A laryngectomy is a surgical procedure to remove part or all of the larynx, the area of the throat that contains your vocal cords. It’s a treatment for laryngeal cancer or damage to the larynx from injury or other health complications. 

Dr. Wayne Koch of Johns Hopkins, a leader in head and neck oncologic surgery, reviews what’s involved with a laryngectomy.

What is a laryngectomy?

A laryngectomy is the surgical removal of the larynx (voice box) under general anesthesia. As part of this surgery, the breathing passage (also known as the windpipe or trachea) is brought to the surface of the neck, to allow for breathing once the larynx is removed. 

Who might need laryngectomy surgery?

Your surgeon will explain why your voice box needs to be removed. The most common reasons are:

• Cancer involving the voice box
• A nonfunctioning voice box that does not allow the patient to use their voice or to eat safely without food going into the lungs (this is also called aspiration). When a laryngectomy is performed for this reason, the patient may already have a feeding tube through the stomach, or a tracheostomy. The goal of the surgery is to give the patient the ability to eat by mouth safely.

Types of Laryngectomy

The larynx is used for breathing, swallowing and talking, so people who have a laryngectomy must adjust to changes in how they eat and communicate. In extensive cases, the entire larynx is removed (total laryngectomy), a procedure that separates the breathing and swallowing passages. For less severe cases, only part of the larynx may be removed (partial laryngectomy), potentially allowing patients to speak and eat more normally.

Preparation and Support for a Laryngectomy

Before surgery, you will meet with a speech-language pathologist. They help patients prepare for the changes they will experience with communication and eating after a laryngectomy. You may also have the opportunity to meet with other patients who have had a laryngectomy. Other preparations include:

• Do not eat or drink anything after 12 a.m. on the day of your surgery. 
• Ask a family member or friend to pick you up after being discharged from the hospital.
• Arrange for someone to be with you at home for one to two weeks after you leave the hospital.

During a Laryngectomy

The surgeon makes an incision on the neck, then removes either part or all of the larynx. They may also remove some lymph nodes and part of the pharynx. The surgeon then creates an opening — called a stoma — in the neck, in front of the windpipe. 

A laryngectomy tube is then placed in the stoma to help with breathing after surgery. The tube is removed in a few weeks or months to allow for everyday breathing through the stoma.

Part of the pharynx, the passage between your nasal cavity and esophagus, may also be removed, and, in some cases, the lymph nodes as well. The surgeon finishes by closing the incision with stitches.

After a Laryngectomy

Patients experience recovery at different rates. Some people may feel tired for the first couple of weeks after surgery. Allow time to rest and recover, and remember that a lot of the initial discomfort is temporary and will improve with time.

Most patients stay in the hospital for seven to 10 days after surgery. You may spend the first postoperative day in the intensive care unit (ICU). In the first few days after surgery, nonverbal communication may be necessary, using methods like pen and paper, a picture board, text-to-speech apps or pointing or gesturing. These methods are slower than speaking and can be frustrating to use. Try to be patient.

Learning to Breathe Through the Neck

Breathing out of your neck is a new and foreign sensation. Feeling like it is difficult to breathe is normal. You can expect the following:

• There may be some swelling, redness or puffiness around the incision and neck. 
• Pain is very normal after surgery. The goal is not to eliminate pain completely but to reduce it to manageable levels. Using too much pain medicine may delay or complicate your recovery. 
• Many symptoms may last for several weeks but will eventually improve with time.

Wound Care

You may have stitches with long tails along the edge of your stoma. These can become crusted. Be sure to apply ointment such as petroleum jelly along your stitches twice each day until they are removed. Here are other tips:

• Do not shower until at least two days after surgery. Keep your wound dry, and use a shower shield to make sure water does not enter your stoma. Pat the wound dry and do not rub it. Keep the head of your bed raised with pillows when you sleep (at least 30 to 45 degrees). This will help reduce swelling.
• A drain is usually placed in the neck to remove blood and fluid in the wound after surgery. This is emptied and measured every four hours in the hospital. If you leave the hospital with a drain in place, you need to empty the fluid at least every eight hours, and measure and record the amount.
• At home, you will need to call a nurse to have your drain removed once the 24-hour output is minimal (typically less than 25 cubic centimeters).
• It is normal for the airway to make mucus. Any time you hear or feel mucus rattling in the airway, clear it to prevent a mucus plug from blocking the airway and stopping your breathing. 
• To clear the mucus, bend forward and cough. If you cannot clear the airway, squirt a sterile saline bullet into the stoma and cough again. Then you will need to suction with a suction machine.  

