A total laryngectomy is a major surgical procedure involving the complete removal of the voice box, or larynx. This surgery is typically performed to address advanced disease, most commonly cancer of the larynx. The procedure permanently alters the body’s anatomy for breathing and speaking, necessitating significant physical and communicative rehabilitation afterward.
Defining the Procedure and Its Purpose
A total laryngectomy involves the surgical removal of the entire larynx, including the vocal cords, the epiglottis, and supporting cartilage structures like the thyroid and cricoid. The primary indication is advanced laryngeal cancer, especially when less aggressive treatments like radiation or partial surgery are insufficient. In rare cases, it is also performed for severe, irreversible trauma or damage.
The removal of the larynx necessitates a complete reorganization of the throat’s internal passages. The natural connection between the airway (trachea) and the swallowing tract (esophagus) is severed. The remaining upper portion of the trachea is brought forward and surgically attached to a newly created opening in the neck, called a stoma.
This anatomical separation is crucial, as it prevents aspiration (food or liquid entering the lungs). Before surgery, the epiglottis protected the airway during swallowing, but with the larynx removed, complete separation is required for safe eating and drinking. Swallowing function through the esophagus is generally preserved, allowing for oral nutrition once healing is complete.
The Permanent Change in Breathing
The creation of the stoma, a permanent opening in the neck, means the individual becomes a “neck breather.” Air bypasses the nose and mouth entirely, flowing directly through the stoma into the trachea and lungs. This physiological change means air no longer travels through the upper respiratory system.
The upper respiratory tract naturally filters, warms, and humidifies inhaled air. With the stoma, the air entering the lungs is often cooler, drier, and contains more particulate matter. The lack of this protective mechanism can cause the lungs to produce more mucus and secretions.
This change requires the patient to manage the quality of the air they breathe. The stoma is the sole respiratory portal, meaning activities involving water near the neck, like showering or swimming, require specific precautions to prevent water from entering the lungs. The loss of airflow through the nasal passages also significantly diminishes the sense of smell, which reduces the sensation of taste.
Methods of Communication After Surgery
The removal of the vocal cords means the patient loses the natural ability to produce sound, making voice rehabilitation a primary focus. There are three main methods to restore a functional voice, each utilizing a different mechanism to create sound. The most common modern method is Tracheoesophageal Puncture (TEP) speech, which involves surgically creating a small fistula between the trachea and the esophagus.
A small, one-way silicone valve, known as a voice prosthesis, is placed into this puncture. To speak, the patient covers the stoma, forcing air from the lungs through the prosthesis into the esophagus. This directed air causes the pharyngoesophageal segment (the upper portion of the esophagus) to vibrate, creating a sound articulated into speech using the tongue, lips, and teeth.
Another option, Esophageal speech, is a non-surgical technique requiring extensive training. The patient learns to inject or “swallow” a small amount of air into the upper esophagus and then release it in a controlled manner. This controlled expulsion causes the esophageal walls to vibrate, producing a low-pitched sound shaped into words.
The third method involves using an artificial larynx, or electrolarynx, a battery-operated handheld device. When held against the neck or cheek, the device produces a mechanical vibration transferred to the throat tissues. The patient shapes this buzzing sound into speech using their mouth, tongue, and lips, resulting in a clear but often “robotic” sounding voice.
Living with a Stoma and Daily Care
Daily life after a total laryngectomy centers on the care and protection of the stoma. Maintaining a clean stoma is necessary to prevent infection and irritation. This routine involves regular cleaning and removal of excess mucus and dried secretions.
A primary aspect of stoma care is compensating for the loss of the upper airway’s functions, often accomplished through Heat and Moisture Exchange (HME) filters. These small devices are worn over the stoma to warm and humidify the air entering the lungs, helping reduce coughing and mucus production. HME filters also help filter out dust and airborne irritants, which the patient must actively try to avoid.
Safety precautions are an important consideration for a neck breather. The stoma must be shielded from water during activities like showering, often using specialized stoma covers. Additionally, the inability to hold one’s breath and bear down means that physical actions like heavy lifting or straining may require a new approach.