Having a Largnectomy...

Introduction

This booklet is designed to give you information about having a laryngectomy and the care you will receive before, during and after your operation.

What is a Laryngectomy?

A Laryngectomy is a surgical operation in which all or part of the larynx is removed. People have a laryngectomy if the voice box (larynx) needs removing. This is mainly due to a malignant tumour (cancer) or, more rarely, a severe mechanical problem.

This results in two major changes following the operation:

1. A new way of breathing

2. Loss of voice

The operation is undertaken with the aim of curing the cancer. This operation is often the first stage of treatment and is usually followed with radiotherapy treatment to ensure that all the cancer is removed.What is the voice box (larynx) and what does it do? The voice box larynx is the area at the top of the windpipe (trachea) through which air passes in order to breathe. The vocal cords stretch across the voice box and vibrate in order to make sounds for speech. The voice box also prevents food, drinks, saliva or any particles from going into your windpipe (trachea).

What does the operation involve?

The operation can differ from person to person depending upon the position of the cancer in the larynx in relation to the surrounding structures, for example the thyroid gland( which sits in font of the larynx) or the pharynx (the upper part of the gullet through which food enters the oesophagus). Your consultant will discuss this with you.

The operation usually involves removal of the voice box and part or all of the thyroid gland which sits in front of the larynx. Some neck glands on either side of the neck are usually removed also to ensure the cancer is completely taken away. This is called a neck dissection, it can vary from person to person and your consultant will discuss this with you.

 

What will I look like after the operation?

Once the voice box has been removed, your windpipe is separated at the top from in front of your food pipe (oesophagus) and bent over to open on the front, lower, middle part of your neck. The opening is called a stoma.

Most people find the stoma a lot smaller and less of a problem than they first thought. It is safe and the stoma (opening) will not close down. Once the surgery has settled you will be advised what to wear on your neck, to protect your stoma, by the hospital staff looking after you.

Following the operation you will not breathe through your mouth or nose or cough up mucus from your chest into your mouth. Instead you will breathe through the opening (stoma) at the lower front of your neck which extends into your windpipe (trachea) and down into your lungs. You will be able to breathe and cough comfortably through this opening. Because air is no longer going through the nose you are no longer able to sniff effectively or purposefully smell.

Once you have recovered from the operation you should not have any problems when eating or drinking after your voice box has been removed.

How will I be able to make myself be understood (communicate) after the operation

When your voice box is removed you will not be able to talk as before. However once the surgery has settled down there are different ways by which you may be able to regain a form of voice. Your consultant and the Speech Therapist will discuss this with you. The method you use will depend on the type of surgery you have and your individual circumstances.

Some of the different ways of communicating are:

•Use oesophageal voice

•Use an artificial larynx

•Use mouthing

•Have surgical voice restoration.

There will always be a way in which you can communicate, such as sound, gestures, writing or other people reading your lips.

All the hospital and community staff are dedicated to help and support you and your family to a new way of communication.

Preparation for surgical voice restoration is usually done at the time of your laryngectomy. A small opening is made at the back of the windpipe so that a voicing valve can be inserted when you have recovered from your surgery. Straight away after surgery you will have a small tube through this opening into your foodpipe. This tube will be used to provide you with liquid food while you are unable to take anything by mouth.

In some hospitals valves are inserted straight away and you will have a tube through your nose which passes into the stomach. This tube then allows you to receive liquid food while you are unable to take anything by mouth. Your speech and language therapist will talk to you about this and give more information so you know exactly what to expect after your operation.

 

Who will be involved in my care?

You and your family may like to find out about what having a laryngectomy really means. You will meet several health professionals before your operation as well as the doctors and nurses.

Head and Neck Macmillan Nurses /Airway specialist Nurse

Will provide both you and your family with information, support and advice concerning all aspects of your illness, treatment and recovery.

