Laryngectomy

A laryngectomy is a procedure to remove a part or whole of the larynx (voice box). The voice box is located in the neck region, in between the pharynx (part of your throat behind your mouth and before your food pipe) and the windpipe. The windpipe and food pipe are two tubes in your neck that are attached together.

During the surgery, the oesophagus (food pipe) and the trachea (windpipe) are separated. A separate opening is made in the neck for breathing and then the larynx is removed. After the surgery, it becomes difficult to speak in a normal manner. So, a partial approach to laryngectomy is preferred to preserve some or all functions of the larynx.

A doctor may recommend laryngectomy in people with:

• Cancer of the larynx, which may not be treatable by other methods. The primary aim of the surgery is to remove larynx tumour (cancerous growth) with the secondary objective being restoring the functions of the larynx such as respiration, swallowing, and speaking.
• Cancer of the hypopharynx (bottom part of the throat)
• Injury to the larynx
• Laryngeal swelling
• Recurring laryngeal cancer

The following are the symptoms of laryngeal cancer:

• Persistent difficulty in swallowing
• Hoarseness
• Weight loss
• Persistent cough

Laryngectomy may not be advised:

• If the surgeon thinks that the tumour is incurable 
• If the cancer has severely metastasised (spread) to other parts of the body
• To those with poor overall health and other systemic conditions.
• If the tumour that involves parts of the tongue or carotid artery (a major blood vessel in the neck).

Before the surgery, your doctor will explain the procedure to you and resolve any doubts that you may have about the surgery. The following investigations and tests are necessary before the surgery:

• A complete physical examination and a thorough vocal cord examination.
• A biopsy, which is a test in which a part of the cancerous tissue is removed and investigated under a microscope.
• A nasendoscopy where an anaesthetic is sprayed in the nose and a tube is inserted into the nose and throat. This tube has a small light at the end and a camera that helps the doctor detect any abnormal-looking parts.
• Scans such as computed tomography (CT) and positron emission tomography (PET) that determine the size and location of the tumour and whether cancer has spread to other body parts.
• An MRI scan and ultrasound may also be carried out for further assessment of the lymph nodes around the region with cancer and to check the spread.

The following preparations are also needed for this surgery:

• Pre-operative counselling is critical to this procedure since it is considered a major surgery. This process includes giving information about the disease, surgery (including the risks and possible consequences), and survival.
• You may be assisted by a speech pathologist to understand the changes in breathing, speaking, and swallowing after the surgery.
• A dietician or a nutritionist may help you to maintain satisfactory physical health prior to the surgery.
• You will also be informed about the time you may need to rest after surgery for which you may have to take leave from work and the need for a family member to take care of you at home, and other such adjustments.
• It is important to inform your surgeon about any medicines (prescription or over-the-counter) or herbal supplements that you may be taking at the time of surgery.
• You should also inform the doctor if you have any allergies.
• If you drink alcohol, you should inform your doctor so that they can plan your care accordingly, since stopping it suddenly can cause health issues.
• If you smoke, it is advisable to quit smoking at least a few days before surgery to prevent breathing difficulties after the surgery.

A laryngectomy may be total or partial and the larynx resection (removal) itself can take one to two hours. The larynx, which is connected to the upper part of the trachea (windpipe) allows the passage of air through it, into the lungs.

In a total laryngectomy, the larynx is fully removed, and the airway is blocked. Hence, a separate permanent stoma (opening) is made, and a tracheostomy tube is inserted.

In a partial laryngectomy or hemilaryngectomy, less tissue is removed, and efforts are made to keep the anatomy and function of the larynx maintained. The tracheostomy tube is eventually removed in this type of laryngectomy.

