LARYNGECTOMY I

The Larynx

The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in the neck. We use the larynx when we breathe, talk, or swallow.

The larynx is at the top of the windpipe (trachea). Its walls are made of cartilage. The large cartilage that forms the front of the larynx is sometimes called the Adam's apple. The vocal cords, two bands of muscle, form a "V" inside the larynx.

Each time we inhale (breathe in), air goes into our nose or mouth, then through the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air goes the other way. When we breathe, the vocal cords are relaxed, and air moves through the space between them without making any sound.

When we talk, the vocal cords tighten up and move closer together. Air from the lungs is forced between them and makes them vibrate, producing the sound of our voice. The tongue, lips, and teeth form this sound into words.

The esophagus, a tube that carries food from the mouth to the stomach, is just behind the trachea and the larynx. The openings of the esophagus and the larynx are very close together in the throat. When we swallow, a flap called the epiglottis moves down over the larynx to keep food out of the windpipe.

The pitch of the male speaker will be of low frequency and where as it will be high pitched in female speakers. The pitch range for males is 90Hz-140Hz and for females it is 190Hz -230Hz. The length of vocal cord in male speaker is around 17-20mm and in female speaker it will be of 14-17mm. The VC in males is of increased length as well as of increased mass, but in females it is less mass as well as reduced length.

The formula given below will represent why the pitch is different in both the speakers.

F= 1 x √T

                 2l   √M

Cancer

Cancer is a group of more than 100 different diseases. They all affect the body's basic unit, the cell. Cancer occurs when cells become abnormal and divide without control or order.

Like all other organs of the body, the larynx is made up of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep us healthy.

If cells keep dividing when new cells are not needed, a mass of extra tissue forms. This mass of tissue, called a growth or tumor, can be benign or malignant.

Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Benign tumors can usually be removed, but certain types may return.

Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream and the lymphatic system. That is how cancer spreads to other parts of the body. This spread is called metastasis.

Cancer of the larynx is also called laryngeal cancer. It can develop in any region of the larynx -- the glottis (where the vocal cords are), the supraglottis (the area above the cords), or the subglottis (the area that connects the larynx to the trachea).

If the cancer spreads outside the larynx, it usually goes first to the lymph nodes (sometimes called lymph glands) in the neck. It can also spread to the back of the tongue, other parts of the throat and neck, the lungs, and sometimes other parts of the body.

Cancer that spreads is the same disease and has the same name as the original (primary) cancer. When cancer of the larynx spreads, it is called metastatic laryngeal cancer.

Cause and Prevention

Cancer of the larynx occurs most often in people over the age of 55.

One known cause of cancer of the larynx is cigarette smoking. Smokers are far more likely than nonsmokers to develop this disease. The risk is even higher for smokers who drink alcohol heavily.

People who stop smoking can greatly reduce their risk of cancer of the larynx, as well as cancer of the lung, mouth, pancreas, bladder, and esophagus. Also, by quitting, those who have already had cancer of the larynx can cut down the risk of getting a second cancer of the larynx or a new cancer in another area. Special counseling or self-help groups are useful for some people who are trying to stop smoking. Working with asbestoscan increase the risk of getting larynx cancer. Asbestos workers should follow work and safety rules to avoid inhaling asbestos fibers.

Symptoms of Larynx Cancer

The symptoms of larynx cancer depend mainly on the size and location of the tumor. Most cancers of the larynx begin on the vocal cords. These tumors are seldom painful, but they almost always cause hoarseness or other changes in the voice. Tumors in the area above the vocal cords may cause a lump on the neck, a sore throat, or an earache. Tumors that begin in the area below the vocal cords are rare. They can make it hard to breathe, and breathing may be noisy.

A cough that doesn't go away or the feeling of a lump in the throat may also be warning signs of cancer of the larynx. As the tumor grows, it may cause pain, weight loss, bad breath, and frequent choking on food. In some cases, a tumor in the larynx can make it hard to swallow.

