Voice After LaryngectomyANDREW W. AGNEW, DO

APRIL 9, 2021

DisclosuresNone

OverviewNormal Anatomy and Physiology

Laryngectomy versus Tracheotomy

Tracheostomy Tubes

Voice Rehabilitation

Case Scenarios

Terminology Laryngectomy – surgical removal of the entire larynx (voice box)

Laryngectomy stoma– opening the neck after a laryngectomy

Tracheotomy – procedure to create a surgical airway from the neck to the trachea

Tracheostomy – the opening in the neck after a tracheotomy

Normal Anatomy of the AirwayUpper airway:

Nasal cavities: ◦ Warm, filter and humidify inspired air

Normal RespirationWe breathe primarily by the action of the diaphragm and rib cage

Thus, whether people breathe through the nose and mouth or a tracheostoma, the physiology of respiration remains the same

Normal Anatomy of the Airway◦ Phonation◦ Respiration◦ Airway Protection during deglutition ◦ Val Salva

Postsurgical Anatomy Contrast

Patient s/p tracheotomy Patient s/p total laryngectomy

Laryngectomy •Removal of the larynx (voice box)

•Indications• Advanced laryngeal cancer• Recurrent laryngeal cancer• Non functional larynx

Laryngectomy•Fundamentally life changing operation

•Voice will never be the same

•Smell decreased or absent

•Inspired air is not warmed and moisturized

•Permanent neck opening (stoma)

•Difficult to have head under water

Laryngectomy

Operative Otolaryngology Head and Neck Surgery. Pou, Anna. Published January 1, 2018. Pages 118-123.

Laryngectomy

Operative Otolaryngology Head and Neck Surgery. Pou, Anna. Published January 1, 2018. Pages 118-123.

Laryngectomy

Operative Otolaryngology Head and Neck Surgery. Pou, Anna. Published January 1, 2018. Pages 118-123.

Postsurgical Anatomy Contrast

Patient s/p tracheotomy Patient s/p total laryngectomy

Tracheotomy •Indications

• Bypass upper airway obstruction • Prolonged ventilator dependence • Pulmonary hygiene

• Reversible

Tracheotomy

Byron J. Bailey ... [and others] ; 237 contributors ; illustrated by Anthony Pazos. Head And Neck Surgery-- Otolaryngology. Philadelphia :J.B. Lippincott, 2014.

Tracheostomy Tube Anatomy• Sizes: #4, #6, and #8

common

• Cuffed vs. Non-cuffed

• Fenestrated vs. Non-fenestrated

• Tubes vary in length and curvature

• Standard tubes vs. Proximal XLT vs. Distal XLT

Daily Cuffed (DCT) vs. Non-Cuffed (DCFS)

Daily Inner Cannulas

Reusable Inner Cannula

XLT Tracheostomy Tubes

Newest Shiley•Smaller face plate

•Tapered balloon/cuff

•Larger inner diameter

Tracheostomy Tube Summary

•Size

•Cuff or not

•XLT or not

What about voice?

Basic Speaking Valve Physiology•Passy-Muir speaking valves are one way valves

•Allow air to be inspired, but not exhaled

•Near normal voice

Basic Speaking Valve PhysiologyPatient cannot have obstruction the passage of exhaled air◦ Examples:

◦ 1. Inflated tracheostomy cuff◦ 2. Obstructing tumor◦ 3. Bilateral vocal fold paralysis

Voice Options After Laryngectomy • Tracheoesophageal puncture (TEP)

• Esophageal Speech

• Electrolarynx

Voice Options After Laryngectomy • Tracheoesophageal puncture (TEP)

• One way valve• Various sizes

•Advantages:• Closest to normal speech

•Disadvantages: • Additional equipment• Prosthesis issues • May require second surgery

Primary TEP Image Credit: Operative Otolaryngology Head and Neck Surgery. Pou, Anna. Published January 1, 2018. Pages 118-123.

Voice Options After Laryngectomy • Tracheoesophageal puncture (TEP)

•Humidification Moisture Exchanger

TEP Example https://www.youtube.com/watch?v=5haB5_abbMk

Esophageal Speech •Air is swallowed and then allowed to escape

•Advantages: • No additional surgery or prosthesis

•Disadvantages:• Learning curve • Short speech segments – 5 words

Esophageal Speech Example https://www.youtube.com/watch?v=UTLg-2N4hyw

Electrolarynx • Mechanical Voice

•Advantage:• Generally less of a learning curve• Sustained speech

•Disadvantage:• Cost of device • Does not resemble normal speech

Electrolarynx HTTPS://WWW.YOUTUBE.COM/WATCH?V=RIHLUOXT1AW

Laryngectomy vs. Tracheostomy Tube

Case Scenarios

Case #1Location: ICU

63 y/o female underwent a tracheotomy today due to ventilator-dependent respiratory failure and prolonged intubation. She returns to the ICU from the OR. Monitors and ventilator are re-attached. 30 minutes later her O2 saturation drops to the 70’s and she becomes tachycardic. She is awake and appears distressed. You can hear her gasping for air. You ask if she is ok, and she replies with a raspy voice, “I can’t breathe”. ◦ What is the diagnosis?

◦ Displaced tracheostomy tube

◦ What are the risk factors?◦ Obesity◦ Excessive coughing or patient agitation◦ Loosely tied tracheostomy ties◦ Failure to suture neck plate to skin◦ Use of a bulky dressing

Displaced Tracheostomy Tube

Case #2Location: General Medical Floor

57 y/o male admitted 2 days ago for acute exacerbation of COPD. History of tobacco abuse – 2 packs per day x 40 years. Per his history and physical he has “laryngeal cancer with permanent trach”. While admitted he experiences worsening dyspnea throughout the morning with increased nasal oxygen requirements to maintain appropriate oxygen saturation. Later, he develops confusion and respiratory distress. A rapid response is called. ◦ How will you respond to this patient’s poor ventilation and perfusion?

◦ Patient had a total laryngectomy, thus keep in mind he breathes entirely from his neck. ◦ Bag-valve-mask to face and attempts at oral intubation will only instill air into his digestive tract.◦ After calling for help, ventilate with a bag-valve-mask fitted with pediatric mask to the patient’s tracheostoma.◦ If patient has had a TEP, his mouth and nose must be sealed to improve ventilation and prevent air leakage

Case #2Is intubation needed? How should it be performed?

If mechanical ventilation is required in the total laryngectomy patient (including CPAP or BiPap), then intubation of the patient’s laryngectomy stoma is required.◦ As above, intubation must be performed through the patient’s stoma. A standard cuffed tracheostomy

tube (#6 or #8) or an endotracheal tube (flexible) can be used for intubation

Laryngectomy Ventilation

Summary • Laryngectomy is a life changing operation

• No laryngectomy tube is required

• Voice Options • Tracheo eosphageal puncture (TEP)• Esophageal speech• Electrolarynx

• A tracheotomy is reversible

• Passy Muir Valves allow speech

• Size, cuff, and length are the most important elements of a tracheostomy tube

• An inner cannula is required to avoid de cannulation

Postsurgical Anatomy Contrast

Patient s/p tracheotomy Patient s/p total laryngectomy

Questions?

Thank you