What is a laryngectomy?
A laryngectomy is very different from a tracheotomy procedure, but is often confused. Confusion over whether an individual has a laryngectomy or tracheostomy during an emergent setting can result in adverse consequences for the patient. It is imperative to understand the differences.
A laryngectomy is the removal of all or part of the larynx and is typically performed as treatment for laryngeal cancer. A laryngectomy is occasionally performed as a last resort for the individual with chronic aspiration, unable to protect the airway either from a prior cancer treatment or complications from other conditions.
In a total laryngectomy the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). The airway is separated from the nose, mouth and esophagus. The trachea is brought forward below the level of the larynx and is sutured to the base of the neck just above the sternal notch, creating a permanent opening in the neck called a stoma. Therefore, the individual does not breathe through the upper airway. Instead, the individual breathes through the stoma. A total laryngectomy is typically performed when the disease cannot be managed with more conservative measures.
Since the mouth and nose are bypassed, special care must be taken to humidify the airway. In the hospital this humidification will be provided with a cool or warm aerosol and a trach mask. Later on, the patient may prefer to use a heat moisture exchange (HME) device.
Since the stoma is the only passageway for breathing, it is important to maintain the airway and suction the trachea through the stoma as needed, using sterile technique. It is also important to clean the stoma, as crusting of secretions may develop that can block or occlude the stoma. It is important to teach the patient, family and/or caregivers how to care for the stoma properly, and what to do in case of an emergency.
Please see the National Tracheostomy Safety Project Algorithm for Emergency Laryngectomy Management.
Anatomy After Total Laryngectomy
A partial laryngectomy is a more common treatment for laryngeal cancer. It is a surgical procedure that is meant to preserve the voice. The airway is not separated from the nose and mouth. One or a partial piece of the vocal fold is removed. A tracheostomy tube may be temporarily placed.
Speech After Laryngectomy
In order to produce natural voicing with a normal airway, there are three main occurrences:
- Air generator: The lungs must generate adequate airflow through the larynx and upper airway.
- Vibrating mechanism- The vocal folds, located in the larynx, quickly open (abduct) and close (adduct) due to a small pressure that is generated in part due to the airflow from the lungs. This results in a vibration to create speech sound.
- Articulation tract- Sound is modulated by the pharynx and shaped into words by the tongue, palate, lips and teeth.
An individual with a total laryngectomy will not produce speech with his/her natural voice because the vocal folds are removed when the entire larynx is removed. Therefore there is no vibrating mechanism to produce sound. The trachea is separated from the upper airway so that airflow no longer flows from the lungs through the upper airway. AIrflow with a laryngectomy is redirected out through a stoma in the neck and does not pass through the articulation tract. Loss of speech is often cited as the most disturbing consequence of a laryngectomy. It can greatly reduce the individual’s quality of life.
Over the past 50 years, there have been significant advances made in techniques for voice restoration for individuals with laryngectomy. Alternative options for speech with a laryngectomy include an electrolarynx, esophageal speech, or tracheal esophageal speech through a tracheoesophageal prosthesis (TEP). A speech-language pathologist may assist in communication options and learning techniques.
Esophageal speech does not require any surgery or mechanical accessories. It is performed by swallowing air into the esophagus and then expelling air, which oscillates the esophagus to produce a sound. The sound is manipulated, as usual, by moving the mouth, lips and tongue to create different speech sounds. Esophageal speech is difficult to learn and may be difficult for people to understand.
An electrolarynx is a device that produces a vibration to act as a sound source when placed on the outside of the neck or cheek. The external vibration replaces the vibration of the vocal folds by producing a tone. The tone is transmitted into the oropharynx, where sound is shaped by the articulators (lips, tongue, teeth, jaw) into meaningful speech. Tone can also be transmitted through an intraoral adapter. The lungs are not used to produce a sound source and therefore there is no reason to exhale during speech production with an electrolarynx.