Any of these symptoms may be caused by cancer or by other, less serious problems. Only a doctor can tell for sure. People with symptoms like these usually see an ear, nose, and throat specialist (otolaryngologist).

Larynx Cancer Diagnosis

Diagnosis done by the SLP

1. Speech Mechanism Evaluation

Here the SLP checks for the movement of articulators to produce speech sounds. It may include the elevation, depression, retraction and puckering of tongue and lips. Movement of soft palate is also observed.

2. Mode of communication;

In this the clinician checks for the way in which the client is expressing his/her needs after surgery. The modes may be various kinds, including speech in his own way, whispering, sings and gestures.

3. Choice of communication mode:

Here the client is given an option to select the way in which he wants to communicate. Or he is allowed to express which type of communication aid he is willing to use. The choices may include Esophageal Speech, artificial Larynx Speech and Tracheo Esophageal speech.

4. Dysphagia assessment:

Every laryngectomee will have problem in digesting food material after the surgery. The assessment done by SLP should focus on whether the client is able to swallow food materials of different temperature and texture. That means hot and cold as well as soft and hard. Other than this some SLP used to give solid and liquid food material for the assessment. Note down the time taken by the patient to finish the food material given. And also note the type of food where the client had maximum trouble in digestion.

5. Intelligibility and Breath pressure:

Patient with Laryngectomy will have very poor speech intelligibility. The main problem with speech intelligibility is due to lack of sufficient breath pressure. As they are nose breathers and don’t have vocal cords to build subglottal breath pressure, the sentences will be of reduced intelligibility. The intelligibility of the client will be assessed based on the findings in standardized intelligibility rating scales. The basic procedure in the clinic to evaluate the breath pressure is the Maximum Phonation Duration (MPD).

To find the cause of any of these symptoms, ask about the patient's medical history and does a complete physical exam. In addition to checking general signs of health, the doctor carefully feels the neck to check for lumps, swelling, tenderness, or other changes. The doctor can also look inside the larynx in two ways:

Indirect Laryngoscope. The doctor looks down the throat with a small, long-handled mirror to check for abnormal areas and to see whether the vocal cords move as they should. This test is painless, but a local anesthetic may be sprayed in the throat to prevent gagging. This exam is done in the doctor's office.

Direct Laryngoscope. The doctor inserts a lighted tube (laryngoscope) through the patient's nose or mouth. As the tube goes down the throat, the doctor can look at areas that cannot be seen with a simple mirror. A local anesthetic eases discomfort and prevents gagging. Patients may also be given a mild sedative to help them relax. Sometimes the doctor uses a general anesthetic to put the person to sleep. This exam may be done in a doctor's office, an outpatient clinic, or a hospital.

If the doctor sees abnormal areas, the patient will need to have a biopsy. A biopsy is the only sure way to know whether cancer is present. For a biopsy, the patient is given a local or general anesthetic, and the doctor removes tissue samples through a laryngoscope. A pathologist then examines the tissue under a microscope to check for cancer cells. If cancer is found, the pathologist can tell what type it is. Almost all cancers of the larynx are squamous cell carcinomas. This type of cancer begins in the flat, scale-like cells that line the epiglottis, vocal cords, and other parts of the larynx.

If the pathologist finds cancer, the patient's doctor needs to know the stage (extent) of the disease to plan the best treatment. To find out the size of the tumor and whether the cancer has spread, the doctor usually orders more tests, such as , a CT (or CAT) scan, and/or an MRI. During a CT scan, many x-rays are taken. A computer puts them together to create detailed pictures of areas inside the body. An MRI scan produces pictures using a huge magnet linked to a computer.

TNM classification

T- Tumor

N-Nodal Involvement

M-Metastasis

While classifying, the TNM are given values from 0-4, indicating the hierarchy of severity. 0 indicates nil and 4 indicating the maximum involvement of cancer.

Pre Operative counseling:

            Explain the normal anatomy of Larynx and voice production

            Explain the present problem the patient is facing.

            Also explain the following

What are the treatment choices?

