Laryngectomy

1
Laryngectomy

• Diane Wisinski, CCC/SLP

2
Laryngectomy

• Surgical removal of the larynx
• A stoma is created by the outward turning of
  the tracheal ring to create a way for the
  individual to breathe
• The stoma is permanent

3
Vertical or Hemi Laryngectomy

• Structures removed
• One true and false vocal fold
• Arytenoid
• One half thyroid cartilage

• Structures left
• Epiglottis
• One true and false vocal fold
• Cricoid
• Post of condition
• Hoarse but serviceable voice, normal airway, no
  problem swallowing

4
Supraglottic or Horizontal Laryngectomy

• Structures removed
• Hyoid bone
• Epiglottis
• False vocal folds

• Structures left
• True vocal folds
• Cricoid cartilage
• Trachea
• Post op condition
• Normal voice
• May aspirate liquids
• Normal airway

5
LARYNGEAL CANCER

• Accounts for 1-2 of all cancer
• Accounts for 20 of all head and neck cancer
• Can occur at subglottic, glottic or supraglottic
  level (or a combination of)

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STAGING OF LARYNGEAL CANCER

• T Stands for primary tumor
• N Are the lymph nodes involved?
• M Is there metastasis?
• Known as the TNM classification

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CANCER STAGING

• T STAGES OF LARYNGEAL CANCER
• T1 Cancer is in one part of larynx and vocal
  folds move normally
• T2 Tumor has grown to another part of the larynx
  and vocal folds may/may not be involved
• T3 The tumor has spread throughout the larynx and
  the vocal folds do not move normally
• T4 The tumor has grown into tissues outside the
  larynx

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CANCER STAGING

• 4 Main Lymph Node Stages
• N0 No lymph nodes contain cancer cells
• N1 Tumor spread to one lymph node as the same
  side of the tumor in the neck, less than 3 cm
• N2 tumor is spread, greater than 3 cm
• N3 Tumor spread to lymph node where it is greater
  than 6 cm

9
CANCER STAGING

• M0 No tumor spread to other organs
• M1 Tumor spread to other organs

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RISK FACTORS FOR LARYNGEAL CANCER

• Chronic irritation from vocal abuse
• Chemical exposure
• Gastric Reflux
• Heavy alcohol use

• Smoking
• Pipe
• Cigar
• Cigarette

11
SYMPTOMS OF LARYNGEAL CANCER

• Hoarseness
• Pain
• Difficulty swallowing
• Ear pain
• Trouble breathing

12
Laryngeal Cancer
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TREATMENT FOR LARYNGEAL CANCER

• Radiation
• Laryngectomy
• Hemilaryngectomy
• Supraglottic laryngectomy

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Pre Surgical Anatomy

• Normal structures present

15
Laryngectomy

• After laryngectomy

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TYPES OF ALARYNGEAL SPEECH

• Esophageal Speech
• Artificial Larynx
• TEP

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Esophageal Speech

• Two methods used
• Injection
• Easiest to teach/use
• Brings compressed air into the esophagus
• Esophageal expulsion vibrates PE segment
• Uses plosive phonemes /t/, /k/, /p/ and also the
  ch and sh sound

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Esophageal Speech

• When teaching the patient
• Start with the dynamics of airflow
• Ask the patient to produce the phonemes
• Add /a/ to each phoneme
• Try words such as church, scotch, pat
• Try for longer duration of ah

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Esophageal Speech

• Inhalation Method
• Explain to patient that chest enlarges by muscle
  action there is a simultaneous enlargement of
  esophagus, and there is a greater chance for air
  to flow in. When chest becomes smaller,
  pulmonary air and esophageal air are likely to be
  forced out.

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Esophageal Speech

• During inhalation method, patient is taught to
  think of rapidly sniffing through his nose, when
  lungs appear to be half inflated, say up.
  Repeat until patient experiences phonatory success

21
Artificial Larynx

• Can be used in the first few days after surgery
• Can be used on cheek or neck
• In early post op days, neck is often
  unavailable for use due to associated lymph
  node surgery, soreness

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Artificial Larynx

• Mouth Type
• Cooper Rand
• A small tube is placed in the mouth and you
  articulate around the tube.