Speech and Language Therapist

Will help you develop new ways of communicating and teach you new skills. You will be invited to meet with a person who has already gone through this operation and this may help you and your family more fully understand what to expect.

Dietician

Will give you advice on all your nutrition needs throughout your treatment and ensure these are met while you are recovering from your surgery.

Physiotherapist

Will help you with your breathing whilst recovering from your laryngectomy.

He/She will also help with neck and shoulder exercises.

Head and Neck Counsellor

Will help give you and your family psychological support through your surgery and treatment and give opportunity for structured counseling if necessary.

Hospital appointments before your surgery

Pre-Treatment Assessment

You may be asked to attend a pre-treatment assessment where you will have a chance to meet and talk to the professionals involved in your care and discuss any issues you have with your treatment and recovery plan. You may be asked to complete some questionnaires in order for your professional team to assess any immediate needs, both physical and psychological, to prepare you and your family for surgery.

Pre-Admission

You may be invited to attend a pre-admission assessment one or two weeks before your operation. This enables both the doctors and the nurses to assess your health needs and carry out tests such as, blood tests, heart tracings (ECG) and chest X-rays. This ensures that it is safe for you to undergo a general anaesthetic. It is important that you bring any medication that you are taking for the medial staff to see.

 

The pre-admission assessment clinic is an opportunity for you to meet the

ward staff and see where you will be admitted on the day of your operation.

It is also a time when you can ask questions and discuss any queries you

may have concerning your operation.

How long does the operation take?

Your operation will be carried out under a general anaesthetic which means that you are fully unconscious for the whole operation. Because having a laryngectomy involves delicate surgery the operation can last between 5 - 12 hours. To prevent vomiting and other complications during the operations it is necessary for you to starve (have nothing by mouth or no chewing gum) for at least 6 hours before the operation. You will be advised of what time to starve from when you attend the pre-admission assessment. How long can I expect to be in hospital?

You should expect to be in hospital for at least 2 - 3 weeks or longer if complications arise.

What are the complications of Laryngectomy?

The main problem following a laryngectomy is wound infection or poor healing. This can delay normal eating and drinking as the wounds need to be fully healed so that food and drink can enter the stomach and not the tissues in the neck. A small tract from the windpipe into the new gullet (called a fistula) can sometimes develop. This needs longer healing time and prevents you taking any food or drink by mouth. There is no immediate operation for this it just needs more healing time.

Bleeding is a risk after any operation and you will be closely observed for this following your surgery. You and your family will be fully informed of any problems.

After any major operation there is a risk of:

Chest Infection... You can help by practicing deep breathing exercises and following the instructions of

the physiotherapist. If you smoke, it is a good idea to stop smoking as far ahead of the operation as possible as this will also reduce the risk of chest infection.

Wound Infection... Antibiotics will usually be given through a drip to help reduce the risk of this happening.

Thrombosis (Blood clot in the leg)...This is due to changes in the circulation during and after surgery. A small dose of heparin (blood thinning medication) may be injected daily until you go home. You can help by moving around as much as you are able and in particular regularly exercising your legs. You may also be fitted with some support stockings for the duration of your stay in hospital. Stopping smoking may also help reduce this risk.

Pulmonary embolism...  Rarely a blood clot from the leg can break off, travel through the heart and get stuck in the lungs. This can be very serious and, rarely, even fatal. The risk of this is less than 1% (1:100).

Bleeding... This is monitored after the surgery and any abnormal bleeding will be dealt with by the medical staff.

Smoking...  Most hospitals now adopt a No Smoking policy and there are no smoking facilities on the ward. If you do smoke it is in your own health interests to stop smoking for at least 24 hours prior to your anaesthetic.

Following your operation you will be unable to smoke as you will not be able to draw in from a cigarette. It is in your best interests to start a giving up smoking programme and the staff at the hospital can help you with this or you can seek advice from your GP’s surgery.

