1

Laryngectomy

2

Cancer of the Larynx

• Any age; infrequent in children

• Males 50-70 most vulnerable

• Laryngeal cancer- less than 2%

• Use of tabacco and heavy alcohol use

• Radical or conservative surgery

3

Tumor Location & Symptoms

• Supraglottal, glottal or subglottal

• Tumors on or near the folds = hoarseness immediately

• As tumors increase in size= disturbed breathing & noise during inspiration

• Supraglottal Tumors may result in:– dysphagia– swelling in neck– discharge– pain

4

Carcinoma

• Primary Voice Symptom:– Hoarseness ( 1 of the 7 warning signs)

• Description & Etiology:– May effect structures of the oral cavity, pharynx, &

larynx– Incidence; 2 -5% of all malignancies– Etiology: smoking (50-70% of oral & laryngeal

cancers), Synergistic effect with smoking & alcohol consumption

– Severity of malignancy evaluated using TNM system

5

TNM System

• T= Primary tumor

• N= Involvement of lymph nodes

• M= Signifies spread of lesion to other parts of

the body (metastasis)

– Low numbers indicate lesser involvement

– Example: T1N0M0= lesion has a local confined

tumor with neither node involved nor any

metastasis

6

Classification of Glottal Cancer• T: Location of primary tumor

– Tx Cannot be staged

– T0 No evidence of tumor

– Tis Carcinoma in situ

– T1 Confined to vocal folds

– T2 Supraglottal or subglottal extension, normal or impaired ability

– T3 Confined to larynx but with fixed cord

– T4 Massive tumor

• N: Involvement of regional lymph nodes– Nx Cannot be assessed

– N0 No involvement

– N1 A single small node on one side

– N2 A single large or multiple small nodes on one side

– N3 Massive nodes on one or both sides

• M: Distant Metastasis– Mx Cannot be assessed

– M0 No known metastasis

– M1 Metastasis present

7

Carcinoma• Perceptual Signs & Symptoms:

– Hoarseness, lump in neck, broadening of larynx (detected on palpitation), tenderness in the neck, dysphagia, odynophagia, dyspnea

– Acoustic Signs-• Depends on extent of carcinoma

• Frequency & amplitude perturbation will increase

• Lower maximum phonation range

• Slightly higher fundamental frequency

• Spectral noise levels increased

• Lower dynamic range

8

Carcinoma• Measurable Physiological Signs:

– Airflows are generally increased– EGG recording reflect reduced time of closure– Subglottal pressure increased (increased stiffens of

vocal folds)

• Observable Physiological Signs:– Laryngoscopy-

• May reveal small undefined tumor to large, diffuse tumor

• Diagnosis requires biopsy & histological analysis

• Most arise from epithelium & are squamous cell

9

Carcinoma• Observable Physiological Signs:

– Stroboscopy-• Early cancer can be diagnosed early by strob

– Small lesions that have a marked effect of vibration

– Can help define level of invasion with small cancers

– More invasive- vocal fold becomes fixed, no movement

– Pathophysiology-• Lesions invade tissue & destroy normal behaving cells

• Effects:– Vocal fold closure

– Reduced horizontal excursion

– Restricted or absent mucosal wave

10

11

12

Treatment

• 1) Surgery

• 2) Radiation Therapy

• 3) Chemotherapy

13

Treatment Strategies

• Factors to consider:1) Site of tumor

2) Extent of tumor

3) Node involvement

4) Metastasis

5) Patient’s age

6) General health of the patient

7) Pulmonary status

8) Preservation of laryngeal function

14

Early Lesion Treatment

•Radiation therapy

•Endoscopic microsurgery

•Laser excision (CO2)

15

Radiation Therapy

• Uses:

1) Early glottic lesions

2) Lesions extending to true vocal folds

3) Often combined with surgery (cordectomy)

4) Advanced supraglottic lesions

• Effects:

