Received: 19 October 2020 Revised: 5 January 2021 Accepted: 15 January 2021

DOI: 10.1111/vco.12681

SPECIAL ISSUE - ORIGINAL ARTICLE

Total laryngectomy and permanent tracheostomy in six dogs

Brad M. Matz | Ralph A. Henderson | Stephanie S. Lindley | Annette N. Smith

Department of Clinical Sciences, College of

Veterinary Medicine, Auburn University,
Auburn, Alabama
Correspondence
Brad M. Matz, Department of Clinical
Sciences, College of Veterinary Medicine,
Auburn University, Auburn, AL, USA.
Email: bmm0007@auburn.edu
Abstract
The objective of this report is to describe the surgical technique for total laryngec-
tomy and outcome in six dogs. Laryngeal cancer is an uncommon and challenging
clinical problem. Total laryngectomy can provide local disease control but is uncom-
monly performed. Detailed procedural descriptions are limited and similarly limited
information is available regarding patient outcome. Institutional medical records were
searched for dogs treated with total laryngectomy. Six dogs were identified. The pro-
cedure resulted in postoperative quality of life similar to permanent tracheostomy
alone. Surgical margin status was evaluated in five of six cases and was complete in
those five. All dogs survived to discharge from the hospital. Complications were
mostly related to tracheostomy occlusion or collapse which is recognized as a compli-
cation associated with permanent tracheostomy. Patient quality of life was accept-
able. Local recurrence was suspected in one dog. Recurrence was not observed in
the case with unknown margin status.

KEYWORDS
cancer, dog, laryngectomy, larynx, tracheostomy

1 | I N T RO DU CT I O N The objective of this manuscript is to present the technique for

Laryngeal neoplasms are uncommon in small animal practice.1,2 Specific
neoplasms previously reported include rhabdomyosarcoma,
oncocytoma, plasmacytoma, chondrosarcoma, fibrosarcoma, carcinoma,
lymphoma, osteosarcoma, leiomyoma, melanoma, granular cell tumour
and mast cell tumour.1-4 Clinical signs vary but typically include dyspho-
nia, stridor, stertor, exercise intolerance, difficulty in swallowing, inappe-
1,2,4
tence, weight loss, hyperthermia and dyspnea. Upper airway
obstruction is a serious clinical sign of a laryngeal mass and this often
results in emergency presentation for specialist evaluation.
The decision to elect total laryngectomy with permanent tracheos-
tomy (TLPT) is significant and informed discussions regarding expecta-
tions and lifestyle changes are important for client decision making.
Immediate resolution of airway obstruction is expected after TLPT. “Stan-
dard of care” recommendations for the treatment of laryngeal neoplasms
have been challenging to determine due, in part, to the limited informa-
tion available in the literature, a general perception that the procedure
does not result in local disease control and perceived poor outcomes.
performing TLPT and to describe complications and outcome in six
dogs that underwent TLPT for laryngeal neoplasia.
2 | M A T E R I A L S A N D M ET H O D S
Institutional medical records were searched from 2000 to 2018 for
dogs with laryngeal neoplasia. Criteria for inclusion included dogs
treated with TLPT and at least 3 months of follow-up. Follow-up
included in person examination and telephone conversations with
owners or primary care veterinarians. Five dogs in the present report
were included in two publications evaluating owner satisfaction and
tracheostomy related outcome.5,6
Preoperative findings, intraoperative complications, postoperative
complications, and need for revision surgery were recorded. Major
complications were defined as those requiring additional surgery to
resolve. Minor complications were defined as those that resolved with
conservative (medical) management.

