Laryngectomy

Definition

A laryngectomy is the partial or complete surgical removal of the voice box (larynx).

Purpose

Because of its location, the voice box, or larynx, plays a critical role in breathing, swallowing, and speaking. The larynx is located above the windpipe (trachea) and in front of the food pipe (esophagus). It contains two small bands of muscle called the vocal cords that close to prevent food from entering the lungs and vibrate to produce the voice. If cancer of the larynx develops, a laryngectomy is performed to remove tumors or cancerous tissue. In rare cases, the procedure may also be performed when the larynx is badly damaged by gunshot, automobile injuries, or other traumatic accidents.

Demographics

The American Cancer Society estimates that, in 2003, about 9,500 people in the United States will be found to have laryngeal cancer. Laryngeal cancer occurs 4.4 times more frequently in men than in women, although, like lung cancer, it is becoming increasingly common in women. Tobacco smoking is by far the greatest risk factor for laryngeal cancer. Others include alcohol abuse, radiation exposure, asbestos exposure, and genetic factors. In the United Kingdom, cancer of the larynx is quite rare, affecting under 3,000 people each year.

Description

Laryngectomies may be total or partial. In a total laryngectomy, the entire larynx is removed. If the cancer has spread to other surrounding structures in the neck, such as the lymph nodes, they are removed at the same time. If the tumor is small, a partial laryngectomy is performed, by which only a part of the larynx, usually one vocal chord, is removed. Partial laryngectomies are also often performed in conjunction with other cancer treatments, such as radiation therapy or chemotherapy.

During a laryngectomy, the surgeon removes the larynx through an incision in the neck. The procedure also requires the surgeon to perform a tracheotomy, because air can no longer flow into the lungs. He makes an artificial opening called a stoma in the front of the neck. The upper portion of the trachea is brought to the stoma and secured, making a permanent alternate way for air to get to the lungs. The connection between the throat and the esophagus is not normally affected, so after healing, the person whose larynx has been removed (called a laryngectomee) can eat normally.

Diagnosis/Preparation

A laryngectomy is performed after cancer of the larynx has been diagnosed by a series of tests that allow the otolaryngologist (a physician often called an ear, nose & throat or ENT specialist) to examine the throat and take tissue samples (biopsies) to confirm and stage the cancer. People need to be in good general health to undergo a laryngectomy, and will have standard pre-operative blood work and tests to make sure they are able to safely withstand the operation.

As with any surgical procedure, the patient is required to sign a consent form after the procedure is thoroughly explained. Blood and urine studies, along with chest x ray and EKG may be ordered as required. If a total laryngectomy is planned, the patient meets with a speech pathologist for discussion of post-operative expectations and support.

Aftercare

A person undergoing a laryngectomy spends several days in intensive care (ICU) and receives intravenous (IV) fluids and medication. As with any major surgery, blood pressure, pulse, and respiration are monitored regularly. The patient is encouraged to turn, cough, and deep-breathe to help mobilize secretions in the lungs. One or more drains are usually inserted in the neck to remove any fluids that collect. These drains are removed after several days.

It takes two to three weeks for the tissues of the throat to heal. During this time, the laryngectomee cannot swallow food and must receive nutrition through a tube inserted through the nose and down the throat into the stomach. Normal speech is also no longer possible and patients are instructed in alternate means of vocal communication by a speech pathologist.

When air is drawn in normally through the nose, it is warmed and moistened before it reaches the lungs. When air is drawn in through the stoma, it does not have the opportunity to be warmed and humidified. In order to keep the stoma from drying out and becoming crusty, laryngectomees are encouraged to breathe artificially humidified air. The stoma is usually covered with a light cloth to keep it clean and to keep unwanted particles from accidentally entering the lungs. Care of the stoma is extremely important, since it is the person's only way to get air to the lungs. After a laryngectomy, a health-care professional will teach the laryngectomee and his or her caregivers how to care for the stoma.

There are three main methods of vocalizing after a total laryngectomy. In esophageal speech, patients learn how to "swallow" air down into the esophagus and create sounds by releasing the air. Tracheoesophageal speech diverts air through a hole in the trachea made by the surgeon. The air then passes through an implanted artificial voice. The third method involves using a hand-held electronic device that translates vibrations into sounds. The choice of vocalization method depends on several factors including the age and health of the laryngectomee, and whether other parts of the mouth, such as the tongue, have also been removed ( glossectomy ).

