orotracheal tube (Figure 24)

Figure 22: Dissecting in the avascular

plane between oesophagus and trachea

• Transect the posterior wall of the tra-

chea, and remove the larynx (Figure
23)
• Inspect the laryngectomy specimen for
adequacy of resection margins, and
resect additional tissue if indicated
Figure 24: Trachea incised

• Transect the thin membranous poste-

rior tracheal wall (Figure 25)

9
Figure 25: Transecting posterior tracheal
wall to expose anterior wall of oesophagus

• Find the dissection plane between tra-

chea and oesophagus and dissect ceph-
alad in this well-defined plane with a
scalpel until the posterior aspect of the
cricoid and the posterior cricoaryte- Figure 27: Entering the postcricoid area of
noid muscles come into view (Figure the pharynx
26)
• Extend the incision to the pyriform fos-
sa contralateral to the cancer
• Once the cancer can be seen through
the pharyngotomy, incise the pyriform
fossa mucosa on the involved side
• By placing an index finger across the
vallecula to palpate the upper extent of
the cancer one can proceed to transect
the base of tongue with an adequate
margin
Pharyngo-oesophageal myotomy

• Optimising speech and swallowing re-

quires a capacious and floppy pharynx
• Always perform a pharyngoesophageal
myotomy to prevent hypertonicity of
the pharyngoesophageal segment
Figure 26: Oesophagus, thyroid laminae, • Insert an index finger into the oeso-
cricoid and posterior cricoarytenoid mus- phagus (Figure 28)
cles exposed • With a sharp scalpel, divide all the
muscle fibres down to the submucosa,
• Transversely incise the pharyngeal mu- and distally to the level of the trachea-
cosa about 1cm below the upper border stoma (Figure 28). The myotomy may
of the cricoid lamina to enter the post- be done in the midline or to the side
cricoid hypopharynx (Figure 27)

10
 the patient via a nasogastric tube, or a
catheter passed through the speech
prosthesis (Postlaryngectomy vocal
and pulmonary rehabilitation)
• Divide the sternal heads of the sterno-
mastoid muscles to create a flattened
peristomal contour and to facilitate dig-
ital stomal occlusion (Figure 30).

Figure 28: Cricopharyngeal myotomy

Tracheo-oesophageal fistula

• Tracheo-oesophageal speech is the best

form of alaryngeal communication
• A tracheo-oesophageal fistula is crea-
ted before closing the pharynx
• Pass a curved artery forceps through
the pharyngeal defect along the oeso-
phagus and tent up the anterior wall of
oesophagus/posterior tracheal wall 5- Figure 29: Creation of tracheo-oesopha-
10mm below the superior margin of the geal fistula
tracheostoma. Placing the fistula too
low makes changing the prosthesis
difficult
• Cut down onto the tip of the artery for-
ceps with a scalpel, and pass the tip of
the forceps through the fistula into the
tracheal lumen
• Hold the tip of a 14-gauge Foley urina-
ry catheter with the artery forceps and
pull the catheter through the fistula into
the oesophagus and pass it through the
pharyngeal defect (Figure 29). Then
advance the catheter down the oesoph-
agus. Avoid accidental displacement of Figure 30: Division of sternal heads of
the catheter by injecting 5ml water into sternomastoid to flatten peristomal area
the bulb and by fixing the catheter to
the skin with a suture Pharyngeal closure
• The catheter acts as a stent to allow the
fistula to mature in preparation for fit- • At least 2.5cm transverse diameter of
ting a tracheo-oesophageal prosthesis, residual pharyngeal mucosa is required
and is initially used for stomagastric for primary pharyngeal closure. The
feeding teaching that the minimum pharynx
• An alternative method is to insert a required is that which may be closed
speech prosthesis ab initio, and to feed over a nasogastric tube is incorrect, as

11
 the neopharynx is then too narrow for
adequate swallowing and voicing
• A horizontal/transverse closure is pre-
ferred as it maximises the capacity of
the pharynx (Figures 31). Only if there
is undue tension on the suture line, then
do T-shaped closure, keeping the
vertical limb as short as possible

Figure 32: Completed 1st layer of trans-

verse closure of pharynx

when the patient flexes the neck, then

trim a crescent of suprastomal skin
from the edge of the apron flap
• Suture the skin to the edge of the tra-
Figure 31: Pharynx well-suited to a trans- cheostomy with half-mattress inter-
verse closure rupted 3-0 vicryl sutures
• Seal the trifurcation at the lateral edge
• Take care not to injure the lingual arte-
of the stoma with a suture as indicated
ries when suturing the pharynx, as in-
below (Figure 33)
jury to the arteries may lead to necrosis
of the tongue
• A 3-layered pharyngeal closure is sug-
gested (Video)
o 1st layer: 3-0 vicryl running modi-
fied Connell or true Connell tech-
nique (Invert mucosa) (Figure 32)
o 2nd layer: 3-0 vicryl running suture
of submucosa and muscle
o 3rd layer: Approximate inferior Figure 33: Suture technique to seal trifur-
constrictors and suture constrictors cation between skin and side of tracheo-
to suprahyoid muscles with inter- stoma
rupted 3-0 vicryl
• Insert a ¼” suction drain
Final steps • Irrigate neck with sterile water
• Reapproximate the platysma with 3-0
• Ask the anaesthetist to do a Valsalva vicryl running sutures
manoeuvre to detect bleeding and a • Close the skin with a running nylon
chyle leak suture or with skin staples
• If there is excessive, lax suprastomal • Suction blood from trachea
skin that may occlude the tracheostomy