• Neck Type
• Servox
• Nu Vois
• Digital Models

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Artificial Larynx

• Cooper Rand Artificial larynx
• Requires tube in mouth
• Battery operated
• Saliva can collect in tube
• Tongue interferes with articulation

24
Artificial Larynx

• Servox

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Artificial Larynx

• Nu Vois

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Teaching of Artificial Larynx

• Teach neck or cheek placement
• Teach flat surface on neck
• Teach on/off timing
• Teach care of artificial larynx
• Teach proper terminology
• Teach phrasing
• Teach loudness/inflections
• Reduce stoma noise if present

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TEP Speech

• Tracheo-esophageal puncture (TEP)
• Can be done primary (with laryngectomy surgery)
• Can be done as secondary surgery (within 6 months
  or longer after initial laryngectomy)

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After TEP

• Voice prosthesis in place

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TEP

• Cricopharyngeal myotomy may also be done if not
  done with initial laryngectomy
• This is done to create a PE segment. Helps with
  adequate vibration after TEP

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Patient Considerations

• Good pulmonary support
• Adequate cognition
• Adequate PE segment
• Good manual dexterity
• Financial resources
• Some insurance companies may not pay for
  prosthesis

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Air Insufflation Test

• May be done prior to TEP
• Done only if doing secondary TEP
• Catheter is placed transnasally
• Can use clinician air or patient air (much more
  sanitary)
• If adequate voice is obtained, patient is
  considered a good candidate.
• If voice not obtained Botox, myotomy

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Air Insufflation Kit

• Air insufflation kit

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TEP

• Simply put
• A fistula is made between the tracheal and
  esophageal wall
• The patient wears a red rubber catheter for a few
  days and then the prosthesis is fit
• A prosthesis must be worn at all times or the
  fistula will close

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Types of Voice Prosthesis

• Duck bill
• Comes in 16 and 20 Fr
• Stay in for 3-4 days before cleaning
• Has a retention collar that allows prosthesis to
  sit in fistula

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Types of Voice Prosthesis

• Low resistance voice prosthesis
• Stays in for 3-4 days before cleaning
• Patient is instructed in removal, insertion and
  cleaning
• Comes in 16 Fr and 20 Fr
• Comes in different lengths

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Types of Voice Prosthesis

• In dwelling voice
• Changed only by medical doctor or speech
  therapist
• Stays in for about 3 months
• Needs cleaning in situ
• Is replaced when leakage occurs

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Other Considerations

• Long handled tweezers are needed
• Occasionally needs medication for prevention of
  Candida
• Patient needs to purchase fitting device

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RISKS of TEP

• Loss of prosthesis
• Closing of fistula
• Aspiration of prosthesis
• No voice
• Weak voice
• Prosthesis that leaks/ causes aspiration

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Fitting Procedure

• Patient has surgery
• Within 3-4 days, prosthesis is fit
• Prosthesis is removed
• Site is cleaned by doctor
• SLP inserts dilator
• After about 10 minutes, SLP inserts sizing device

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Supplies

• Dilator
• Comes in 16 Fr or 20 FR sizes

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Supplies

• Sizing device
• Comes in 16 Fr and 20 FR

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Supplies

• Inserting kit
• Gel cap, inserter

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Follow Up Therapy

• If patient has duckbill, or low resistance
• Teach cleaning procedure
• Teach in/out procedure
• Instruct patient in how to order his own supplies
• Teach stomal occlusion for speech
• Fit with tracheostoma valve if appropriate

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Follow Up Therapy

• Indwelling
• Provide patient with instruction on how to order
  independently if they wish
• Instruct in cleaning procedure (in situ)

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Cleaning System

• Cleaning system
• Filled with saline

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Other supplies

• Flashlight
• Stoma covers
• Foam filters
• Long handled tweezers
• Saline solution
• Tape
• COSTLY!

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Tracheostomy Tubes