Laryngectomy

Clinical Indicators
Laryngectomy

Procedure	CPT	FUD
Total	31360	90
Total, with neck dissection	31365	90
Subtotal, supraglottic	31367	90
Subtotal, supraglottic & neck dissection	31368	90
Partial, hemilaryngectomy, horizontal	31370	90
Partial, hemilaryngectomy, laterovertical	31375	90
Partial, hemilaryngectomy, anterovertical	31380	90
Partial, hemi, antero-latero-vertical	31382	90
pharyngectomy & RND	31390	90
pharyngectomy & RND & reconstruction	31395	90
Epiglottectomy	31420	90

Indications

1. History... all required

a)	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.
b)	Amount and duration of smoking and alcohol use.
c)	Describe any previous treatment for complaint.

2. Physical Examination... all required

a)	Complete head and neck exam including description of larynx, pharynx, and neck.
b)	Assessment of size, extent and location of tumor and any neck nodes.
c)	TMN staging of laryngeal tumor.

3. Tests

a)	Chest X-Ray.
b)	Barium swallow.
c)	Pulmonary function test.
d)	Tumor biopsy confirming malignancy.
e)	CT scan neck.
f)	Panendoscopy (can be done at time of definitive surgery).
g)	Appropriate LFT's.
h)	Fine needle aspiration.
i)	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

a)	Wound--Is wound healing satisfactory?
b)	Stoma--Is laryngostoma adequate size? Is there frequent crusting? Is there bleeding or granulation?
c)	Postoperative management--Has additional treatment (management of cancer or rehabilitation) been initiated based on pathology report or preoperative plan?
d)	Cancer registry--Has the patient been entered?
e)	Speech rehabilitation--Is the patient enrolled in speech rehabilitation? Has the patient developed intelligible speech? If not, is additional training appropriate?
f)	Frequent scheduled appointments with head and neck oncologic surgeon for a minimum of five years.

2. Beyond One Year

a)	Speech rehabilitation--Has patient developed intelligible speech? If not, is additional training appropriate?
b)	Aspiration--Is there evidence of chronic aspiration? Is additional treatment required?
c)	Control of malignancy--Has there been any evidence of recurrence? Has follow-up been provided by surgeon and to the tumor registry?

Associated ICD-9 Diagnostic Codes

197.3	M2-Neoplasm, respiratory NEC
212.1	B-Neoplasm, larynx
212.2	B-Neoplasm, trachea
215	B-Neoplasm of connective tissue; head and neck
231	Carcinoma in-situ, larynx
235.1	Carcinoma in-situ, trachea
235.6	Neoplasm of uncertain behavior, lip, oral cavity, pharynx
478.5	Other disease of vocal cords (nodules, leukoplakia, granuloma, abscess)
478.6	Edema of larynx
478.71	Cellulitis and perichondritis of larynx
478.74	Stenosis of larynx
496	Chronic airway obstruction
508	Chronic aspiration
519	Tracheostomy complication
519.1	Tracheal stenosis
730.18	Chronic osteomyelitis NEC
748.3	Laryngotracheal anomalies, Other
750.3	Tracheoesophageal fistula, esophageal atreasia and stenosis
807.5	Closed fracture of larynx
807.6	Open fracture of larynx and trachea

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 Notice

The Clinical Indicators for Otolaryngology--Head and Neck Surgery are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The American Academy of Otolaryngology-Head and Neck Surgery, Inc. 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.