Laryngeal cancer accounts for approximately 1 percent of all new cancer diagnoses worldwide.1 Total laryngectomy (TL) may be recommended for some individuals with advanced stages of laryngeal cancer, failure of targeted organ preservation therapies, recurrent disease, or a dysfunctional larynx.
Speech-language pathologists (SLP) play a critical role in the evaluation and treatment of individuals undergoing TL throughout the continuum of care, from pre-surgery through the survivorship phase. Management of individuals undergoing TL requires a specific set of knowledge and skills to ensure successful postoperative outcomes.
What is Total Laryngectomy?
TL is a surgical procedure that involves complete removal of the larynx, or voice box. Air breathed in and out will no longer pass through the nose or mouth, but rather through an opening at the front of the neck.
The impact of TL is far-reaching. It affects the vital processes of breathing, speaking, and swallowing.
Why Is Total Laryngectomy Recommended?
Typically, TL is recommended for individuals with advanced-stage laryngeal cancer as the definitive treatment for their disease. Individuals who unsuccessfully undergo chemoradiation (CRT) with the intent of curing their laryngeal cancer may also ultimately have a salvage TL if the CRT was not successful in curing the disease.
Individuals who have previously been treated for head and neck cancer and subsequently have a recurrent disease that further compromises their laryngeal function may also undergo a TL. Some individuals undergo a TL in the absence of active disease, but in the presence of a dysfunctional larynx diagnosis—a condition that renders their larynx non-functional for breathing, speaking, and/or swallowing. This is either due to the late effects of previous head and neck cancer treatment or, in some cases, due to profound dysphagia as a result of a neurologic insult. This is known as a functional laryngectomy.
What Structures are Impacted by Total Laryngectomy?
The structures that are removed during total laryngectomy include the hyoid bone, the epiglottis, the vocal folds (both true and false), the thyroid and cricoid cartilages, and a few rings of the tracheal cartilage. In addition, a total laryngectomy procedure may also include removal of a portion of the pharyngeal wall (pharyngectomy), neck dissection (usually bilateral), or partial or total thyroidectomy. In some more advanced cases, partial or total glossectomy may also be part of the surgical resection depending on the spread of the disease.
Detailed information regarding the total laryngectomy procedure is available online from the Iowa Head and Neck Protocols on total laryngectomy.
How Does Total Laryngectomy Impact Breathing?
Following TL, the lower respiratory tract, and the trachea, specifically, ends at the neck where it forms a stoma, or opening, along the inferior portion of the anterior neck. All air exchange will now bypass the upper respiratory tract, and inhalation and exhalation will occur directly from the ambient environment through the trachea and into the lungs.
As you can imagine, loss of airflow through the upper airway on its way to the lungs can have extensive effects. Without the upper airway filtering, humidifying, and warming the air before it reaches the lungs, significant irritation of the trachea and the lungs can occur. This can lead to an increase in mucus production and, potentially, airway infections. In addition, the changes in airflow can also impact the individual’s senses of taste and smell.
How Does Total Laryngectomy Impact Communication?
Total removal of the larynx can create challenges in the ability to communicate with ease and result in the loss of voice (as the patient knows it.) Fortunately, there are several methods of voice restoration available post-TL.
The SLP is the primary professional that collaborates with the individual following total laryngectomy to determine the best alaryngeal communication option based on their personalized needs. Later steps in establishing alaryngeal communication include testing additional options such as the use of an electrolarynx, esophageal speech, and/or tracheoesophageal speech using a voice prosthesis.
In the immediate postoperative period, communication may occur via low-tech means of alternative communication. For example, individuals may communicate their needs using writing (pencil & paper, dry erase boards, Boogie BoardsÒ, etc.), gesturing, mouthing words, a basic communication board, or through use of a text-to-speech app on their smartphone or tablet.
How Does Total Laryngectomy Impact Swallowing?
Most SLPs learn that swallowing function should be “normal” after laryngectomy, that laryngectomees cannot aspirate after their surgery, and that dysphagia is a rare complication post-laryngectomy.
In contrast, aspiration can occur post-TL, dysphagia symptoms are common, and gastroesophageal reflux is common postoperatively.
The Role of the Speech-Language Pathologists Following Total Laryngectomy
As SLPs we are in a unique position to collaborate with individuals undergoing TL, and their families, to improve quality of life through optimizing aspects of breathing, communication, and swallowing function. SLPs are experts in the areas of speech production, communication, swallowing, and voice. As such, we can offer evaluation, counseling, education, and treatment to these individuals and their support team throughout the process—from diagnosis through the many phases of survivorship.
To further develop the skills necessary to care for individuals for whom total laryngectomy has been recommended, I offer a series of courses covering the various stages of total laryngectomy management, including pre and postoperative care, rehabilitation, and life thereafter.
- Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 68(6), 394–424. https://doi.org/10.3322/caac.21492