Would a clinical trial be appropriate?

What are the expected benefits of each kind of treatment?

What are the risks and possible side effects of each treatment?

How will they speak after treatment?

How will they look?

Will they need to change their normal activities? If so, for how long?

When they will be able to return to work?

Post operative counseling

Information on surgical procedure (TEP)

Information on post surgical management

Swallowing difficulties

Communication evaluation

How to use the artificial larynx and other aids

Stoma care

Oral and physical examination

Removal of nasogastric tube

Associated problems of Laryngectomy

Swallowing, taste, smell, digestion

Difficulty lifting heavy objects

Difficulty in Swimming

Treatment Methods for Larynx Cancer

Cancer of the larynx is usually treated with radiation therapy (also called radiotherapy) or surgery. These are types of local therapy; this means they affect cancer cells only in the treated area. Some patients may receive chemotherapy, which is called systemic therapy, meaning that drugs travel through the bloodstream. They can reach cancer cells all over the body. The doctor may use just one method or combine them, depending on the patient's needs. In some cases, the patient is referred to doctors who specialize in different kinds of cancer treatment. Often several specialists work together as a team.

The medical team may include

Surgeon; ear, nose, and throat specialist;

Cancer specialist (oncologist); radiation oncologist;

Speech pathologist;

Nurse;

Dietitian.

Radiation therapy uses high-energy rays to damage cancer cells and stop them from growing. The rays are aimed at the tumor and the area close to it. Whenever possible, doctors suggest this type of treatment because it can destroy the tumor and the patient does not lose his or her voice. Radiation therapy may be combined with surgery; it can be used to shrink a large tumor before surgery or to destroy cancer cells that may remain in the area after surgery. Also, radiation therapy may be used for tumors that cannot be removed with surgery or for patients who cannot have surgery for other reasons. If a tumor grows back after surgery, it is generally treated with radiation.

Radiation therapy is usually given 5 days a week for 5 to 6 weeks. At the end of that time, the tumor site very often gets an extra "boost" of radiation.

Surgery or surgery combined with radiation is suggested for some newly diagnosed patients. Also, surgery is the usual treatment if a tumor does not respond to radiation therapy or grows back after radiation therapy. When patients need surgery, the type of operation depends mainly on the size and exact location of the tumor.

If a tumor on the vocal cord is very small, the surgeon may use a laser, a powerful beam of light

Surgery to remove part or the entire larynx is a partial or total Laryngectomy. In either operation, the surgeon performs a tracheostomy, creating an opening called a stoma in the front of the neck. (The stoma may be temporary or permanent.) Air enters and leaves the trachea and lungs through this opening. A tracheostomy tube, also called a trach ("trake") tube, keeps the new airway open.

A partial Laryngectomy preserves the voice. The surgeon removes only part of the voice box -- just one vocal cord, part of a cord, or just the epiglottis -- and the stoma is temporary. After a brief recovery period, the trach tube is removed, and the stoma closes up. The patient can then breathe and talk in the usual way. In some cases, however, the voice may be hoarse or weak.

In a total Laryngectomy, the whole voice box is removed, and the stoma is permanent. The patient, called a laryngectomee, breathes through the stoma. A laryngectomee must learn to talk in a new way.

If the doctor thinks that the cancer may have started to spread, the lymph nodes in the neck and some of the tissue around them are removed. These nodes are often the first place to which laryngeal cancer spreads.

`           Total Laryngectomy (TL) significantly alters speech production. For a speech production system to be functional, the following 3 basic elements are necessary: (1) a power source, (2) a sound source, and (3) a sound modifier. For laryngeal speakers, lung air is the power source, the larynx is the sound source, and the vocal tract (i.e., pharynx, oral cavity) is the sound modifier. During total Laryngectomy (TL), the sound source is removed and the lungs are disconnected from the vocal tract.

Chemotherapy is the use of drugs to kill cancer cells. The doctor may suggest one drug or a combination of drugs. In some cases, anticancer drugs are given to shrink a large tumor before the patient has radiation therapy or surgery. Also, chemotherapy may be used for cancers that have spread.