Few states provide access to free to assistive equipment for hearing, mobility or speech disabled. The Telecommunications Equipment Distribution Program has a map of states that participate.
Trache0esophageal prosthesis (TEP)
Speech with a trachesophageal prosthesis (TEP) is the most natural and intelligible speech following laryngectomy. A small surgical passage way or tracheoesophageal puncture is created from the posterior wall of the trachea connecting to the esophageal wall. The puncture can be made either during the laryngectomy procedure or afterward in a separate procedure.
A small voice prosthesis is then placed into the passageway to enable speech. The TEP uses a one-way prosthesis to let air pushed up from the lungs to pass through from the trachea and enter the esophagus, causing the walls of the esophagus to vibrate as a new voice. The airflow then travels through the oropharynx where sound is shaped by the articulators. The stoma must be covered for speech to occur and airflow to divert through the TEP.
A properly functioning TEP remains closed so that food and liquids are prevented from entering from the esophagus and into the trachea. One of the most difficult complications to manage after TEP is enlargement of the TE puncture that results in aspiration of saliva, liquid, and/or food around the prosthesis into the trachea. Leakage of saliva or ingested food around the prosthesis occurs with the reported rate ranging from 7% to 42% of the cases (Laccourreye et al, 1998).
Although many advances have been made over the years, these devices are no permanent and will require periodic replacement by a skilled clinician, typically an ENT or SLP.
Eating after Laryngectomy
It was previously believed that after a total laryngectomy, swallowing would not be affected. However, dysphagia is recognized as a common occurrence following laryngectomy. In a total laryngectomy, since there is separation of the trachea and esophagus, aspiration is anatomically not possible unless there are complications.
Aspiration is possible when there is a fistula present. Pharyngocutaneous fistula (PCF) creates a communication between the pharynx and the cervical skin or less frequently with the stoma. It is the most common postoperative complication of laryngectomy, with variable ranges of 3% to 65% in reported series, most falling within 10%–40% (Paydarfar & Birkmeyer, 2006). The most common symptom is leakage of pharyngeal contents, usually saliva, or food if an oral diet has been implemented, flowing through the fisula and emerging from the cutaneous orifice. A barium swallow is indicated to exclude the presence of a PCF.
Oral feeding is typically resumed 5-7 days following the laryngectomy surgery in uncomplicated cases. A liquid diet is first implemented, and then a gradual implementation to solid foods as tolerated. Oral feeding may be delayed 7-10 days for more extensive surgeries or if there was radiation, which may increase healing time.
Comparison of Laryngectomy and Tracheostomy
It is sometimes difficult to discern whether an individual has a laryngectomy or a tracheostomy. It is vital to determine the difference and which one is present, particularly for emergencies. Communication and teamwork are also critical to keeping patients safe and preventing adverse events.
The patient with a tracheostomy has a potentially patent upper airway as an alternative meals of ventilating and oxygenating the patient. A patient who has had a laryngectomy does not have any communication between the upper airways (nose, mouth, pharynx) and the lungs and can only be oxygenated and ventilated via the laryngectomy opening.
The following algorithms and bedhead signs are available through the National Tracheostomy Safety Project:
There are several types of laryngectomy tubes, and since many of them look identical to tracheostomy tubes, it is important to recognize the differences in this airway. ‘Lary’ tubes are sometimes used in place of a tracheostomy tube to maintain the patency of the stoma. Their length and bending angle are designed for an optimum fit into the newly constructed airway.
Laccourreye O, Menard M, Crevier-Buchman L, Couloigner V, Brasnu D. In situ lifetime, causes for replacement and complications of the Provox voice prosthesis. Laryngoscope 1997;107:527-30.
Paydarfar JA, Birkmeyer NJ. Complicationsin head and neck surgery: a meta-analysis of postlaryngectomy
pharyngocutaneous fistula. Arch Otolaryngol Head Neck Surg. 2006;132:67–72.
National Tracheostomy Safety Project