What to bring

Please bring nightwear, day wear, dressing gown, towels, toiletries, slippers, books/magazines and a pen. It is important that you bring any medication you are currently taking, including any inhalers. It will also be helpful to arrange for a relative or friend to wash your nightwear etc and bring in fresh supplies. Hospital nightwear is available if necessary.

Please DO NOT bring any valuables such as jewellery or large sums of money with you. The hospital cannot take responsibility for your valuables. On your admission you will be asked to sign a disclaimer for any valuables you may have with you, accepting your responsibility.

Valuables may be taken for temporary safe keeping, by the ward staff, while you have your operation and you will be issued with a receipt.

 

Before your operation

When you have been taken to your bed the nurse will welcome you and check your details. It is necessary for you wear a theatre gown for your operation. This will be given to you by the nurse and she will instruct you how to wear it and give assistance if required.

Please only wear cotton pants/ underpants under your gown. All other underwear must be removed to provide safety in the use of equipment in the operating theatre.

You will also be given a pair of white elastic stockings to wear during and after the operation which will help to prevent blood clots in your legs. They will feel quite tight to wear and the nurses will help you put these on.

You may need to have your neck shaved before the operation. This may be done in the theatre.

Going to theatre

Just before going to theatre a checklist is completed by the nurse. You will then be taken on you bed to the operating theatre usually by a porter and a nurse. Dentures, glasses and hearing aids can be taken out in the anaesthetic room and taken back to the ward by the nurse or you may like to put them in your locker before the your operation.

Here the anaesthetist will insert a small needle into the back of your hand through which you will receive the anaesthetic. The nurse will stay with you until you are fully under the anaesthetic and fully asleep. You will be in the theatre for most of the day. You will not wake up until the operation is over and you are back on your bed in the recovery area. You will then be taken back to the ward, on your bed, by a porter and a nurse.

Back on the ward  

Back on the ward you will be made comfortable and a nurse will probably stay with you for most of the time. You will be nursed in a fairly upright position, in your bed, supported by several pillows. This will help reduce swelling in the neck area and make breathing easier.

You will have your blood pressure, pulse and oxygen levels checked. This will be monitored by a machine which has a blood pressure cuff and a rubber attachment to fit on your finger.

There will be a fluid drip going into a vein probably in the back of hand which will is to help to keep up your fluid levels as you will not be able to eat and drink for about 7 days after your operation. You may have a long feeding tube going into your stomach through your nose or through the opening made at the back of your windpipe (if you have had a primary voice restoration procedure). This will be used to give you water and liquid feeds a day or so after your operation.

Pain relief may be given through a fluid drip, by injections/liquid medication or by a pump which you may be able to operate yourself (PCA).

You will have a tube in your throat in the stoma and some stitches around the operation area. There will be a mask around your neck to give you oxygen and moisture in your lungs. There may be metal clips on either side of your neck if you have also had a neck dissection. You will have a small tube on either side of the neck. These tubes are quite long and attach to drainage bottles and remove excess fluid from around the neck area. It is normal for there to be some generalized swelling in the neck and around the jaw line after surgery. As the drainage reduces the tubes will be removed, usually 2-4 days after surgery.

Because you are now breathing through the tube in your stoma you will have more mucus to cough up and you may find this tiresome at first. The nurses will help you with this. A small narrow tube connected to a suction machine will be inserted into your stoma to remove this mucus and this will make breathing feel easier. This is called suctioning. You will learn, with help from the physiotherapist and the nursing staff how to cough this mucus out through your stoma by yourself. The mucus may be blood-stained at first – do not worry as this is normal.

You will be given a mist to breathe in and out through a mask over your stoma and this will help to loosen mucus so that you can cough it out. This is called a nebuliser.

The tube through which you breathe, in your neck, will be removed after a couple of days and the stoma will be cleaned regularly. The nurses will begin to show you this. You may or may not have to wear a laryngectomy tube in your stoma but your nurse will explain all this to you. After a few days as your wounds removed and gradually some of the clips and stitches taken out on the ward.