1) Edema, fluid build-up, skin redness, necrosisCompComplications (tissue necrosis, skin irritation)

3) Common side-effects

16

Chemotherapy

• Used in advanced malignancies

• Used less because of the effectiveness of

radiation therapy & surgical excision

• Also, coexisting illness due to toxicity of

chemotherapy can be avoided

17

Laryngectomy

• Removes larynx- “ectomy”

• “Laryngectomee”

• Total or partial removal of larynx

• Conservation surgical procedures– patients best suited

– conservation procedures

• Reconstruction

• Surgery for advanced laryngeal cancer

18

Surgery• Partial Laryngectomy Procedures:

– Used for discrete, superficial glottic carcinoma (up to T2) or for those with more extensive T1 lesions

• Cordectomy:

– Tumor well localized to a single vocal fold (lot larger than 5 mm, confined to middle third)

• 1. Entrance into the endolarynx via vertical incision at midline of thyroid cartilage

• 2. Tumor is then resected (includes tissue wedge including tumor & surrounding tissue)

19

Cordectomy Procedure

20

Cordectomy Procedure

Excision Area

21

Cordectomy Procedure

22

Surgery• Partial Laryngectomy Procedures:

– Hemilaryngectomy:

• One half of larynx is removed; Used for both T2 & T3 lesions or small number of glottic carcinoma cases where vocal fixation is present

• 1. Entrance into laryngeal region through thyroid

–2. Tumor & surrounding tissue resected

–3. Midsection of thyroid cartilage is prepared as a flap

23

Hemilaryngectomy Procedure

Excision Area

24

Hemilaryngectomy Procedure

A. Thyrotomy

B. Excision areaidentified

25

Hemilaryngectomy Procedure

G. Closure of strap muscles & neck

26

Surgery• Partial laryngectomy Procedures:

– Vertical partial Laryngectomy:• For tumors involving one-half of larynx, however cancer

can’t restrict vocal fold movement

• Appropriate for:• Tumor has been staged from T1 to early T3

– Antero-Frontal Partial laryngectomy:• Recommended for tumors that involve the glottis

bilaterally (cancer crosses anterior commissure to involve membranous segment of both true vocal folds)

• Must retain normal movement or exhibit only limited reductions in mobility

• Stage T2 lesions

27

Surgery• Total Laryngectomy:

– For laryngeal tumors not suitable for conservative surgical approaches

– Advanced tumors T3 lesions or greater• Require a wide field approach

– 1. Removal of entire laryngeal framework (thyroid, cricoid, arytenoid, epiglottis) & all laryngeal membranes & muscles

– 2. Trachea is then brought to midline of the neck

28

Total Laryngectomy Procedure

Excision Area

29

Total Laryngectomy Procedure

30

Total Laryngectomy

31

• No passage of air from mouth, nose & pharynx into the lungs

Normal Exhalation Laryngectomy Exhal.

CO2

Speech

CO2

32

Rehabilitation team

• Physicians

• Nurses

• Physical therapists

• Speech Pathologists

• Social Workers

• Family members

• Self-help groups

33

• 1. Evaluate preoperative speaking skills:– Articulation errors– Speaking rate– Dialectical patterns– Degree of oral opening during speech

• 2. Detailed description of forthcoming surgery:– Pamphlets regarding laryngectomy surgery &

rehabilitation• “Helping Words for the Laryngectomee”• “Your New Voice”

– IAL (International Association of Laryngectomees– American Cancer Society

Preoperative Visit: Advantages

34

Preoperative Visit: Advantages

• 2. Provide patient & family emotional support

– Reassure patient and family patient will talk again• Describe methods of speaking without a larynx

– Esophageal speech

– Demonstration of artificial larynx

– Voice therapy following surgery

• 3. Meet and interact with a successful rehabilitated laryngectomee

– Give name, occupation & provide a brief explanation of person’s procedures

35

Preoperative Visit• Provision of reassurance and support

• Written materials describing surgery etc.