Anticancer drugs for larynx cancer are usually given by injection into the bloodstream. Often the drugs are given in cycles -- a treatment period followed by a rest period, then another treatment and rest period, and so on. Some patients have their chemotherapy in the outpatient part of the hospital, at the doctor's office, or at home. However, depending on the drugs, the treatment plan, and the patient's general health, a hospital stay may be needed.

Side Effects of Treatment

The methods used to treat cancer are very powerful. It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed; healthy cells also may be damaged. That's why treatment often causes unpleasant side effects.

Successful voice restoration following total Laryngectomy (TL) requires identification of an alternative sound source with a viable power source.

The 3 basic options for voice restoration after total Laryngectomy (TL) are (1) Artificial larynx speech, (2) Esophageal speech, and (3) Tracheo Esophageal speech. Selection of a method should be based on input from the surgeon, speech pathologist, and patient. The decision is best made keeping in mind the patient's communicative needs, physical and mental status, and personal preference.

Esophageal speech

Principle: Esophageal speech is produced by insufflation of the esophagus and controlled egress of air release that vibrates the pharyngoesophageal (PE) segment for sound production. Anatomic structures for articulation and resonance are usually unaltered.

Techniques: The 2 basic approaches to esophageal insufflation are injection and inhalation. Both techniques are based on the pressure differential principle that air flows from areas of higher pressure to areas of lower pressure. Injection involves using the articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. Inhalation involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax so air insufflates the esophagus. Proficiency in esophageal speech typically requires several months of speech therapy.

Advantages: No apparatus must be purchased or maintained, and no further surgery is required.

Disadvantages: Speech acquisition is delayed because of the learning curve, and difficulties with phrasing and loudness are possible.

Artificial larynx speech

Principle: An external mechanical sound source is substituted for the larynx. Anatomic structures for articulation and resonance are usually unaltered.

Techniques: Two general types of electro larynx are available, the neck type and the intraoral type. The neck type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted into the oropharynx and articulated normally. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. A small tube is placed toward the posterior oral cavity, and the generated sound is then articulated. The tube has minimal effect on articulatory accuracy if the patient is taught properly and learns to use it well. A third type of electro larynx has been developed using an electromyography (EMG) transducer in the strap muscles to activate a sound source for hands-free use.¹

Advantages: Voice restoration after surgery is immediate, and the maintenance for the electro larynx is minimal (may last 2-10 y).

Disadvantages: The voice quality sounds mechanical. 

Tracheoesophageal speech

Principle: A surgical fistula is created in the wall separating the trachea and esophagus. This puncture tract can be created primarily, at the time of total laryngectomy (TL), or secondarily, weeks or years following the total laryngectomy (TL). Several days after surgery, a one-way valved prosthesis is placed in the puncture tract, allowing lung air to pass into the esophagus. The lung air induces vibration of the PE segment for sound production. The mechanics of the one-way valve allow lung air to pass into the esophagus without food and liquids passing into the trachea.

Technique: During the initial evaluation, a speech pathologist measures the length of the puncture tract and selects a size and style of prosthesis for placement. Once in place, the patient digitally occludes the Tracheostoma to direct air through the prosthesis into the esophagus for phonation. Hands-free external airflow valves are also available as accessories.

Advantages: The air supply for speech is pulmonary, phonation sounds natural, and voice restoration occurs within 2 weeks of surgery.

Disadvantages: Additional surgery is required for secondary punctures, the prosthesis must be maintained, and aspiration may occur if liquids leak through a malfunctioning valve.

Selecting a Prosthesis

Several sizes and styles of tracheoesophageal prostheses are available. Selecting a valve should be a conscientious decision. The following 4 main issues should be considered when selecting a device:

Phonatory effort

Before any prosthesis is inserted, phonation should be sampled with a patent puncture tract. The perceptual quality and effort of that sample guides decision-making. For example, if the voice quality is effortless, loud, and consistent, then the patient may do well with a higher-resistance device with increased durability. If the voice quality is strained and effortful, a lower-resistance device of greater diameter (20F) may be appropriate.

