Laryngectomy is the removal of the voice box (larynx)
from the neck, usually due to cancer. The larynx protects the
airway to the lungs during swallowing and also contains the vocal
chords (more technically, the vocal folds ) that act as the sound
source for speech. Therefore, after a total laryngectomy, a person
must use a new way of breathing and a new sound source for speech.
Diagnosis of laryngeal cancer does not always mean surgical
removal of the entire larynx. Depending on the size, location, and
time of cancer detection, one or more of the following approaches
may be used: radiation therapy, chemotherapy, partial laryngectomy.
In these cases, voice may be preserved although its quality may not
be normal because of removing parts of the larynx, changes to
laryngeal tissue from radiation or chemotherapy, or removal of
nearby neck muscles (to prevent or stop the spread of the cancer).
In other cases, total laryngectomy, with or without
radiation therapy or chemotherapy, may be the only life-saving
solution. During this operation, a new route for breathing is
surgically created. The larynx-end of the windpipe ( trachea) is
connected to a hole ( stoma ) that is made in the neck. Rather than
using the mouth and the nose, the person with the laryngectomy will
breathe through this stoma.
Speech-Language Pathology Before
Surgery
The speech-language pathologist
will meet with the patient and family before surgery. He or she will
evaluate factors like vocal quality, pitch
range, and presence or absence of accent or regional speech
variations. This evaluation allows the speech-language pathologist
to understand the person's speech and voice capabilities. This
understanding helps to plan treatment after surgery.
The speech-language pathologist will also
explain the anatomy and physiology of the larynx,
describe how surgery will change this, and provide information on
what will happen in the intensive care unit
immediately following the surgery.
- Due to post-operative swelling, the patient will not
be able to swallow and will have a feeding tube
inserted through the nose into the stomach. This tube will be
removed when post-operative swelling decreases. A regular diet
can then be gradually introduced.
- There will be no voice as the
source of sound for speech will have been removed. The
speech-language pathologist will provide a pad of paper and a
pen or another writing device for expressing basic needs to
nurses, doctors, family, and friends.
- The speech-language pathologist will describe the
long-term treatment program that follows
discharge from the intensive care unit. This program will
provide a new sound source and replace the temporary writing
system.
Speech-Language Pathology After Surgery
After surgery, the speech-language pathologist's primary
goal is to provide the patient with a new sound source for speech.
There are three primary options:
- Esophageal Speech : Following a
laryngectomy, a person is unable to speak by exhaling air from
the lungs through the mouth. Using esophageal speech, a person
takes air in through the mouth, traps it in the throat, and then
releases it. As the air is released, it makes the upper parts of
the throat/esophagus vibrate and produces sound. This sound is
shaped into words in the same way it was before surgery: with
the lips, tongue, teeth, and other mouth parts.
This type of alaryngeal speech is difficult to learn and
use effectively, especially in rushed or stressful communication
situations.
- Artificial Larynx : The person uses
an electronic or mechanical instrument that provides the sound
source for speech. Some of these devices are held against the
neck, and others have a tube that the patient inserts in his
mouth. The mouth shapes the sound into words, as occurred before
surgery.
Many people use an artificial larynx as their first means
of alaryngeal speech. Esophageal talkers may still keep an
artificial larynx for use in certain situations, e.g., in noisy
places where their esophageal speech is not loud enough to be
heard.Effective use still requires training and
practice, and some disadvantages exist. The artificial larynx
has a mechanical voice quality, requires the use of one hand,
and draws attention to the speaker.
Tracheoesophageal Puncture (TEP): This
surgical procedure, one of the more popular methods of
alaryngeal speech production, can be performed at the time of
the laryngectomy surgery or afterwards. The surgeon creates a
connection between the trachea and the esophagus with a small
puncture. A small, one-way shunt valve is then inserted into
this puncture. To speak, the person inhales air through the
stoma and into the lungs. Then, he or she covers the stoma with
a finger. Air from the lungs is then directed from the trachea,
through the shunt valve, and into the esophagus. The esophagus
vibrates, creating a sound source for speech. This sound is then
shaped into speech sounds in the mouth in the same way it was
done before laryngectomy. The SLP will assist the individual in
selecting and fitting the prothesis and can teach proper
prothesis care and use.
Other Problems
Patients who have undergone radiation treatment as a
supplement to surgery may have dry and/or red skin at the site of
the treatment, sore throat, dry mouth, sensitive mouth, mouth sores,
difficulty swallowing, decreased taste, fatigue, and breathing
difficulties from swelling.
Patients who have received chemotherapy, often for the
treatment of metastasized cancer, may have nausea or vomiting,
increased chance of infection, bleeding or bruising, fatigue, and
shortness of breath. These side effects often stop after the
chemotherapy is discontinued.
Because the patient with the laryngectomy breathes through
a stoma, the air inhaled into the lungs is no longer warmed or
moisturized by structures of the nose and mouth. As a result, the
lining of the breathing tubes can become irritated and create a
thick mucous. This mucous may also crust on the stoma and require
routine removal. The patient may benefit from additional room
humidification and a cover to protect the stoma.
Who Is Affected?
Cancers of the larynx account for approximately 2-5% of
diagnosed cancers. More than twice as many men as women are
diagnosed. Most cases occur between the ages of 50 and 70.