Vet Comp Oncol. 2021;1–7. wileyonlinelibrary.com/journal/vco © 2021 John Wiley & Sons Ltd 1
2 MATZ ET AL.
3 | T O T A L L A R Y N G EC TO M Y P E R M A N E N T
TRACHEOSTOMY SURGICAL PROCEDURE
The procedure for TLPT varied based on patient factors and the ana-
tomical position of the tumour within the larynx. One of the dogs
reported here was presented for total laryngectomy following previ-
ously performed permanent tracheostomy. The other cases either had
a pre-existing temporary tracheostomy (for emergency airway man-
agement) or a temporary tracheotomy was created during TLPT for
intubation following laryngeal excision.
A midline cervical approach was made over the ventral aspect of
the larynx. The sternothyroid/hyoideus muscles were transected from
their laryngeal attachments. Any paralaryngeal vasculature was ligated
or sealed/divided with a bipolar vessel sealing device. This included
the hyoid venous arch. Portions of the hyoid apparatus were dis-
articulated as needed to allow further laryngeal exposure/mobiliza-
tion. A distally located tracheotomy (when needed) was created
following tracheal exposure and incision of approximately 50% of the
ventral aspect of an annular ligament. When present, orally placed
endotracheal tubes were removed and replaced with a sterile tube via
F I G U R E 1 Cranial is to the bottom of the image. The epiglottis is
retracted with an Allis tissue forceps
the distally positioned tracheotomy and passed to the anaesthetist
under the drapes. The pharynx was entered (Figure 1) rostral to the
epiglottis and the pharyngeal mucosa was sharply transected circum-
ferentially ending caudally at the pharyngoesophageal limen (ie, junc-
tion of the pharynx and oesophagus) (Figure 2). Once the larynx was
freed, the trachea was transected between proximal rings or through
the cricoid cartilage (when appropriate) and the larynx removed
(Figure 3).
The pharyngeal mucosa was apposed with simple continuous, del-
ayed absorbable monofilament suture (3-0 or 4-0 depending on dog
size) placed in the submucosa. Direct mucosal closure was avoided in
all dogs. The proximal end of the trachea was brought ventrally and
the sternothyroid/hyoideus muscles and sternocephalicus muscles
were apposed dorsal to the trachea. Skin along both sides of the inci-
sion was excised from two dogs to remove excess skin that might
occlude the tracheostomy site after surgery. The remaining wound
was apposed routinely.
The tracheal opening was enlarged by removing the ventral
aspects of an additional 2 to 3 tracheal rings creating a larger stoma
for the permanent tracheostomy. Absorbable monofilament sutures
F I G U R E 2 Cranial is to the bottom of the image. The oesophagus
is shown relative to the dorsal laryngeal region
MATZ ET AL.
FIGURE 3 Excised larynx
were placed between the subcutis and the cartilage of several tracheal
rings to relocate the stoma more superficially and to minimize tension
on the mucosal/epithelial apposition of the stoma. The tracheal
mucosa was then sutured to the skin with monofilament suture (both
absorbable and non-absorbable sutures were used depending on pref-
erence) (Figure 4).
To minimize peristomal debris accumulation, the stoma was either
misted with sterile saline from a spray bottle or nebulized with saline
every 4 hours. A thin layer of triple antibiotic ointment was applied to
the peristomal skin every 4 hours. Intravenous mu agonist opioids and
fluids were administered for the first 24 to 48 hours after surgery.
Oral pain medications were administered after that time for approxi-
mately 1 week and owners were instructed to clean the peristomal
skin as needed but to avoid contact with the mucocutaneous sutures.
Periodic exposure to warm, humidified air was also recommended for
