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Post Laryngectomy


Medical editor Jan Folkvard Evensen
Onkolog dr.med.
Radiumhospitalet
Oslo universitetssykehus HF

General

Laryngeal cancer is treated primarily by curative radiation therapy. 

In cases where radiation therapy is not sufficient, or for advanced cancer, the larynx must be removed. 

A laryngectomy causes significant lifestyle changes for the patient by losing normal speech function and breathing through a tracheotomy.

Indication

  • Laryngectomy patients after laryngeal cancer.

Goal

  • Prevent problems related to lifestyle changes after laryngectomy.

Background

Tracheotomy

After the entire larynx is removed, the patient will breathe through a tracheotomy.

When breathing through the nose, the air is warmed and moistened. This is not the case when the larynx is removed, therefore the air will be colder, dryer, and more polluted. This irritates mucosa which produces mucous. The mucous then adheres like a scab in a trachea or stoma and is often difficult to cough up. In addition, the patient is more disposed for infections because of the short distance from the stoma down to the lungs (1).

This problem is reduced by covering the stoma with a moisture and heat filter. The principle behind this is to preserve the moisture and heat in the breath of exhalation to transfer to the breath of inhalation. This is equivalent to the function of the nose before the operation.

Function of speech

There are three alternatives for speech after laryngectomy:

Electronic speech

Electronic speech is created by a device which replaces the vocal cords. The device creates vibration and is held against the neck where the sound travels to the mouth and creates speech in the same way as before surgery (1).

Esophageal speech

Esophageal speech is created by pressing air down under the muscles in the upper esophagus. When the air is forced into the mouth, it causes the esophagus and pharynx to vibrate causing sound. This sound is changed in the mouth and becomes the voice (1).

Tracheo-esophageal speech

Tracheo-esophageal speech uses a prosthetic device surgically placed between the windpipe and esophagus. A one-way vent allows air from the trachea under the muscles in the upper esophagus. The muscles vibrate with the help of air from the lungs. The sound is then changed in the same way as before surgery. In order to activate the prosthesis, a finger must be held over the stoma when breathing out. There are also vent systems to activate the prosthesis in other ways, such that both hands can be free (1).

 

1. Reference: Den Norske Kreftforening. Strupekreft. Informasjon til pasienter, pårørende og andre interesserte. Oslo, 2000


Preparation

Before the surgery, the patient will be given thorough information by a:

  • doctor 
  • nurse 
  • speech therapist 
  • laryngectomee
  • social worker
  • physical therapist  

Implementation

Supplementary treatment may improve living with the disease or completing treatment.

  • Physical therapy - effective for conditions of the neck and helps/improve respiratory infections (2).
  • Treatment for lymph edema - relieve symptoms if the lymph system is injured.

Tracheotomy

Patients are instructed how to maintain the stoma.

Soreness may occur around the stoma due to moisture and filter tape/bandaging. This can be prevented by using the correct type of tape/bandaging and moisturizing with lotion (1).

The patient should not stay outside if the temperature is colder than - 5 to -10°C (1).

Laryngectomees generally sleep more quietly than before. This may create anxiety for the spouse (1).

New method of speech

All laryngectomees are offered stay at the Bredtvedt Center where patients are followed-up for speech function.

In cooperation with the patient, the most suitable method of speech is determined.

About 6 weeks after the procedure, the patient will start learning how to use their esophageal voice or electronic speech device.

After some time, a speech ventilator is inserted. (For some, this is done during the operation).

Insertion of the speech prosthesis
  • The hypopharyngoscope is inserted.
  • The tip of the scope is palpated in the top of the stoma.
  • A needle is inserted to determine the point of puncture for the trocar that will be used to place the prosthesis.
  • The trocar is inserted in the same place as the needle and into the scope. 
  • A mandrin is threaded through the trocar and up through the scope to the mouth. 
  • The prostheisis is attached to the mandrin, which is retrieved through the stoma. 
  • The prosthesis is adjusted and the attachment is cut off.

Speech ventilator is changed as needed.

Regardless of what speech alternative the patient chooses, their voice will be weaker than before. The patient's spouse may need a hearing test/apparatus (1).

Some laryngectomees master their new method of speech so adequately that they are able to speak on the phone, and some in other languages.

Nutrition

Special considerations after surgery: 

  • The patient will no longer be able to blow on warm food and drink.
  • Sense of smell will not function as before, therefore food will taste different.
  • Scar formation and/or injury from radiation in the hypopharynx/esophagus (upper area) may cause difficulty swallowing. 

Psychosocial

It is easy to isolate oneself during the first period after surgery (1). Many patients experience not being able to eat and speak at the same time as problematic. In addition, the stoma must be cleaned often and away from the table. The patient may find this difficult in social situations.

Many patients have found comfort and benefit in having contact with another laryngectomee.

 

1. Reference: Den Norske Kreftforening. Strupekreft. Informasjon til pasienter, pårørende og andre interesserte. Oslo, 2000

2. Referebce: Storaker KA. Kartlegging av skulderfunksjon etter lymfeknutedisseksjon. Oslo: Rikshospitalet Universitetsklinikk, 2002


Follow-up

Late complications

Infection in the lower airways

Tracheotomees are more disposed for respiratory infections than before.

Scab formation

Scabs may form in the stoma and trachea due to lack of moisture and conditioning of the respiration air.

This is treated by regularly dripping salt water in the stoma, manual removal of scabs, and using a thick cream to moisturize the edge of the stoma.

Difficulty swallowing

Swallowing difficulties may occur due to stenosis in the hypopharynx or in the the transition between the hypopharynx and esophagus.

This is treated by blocking or with PEG if blocking does not help.

Stomal stenosis 

Stomal stenosis causes increased breathing difficulty. This is treated surgically by stomaplasty (3).

 

 

3. Reference: Bretteville G. Søberg R. Boysen M.: A new method for treating tracheostomalstenosis following laryngectomy. Clin. Otolaryngol. 1992; 17: 44-48


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