The procedure of a total laryngectomy is:

• A doctor will place a urinary catheter in your bladder to drain urine.
• An intravenous (IV) line will be placed in your arm to provide fluids.
• After giving general anaesthesia (to put you to sleep during the procedure), an artificial tube will be inserted into your windpipe through your neck (intubation) so that you can breathe while your natural airway is compromised.
• Following this, the surgeon will do a laryngoscopy (using a small device used to check the larynx and throat) to check the extent of cancer. A laryngoscopy also helps the surgeon to determine whether the surrounding structures can be surgically removed or not.
• Next, the surgeon will make an incision (cut) on your neck. In case you have an existing tracheostomy, the opening for the tracheostomy will be incorporated into the cut.
• The surgeon will extend the incision deeper to expose the underlying organs, nerves, and blood vessels.
• He/she will remove other cancerous structures surrounding the larynx and then the whole larynx itself.
• Once the larynx has been removed, the surgeon will suture the cut. However, before that he/she will create a permanent stoma (opening) in your neck and insert a tracheostomy tube through it. The end of the windpipe that was originally connected to the larynx will now be attached to this stoma at the base of your neck, enabling you to breathe.
• In the end, the surgeon will place drains near the wound to drain any fluid that collects after the procedure.

A partial laryngectomy may be carried out through the oral opening or through a cut made over the neck. The hole (tracheostoma) made for surgery is temporary in most partial laryngectomy cases. A part of the vocal cord is preserved in most cases so that you can still speak after the surgery.

During the surgery, the surgeon also examines and may remove some of your lymph nodes if needed. This is considered a major surgery which lowers the chance of cancer recurrence.

Sometimes, you may also be given radiation treatment after the surgery. Treatment is usually given one day at a time and does not require long hospital stays by itself.

You can expect the following after the surgery:

• You will have an IV line and catheter in place for a while.
• Pain relief medicines will also be administered to reduce discomfort. 
• During the first few days after surgery, you will be fed by a tube that goes into your stomach through your nose, neck or through the abdomen. This tube is removed in one or two weeks if wound healing is satisfactory.
• The tracheostomy tube will be kept in place to prevent the stoma from closing. 
• The hospital staff will initially clean the opening through which you are going to breathe (stoma), and in a few days, you will be trained in keeping it clean.
• It is difficult to talk in the days following surgery, and you will be given a notepad or whiteboard to communicate.
• An electronic device may be placed under your tongue or near your neck and, later, a special valve may be placed between your gullet and windpipe, which will allow sound to come out of your mouth, thus allowing you to communicate.
• You will be closely monitored by a speech pathologist to help you learn the new ways of communication and choose one that suits you the best.
• You will stay in the hospital for up to 14 days after your surgery.

The following things need to be taken care of at home after a laryngectomy:

• The medical team will train you in using a nebulizer to keep the air humid and filtered when you breathe.
• Use a sterile, damp, moist gauze to clean the skin around the stoma. If you notice crusting of the skin, carefully wipe it by cleaning it with a cloth wet with saline.
• You can also consult a dietician to maintain your nutrition intake in the first few weeks, as eating regular foods can be difficult.
• An occupational therapist can help you adapt to the various daily activities (such as showering with a hand shower instead of standing under a regular shower to avoid water from going into the stoma).
• You will also need the help of a family member or caregiver to assist you with daily activities such as cleaning, laundry, etc.
• After surgery, it is important to consume plenty of fluids and fibre to avoid constipation.

In a partial laryngectomy, the functional outcomes are usually good, and most people do not need feeding tubes for very long.

When to see the doctor?

Call or visit your doctor immediately if you have the following:

• Formation of crust (a dry, protective layer) around the stoma
• Difficulty in breathing or swallowing
• Bleeding
• Stoma reduces in size
• Blisters

Some risks associated with laryngectomy are:

• Infection
• Bleeding
• Breakdown of the wound
• Formation of a fistula (abnormal connection between two hollow spaces in the body)
• Poor voice after surgery
• Difficulty in swallowing
• Delayed healing and soreness around the stoma
• Inflammation and damage to the skin around the stoma
• Risk of requiring a permanent tube in the nose, stomach, and/or mouth for feeding
• Recurrence of the cancer

Your doctor will tell you when to have a follow-up visit after the surgery. In the follow-up right after the surgery, the doctor will check if you have been recovering as desired.

In subsequent follow-up visits, the medical team may advise some tests to check on your recovery as well as to check for the return of cancer. Usually, these appointments are scheduled more frequently in the first few years, and then reduced to once or twice a year for several years.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.