Candidacy for independent insertion

If the patient and his or her spouse or caregiver appears able and willing to participate in prosthesis management, a valve with no restrictions on placement procedures should be considered. Indwelling devices, although touted for their advanced design, must be inserted by a trained professional. This stipulation creates a situation of patient dependency on the health care professional. Autonomy offered by devices that can be changed without restriction is appealing to many patients. Conversely, if the patient is unable or unwilling to change the valve independently, an indwelling style device offers more security from dislodgement.

Durability

Occasionally, the device that provides the least Phonatory effort also has a patient-specific tendency to malfunction rapidly. If the device recurrently leaks in less than a couple of months with no treatable cause (egg, candidal infection), a device with higher resistance and durability should be considered.

Cost

Prices for valves vary from $28 (Inhealth 16F duckbill) to $199 (Provox 2 indwelling, Atos Medical). See the Prosthetic Supply Vendors section for vendor information. Cost issues should be considered when devices are comparable in style and performance. Certain health insurance policies do not cover prosthetic supplies. Patients without prosthesis coverage should be provided cost options when selecting a device.

Prosthesis Choices

Duckbill

Size: The prosthesis is 6-28 mm in length and 16F or 20F in diameter.

Advantages: It has good durability, can be changed independently, and is inexpensive.

Disadvantages: Airflow resistance is increased.

Low resistance/pressure

Size: It is 6-28 mm in length and 16F or 20F in diameter.

Advantages: It has decreased airflow resistance, has shorter esophageal extension, and can be change independently.

Disadvantages: It has decreased durability and is sensitive to esophageal pressure changes.

Indwelling

It is 6-22 mm in length and 20F or 22F in diameter.

Advantages: It has decreased airflow resistance, increased security from dislodgement, and a removable strap.

Disadvantages: It is clinician-dependent and has the potential for gastric distention from excess air insufflations. Also, it is expensive ($130-199).

Steps for Fitting Prosthesis

1.      Evaluate phonation with a patent puncture tract and stoma occlusion to rule out technique problems.

2.      Measure the length of the puncture tract

3.      Select and prepare prosthesis.

4.      Dilate the puncture tract to slightly wider than the prosthesis.

5.      Align the prosthesis with the puncture tract for insertion; alignment is more important than pressure

6.      Have the patient drink liquid, and watch for any leak through or around the prosthesis

7.      Assess patient phonation with stoma occlusion.

Hands-free tracheostomy valves

Tracheostoma valves provide 2 primary functions: hands-free speech and housing for heat and moisture filters. These external valves are adhered to the neck, with valve housing directly over the stoma. For speech, the air pressure generated during increased exhalatory effort closes the Tracheostoma valve and directs air back through the tracheoesophageal prosthesis. An adequate adhesive seal is essential to generate hands-free speech. Without a tight external seal, stomal air escape reduces the amount of airflow available for speech. Heat-and-moisture–exchange filters are also available to place over, or in lieu of, the Tracheostoma valve. These filters modify the inhaled environmental air. Benefits of the filters include decreased airway irritation and maintenance of airway humidification, which may reduce tracheal secretions.

Follow-up Care

Regular follow-up is very important after treatment for cancer of the larynx. The doctor will check closely to be sure that the cancer has not returned. Checkups include exams of the stoma, neck, and throat. From time to time, the doctor does a complete physical exam, blood and urine tests, and x-rays. People treated with radiation therapy or partial Laryngectomy will have a laryngoscope.

People who have been treated for cancer of the larynx have a higher-than-average risk of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who smoke. Most doctors strongly urge their patients to stop smoking to cut down the risk of a new cancer and to reduce other problems, such as coughing.

References:

Voice and Voice disorders, Boone

www.speechpathology.com

Clinical voice pathology, stemple

Larycare 2005