the first month after surgery.
4 | RESULTS
All dogs were presented for evaluation of a laryngeal mass causing
dysphonia and variable degrees of upper airway obstruction. Total lar-
yngectomy/permanent tracheostomy was performed in all six dogs.
Breeds included Labrador Retriever, Golden Retriever, Shar-pei,
American Staffordshire Terrier, Fox Terrier and Shetland Sheepdog. There
were three castrated males, one intact male, one spayed female and one
intact female. Age at presentation ranged from 3 to 8 years. (Table 1).
Clinical signs included dyspnea, inspiratory stridor, increased respira-
tory effort, choking, lethargy, disrupted sleep and stertor. The duration
of clinical signs prior to presentation was available for four dogs and the
median duration was 7.5 weeks (range 2-52 weeks). Two dogs were
evaluated by their primary care veterinarian and diagnosed with a laryn-
geal mass via endoscopy (1) or orolaryngeal exam (1). One dog was
referred for laryngectomy after diagnosis of laryngeal sarcoma and had a
permanent tracheostomy performed by the referring veterinarian.
Diagnostic evaluation included pre-surgical biopsy in 3 dogs and
results were consistent with squamous cell carcinoma, grade 3 soft
3
FIGURE 4 Resultant closure
tissue sarcoma and neurofibroma. Cytology of the laryngeal mass was
performed in 4 dogs and was diagnostic for cancer in 3. Lymph node
cytology included evaluation of mandibular lymph nodes in 3 dogs
and superficial cervical lymph nodes in 2 dogs. Metastasis was not
found in any sample. Complete blood count and biochemistry analysis
was performed in all dogs and no clinically significant abnormalities
were detected in any dog. Urinalysis was evaluated in 2 dogs and
showed isosthenuria in 1 dog.
Three-view thoracic radiographs were performed in all dogs and
no evidence of metastatic disease was found in any dog. Radiographs
of the cervical region were obtained in 3 dogs and were consistent
with the presence of a soft tissue opaque mass in the laryngeal region
in all dogs. Cervical computed tomography scans were performed in
3 dogs and magnetic resonance imaging in 1 dog. All cross sectional
imaging studies were consistent with a soft tissue mass in the laryn-
geal region. Abdominal ultrasound was performed in 1 dog and was
consistent with benign prostatic hyperplasia and prostatitis.
Operative complications were not recorded for any dog. Major
immediate postoperative complications occurred in 2 dogs. In one dog,
the stoma was judged to be subjectively small. The other dog had a pre-
viously performed permanent tracheostomy and the stoma position
changed after laryngeal excision resulting in obstruction. Revision surgery
was necessary to enlarge the tracheostomy in both dogs during the same
hospitalization as the initial surgery. Additional major complications
occurred after initial discharge from the hospital in 1 dog requiring stoma
modification 2 additional times, 2 years after TLPT. Another dog required
2 stoma modifications 2 and 3 months after TLPT. Another dog required
stoma modification 6 months after TLPT (Table 1). Minor complications
included gastrointestinal signs (vomiting and regurgitation) and purulent
nasal discharge in 1 dog. Both resolved with conservative treatment.
Histologic diagnosis confirmed 3 benign and 3 malignant tumours.
Complete excision was confirmed for 5 dogs. Margin status was not
reported for the remaining dog. Pulmonary metastatic disease was
later confirmed in 2 dogs. One dog was diagnosed with squamous cell
carcinoma and the other with grade 3 soft tissue sarcoma 730 and
380 days after TLPT respectively. Metastasectomy was pursued for
both dogs. These dogs survived 1460 and 575 days after TLPT
4 MATZ ET AL.