Now as you breathe air does not pass through the nose, which previously moistened and filtered the air before it reaches your lungs. Instead air goes straight through your stoma to your lungs. To replace moisture needed you will have moistened oxygen given through a mask into your neck stoma – this can be quite noisy! After a days you will progress to wearing a humidification cover (bib) or filters which help warm and moisten the air that you breathe.

At first when you need to use the toilet the ward staff will bring you a commode or bedpan. However soon you will be able to walk to the bathroom yourself. For the first couple of days you may have a urinary catheter to make recovery from the anaesthetic easier for you.

You will have a call bell by which you can contact the ward staff for assistance as needed. As you will have no voice initially you can communicate by writing, picture cards and by others lip-reading.

Following your operation you may not feel very sociable so it is wise to only have a couple of visitors. The visiting hours vary in the different hospitals and you will be advised about this.

Recovering from your Laryngectomy

Will I be able to eat and drink as before?

You will receive liquid food through a tube which will be place in your nose or through the back of the stoma. This will continue for about a week. You may have a swallow test (called a barium swallow or a gastrograffin) in the X-ray department to determine if all the internal wounds have healed. Your doctors will let you know when you can start to drink. You will then gradually increase drinks and food by mouth and the liquid food will be reduced and stopped.

 

Will I be able to cope?

Most people when first told they need a laryngectomy say they feel all sorts of mixed emotions, while others feel numb, some feel they knew all the time that they would need surgery.

We are all individuals and cope in different ways and need different lengths of time to get used to the changes we face. Support and help is available from all the Head and Neck Unit Staff.

Professional support at home

When you go home you will be able to have some help arranged for you if this is needed. This may include visits from the District Nurses, Home Helps, Social Services and your GP for example. District Nurses are often invited to meet you in hospital before you go home to assess your needs and see what is required of them at home. The specialist nurses who have looked after you in the hospital may be able to visit you at home if this is needed.

You will be given contact numbers for the ward so that if you have any immediate problems then you can get advice as to what to do. There is always somebody there 24 hours a day.

Stoma care following a Laryngectomy

Before you leave hospital you will be taught by the nurses how to take care for your laryngectomy (stoma). You will go home when you are confident and feel ready. Most people are surprised how easily they learn to look after their airway. Also the care needed is safe, simple and does not take too much time.

Cleaning your stoma

•Do not allow any secretions to build up around your stoma area or down the airway.

•Check for secretions in and around the stoma at least 3 times daily -morning, midday and before going to bed.

•You may wear a stoma tube or stud so you will need to remove it and replace it with a clean one when you clean your stoma.

How to clean your stoma

•You will need a free standing table mirror, a good light (pen torch) , gauze swabs and some cleaning solution (freshly boiled and cooled water or saline solution).

•Once the tube is removed clean around the stoma with gauze dampened in the cleaning solution wiping away any secretions. You may need to do this on the inside of your stoma also.

•Moisten any dried secretions with damp gauze and gently remove using angled forceps. You may need a relative, friend or District Nurse to help you. Using a pen torch check that the inside of your stoma is clear.

•When your stoma is clean reinsert a clean tube or stud.

•Occasionally the skin around the stoma may become sore. Vaseline, Ugmentin Merck, E45 cream or Cavilon can be used to protect the skin.

Report any changes in your stoma such as size, redness, swelling or sores to your G.P. or nurse.

 

Preventing mucous build-up inside your stoma

•You will be able to feel, when you breathe in and out, whether your airway is clear. By placing your hand near your stoma you will feel a good volume of warm as you breathe out.

•You will have chest secretions to cough up and clear away from your stoma area. The amount of secretions can vary from person to person.

•Hold some clean tissue or gauze near to your stoma, take some deep breathes and cough any secretions to the top of your airway and then wipe away.

