"LARYNGECTOMY"

A Total laryngectomy is a surgical operation in which your voice box is removedto cure the voice box cancer. This results in two major changes following the operation:

• A different way of breathing

• A different way of speaking

The voice box is the area at the top of your windpipe through which air passes in order to breathe There are two bands called vocal cords that stretch across your voicebox and vibrate in order to make sounds. This sound is shaped by your throat, tongue, cheek and lips to produce speech. Your voice box also prevents food, drinks, saliva or any particles from going into your windpipe.

The operation usually involves removal of your voice box and usually some lymph glands on either side of your neck to ensure the cancer is completely taken away. This is called a neck dissection. More information about neck dissection can be found in the ‘Neck Dissection’ section. This can vary in extent depending on the extent of cancer spread to them.

After the operation, you will have a hole in the lower part of your neck, the stoma. In addition, if you have had neck dissection, your neck will look thinner in the front.

Once the voice box has been removed, your windpipe is separated at the top from your throat and will open in a hole on the front of your neck. The opening is called a stoma. Having a stoma is safe and it will not close down.

Following the operation you will NO longer breathe through your mouth or nose or cough up mucus from your chest into your mouth. Instead, you will breathe through the stoma, which extends into your windpipe and down into your lungs . You will be able to breathe and cough comfortably through this opening. Because air is no longer going through the nose you are no longer able to sniff effectively and you will lose your sense of smell.

Once you have recovered from the operation you should not have any problems with eating or drinking, however it may take longer to eat than you are used to and some consistencies of food may be more difficult to eat than others.

After the surgery, you will be able to talk but this will be different from normal speech. Once you have recovered from the surgery there are different ways in which you may be able to regain a form of voice. We will discuss this with you before the operation and you will be given some more information on communicating after your surgery.

Some of the different ways of restoring your speech are:

Through a ‘speech tube’ that we can insert during your operation

• Use voice generated through your food pipe and throat

• Use an artificial voice box that you can hold from outside against your neck

• Use mouthing

• Have surgical voice restoration

There will always be a way in which you can communicate, such as sound, gestures, writing or other people reading your lips.

I can do an operation to restore your voice. In most people, this leads to an excellent voice though this will be different from the voice of a normal person. This is usually done at the time of your Laryngectomy. A small opening is made at the back of the windpipe so that a voicing valve can be inserted when you have recovered from your surgery. Straight away after surgery you will have a small tube through this opening into your food pipe. This tube will be used to provide you with liquid food while you are unable to take anything by mouth. If you have other kinds of more complex surgery then voice restoration may need to be done at a later time. We will talk to you about this and give more information so you know what to expect after your operation.

Your operation will be carried out under a general anaesthetic which means that you are fully unconscious for the whole time.The operation can last between six and nine hours.

You should expect to be in hospital for at least two weeks after the operation. This may be longer if complications arise.

After your operation, you will be back on the ward. You will have your blood pressure, pulse and oxygen levels checked. This will be monitored by a machine, which has a blood pressure cuff and a rubber attachment to fit on your finger. There will be a fluid drip going into a vein probably in the back of hand which will help to keep up your fluid levels as you will not be able to eat and drink for about seven days after your operation.

You will have a long feeding tube going into your stomach through your nose or through the opening made at the back of your windpipe (if you have had a primary voice restoration procedure). This will be used to give you water and liquid feeds a day or so after your operation. You may have a tube in your throat in the stoma and some stitches around the operation area. There may be a mask around your neck to give you oxygen and moisture in your lungs.

You will have a small tube on either side of the neck. These tubes are quite long and attach to drainage bottles and remove excess fluid from around the neck area. It is normal for there to be some swelling in the neck and around the jaw line after surgery. As the drainage reduces the tubes will be removed, usually between two and four days after surgery. Pain relief may be given through a fluid drip, by injections/liquid medication or by a pump, which you may be able to operate yourself.

Because you are now breathing through the tube in your stoma you will have more mucus than you are used to and you will need to cough this up. You may find this tiresome at first. The nurses will help you with this. A small narrow tube connected to a suction machine will be inserted into your stoma to remove this mucus and this will make breathing feel easier. This is called suctioning. You will learn, with help from the physiotherapist and the nursing staff how to cough this mucus out through your stoma by yourself. The mucus may be blood-stained at first – do not worry as this is normal.

You will be given a mist to breathe in and out through a mask over your stoma and this will help to loosen mucus so that you can cough it out. This is called a nebuliser. The tube in your neck, through which you breathe, will be removed after a couple of days and the stoma will be cleaned regularly. The nurses will begin to show you how to do this. You may or may not have to wear a laryngectomy tube in your stoma but your nurse will explain all this to you. After a few days as your wounds some of the clips and stitches will be taken out on the ward.

Now as you breathe air does not pass through the nose, which previously moistened and filtered it before it reaches your lungs. Instead air goes straight through your stoma to your lungs. To replace the moisture needed you will have moistened oxygen given through a mask into your neck stoma – this can be quite noisy. After a few days you will progress to wearing a humidification cover (bib) or filters which help warm and moisten the air that you breathe.

At first when you need to use the toilet the ward staff will bring you a commode or bedpan. However soon you will be able to walk to the bathroom yourself. You will have a call bell by which you can contact the ward staff for assistance as needed.

As you will have no voice initially you can communicate by writing, picture cards and by others lip-reading. You should bring a pen and notebook, touchpads or mobile phone for texting family and friends. Following your operation you may not feel very sociable so it is wise to only have a couple of visitors. You will be advised about the visiting hours.

You should read information about risks associated with surgery in general and with neck dissection. Most people will not experience any serious complications from Total Laryngectomy. However risks do increase if you have already had radiotherapy before the operation or have serious medical problems.