• Communication methods post surgery

• Demonstration of artificial larynx

• Review changed breathing mechanism (next diagram)

• Physical changes related to swallow, smell, taste & diet

• Grieving period

36

• Altered breathing mechanism, removal of larynx

StomaEsophagus

37

Pre- & Post Operative

• Review changed breathing mechanism

• Grieving

• Counseling

• Physical changes

• Hygiene concerns

• Safety concerns

38

Postoperative Visit• Consult with physician:

– When patient will be able to begin voice therapy

– Any medical considerations preventing from the immediate use of an artificial larynx

• Tube in the mouth device can be used as an option here

• Role of accompanying laryngectomee:– Preoperative & postoperative visit

– Develop motivation & to provide a model

– Answer questions about fears, worries, support groups

39

Hygiene Concerns

• Care of tracheostomy, cannula and/or stoma button

• Stoma, cannula & stoma button must be kept clear of mucous

• Stoma covers (gauze, foam rubber or decorative jewelry)

• Excessive mucous

40

Stoma Hygiene• Daily cleaning of the stoma

– 1. Wash hands first– 2. Rinse a cotton washcloth with warm water,

gently place the washcloth against stoma & wipe gently

• Don’t use bits of paper or cotton balls

• Do not use soap (irritation or coughing if enters into stoma)

– 3. Lubricate stoma with Vaseline or Abolene cream

• Leave on for about 2 minutes and then wipe off

41

Cannula Hygiene• Hospital staff should instruct patient

• Must be cleaned using warm water, soap & brushes– Several cleanings during the course of the day– Outer tube requires less frequent cleaning

• Weaning of cannula begins 6 weeks post surgery (gradual over several weeks)– First: 1hour a day– Second: Gradual increase until the patient does not

wear the cannula in the daytime– Third: Removal for 24 hour periods

42

Stoma Covers• Stoma must be covered at all times

• Covers:– Gauze-like bib– Foam rubber– Scarves, jewelry, turtle neck

• Protective Functions:– Creates a warm, insulated space between stoma &

atmosphere– Filter out dust, small insects, lint– Muffles stoma noise during sleeping, absorb

mucous

43

Stoma Safety & Other Problems• Precautions while bathing or showering

– Rubber shower shield– Do not stand directly under water– Rubber shower mat to prevent falls– Heavy perfumed soaps should be avoided

(irritation & coughing)

• Problems swallowing, taste & smell and digestion– Postsurgical narrowing of the esophagus– Sense of taste & smell are reduced (no exchange of

air through nose) (limited to sweet & sour)

44

Stoma Safety & Other Problems

• Problems swallowing, taste & smell and digestion (cont.)– Digestive problems associated with esophageal speech

• Air trapping poor & air moves lower down causing

– Boating

– Abdominal pain

– Chronic flatulence

• Problems related to trapping air within the lungs– Difficulty in lifting heavy objects

– Difficulty in eliminating body waste

– Difficulty with child birth

45

Voice Training: Artificial Larynx• Controversy: Artificial larynx or esophageal

speech first?

• Types of artificial laryges:

– Manner in which vibratory source is powered

– Place at which the artificial larynx is positioned in order to deliver sound into the oral cavity

• Tube in the mouth

• Denture Type

• Neck Type

46

Artificial Larynges

Tube in mouth (Cooper Rand Neck Type (Western Electric)

Pneumaticall powered (Tokyo)

Dental Appliance Type (Speechmaster)

47

Pneumatically Powered Voice Prosthesis

• Utilizes air from lungs

• Pulmonic air enters the voice prosthesis via airtight cover that is fitted to stoma

• To speak, user places mouthpiece end into mouth– Van Humen Artificial Larynx

• Vibrating reed in tube is source, then patient does the articulation

48

Electronically Powered Voice Prosthesis

• Battery-operated

• Quality depends on the acoustic characteristics of the device & degree of surgery