•Try to look inside your stoma with a pen torch and a mirror to ensure that there is no build-up of mucus. If this is difficult then a relative or your district nurse may help you.

•If you allow mucus to build up in your stoma this may alter your breathing.

•You will need to clean your stoma at regular intervals morning, midday and night.

•Keeping your mucous thin will help make it easier to cough up and should help reduce build-up.

How to keep your mucous thin

•You should wear a stoma protector or filter system which will heat and moisten your mucous, helping to keep it thin. While you are in hospital your nurses will discuss this with you and show you how to use them.

•Drinking plenty of water will help to keep the body tissues moist, which will help to keep the secretions in your chest thin and make it easier to cough up.

•You may have a nebuliser and if you use sterile water or saline it may help to loosen the mucous to enable you to cough it up.

•Practice deep breathing exercises regularly throughout the day.

•You may need to continue using suction for a little while if you find it difficult to clear your airway. This equipment will be ordered for you before you leave hospital. The nursing staff will teach you and your relatives how to do this.

•Breathing in steam from a bowl of hot water may be helpful if your mucus is becoming thick and difficult to cough up.

Remember that your mucus may change according to the time of year. Your mucus may also become thicker during a cold or flu so you may need to take steps to ensure that you are able to clear your airway.

 

Things to remember about your laryngectomy stoma – Safety needs

•You should wear a stoma protector or filter system which will heat and moisten your mucus, helping to keep it thin and also filter out the dust and dirt in the air. While you are in hospital your nurses will discuss this with you and show you how to use them.

•Remember that during the Summer time there are more flies, wasps, blossom leaves and dust in the air which may present a hazard to the unprotected stoma.

•Never cut -up small pieces of gauze to clean around the stoma as fragments may fall into the stoma.

•Do not use cotton wool as small fibres may be inhaled causing irritation in the airway which is often difficult to relieve. Be careful when using cotton buds around the stoma and make sure they are moistened first so that small fibres are not inhaled.

•You need to take care not to get water into your stoma as it will go straight into your lungs. Take care when bathing and you may wish to ask a relative or friend to help you wash your hair.

•You can use a plastic shower shield to protect your stoma when showering and shaving etc. These are not available on prescription but can be obtained from your delivery company.

•Do not go swimming unless you have the correct breathing equipment and have had lessons in how to use it.- your local laryngectomy support group may run these.

•Take care not to spray aerosols such as polish, perfume etc too near the stoma area as this may irritate your airway causing coughing.

•During hot weather take care to protect your skin from harmful effects of the sun - a sun burnt stoma is very painful!

•While on the beach take care not to get sand in the stoma. Remember that it gets windy on the beach so protect that stoma!

It would also be useful for your friends/relatives etc to be aware of how to carry out mouth to stoma resuscitation in case of emergency.

Most people find that once they return home with a few adaptations they are soon able to settle back independently life and living.

 

Useful Contacts:

Your local Head and Neck Specialist team

Maria Rogers

Clinical Nurse Specialist

University Hospital Birmingham Foundation Trust

Queen Elizabeth hospital

Metchley Lane

Edgbaston

Birmingham. B15 2TH

Product Specialists

Forth Medical Ltd

Forth House

42 Kingfisher Court

Hambridge Rd

Newbury. Berkshire. RG 14 5SJ

01635 550100

Email: service @ForthMedical.ltd.uk

Kapitex Healthcare Ltd

Kapitex house

1 Sandbeck Way

Wetherby. West Yorkshire LS22 7GH

01937 580211

Email: www.kapitex.com

Platon Medical

PO Box 2568

Eastbourne

East Sussex. BN21 3HZ

01323 431930

Email: platon@mistral.co.uk

Countrywide Supplies Ltd

Freepost MID 24658

32 Meadow Road

Netherfield

Nottingham. NG4 2X

Freephone 0800 7831659

Countrywide supply all items that are available on prescription and deliver to your door.

sitemap