Without a larynx

What are the implications for resuscitating and communicating with these patients? Hannah Blagnys and Paul Montgomery discuss

In 2003 more than 1700 people were diagnosed with cancer of the larynx in England.^w1 Many of these with advanced or recurrent disease will go on to have a laryngectomy (removal of the larynx). How is it possible to communicate without a voicebox? This article discusses the communication options available to someone who has had a laryngectomy (a laryngectomee) and the techniques needed for resuscitation.

The larynx is a specialised organ responsible for maintaining a patent airway and providing a protective sphincter at the top of the airway during swallowing to prevent aspiration of food and drink. It is also responsible for the generation of the sound that is shaped into intelligible speech by movement of the lips and tongue. The larynx lies in the anterior neck from C3 to C6 and connects the inferior part of the pharynx to the trachea. It is split anatomically into three parts, the supraglottic, glottic, and subglottic areas, which are used in the description of laryngeal cancer.

Laryngeal cancer

In the United Kingdom laryngeal cancer is currently the 17th most common cancer in men and the 23rd in women.^w1 It is by far the most common indication for laryngectomy.^w2 Smoking is the greatest risk factor for laryngeal cancer^w2 because the carcinogens in smoke are in contact with the epithelial cellular surfaces of the upper aerodigestive tract. Gastro-oesophageal reflux,^w3 alcohol, diet, occupation, and genetic susceptibility also increase a person’s chance of laryngeal cancer.^w2

Hoarseness of the voice is a common sign of laryngeal cancer, which shows that the pathology has glottic involvement. Supraglottic involvement may present as ill defined throat irritation and may go undetected, therefore, for long periods of time.^w3 Guidelines from the English Department of Health for the referral of suspected head and neck cancer should be used in conjunction with the normal two week wait system for cancer referral (box 1).

Box 1: Urgent referral guidelines for head and neck cancer^w4

Hoarseness for more than six weeks
Ulceration of oral mucosa for more than three weeks
Oral swellings for more than three weeks
All red or red and white patches of the oral mucosa
Dysphagia for more than three weeks
Unilateral nasal obstruction, particularly when associated with purulent discharge
Unexplained tooth mobility not associated with periodontal disease

Surgery

Staging of laryngeal cancer is needed to assess a patient’s case for surgery. The TNM system is used. The tumour, or T, staging is classified according to the three anatomical parts of the larynx. The metastasis to nodes, or N, classification is divided according to node size and number. The distal metastasis, or M, classification indicates disease beyond the neck and larynx.^w3 T4 cancers, in which the tumour invades through thyroid cartilage or extends to other tissues beyond the larynx, are treated with a total laryngectomy and radiotherapy, with or without chemotherapy.

A total laryngectomy operation involves the removal of the hyoid, all of the thyroid and cricoid cartilages, and 1 or 2 tracheal rings (fig 1). The overlying strap muscles are resected and the supraglottal, glottal, and subglottal areas are removed. The resultant cut end of the trachea is then sutured to the skin of the neck creating a permanent stoma.^w3

Fig 1 Dissection of the strap muscles and thyroid gland to show the larynx

After laryngectomy

The patient now breathes independently through a stoma because there is no longer a connection between the trachea and the nose or mouth (figs 2 and 3). Immediately postoperatively the patient must be fed either through a nasogastric tube or by percutaneous endoscopic gastrostomy, which continues until the tissues in the neck are healed and there are no signs of leakage through the wound. Healing takes about 10 days, after which the ability to start eating and drinking by mouth is confirmed by performing a barium swallow test.^w5

Fig 2 Airflow before laryngectomy

Fig 3 Airflow after laryngectomy

Olfaction (sense of smell) and sensations of flavour related to smell deteriorate after total laryngectomy.^w6 This is because of the absence of nasal airflow. We usually breathe through our nose to elicit a sense of smell. However, as someone who has had a laryngectomy breathes through his or her stoma, this is not possible. Lack of smell and taste can diminish a patient’s quality of life, and particular attention should be paid if appetite is affected.^w7

Communicating without a larynx

A laryngectomy operation involves removal of the larynx, which is the organ of voice production. Communication after laryngectomy, therefore, is severely impaired. Articulation is usually intact unless damage to a nerve has caused dysarthria (slurring of the speech).^w8 Someone who has had a laryngectomy has various options for communication—an electronic larynx, oesophageal voice, a voice prosthesis (valve), silent articulation (mouthing words), and pen and paper.