• Certain devices generate sound source:– Extrorally with tube method

– Through denture plate introrally

– Tone conducted from external surface of neck to hypopharynx

49

Benefits: Artificial Larynx• Immediate and relatively intelligible oral

communication

• Effective if voice therapy is delayed due to healing

• Provides a method of communication– 35% of laryngectomees cant learn esophageal

speech

• Provides a higher intensity level than esophageal speech

• Temporary alternative for fatigue, URI or emotionally upset

50

Goals of SLP for Artificial Larynges

• Acquaint patient with types available

• Coordination of hand to mouth movements to synchronize sound source and articulatory onset

• Placement, seal

• Reduce stoma noise

• Normal phrasing

• Explain device to strangers

51

Esophageal Speech• Consonant injection method• Glossopharyngeal Press• Inhalation Method• Swallow Method

– Greater air pressure in the oral cavity will flow to a chamber containing less pressure (esophagus)

– Goals:• Patient should reliably phonate on demand

• Patient should use rapid air intake

• Short latency between air intake & phonation

• Produce 4 -9 syllables per air charge

• Speaking rate of 85-129 words per minute

• Good intelligibility

52

Esophageal Speech Production

• Consonant Injection:– Most efficient method of getting air into esophagus

– Start with words: pie, tie, cake, stop, scotch, skate

• Allows esophagus to increase in pressure easily

– Phrases that allow the esophagus to become loaded:

• “Pick that skate”; “Take it to heart”; “Put it back”

– Phrases that are mostly vowels are harder (low

pressure):

• “I am well’; “In a house”

53

Esophageal Speech Production• Consonant Injection:

• General Instructions-

1)take air into top of esophagus, trap air & release it

2) vibration occurs in P-E segment

3) patients inject or move air by using tongue “pumping”

4) rapid successive productions of sounds such as /p/, /t/ & /k/ in combination with a vowel are practiced first

• Progression-

– Produce intraoral whispers or plosive consonants

– Compress air and explode it through lips: /p/

– Attempt the syllable- /pa/

– Production of other plosives, fricatives or affricates

– Monosyllabic words with plosives: Pie, Tie

54

Esophageal Speech: Glossopharyngeal Press

55

Esophageal Speech: Problems• Excessive Stoma Noise:

– Forceful movement of air through stoma during exhalation

– Coes tes with esophageal production– Instructions to reduce force of exhalation (“say it

softer”)• Biofeedback: Wear a stethoscope with diaphragm near

stoma; mirror, place piece of tissue paper over stoma

• Klunking:– Noise from attempting to rapidly & forcefully

inject air– Alter head position or reduce force of injection

56

Surgical or Prosthetic Methods

• Shunting the pulmonary air into lower esophagus

1) Reconstructive and prosthetic methods (TE approaches)

2) Reduces effort, avoids extraneous movement

3) Phrasing is more natural, smooth & fluent

4) Allows for redirection of exhalation

57

Tracheoesophageal Puncture (TEP)

1) Solved problems of shunt (aspiration of saliva, liquids and food into trachea & stenosis of shunt)

2)15-20 minute surgical procedure creating fistula

3) Voice prothsesis or “duckbill” inserted in fistula

4) Prevents aspiration & stenosis5) One-way valve allowing pulmonary air to

enter the esophagus when stoma is occluded while exhaling

6) Automatic valve available

58

Types of Prothsesis• Blom-Singer

• Panje- Voice Button Prosthesis

• Passy-Muir Speaking

Tracheostomy Valve

59

Readings

• Other Sources:– Salmon, S.J. & Mount, K.H. (1991).

Alaryngeal Speech Rehabilitation. Pro-Ed

– Doyle, P.C. (1994). Foundations of Voice and Speech Rehabilitation Following Laryngeal Cancer. Singular Publishing