Minimizing Complications of Total Laryngectomy

By Beth Hohman, MS, CCC-SLP

A total laryngectomy is a life-changing ordeal for most patients, and postoperative complications can make matters even worse. At the Head & Neck Institute (HNI), we have taken steps to minimize postoperative sequelae, especially with respect to breathing and voice rehabilitation.

According to the American Cancer Society’s estimates, approximately 13,430 new cases of laryngeal cancer will be diagnosed in the U.S. in 2016, and approximately 3,620 patients (2,890 men and 730 women) will die from it.1

Total laryngectomy is a surgical option for patients with advanced laryngeal cancer. The operation involves the surgical removal of the larynx and the complete separation of the trachea from the mouth, nose and esophagus.

At Cleveland Clinic, the preferred method of voice restoration after a total laryngectomy is tracheoesophageal puncture (TEP). ENT surgeons perform primary TEP and place a voice prosthesis at the time of the laryngectomy. This facilitates a rapid restoration of speech.

Restoring a Healthy Airway

Breathing and pulmonary health present a different challenge. During a total laryngectomy, the upper and lower airways become disconnected. As a result, the patient must breathe through a permanent tracheostoma in the neck. This results in loss of filtering, a loss of humidification and warming of inspired air. The loss of some nasal functions and changes in the intratracheal climate can also result in poorer pulmonary function and lead to frequent coughing, an increase in pulmonary secretions, shortness of breath and dryness or crusting of secretions. All these postoperative changes can diminish the quality of life of a patient who is already coping with a difficult situation.

In order to improve postoperative pulmonary health, several studies have investigated the use of a heat moisture exchanger (HME). These studies have documented several clinical benefits, including reductions in mucus production, coughing and the need for stoma cleaning. Other benefits include improved voicing and sleep and less anxiety and fatigue. At the HNI, we have been using the HME system for some time in the outpatient setting.

The Sooner the Better

However, recent studies have shown that the sooner this system is initiated, the sooner the patient will reap its benefits. Therefore, our speech-language pathology (SLP) team teamed up with ENT surgeons, our ENT clinical nurse specialist, our acute care ENT nursing staff and the acute care respiratory therapy section to develop protocols for initiating HME use as soon as possible following surgery.

Figure 1. A: The LaryTube is placed in the tracheostoma. B: The tube is secured with the LaryTube holder.

Figure 2. A: The HME cassette is placed into the tube. B: With the tube and cassette in place, the patient can breathe with optimal pulmonary benefits.

Working with Atos Medical, manufacturer of the Provox® Laryngectomy Pulmonary Kit (LPK), we customized the kit so that it contains all the supplies necessary to initiate HME as soon as possible after surgery. An LPK is issued to our patients when they leave the OR and kept throughout their hospital stay. Once a patient is weaned from the ventilator and extubated, he or she is ready to begin using the HME system. A LaryTube™ is inserted into the tracheostoma (Figure), and an HME cassette is placed into it. Immediately upon placement, patients are able to receive the maximum pulmonary benefits and begin their journey to recovery.

In addition to promoting better respiration, the SLP team has been able to document that early initiation of the HME system leads to an easier and faster transition to hands-free tracheoesophageal voicing.

We in the SLP service are proud of our team’s accomplishments, which truly improve the quality of life and the speed of recovery of our total laryngectomy patients.

Reference

1. Laryngeal and Hypopharyngeal Cancer. American Cancer Society website. http://www.cancer.org/cancer/laryngealandhypopharyngealcancer/detailedguide/laryngeal-and-hypopharyngeal-cancer-key-statistics. Updated Feb. 17, 2016. Accessed July 28, 2016.
2. Merol JC, Charpiot A, Langagne T, Hemar P, Ackerstaff AH, Hilgers FJ. Randomized controlled trial on postoperative pulmonary humidification after total laryngectomy: external humidifier versus heat and moisture exchanger. Laryngoscope. 2012;122(2);275-281.

Ms. Hohman is a clinical speech-language pathologist on Cleveland Clinic’s speech-language pathology team in the Head & Neck Institute.