Laryngectomy

Overview

The removal of the larynx and separation of the airway from the mouth, nose, and esophagus is known as laryngectomy. The whole larynx is removed during a complete laryngectomy (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings).

A partial laryngectomy removes only a segment of the larynx. Following the operation, the individual breathes via a stoma in the neck. In situations of laryngeal cancer, this operation is normally performed by an ENT surgeon. Many instances of laryngeal cancer are treated conservatively (through oral surgery, radiation, and/or chemotherapy).

When these therapies fail to save the larynx or when the cancer has advanced to the point where normal functioning is impossible, a laryngectomy is performed. Laryngectomies are also done on patients suffering from different forms of head and neck cancer. Voice restoration, oral eating, and, more recently, smell and taste rehabilitation are all part of post-laryngectomy rehabilitation. Following surgery, an individual's quality of life may improve.

What is the Larynx?

The larynx is a part of the respiratory system. It's a hollow tube that transports air from your neck (pharynx) to your trachea and then to your lungs. It also houses your vocal chords and is necessary for human speech, thus it's also known as the voice box.

What is laryngectomy?

The surgical removal of the larynx is known as a laryngectomy. The larynx is the part of your throat that contains your vocal chords, which allow you to make sound. The larynx is the tube that links your nose and mouth to your lungs. It also protects your respiratory system by keeping food and drink in your esophagus and out of your lungs.

Removing the larynx is a hazardous but essential therapy for those who have laryngeal cancer, have suffered severe neck injuries, such as a gunshot wound, or have radiation necrosis (damage to the larynx stemming from radiation treatment).

Your doctor will perform a partial or total laryngectomy depending on your situation.

Why is Laryngectomy Performed?

A laryngectomy is most usually used to remove a laryngeal carcinoma or some other benign conditions. The larynx can be removed entirely (total laryngectomy) or partially (partial laryngectomy).

The procedure entails constructing a new airway in the lower neck for breathing. After a whole laryngectomy, this new airway is permanent; after a partial laryngectomy, it is transitory.

Because it has such a negative impact on quality of life, a total laryngectomy is typically reserved for advanced tumors that cannot be properly treated without such severe surgery. If you require a laryngectomy, you will be met by a team of health specialists who will assist you in dealing with the operation and managing your speech, breathing, and swallowing thereafter.

Function of the Larynx

Your larynx has three main functions in your body:

• Breathing.
• Creating vocal sounds.
• Preventing food and other particles from getting into your trachea, lungs and the rest of your respiratory system.

Structure of the Larynx

• Anatomical Structure:

A cartilaginous skeleton holds the larynx together by ligaments and membranes. The laryngeal muscles move the laryngeal components for phonation and breathing. 

The inside chamber of the larynx is separated into three regions anatomically:

1. Supraglottis - The region between the inferior surface of the epiglottis and the vestibular folds (false vocal cords).
2. Glottis - Contains the voice cords and is located 1cm below them. The rima glottidis is the opening between the vocal cords, the size of which is controlled by the phonation muscles.
3. Subglottis - The space between the inferior border of the glottis and the inferior border of the cricoid cartilage.

The larynx's internal surface is lined by pseudostratified ciliated columnar epithelium. The real vocal cords, which are bordered by a stratified squamous epithelium, are a significant exception.

• Vasculature:

The superior and inferior laryngeal arteries feed the larynx with blood.

• The superior thyroid artery has a branch called the superior laryngeal artery (derived from the external carotid). It enters the larynx through the internal branch of the superior laryngeal nerve.
• The inferior thyroid artery branches into the inferior laryngeal artery (derived from the thyrocervical trunk). It enters the larynx through the recurrent laryngeal nerve.
• The superior and inferior laryngeal veins drain the venous system. The superior thyroid vein drains to the internal jugular vein, whereas the inferior thyroid vein drains to the left brachiocephalic vein through the inferior thyroid vein.

• Innervation:

The vagus nerve branches that innervate the larynx provide both motor and sensory innervation:

The recurrent laryngeal nerve supplies sensory innervation to the infraglottis as well as motor innervation to all of the internal laryngeal muscles (except the cricothyroid).

The internal branch of the superior laryngeal nerve innervates the supraglottis, whereas the external branch innervates the cricothyroid muscle.