TABLE 1 Summary of diagnoses, complications and oncologic outcome following TLPT.

Case Signalment Diagnosis Complications Outcome Survival time

1 8 year old, Rhabdomyoma 1. Airway obstruction due to stoma Unwitnessed death at 135 days
male castrated, shar- (complete size. Reoperated 3 days after home
pei excision) TLPT to enlarge stoma.
2. Stomal collapse revised 38 days
after TLPT with dorsally placed
sutures in tracheal rings and
stoma enlargement
3. Continued airway obstruction.
Excision of redundant tracheal
membrane 37 days after first
revision
2 4 year old, male Neurofibroma 1. Airway obstruction due to Developed Alive at last follow up,
castrated, golden (complete peristomal skin folds. Skin fold nonresectable mass, 1095 days after
retriever excision) resection 210 days after TLPT 1030 days after TLPT TLPT
2. Malignant peripheral nerve sheath
tumor near previous surgical site
treated with radiation therapy
3 3 year old female Rhandomyoma None Alive at last follow up, Alive at last follow up,
spayed, Labrador (complete excision) 1460 days after TLPT 1460 days after
retriever TLPT
4 7 year old, male Soft tissue sarcoma, 1. Mucous plug resulting in airway Death under anesthesia 910 days
castrated grade 2 (complete obstruction. Removed under while rechecking a
Fox terrier excision) sedation. brain MRI
2. Airway obstruction resulting in
stoma stenosis/revision 510 days
after TLPT
3. Inflammatory bowel disease
4. Airway obstruction due to
peristomal skin folds. Skin fold
resection 600 days after TLPT
5. Suspected meningioma 730 days
after TLPT
6. Stereotactic radiation therapy for
brain tumor
7. Cardiopulmonary arrest during
recheck MRI
5 8 year old, female Squamous cell Mild stoma irritation 1. Lung lobectomy Euthanasia 1460 after
Shetland sheepdog carcinoma (margin 730 days after TLPT TLPT for unrelated
status not known) for metastatectomy. reason
2. Cytotoxic
chemotherapy given
6 7 year old, male, Soft tissue sarcoma, Airway obstruction due to stoma 1. Cytotoxic Euthanasia 575 days
English grade 3 (complete collapse. Revised 6 days after chemotherapy after TLPT for
Staffordshire excision) TLPT 2. Accessory and right progressive disease
terrier caudal lung lobectomy
for presumed
metastatic sarcoma
380 days after TLPT