Risks

Laryngectomy is often successful in curing early-stage cancers. However, it requires major lifestyle changes and there is a risk of severe psychological stress from unsuccessful adaptations. Laryngectomees must learn new ways of speaking, they must be constantly concerned about the care of their stoma. Serious problems can occur if water or other foreign material enters the lungs through an unprotected stoma. Also, women who undergo partial laryngectomy or who learn some types of artificial speech will have a deep voice similar to that of a man. For some women this presents psychological challenges. As with any major operation, there is a risk of infection. Infection is of particular concern to laryngectomees who have chosen to have a voice prosthesis implanted, and is one of the major reasons for having to remove the device.

Normal results

Ideally, removal of the larynx will remove all cancerous material. The person will recover from the operation, make lifestyle adjustments, and return to an active life.

Morbidity and mortality rates

For 2003, the American Cancer Society estimates a 40% mortality rate for laryngeal cancer, meaning that about 3,800 people will die of this disease.

Alternatives

There are two alternatives forms of treatment:

• Radiation therapy, a treatment that uses high-energy rays (such as x rays) to kill or shrink cancer cells.
• Chemotherapy, a treatment that uses drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body to the cancer site.

See also Glossectomy ; Tracheotomy .

Resources

BOOKS

Algaba, J., ed. Surgery and Prosthetic Voice Restoration after Total and Subtotal Laryngectomy. New York: Excerpta Medica, 1996.

Casper, J. K. and R. H. Colton. Clinical Manual For Laryngectomy And Head/Neck Cancer Rehabilitation. Independence, KY: Singular Publishing, 1998.

Singer, M. I. and R. C. Hamaker. Tracheoesophageal Voice Restoration Following Total Laryngectomy. Independence, KY: Singular Publishing, 1998.

Weinstein, G. S., O. Laccourreye, D. Brasnu, and H. Laccourreye. Organ Preservation Surgery For Laryngeal Cancer. Independence, KY: Singular Publishing, 1999.

PERIODICALS

King, A. I., B. E. Stout, and J. K. Ashby. "The Stout prosthesis: an alternate means of restoring speech in selected laryngectomy patients." Ear Nose and Throat Journal 82 (February 2003): 113–116.

Landis, B. N., R. Giger, J. S. Lacroix, and P. Dulguerov. "Swimming, snorkeling, breathing, smelling, and motorcycling after total laryngectomy." American Journal of Medicine 114 (March 2003): 341–342.

Nakahira, M., K. Higashiyama, H. Nakatani, and T. Takeda. "Staple-assisted laryngectomy for intractable aspiration." American Journal of Otolaryngology 24 (January-February 2003): 70–74.

ORGANIZATIONS

American Academy of Otolaryngology - Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. (703) 806-4444. http://www.entnet.org .

American Cancer Society. National Headquarters. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS -2345. http://www.cancer.org .

Cancer Information Service. National Cancer Institute. Building 31, Room 10A19, 9000 Rockville Pike, Bethesda, MD 20892. (800)4-CANCER. http://www.nci.nih.gov/cancerinfo/index.html .

International Association of Laryngectomees (IAL). http://www.larynxlink.com/ .

National Institute on Deafness and Other Communication Disorders. National Institutes of Health. 31 Center Drive, MSC 2320, Bethesda, MD 20892-2320. http://www.nidcd.nih.gov .

The Voice Center at Eastern Virginia Medical School. Norfolk, VA 23507. http://www.voice-center.com .

OTHER

"Laryngectomy: The Operation." The Voice Center. http://www.voice-center.com/laryngectomy.html .

Kathleen Dredge Wright
Tish Davidson, A.M.
Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A laryngectomy is usually performed by an otolaryngologist in a hospital operating room. In the case of trauma to the throat, the procedure may be performed by an emergency room physician.

QUESTIONS TO ASK THE DOCTOR

• Is laryngectomy my only viable treatment option?
• How will drinking and eating be affected?
• How will I talk without my larynx?
• How will my breathing be affected?
• What about my usual activities?
• Is there a support group in the area that can assist me after surgery?
• How long will it be until I can verbally communicate? What are my options?
• What is the risk of recurring cancer?