A total laryngectomy is a major surgical procedure involving the complete removal of the larynx, or voice box. This operation is typically performed to treat advanced laryngeal cancer, profoundly altering the body’s anatomy and function. While the goal is to remove the diseased organ and achieve a cure, the procedure results in permanent changes to how a person breathes, speaks, and smells. Understanding the medical necessity and resulting physiological changes is crucial for navigating life after the operation.
Indications and Surgical Scope
Indications
The primary reason a total laryngectomy is performed is to treat advanced laryngeal cancer, typically classified as Stage III or Stage IV disease. This surgery is necessary when the tumor is too extensive for less invasive methods, such as radiation, chemotherapy, or partial laryngectomy, or when prior treatments have failed. Less common indications include severe, irreparable trauma or extensive tissue damage causing intractable aspiration.
Surgical Scope
The procedure requires the removal of the entire larynx, including the vocal cords, thyroid and cricoid cartilages, and the epiglottis. Surgeons often remove the hyoid bone and a small portion of the upper trachea to ensure clear surgical margins. A neck dissection is frequently performed concurrently to remove regional lymph nodes that may contain cancerous cells. The overall surgical goal is to achieve complete oncological clearance while separating the digestive and respiratory tracts. This separation is accomplished by rerouting the trachea to a permanent opening in the neck, and the pharynx is then reconstructed to allow for safe swallowing.
Permanent Anatomical Changes
The most significant anatomical change following a total laryngectomy is the creation of a permanent opening in the neck called a stoma. The lower trachea is brought forward and sutured directly to the skin of the lower neck, becoming the patient’s new and only airway. Air no longer passes through the mouth or nose to reach the lungs.
This surgical rerouting completely separates the airway from the pharynx and esophagus. This separation eliminates the risk of life-threatening aspiration, as food or liquid cannot accidentally enter the lungs. However, this change also bypasses the natural air-conditioning functions of the nose and mouth.
Air entering the lungs through the stoma is no longer warmed, filtered, or humidified, leading to physiological consequences for the respiratory system. The dry, cold air irritates the trachea, causing increased mucus production. This thicker mucus is harder to clear and can lead to crusting or mucus plugs that obstruct the airway. To mitigate these effects, a Heat and Moisture Exchanger (HME) is often worn over the stoma to retain heat and moisture from exhaled air.
Restoring Voice and Communication
The loss of the vocal cords means the patient loses their natural voice, but three primary methods exist for restoring communication after a total laryngectomy.
Tracheoesophageal Puncture (TEP) Speech
TEP speech is the most common and successful modern technique. It involves placing a small, one-way silicone voice prosthesis in a surgically created puncture between the trachea and the esophagus. To speak, the patient covers the stoma, redirecting lung air through the prosthesis into the esophagus. This air causes the tissue in the upper esophagus to vibrate, producing sound that is shaped into words by the mouth. TEP speech provides the most natural voice quality and allows for fluent speech. However, the prosthetic device requires daily cleaning and regular replacement, typically every few months, due to wear or leakage.
Electrolarynx
The electrolarynx is a battery-operated device that generates a mechanical vibration. The device is held against the neck or cheek, transferring vibration into the mouth and throat to create a sound source. The patient then articulates this sound into speech. This method is easy to learn and provides immediate voice restoration, but the resulting voice has a characteristic monotone or robotic quality.
Esophageal Speech
Esophageal speech requires no device and is achieved by intentionally taking air into the esophagus and then slowly releasing it. The expelled air vibrates the pharyngoesophageal segment to produce sound. While this method is hands-free, it is difficult to learn. The resulting voice is typically low in volume and limited to short phrases.
Long-Term Daily Living Adjustments
Adjusting to life after a total laryngectomy involves mastering new daily routines focused on stoma care and safety. The stoma must be kept clean to prevent infection and maintain a clear airway, often requiring daily cleaning of the surrounding skin and the use of suctioning devices to remove mucus. The use of an HME is important for pulmonary health, compensating for the lost air-conditioning function by preserving warmth and moisture in the airway.
A significant change is the loss of smell, known as anosmia, because air no longer passes through the nasal passages to reach the olfactory receptors. Since smell contributes heavily to flavor perception, many patients also experience a reduced sense of taste, or dysgeusia. Specialized techniques can help patients momentarily draw air into the nasal cavity to stimulate the sense of smell.
Most individuals return to a normal diet after the initial healing period, though some may require swallowing exercises to manage potential strictures or difficulty with certain food textures. Safety considerations regarding water exposure are paramount, as water entering the stoma can cause severe respiratory distress. Patients must use special shields when showering and must avoid swimming entirely. Additionally, patients must wear medical identification to alert emergency responders that they are a “neck breather” requiring direct stoma-to-stoma resuscitation.