Types of Laryngectomy

There are several types of laryngectomies, including:

1. Partial laryngectomy: Part of the larynx is removed during a partial laryngectomy, which is utilized for smaller malignancies. Though there are numerous types of partial laryngectomy operations, the goal is the same: to remove only a piece of the larynx (the complete malignant region) while leaving as much of the larynx as possible intact.
2. Supraglottic laryngectomy: Supraglottic laryngectomy involves the removal of portion of the larynx above the vocal chords. After a supraglottic laryngectomy, you may be able to talk normally again.
3. Hemilaryngectomy: Hemilaryngectomy is a procedure used to treat minor tumors of the voice cords. It entails removing one vocal chord while keeping the others intact. You can talk after a hemilaryngectomy, but your ability is restricted.
4. Total laryngectomy: The larynx is totally removed during a total laryngectomy. It impairs your ability to talk normally, but you can learn to communicate in different ways, such as using a mechanical voice or esophageal speech training.

Your doctor will decide which laryngectomy to conduct based on the location of the malignancy and the stage of throat cancer.

Before the Procedure

Before surgery, you will have doctor checkups and testing. 

• A full physical checkup and blood tests are among them. Imaging investigations may be carried out.
• A visit to a speech and swallowing therapist to prepare for changes following surgery.
• Nutritional advice.
• Counseling for quitting smoking. If you are a smoker who has not yet quit.

Always tell your doctor or nurse:

• If you are or may become pregnant.
• What medications you are taking, including any pills, supplements, or herbs purchased without a prescription.
• If you have been consuming a lot of alcohol, more than 1 or 2 drinks each day, you should consult a doctor.

During the days before your surgery:

• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), clopidogrel (Plavix), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
• Ask which drugs you should still take on the day of your surgery.

On the day of your surgery:

• The night before your procedure, you will be instructed not to drink or eat anything after midnight.
• Take the medications your doctor prescribed with a little sip of water.
• You will be told when to arrive at the hospital.

What Happens During Laryngectomy Procedure?

Laryngectomy is a significant surgical procedure that is performed in a hospital. You will be given general anesthetic prior to surgery. You'll be deep sleeping and pain-free.

The whole larynx is removed during a complete laryngectomy. A portion of your pharynx may also be removed. The mucous membrane-lined channel between your nasal passages and esophagus is known as the pharynx.

• To open up the region, the surgeon will make an incision in your neck. Major blood arteries and other critical structures are preserved.
• The larynx and surrounding tissue will be removed. The lymph nodes may be removed as well.
• The surgeon will next open your trachea and drill a hole in front of your neck. This hole will be connected to your trachea. The hole is known as a stoma. You will breathe via your stoma after surgery. It will never be taken down.
• Your esophagus, muscles, and skin will be closed with stitches or clips. After surgery, you may have tubes emerging from your incision for a period.

The surgeon may also do a tracheoesophageal puncture (TEP).

• A TEP is a small hole in your windpipe (trachea) and the tube that moves food from your throat to your stomach (esophagus).
• Your surgeon will place a small man-made part (prosthesis) into this opening. The prosthesis will allow you to speak after your voice box has been removed.

There are many less invasive surgeries to remove part of the larynx.

• Endoscopic (or transoral resection), vertical partial laryngectomy, horizontal or supraglottic partial laryngectomy, and supracricoid partial laryngectomy are some of these treatments.
• These methods may be effective for some persons. The sort of surgery you receive is determined by how far your disease has gone and the type of cancer you have.

The procedure might take anything from 5 to 9 hours.

Risks & Complications Associated With Laryngectomy

A laryngectomy is not without risks and adverse effects. The following risks and harmful impacts are possible:

• Anesthesia reaction (Anesthesia is the medicine given to you to help you sleep during the procedure, forget about it, and manage discomfort.) Wheezing, redness, edema, and low blood pressure are all possible reactions.)
• Bleeding.
• Blood clots.
• Infection.
• Pneumonia.
• Heart or lung problems.
• Loss of normal speech.
• Nerve injury.
• Swelling.
• Stenosis is a constriction of the throat or larynx that may need the installation of a tracheostomy tube.
• Stoma stenosis is the narrowing of the stoma.
• Trouble swallowing, which may necessitate the use of a feeding tube.
• The formation of a fistula (an improper connection between the pharynx and the skin), which may need surgery to rectify.
• Thyroid and parathyroid glands are among the adjacent organs that have suffered damage. This can result in hypothyroidism and/or calcium imbalances. The trachea and esophagus are two more organs that might be affected.
• Hematoma (collection of blood).

After the Procedure

You will be need to stay in the hospital for many days following surgery.