The most important possible complication following a Laryngectomy is wound infection or poor healing.A small tract from inside your new throat going into the neck (called a fistula) can sometimes develop. This can delay normal eating and drinking, as the wound needs to be fully healed so that food and drink enters the stomach and not the tissues in the neck. There is no immediate operation for this it just needs more healing time. Very rarely, if this fails to heal, we may need to do another operation to seal this leak.

Recovering from your laryngectomy

You will receive liquid food through a tube, which will be placed, in your nose, into your stomach, or through the back of your stoma. This will continue for about a week. You may have a swallow test in the X-ray department to determine if all the internal wounds have healed. I will let you know when you can start to drink. You will then gradually increase drinks and food by mouth and the liquid food will be reduced and stopped.

Most people when first told they need a Laryngectomy feel all sorts of mixed emotions. Some feel numb; others feel they knew all the time that they would need surgery. We are all individuals and cope in different ways and need different lengths of time to get used to the changes we face. Support and help is available from all the Head and Neck Unit staff.

When you go home you will be able to have some help arranged for you if you need this. For example this could include visits from the nurses, speech therapist or physiotherapists.

You will be given contact numbers so that if you have any immediate problems then you can get advice as to what to do.

Before you leave hospital the nurses will teach you how to care for your stoma. You will go home when you are confident and feel ready. Most people are surprised how easily they learn to look after their airway. The care needed is safe, simple and does not take too much time. You should:

• Not allow any secretions to build up around your stoma area or down the airway.

• Check for secretions in and around the stoma at least three times daily – morning, midday and before going to bed.

You may wear a stoma tube or stud so you will need to remove it and replace it with a clean one when you clean your stoma.

For cleaning your stoma you will need to get the following equipment:

• A free standing table mirror.

• A good light (pen torch).

• Gauze swabs.

• Freshly boiled and cooled water

• Angled forceps.

You will then need to do the following:

  • Once the tube is removed, clean around the stoma with gauze dampened in the cleaning solution wiping away any secretions. You may also need to do this on the inside of your stoma Moisten any dried secretions with damp gauze and gently remove using angled forceps. You may need a relative, friend or nurse to help you. Using a pen torch check that the inside of your stoma is clear.
  • When your stoma is clean reinsert a clean tube or stud.
  • Occasionally the skin around the stoma may become sore, Vaseline, E45 cream or another good quality moisturizer can be used to protect the skin.

Report any serious changes in your stoma such as size, redness, swelling or sores to us.

You will be able to feel, when you breathe in and out, whether your airway is clear. By placing your hand near your stoma you will feel a good volume of warm air as you breathe out.

You will have chest secretions to cough up and clear away from your stoma area. The amount of secretions can vary from person to person.

  • Hold some clean kitchen towel or gauze near to your stoma, take some deep breaths and cough any secretions to the top of your airway and then wipe away.
  • Try to look inside your stoma with a pen torch and a mirror to ensure that there is no build-up of mucus. If this is difficult then a relative or your district nurse may help you.
  • If you allow mucus to build up in your stoma this may alter your breathing.
  • You will need to clean your stoma at regular intervals morning, midday and night.
  • Keeping your mucous thin will help make it easier to cough up and should help reduce build-up.

  • You should wear a stoma protector or filter system that will heat and moisten your mucus, helping to keep it thin. While you are in hospital our nurses will discuss this with you and show you how to use them.
  • Drinking plenty of water will help to keep the body tissues moist, which will help to keep the secretions in your chest thin making it easier to cough up.
  • You may have a nebuliser and if you use sterile water or saline it may help to loosen the mucus to enable you to cough it up.
  • Practice deep breathing exercises regularly throughout the day.
  • You may need to continue using suction for a little while if you find it difficult to clear your airway. This equipment will be ordered for you before you leave hospital. The nursing staff will teach you and your relatives how to do this.
  • Breathing in steam from a bowl of hot water may be helpful if your mucus is becoming thick and difficult to cough up.

Remember that your mucus may change according to the time of year. Your mucus may also become thicker during a cold or flu so you may need to take steps to ensure that you are able to clear your airway. The mucus is also going to be thick and discolored with crusts if you go out in a dusty polluted environment. When you expect this, make sure to use the stoma filter system before stepping out.

  • You should wear a stoma protector or filter system all the time, including when you sleep. This will heat and moisten your mucus, help to keep it thin and also filter out the dust and dirt in the air. While you are in hospital your nurses will discuss this with you and show you how to use them.
  • Remember that in India, especially during the summer time there are more flies, wasps, blossom leaves and dust in the air, which may present a hazard to the unprotected stoma.
  • Never cut up small pieces of gauze to clean around the stoma as fragments may fall into the stoma.
  • Do not use cotton wool or tissues as small fibers may be inhaled causing irritation in the airway, which is often difficult to relieve.
  • Be careful when using cotton buds around the stoma and make sure they are moistened first so that small fibers are not inhaled. Thin white kitchen roll is best.
  • You need to take care not to get water into your stoma, as it will go straight into your lungs. Take care when bathing and you may wish to ask a relative or friend to help you wash your hair.
  • You can use a plastic shower shield to protect your stoma when showering and shaving etc. These may be obtained from your pharmacy.
  • Do not go swimming unless you have the correct breathing equipment and have had lessons in how to use it.
  • Take care not to spray aerosols such as polish, perfume etc. too near the stoma area as this may irritate your airway causing coughing.
  • During hot weather take care to protect your skin from harmful effects of the sun – a sunburnt stoma is very painful.
  • While on the beach take care not to get sand in the stoma. Remember that it gets windy on the beach so protect that stoma.

For more information, I strongly recommend that you visit this website that has excellent leaflet to help you adjust after the operation

http://www.laryngectomy.org.uk/publications/

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