Suctioning at Home

Before patients leave the hospital, they receive instructions on caring for their laryngectomy at home. This includes suctioning. Supplies and equipment needed to care for the airway at home include a portable, battery-operated suction machine, suction catheters, saline bullets and supplies to clean the stoma. During preoperative visits, a speech pathologist may also help patients obtain specific laryngectomy products.

• Suctioning instructions:

1. Wash your hands and open the suction kit.
2. Disconnect the Yankauer (blue) suction tip from the suction tubing.
3. Turn on the suction machine.
4. Put on gloves.
5. Open the suction catheter and attach it to the suction machine.
6. Test the setup by dipping the end into a cup of saline water and covering the suction port.
7. Insert saline into the stoma.
8. Breathe in deeply and cough.
9. Insert the suction tube catheter suction port into the stoma until you start to cough.
10.  Breathe out and try to cough.
11.  Pull the mucus out of your airway:
    
    a. Cover the suction port with your thumb.
    
    b. Rotate the catheter in a circle-like motion to reach all areas inside the trachea while slowly pulling out the catheter, then catching your breath.
12. Repeat the steps in number 11 above as many times as needed to clear the airway of extra mucus.
13. Clear the suction catheter of mucus by pulling saline up through it until it is clear.
14. Wash your hands when you are done.

Speaking After a Laryngectomy

Although laryngectomy surgery removes the patient’s vocal cords, they are able to speak after the procedure. There are several options:

• Electrolarynx
  • An electronic, hand-held device creates vibrations that are passed through the neck, cheek or mouth (with a plastic tube), so the mouth and throat can produce understandable speech.
  • This is not always easy to learn.
  • Some patients do not like how the voice sounds with an electrolarynx. Some feel it sounds robotic and unnatural.

• Tracheoesophageal puncture (TEP)
  • A tracheoesophageal puncture creates an opening between the windpipe (trachea) and food tube (esophagus). A one-way valve allows air to be directed from the trachea to the esophagus.
  • The stoma must be covered with a finger to produce sound. 
  • Vibrations created by air going through the TEP into the throat and mouth are shaped into intelligible speech.
  • TEP placement requires a minor procedure that can sometimes be performed at the same time as the laryngectomy. Other times the procedure is done later. This decision depends on factors that might affect wound healing.
  • If you get a TEP at the time of surgery, you will not be able to use it for speech immediately. You will use an electrolarynx during your hospital stay.

• Esophageal speech
  • This method does not require any equipment.
  • Air is pushed by your tongue down the esophagus and emitted to create vibrations that are used to form words.
  • This method is more difficult to learn and is less commonly used. 

Eating After a Laryngectomy

After recovering from laryngectomy surgery, swallowing becomes relatively normal and most people return to eating a normal diet. 

However, immediately after the laryngectomy, eating by mouth is not allowed for at least seven days. During this time, a feeding tube placed during surgery is used. This tube, which can be placed through the nose or the abdomen, provides liquid nutrition while the body heals. The tube may be in place for a short period (e.g., weeks) or it may need to remain longer (e.g., months). 

Complications After a Laryngectomy

• Bleeding: This is possible after any surgery, but the medical team should ensure there is no active bleeding when the incision is closed. Bleeding may look like an area of swelling in the neck, and the skin may look bruised.
• Seroma: A seroma is fluid collection at the surgical site that looks like an area of swelling. A drain is usually placed in the neck to minimize the possibility of a seroma occurring. A seroma can usually be managed by removing the accumulated fluid with a needle.
• Wound infection

• Salivary leak: A salivary leak can sometimes be detected by drinking fluids that are dyed and seeing if colored fluids come out of the neck drains. Sometimes an X-ray is performed while the patient drinks a liquid with contrast to see if there is any leak into the neck.
  • A salivary leak may show up as neck swelling or may appear as a possible infection. It may also look like an opening in the neck skin with saliva draining through it. If you have a salivary leak, your doctor most likely will have you stop eating and drinking by mouth, and you will use a feeding tube until the leak is healed.
  • Your surgeon may also open your neck incision and pack it with gauze to help with healing from the inside out. Most cases are resolved with packing alone, but sometimes additional surgery is needed.

Being Safe With Your New Airway at Home

• Do not smoke or be around smoke. 
• Do not swim. 
• Cover the stoma during shaving and haircuts, and when around dust, soot, smoke, insects or people with colds. 
• Be sure smoke alarms are working. Sense of smell may be decreased, increasing the risk of not smelling smoke or a gas leak.