(730 and 195 days after metastasectomy respectively). Survival times
for all dogs ranged from 135 to 1460 days (Table 1).
One dog reported here experienced unwitnessed death at home
and this was believed but not confirmed to be because of airway
obstruction. Another dog died under anaesthesia during an MRI and
the cause was not determined. This dog had previously been diag-
nosed with a brain tumour and was being imaged after completing
radiation therapy.
5 | DI SCU SSION
This is the first case series in veterinary medicine detailing cases
treated for laryngeal neoplasms with TLPT. Additional animals with
laryngeal neoplasms have been reported but few have been treated
with TLPT.2-4,7-9 By comparison, humans experience laryngeal cancer
more commonly and more has been described about the procedure in
the human surgical literature.10-16
MATZ ET AL.
Awareness of TLPT as a treatment option, minimizing complica-
tions by familiarity with the procedure and knowledge of long-term
tumour control rates may influence more use of the procedure. Unfor-
tunately, little is known from the veterinary literature; however, data
available from human literature may be adaptable to veterinary
patients.
Laryngeal neoplasms occur with some frequency in humans
1
accounting for approximately 2% of cancers. Voice quality changes
may be more obvious, resulting in earlier detection of lower grade/
stage disease than typically encountered in veterinary medicine and
1
good to excellent rates of disease control. The maintenance of
speech is important during laryngeal cancer management in human
beings and is approached with intent for preservation of laryngeal
function. Small and histologically benign lesions are treated by local
excision and radiation therapy. With increasing grade of malignancy
and size of neoplasm, preservation of life becomes the principal deter-
minant and the treatment option of laryngectomy is considered as the
primary treatment. Veterinary patients do not follow these same con-
straints. Speech and vocal rehabilitation are of less importance in ani-
mals; however, issues related to tracheostomy management and
associated risks may be greater in animals such as inefficiency of
panting for cooling and accidental drowning. Other issues reported
include development of aspiration pneumonia, occlusion of the tra-
cheostomy site by adjacent skin folds, stenosis of the stoma, collapse
of the stoma, need for revision surgery and dyspnea among
others.5,17,18
Case selection is important and the surgical dose should be tai-
lored to the patient. The author's opinion is that neoplasms contained
within the luminal structures or within the intrinsic muscles would be
optimally treated by TLPT. These criteria would also likely result in
removal of an appropriate soft tissue envelope to effect local control.
Tumours extending beyond the extrinsic laryngeal muscle might also
be considered for TLPT but tumour free margins would be more diffi-
cult to achieve and complication risk would increase. Extension
beyond the extrinsic laryngeal muscles, involvement of the cricoid car-
tilage caudally or invasion of the pharyngeal mucosa would require
reconstructions that would be more likely to suffer from stoma col-
lapse, oesophageal dysfunction, tension and potentially pharyngeal
dehiscence.
TLPT is divided into three components: (1) Laryngeal excision, (2)
Water-tight pharyngeal reconstruction and (3) Permanent tracheos-
tomy creation. When local control is achieved, and no adjuvant
therapy is indicated, the primary continued patient management is for
the tracheostomy.
With minor differences, the cases reported here were treated
with similar laryngeal excision techniques. This portion of the proce-
dure may require modification depending on tumour location relative
to the larynx and tumour behaviour (eg, degree of local invasion). The
point of tracheal transection seems to have the most inconsistency
resulting in varying types of tracheostomy. For example, tran-
section locations could be through a portion of the cricoid cartilage or
through the proximal trachea depending on the location of the
tumour. Moreover, the thyroparathyroid blood supply should be
5
preserved, unless en bloc excision of these tissues is needed for
tumour control. Specific locations for muscle transection and need for
removal of portions of the hyoid apparatus depend on tumour loca-
tion and planned resection margins.
Failure to achieve adequate pharyngeal closure, or disruption of
the closure, is an important and potentially serious complication
reported in 3% to 65% of human cases.10,11
Factors associated with increased risk of fistula formation include
decreased haemoglobin, presence of comorbidity, decreased albumin,
need for red blood cell transfusion and lymph node metastasis.
Another study reported hypothyroidism and neoadjuvant radiation
therapy to be significant risk factors for fistula formation in human
beings.11 Pharyngeal closure was accomplished with suture patterns
that resulted in mucosal inversion into the pharyngeal cavity. Intra-
operative leak testing was performed and additional sutures placed if
a leak occurred. The authors of the study reported here prefer to
place sutures in the pharyngeal submucosa with the needle entering
and exiting near the wound edge for apposition and support (no direct
mucosal closure is performed). This allows for suture placement in the
strength layer of the tissues, slight wound eversion of the mucosa into
the pharynx and avoids suturing the exceptionally thin pharyngeal
mucosa. Direct suturing of the thin mucosa may result in inaccurate
apposition and interposition of the mucosal edge in the wound leading
to dehiscence or delayed healing. With slight mucosal eversion,
wound alignment is more consistent and there is greater opportunity
for direct or primary epithelial migration and first intention healing.
An alternative to hand-suturing the pharyngeal closure is the
use of a linear stapler. In a study of 21 TLPTs in human beings,
tumour free margins were reported in all cases and fistula formation