12
• Insert a cuffed tracheostomy tube, and
suture it to skin

Postoperative care

• Antibiotics x 24 hours
• Omeprazole (20mg/day) via Foley or
mouth x 14 days to reduce risk of
developing pharyngocutaneous fistulae
(See references)
• Chest physiotherapy
• Remove suction drains when <50mls
drainage per 24hrs (See references)
Figure 34: Stoma and Foley catheter
• Day 1: Mobilise to chair, remove uri-
feeding tube one week following surgery
nary catheter
• Day 2: Commence oral feeding. Early
oral feeding is safe, and does not cause
pharyngocutaneous fistulae (See refe-
rences)

Early feeding protocol

Intravenous general maintenance
Day 1
solution & stomagastric feeds
Day 2 Clear oral fluids & stomagastric feeds
Day 3 Free oral fluids
Day 4 Soft diet
Day 5 Normal diet

• Day 7: Remove sutures

Figure 35: Speaking valve
• Day 10: Insert speaking valve; no an-
aesthetic required (Figures 34, 35)
• Cover the stoma with a bib (Figure 36)

Pharyngeal reconstruction

Following resection of large pyriform fos-

sa tumours (Figure 37) or tumours that ex-
tend close the cricopharyngeus, or involve
the postcricoid area, only a narrow strip of
mucosa may remain to reconstruct the neo-
pharynx. If the residual pharyngeal mucosa
is <2.5cms in width, then additional tissue
is required to avoid pharyngeal stenosis, Figure 36: Bib
dysphagia and poor speech (Figure 38).
Reconstructive options include pectoralis All these flaps can be used to augment the
major, latissimus dorsi and supraclavicular pharyngeal repair, or when the pharynx has
flaps, or microvascular free tissue transfer been completely resected, may be tubed to
flaps (radial forearm, anterolateral thigh). entirely replace the pharynx (Figures 39 –
42).

13
Following pharyngeal reconstruction with
a flap, a contrast swallow X-ray is done on
about day 7 to exclude an anastomotic leak
before commencing oral feeding.

Figure 39: Pectoralis major augmentation

of pharynx

Figure 37: Large carcinoma of hypo-pha-

rynx that requires pharyngeal reconstruc-
tion

Figure 40: Tubed pectoralis major flap

Figure 38: Insufficient pharyngeal mucosa

for primary closure of pharynx

Figure 41: Tubed anterolateral thigh flap

14
 from South Africa. Curr Opin Oto-
laryngol Head Neck Surg. 2013
Jun;21(3):199-204
• Quail G, Fagan JJ, Raynham O, Kry-
nauw MH, John LR, Carrara MH. The
effect of cloth stoma covers on tracheal
climate of laryngectomy patients. Head
Neck. 2016 Apr;38 Suppl 1:E480-7

Clinical Practice Guidelines

• Cancer of Glottis:
https://developingworldheadandneckcance
Figure 42: Free jejunal flap rguidelines.com/index-page-glottic-
cancers/
Useful references • Cancer of Supraglottis:
https://developingworldheadandneckcance
rguidelines.com/index-page-supraglottic-
• Stephenson K, Fagan JJ. The effect of
cancers/
perioperative proton pump inhibitors • Cancer of Hypopharynx:
on the incidence of pharyngocutaneous https://developingworldheadandneckcance
fistula following total laryngectomy: a rguidelines.com/index-page-
prospective randomized controlled hypopharyngeal-cancers/
trial. Head Neck 2015 Feb;37(2):255-9
• Aswani J, Thandar MA, Otiti J, Fagan
JJ. Early oral feeding following total Author & Editor
laryngectomy. J Laryngol Otol. 2009;
123:333-338 Johan Fagan MBChB, FCS(ORL), MMed
• A practical guide to post-laryngectomy Professor and Chairman
vocal and pulmonary rehabilitation - Division of Otolaryngology
Fourth Edition: Postlaryngectomy vo- University of Cape Town
cal and pulmonary rehabilitation Cape Town, South Africa
• Fagan JJ, Lentin R, Oyarzabal MF, S johannes.fagan@uct.ac.za
Iaacs, Sellars SL. Tracheo-oesophageal
speech in a Developing World Com- THE OPEN ACCESS ATLAS OF
munity. Arch Otolaryngol 2002, 128 OTOLARYNGOLOGY, HEAD &
(1): 50-3
• Fagan JJ, Kaye PV. Management of the
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
thyroid gland with laryngectomy for
cT3 glottic carcinomas. Clin Otolaryn-
gol, 1997; 22: 7-12
• Harris T, Doolarkhan Z, Fagan JJ. Ti-
The Open Access Atlas of Otolaryngology, Head &
ming of removal of neck drains with Neck Operative Surgery by Johan Fagan (Editor)
head and neck surgery. Ear Nose johannes.fagan@uct.ac.za is licensed under a Creative
Throat J. 2011 Apr; 90(4):186-9 Commons Attribution - Non-Commercial 3.0 Unported
License
• Fagan JJ, Lentin R, Quail G. Interna-
tional Practice of Laryngectomy Reha-
bilitation Interventions - A Perspective

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16