2-36
2-36. LARYNGECTOMY
a. Surgery of the larynx is done most often to remove a tumor or growth that may be malignant.
(1) A malignant growth may occur on the vocal cords (intrinsic) or on another part of the larynx (extrinsic). The type of surgery done depends upon the location and involvement of the growth.
(2) Newly developed surgical procedures are being used in the management of laryngeal growths. Some procedures involve resection of the larynx or formation of an air passage from the trachea to the pharynx. The objective of these procedures is to preserve the voice.
b. Partial laryngectomy is the removal of that portion of the vocal cord that is involved with abnormal growth. A tracheostomy tube may be left in the neck wound for a few days postoperatively. The neck wound will eventually heal, and the normal respiratory system and voice are preserved.
c. Total laryngectomy is the removal of the larynx, vocal cords, thyroid cartilage, and the epiglottis. The trachea is sutured to the anterior surface of the neck as a permanent tracheostomy. The patient breathes exclusively through the neck opening (stoma) and is referred to as a total neck breather, since the airway between the mouth, nose, and throat has been completely closed.
(1) Total laryngectomy with laryngoplasty involves the formation of a tube that leads from the upper trachea to the lower pharynx. This "speaking" tube allows for speech that sounds almost normal. A patient having this type of laryngectomy is referred to as a partial neck breather, since the tube allows the passage of air from the nose and mouth into the trachea.
(2) When the patient has a total laryngectomy, the surgeon will most likely place a laryngectomy tube in the newly formed stoma. This tube may be removed when the stoma has healed, usually within 4-6 weeks. The laryngectomy tube is shorter, but larger in diameter, than a tracheostomy tube. Care of the laryngectomy tube is the same as that for the tracheostomy tube.
(3) Since the patient will not be able to speak initially, some means of communication must be developed for the patient. Commonly used techniques are simple note writing, flash cards, magnetic letter boards, and magic slates. Always have a call bell within the patient's reach. When the stoma has healed, the speech pathologists will work with the patient to help him learn new speaking methods.
d. Special considerations for the laryngectomee include the following:
(1) For the laryngectomee, air passes directly into the trachea without being moistened and warmed by the upper respiratory mucosa. This causes the trachea and bronchi to secrete excessive amounts of mucous, and the patient may experience frequent bouts of coughing. In time, the mucosa of the trachea and bronchi will adapt to this altered physiology. In the meantime, however, the patient will be more comfortable with added humidification in the inspired air. This may be provided by steam or cool mist humidifiers.
(2) Precautions must be taken in the shower to prevent water from entering the stoma. A small plastic bib worn around the neck works well. Swimming is not recommended, as the laryngectomee may drown without ever putting his face in the water.
(3) Care must be taken to prevent hair spray, powder, loose hairs, and any other foreign objects from entering the stoma.
(4) A laryngectomee should carry or wear identification that will alert a first-aid giver to his special resuscitation needs. A laryngectomy stoma may be hidden by a scarf and not noticed by the first-aid giver. A neck breather, whether partial or total, requires artificial ventilation through the stoma. This may be done by mouth-to-stoma artificial respiration or by bag-mask to stoma. If the patient wears a tube in his stoma, do not remove it. Give artificial ventilation through it. The mouth and nose must be sealed closed to prevent the escape of air from the nose and mouth, in the event that the patient is a partial neck breather.