You will feel sleepy and unable to talk after the treatment. Your stoma will be fitted with an oxygen mask. To enhance blood flow, keep your head elevated, relax frequently, and exercise your legs from time to time. Keeping your blood flowing lowers your chances of having a blood clot.

Warm compresses can help relieve pain around incisions. You will be given pain medication.

You will be fed via an IV (a tube that enters into a vein) and tube feedings. Tube feedings are administered by a tube that is inserted through your nose and into your esophagus (feeding tube).

You may be able to eat and drink as soon as 2 to 3 days after surgery. However, it is more typical to wait 5 to 7 days following surgery before beginning to eat via your mouth. A swallow study, in which an x-ray is obtained while you sip contrast material, may be performed. This is done to ensure that there is no leaking before beginning to consume.

Your drain might be eliminated in two to three days. You will be shown how to care for your stoma and laryngectomy tube. You will learn how to shower securely. You must be cautious not to allow water to enter your stoma.

Speech rehabilitation with a speech therapist will help you relearn how to speak.

You will need to avoid heavy lifting or strenuous activity for about 6 weeks. You may slowly resume your normal, light activities.

Follow up with your provider as you are told.

What is Recovery Like?

The sort of laryngectomy you have will determine how quickly you recover. At times, an extended hospital stay is needed. You may require a feeding tube to acquire nutrients while your throat recovers.

Before leaving the hospital, you will be instructed on how to care for your incisions, tracheostomy, feeding tube, and various drains, as well as any additional requirements. Your healthcare team will discuss the use of nebulizers to humidify the air you breathe via your tracheostomy with you.

Your medical team will go through the drugs you'll be taking with you, such as those for pain, blood clot prevention, infection prevention, constipation prevention, and/or other illnesses.

Most likely, you will visit with a speech pathologist who will discuss communication and swallowing skills with you.

Your provider will discuss any limits you may have. Generally:

• For the next six weeks, avoid heavy lifting and intense activity.
• Bending and straining should be avoided unless instructed by your healthcare staff.
• Follow the instructions for stoma and wound care.
• Speak with your healthcare provider about when you can shower and how to keep your stoma dry and free of water.
• Avoid wearing apparel that is too tight around your neck.
• Avoid secondhand smoking and those who have respiratory ailments.
• Avoid participating in contact sports.

Caring for Your Stoma

Because you will be breathing via your stoma after surgery, it is critical that you learn how to care for it. Your doctor will provide you with specific instructions.

1. Hand washing is recommended. Before and after care for your stoma, wash your hands. Make certain that all of your materials are clean.
2. Keep your stoma clean. Check for crusts and mucus around your stoma and within your trachea wall every morning and evening. Wash the skin surrounding your stoma gently with mild soap and water. Wipe it clean.
3. Maintain a wet airway. Coughing will be reduced, and mucus will not dry out. Because the air you breathe does not flow via your nose and mouth, you must humidify it.
4. A saline spray can be useful. Using a humidifier at home, particularly at night, produces humid air. To avoid infections, keep your humidifier clean.
5. Taking off crusts. Cough up any mucous in your stoma. Using a saline spray can be beneficial. Alternatively, place a warm, moist towel over your stoma.
6. Protect your stoma. Covering it will keep dirt and dust out of your airway. You might wish to use a stoma cover. To hide your stoma, you can use scarves or turtleneck shirts.

When to Call Your Doctor?

• Swelling, bleeding, blistering, scabbing or discharge at the incision.
• New or worsening pain. 
• Nausea and vomiting.
• Change in color and/or thickness of sputum.
• Trouble swallowing.
• Change in the size of your stoma.
• Coughing, shortness of breath, chest pain and/or any other concerning symptoms.

Outlook (Prognosis)

It will take 2 to 3 weeks for your wounds to heal. You should anticipate to be completely recovered in approximately a month. Often, removing the larynx will remove all cancerous or damaged tissue. People learn how to live without their voice box and adapt their way of life. Other therapies, such as radiation or chemotherapy, may be required. You should be able to resume an oral diet around 2 weeks following the treatment. You might also begin working with a speech therapist to improve your speech.

Conclusion

A laryngectomy is a surgical procedure that removes your voice box, or larynx.

The larynx is the section of your throat that houses your voice box. It is placed at the top of your windpipe (trachea). Breathing, swallowing, and speaking all rely on your larynx.

A laryngectomy is performed for a variety of reasons, including:

• Cancer of the larynx (cancer of the larynx).
• Chondronecrosis of the larynx – an uncommon condition in which your larynx is damaged, generally as a result of radiation therapy.
• Larynx fracture or severe injury.