Electronic larynx

An electronic or artificial larynx is a small vibrating device that is held against the neck, chin, or cheek. It sends vibrations through the tissues that vibrate the air inside the mouth. The sound produced is shaped into intelligible speech by moving the lips and tongue as we normally do when speaking. This means of communication may not be appropriate immediately after the operation because of oedema or if the tissues have hardened after radiotherapy.^w8 Many patients use an electronic larynx with other methods. They are especially useful in noisy surroundings, on the telephone, with a hard of hearing partner, or when feeling very tired.^w5

Oesophageal voice

Oesophageal voice is achieved by learning the technique of pumping air from the mouth into the upper oesophagus. This is done using a “burp-like” action, which causes a small segment of muscle fibres to vibrate in the oesophagus as the air is returned to the mouth.^w5 When the air is released from the upper oesophagus, a hoarse low pitched voice is produced.^w8 Not all patients can master this technique and some may need to use an electronic larynx if they need greater volume or fluency.

Voice prosthesis

A voice prosthesis or valve is a surgical means of voice restoration. A prosthesis is placed into a surgically created puncture hole between the trachea and oesophagus either at the time of surgery or later.^w8 Once in place, the patient occludes the stoma by placing a finger, thumb, or filter device over the stoma when they wish to speak, thereby directing air into the oesophagus. This produces voice in the same way as oesophageal voice, but it usually is louder and more fluent.^w8

Not all patients can achieve audible voice after surgery. For this minority, silent articulation or use of pen and paper are their only ways of communication. We can only begin to imagine what it would be like to be unable to speak normally or to speak with a different quality. Box 2 gives some advice to help us listen and communicate better with people who have had laryngectomy.

Box 2: Communicating after laryngectomy^w6

Do

Give the person plenty of time to speak
Ask them to repeat if you don’t understand
Watch a person’s lips if you are finding it hard to understand
Ask about the voice prosthesis if at all possible; most will be able to tell you how to change their valve and whether it is blocking their airway

Don’t

Hurry them; pressure affects ability to communicate
Pretend you understand if you don’t—it will be obvious
Avoid eye contact during the conversation
Remove a voice prosthesis if the patient is unconscious unless it is obviously fully displaced and blocking the trachea. Removing certain types of prosthesis by pulling can damage the trachea. Valves normally protrude slightly into the trachea but do not affect breathing

Resuscitation guidelines

In an emergency normal mouth to mouth resuscitation cannot be used for people who have had laryngectomy. Because patients cannot breathe through their nose or mouth it is essential to give mouth to stoma resuscitation when you would normally give mouth to mouth resuscitation.^w10

Ensure you are familiar with your hospital’s most recent cardiopulmonary guidelines, including ratios of chest compressions to rescue breaths. The breathing techniques must be adapted, however, for patients who have had laryngectomy and tracheostomy. The following are the initial steps for resuscitation.^w10

Step 1: Check the neck

Lie the victim on his back as you would any other CPR patient
Remove clothing from around the neck. DO NOT remove any tubes or voice prostheses that are in place

Step 2: Clear the airway

Wipe any mucus from the stoma or tube (this may require suction)
Make sure the stoma is clear before proceeding. There may be a silicone speaking valve (voice prosthesis) in the stoma situated in the posterior tracheal wall. This should not be removed because if dislodged it provides a direct route for fluid to pass into the lungs
If an endotracheal tube is needed this should be inserted through the stoma

Step 3: Position for resuscitation (fig 4)

Kneel beside the patient on his or her back, and gently extend the airway by tilting the head backwards
Place two fingers each side of the nose and put your thumb under the chin
Close your fingers to prevent escape of air from the nose and mouth

Fig 4 Positioning for resuscitation: extend the airway and pinch the nose and mouth shut to stop air escaping

Step 4: Resuscitation

Take a deep breath and place your mouth over the stoma to make a seal, or place a face mask with the nose end pointing downwards over the stoma and press down to make a seal
Blow into the victim’s stoma until the chest rises
Release your fingers between each blow