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Laryngectomy
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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
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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:
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dysphagia
swelling in neck
discharge
pain
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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
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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
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Classification of Glottal Cancer
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T: Location of primary tumor
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Tx
T0
Tis
T1
T2
– T3
– T4
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N: Involvement of regional lymph nodes
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Cannot be staged
No evidence of tumor
Carcinoma in situ
Confined to vocal folds
Supraglottal or subglottal extension,
normal or impaired ability
Confined to larynx but with fixed cord
Massive tumor
Nx
N0
N1
N2
N3
Cannot be assessed
No involvement
A single small node on one side
A single large or multiple small nodes on one side
Massive nodes on one or both sides
M: Distant Metastasis
– Mx
– M0
– M1
Cannot be assessed
No known metastasis
Metastasis present
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Carcinoma
• Perceptual Signs & Symptoms:
– Hoarseness, lump in neck, broadening of larynx
(detected on palpitation), tenderness in the neck,
dysphagia, odynophagia, dyspnea
– Acoustic Signs•
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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
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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
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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
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Treatment
• 1) Surgery
• 2) Radiation Therapy
• 3) Chemotherapy
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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
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Early Lesion Treatment
•Radiation therapy
•Endoscopic
microsurgery
•Laser excision (CO2)
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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
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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
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Laryngectomy
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•
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Removes larynx- “ectomy”
“Laryngectomee”
Total or partial removal of larynx
Conservation surgical procedures
– patients best suited
– conservation procedures
• Reconstruction
• Surgery for advanced laryngeal cancer
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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
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tissue)
Cordectomy Procedure
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Cordectomy Procedure
Excision
Area
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Cordectomy
Procedure
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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
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Hemilaryngectomy Procedure
Excision
Area
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Hemilaryngectomy Procedure
A. Thyrotomy
B. Excision area
identified
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Hemilaryngectomy Procedure
G. Closure of strap muscles & neck
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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
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• Stage T2 lesions
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
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Total Laryngectomy Procedure
Excision
Area
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Total Laryngectomy Procedure
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Total Laryngectomy
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CO2
CO2
Speech
Normal Exhalation
Laryngectomy Exhal.
• No passage of air from mouth, nose & pharynx
into the lungs
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Rehabilitation team
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Physicians
Nurses
Physical therapists
Speech Pathologists
Social Workers
Family members
Self-help groups
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Preoperative Visit: Advantages
• 1. Evaluate preoperative speaking skills:
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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
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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
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Preoperative Visit
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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
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Esophagus
Stoma
• Altered breathing mechanism, removal of
larynx
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Pre- & Post Operative
• Review changed breathing
mechanism
• Grieving
• Counseling
• Physical changes
• Hygiene concerns
• Safety concerns
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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
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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
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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
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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
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– Third: Removal for 24 hour periods
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
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mucous
Stoma Safety & Other Problems
• Precautions while bathing or showering
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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)
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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
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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
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Artificial Larynges
Tube in mouth (Cooper Rand Neck Type (Western Electric)
Dental Appliance Type (Speechmaster)
Pneumaticall powered (Tokyo)
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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
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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
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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
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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
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Esophageal Speech
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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:
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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
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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”
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Esophageal Speech Production
• Consonant Injection:
• General Instructions1)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
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– Monosyllabic words with plosives: Pie, Tie
Esophageal Speech: Glossopharyngeal Press
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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
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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
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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 & stenosis
5) One-way valve allowing pulmonary air to
enter the esophagus when stoma is occluded
while exhaling
6) Automatic valve available
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Types of Prothsesis
• Blom-Singer
• Panje- Voice Button Prosthesis
• Passy-Muir Speaking
Tracheostomy Valve
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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
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