was reported in one patient.12 The stapler was placed prior to
mucosal incision and the authors' speculated intraoperative contam-
ination to be less as the pharyngeal cavity was not directly opened.
The fistula was reported to have occurred in a patient who had
recurrence following radiation therapy, consistent with another
report, and the fistula closed in 2 weeks with conservative manage-
ment. There are no reports of stapled pharyngeal closure in the
veterinary literature.
Modified supracricoid laryngectomy has been reported in people
with the primary goal of speech maintenance.13 Preservation of barking
function or phonation is of much less importance in dogs and most
dogs with tracheostomy lose vocal ability even without laryngectomy.19
However, noted above, the authors recommend preservation of the cri-
coid cartilage or a portion of the cartilage if possible. Preservation of all
or some of the cricoid cartilage maintains the tubular rigidity of the
proximal trachea possibly allowing for a more rigid tracheostomy.
The sternohyoideus muscles are closed as the most ventral layer of the
muscular portion of the wound. The trachea is then rolled
cranioventrally to the skin surface. Approximating sutures can be
placed from the subcutis to the cartilage circumferentially around the
trachea to help relocate the trachea superficially. This modification to
the technique has several advantages. The need to close the proximal
trachea (as previously reported) is eliminated because the proximal tra-
chea is rolled and anastomosed to the skin. This eliminates the proximal
6 MATZ ET AL.
tracheal closure as a potential access point to the tracheal lumen, effec-
tively eliminating this as a potential entry to the airway, thereby sepa-
rating the GI and respiratory systems.
In the dogs reported here, stoma care, peristomal skin hygiene
and lifestyle changes were needed. Typically, the stoma care
decreases as the tracheostomy matures and healing is complete.
Despite lifestyle modifications and increased attention needed to care
for their pets, most owners are satisfied following permanent
tracheostomy.6
Tracheostomy creation with laryngectomy following at a later
date may seem an attractive option. This manages the emergency
associated with airway obstruction. The authors' experience with this
approach has been that the tracheostomy ultimately has required revi-
sion. It may remain optimal to perform the procedure in a single stage
so the tracheostomy can be created without proximal laryngeal
attachment and without the possibility of tracheal position changes
when later divided from the larynx.
Other issues of importance in the human literature include consti-
pation secondary to inability to generate a forceful abdominal press
(lack of glottic closure), increased colonic transit times, infective
coughing, speech, smell, social/psychological issues and eating/
swallowing problems.14,15
Closure of the glottis allows for abdominal pressure generation,
known as a Valsalva manoeuvre. Contraction of abdominal muscula-
ture aided by exhalation against a closed glottis aids the process of
defecation. TLPT creates inability to generate a closed glottic attempt
at exhalation. In a study of 28 TLPT human patients, 70% reported
problems with constipation and colorectal transit was significantly
increased compared with the control population.15 Constipation is not
known to occur following TLPT in dogs, however an awareness of the
possibility is important because this would affect quality of life.
Pharyngoespohageal spasm has been reported following TLPT in
human patients.16 Spasm can result in impaired speech and problems
with swallowing. A small case series reported improvement of clinical
signs following injection of botulinum toxin, though some patients
required multiple interventions.16 Dysphagia has not been reported in
dogs previously and was not encountered in the dogs reported here. It is
reasonable to assume minor disability or decreased function likely occurs
but may remain clinically silent. To the author's knowledge, no imaging
studies have been performed in dogs to evaluate swallowing after TLPT.
Two dogs in this report developed pulmonary metastatic disease.
Both dogs were treated with lung lobectomy and their survival times
were 575 and 1460 days. It seems that the owners felt their dogs'
quality of life was sufficiently good that they elected additional sur-
gery for disease control.
Limitations to this report are those inherent to small case series.
Limited numbers of dogs and variable postoperative adjuvant plans
limit drawing sweeping conclusions. Lymph node sampling was con-
ducted in a non-standardized fashion. Sentinel lymph node mapping
could be considered to direct staging tests, need for lymph node exci-
sion, help determine prognosis and need for adjuvant therapy. A spe-
cific client survey was not used for evaluation but the authors had
substantial follow-up with all dogs and owners and 5/6 were satisfied
with the capabilities of their pet.
In conclusion, TLPT resulted in local tumour control, functional
patient results, acceptable quality of life and owner satisfaction with
surgical outcome in the six dogs reported here. TLPT should be con-
sidered a treatment option for laryngeal neoplasms. Maintenance of
the cricoid cartilage, if appropriate, eliminates the need for proximal
tracheal closure and provides for a more rigid tracheostomy.
ACKNOWLEDG MENTS
The authors would like to acknowledge Drs. Michael Tillson and Dan-
iel Linden for their assistance with proofreading the manuscript.
CONFLIC T OF INT ER E ST
The authors declare no potential conflict of interest.
DATA AVAILABILITY STAT EMEN T
Author elects to not share data because it was generated from medi-
cal records.
OR CID
Brad M. Matz https://orcid.org/0000-0002-6478-9536
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How to cite this article: Matz BM, Henderson RA, Lindley SS,
Smith AN. Total laryngectomy and permanent tracheostomy in
six dogs. Vet Comp Oncol. 2021;1–7. https://doi.org/10.1111/
vco.12681