Surgery for cancer of the voicebox (larynx)
The type of surgery you have will depend on the stage of the cancer.
Surgery is used:
if the cancer is small enough to be removed through the mouth using an endoscope when the cancer is locally advanced
if radiotherapy has not completely got rid of all the cancer (this is rare)
if cancer comes back after radiotherapy
to control symptoms when the cancer is advanced.
The main aim of surgery is to remove the cancer completely. Your surgeon will also try to reduce any changes that an operation may have on your speech and swallowing.
Before the operation, the surgeon will explain the procedure to you. It’s important you understand what it involves and how it will affect you in the short- and long-term.
If your speech, swallowing or eating could be affected, you’ll usually meet other members of the MDT. This can include a specialist nurse, speech and language therapist, and a dietitian.
You’ll have some tests to make sure you’re fit enough for the operation. This is likely to include blood tests, a chest x-ray and an electrocardiogram (ECG) to check your lungs and heart. You may have these done at a pre-assessment clinic before you go into hospital.
There are different operations used to treat cancer of the larynx:
removing the cancer through the mouth (endoscopic resection)
removing part of the larynx (partial laryngectomy)
removing all of the larynx (total laryngectomy).
Your surgeon may be able to remove the cancer through your mouth if you have early stage cancer. It’s done with a general anaesthetic and you only need a short stay in hospital.
Doctors may also use this type of surgery to improve speaking and swallowing when the cancer is advanced and can’t be cured.
The surgeon passes an endoscope down into your throat. They use a small camera to show images on a screen in the operating theatre. They can guide surgical instruments through the endoscope into your larynx to remove the cancer.
Or they may guide in a laser (high-power light beam) to remove the cancer. This is called transoral laser microsurgery (TLM). The surgeon directs the laser beam at the tumour and removes the cancer and a small margin of healthy tissue. This is to try to make sure they’ve removed all the cancer cells. They use the laser to control bleeding during surgery.
Another type of treatment called photodynamic therapy (PDT) is sometimes used along with a light-sensitive drug to try to destroy cancer cells. Doctors occasionally use it to treat very small, early cancers but usually only as part of a clinical trial. PDT is sometimes used to relieve symptoms (palliative treatment).
After an endoscopic resection
You may have some pain in your throat and difficulty swallowing for a couple of days afterwards. You can take painkillers until this improves.
If the surgery involved a vocal cord, your voice may be hoarse. Your doctor might ask you to rest it for a few days. Some people may find they’re left with a permanent change to their voice.
Rare side effects of this type of surgery include bleeding, infection and damage to your teeth. Your doctor or specialist nurse will give you more information about this before you go home.
This can sometimes be done if the cancer can’t be removed with an endoscope. The surgeon makes a cut in the neck and removes the affected part of the larynx. This operation is used less often because radiotherapy or chemoradiation can be given instead.
After a partial laryngectomy, you should be able to speak because you’ll have part of your voicebox. However, your voice is likely to be weak or hoarse.
During your operation, the surgeon may also remove some lymph nodes to check for cancer cells, or to remove affected lymph nodes. This is called a neck dissection. Your surgeon will discuss this with you before your operation. The nodes that are removed are sent to a laboratory to be examined for cancer cells.
After the operation, your neck and shoulder may be stiff on the side where the surgery took place. A physiotherapist can give you some exercises to help with this.
Sometimes, surgery to the larynx can cause temporary swelling. The swelling can narrow your airway and may affect your breathing. If this happens, the surgeon will make a small opening in your windpipe that you can breathe through until the swelling goes down. This is called a tracheostomy.
The opening at the front of your neck is held open with a small plastic tube a few centimetres long. When the swelling goes down (after about 5-7 days) and you can breathe easily, a nurse takes the tube out. The opening heals over naturally.
If you have a tracheostomy, you won’t usually be able to speak with the tube in place. Your speech therapist will give you advice on how to cope with this.
Your surgeon will tell you in advance if you’re likely to have a tracheostomy for a short time after your operation. This means you have time to prepare and you can ask questions before your operation. The specialist nurse or speech and language therapist will talk to you about it with you.
Some people need an operation to remove all of the voicebox to get rid of the cancer. You may also need to have some lymph nodes in the neck removed.
When the surgeon removes all of the larynx, there’s no longer a connection between the mouth, nose and the lungs. After this, you will no longer breathe or speak as you did before.
A laryngectomy stoma is a permanent hole made by the surgeon in the lower part of your neck. After your larynx is removed, you will breathe through this. The stoma stays open on its own.
Some people need a temporary tube to keep their stoma open for the first few days after surgery, but this is rare.
You have your stoma for the rest of your life and you breathe through it from the time of your operation. Your surgeon, specialist nurse and speech and language therapist will talk to you about this before your operation.
The thought of having a laryngectomy stoma can be frightening. But you’ll be given a lot of support and information from your healthcare team. When you’re well enough, your nurse will teach you how to how to clean and take care of the stoma.
You will usually be taken back to the ward after your operation, or you may be looked after in an intensive care or high dependency unit at first. This doesn’t mean your operation hasn’t gone well. The doctors and nurses will want to make sure your breathing is safe and your pain is well controlled.
After your operation, you’ll be encouraged to start moving around as soon as possible. This is an important part of your recovery. It’s important to do regular leg movements and deep breathing exercises. A physiotherapist will explain these to you.
Breathing and speaking
Immediately after a total laryngectomy, you will start to breathe through the stoma. You may need extra oxygen to help with your breathing for a short while. The nurses give you oxygen through a special mask, which fits over your stoma.
You might notice you have mucus in your airway and that you cough a lot in the beginning. This should settle within a week. Your nurse will use a thin flexible tube (suction tube) to remove the mucus until you get used to the changes in your breathing. The nurses and physiotherapist will also give you breathing exercises to help with this.
You won’t be able to speak at first but you can communicate by writing or using a picture book. In the section on voice restoration, we discuss the different ways of communicating after laryngeal surgery.
There are effective ways of preventing or controlling pain after surgery. Your doctor or nurse will explain how this will be done.
You may be given pain relief through a syringe connected to an electronic pump. The pump is set to give you a continuous dose of painkiller (analgesia).
You may also have a hand control with a button to press if you feel sore. This is called patient-controlled analgesia (PCA). It’s designed so you can’t have too much painkiller, so it’s okay to press it whenever you’re uncomfortable. Always let the nurses know if you’re in pain.
Drips and drains
You may have several drips and drains in place for a few days after surgery. You will be encouraged to sit out of bed and move around from the first day after surgery, so you will be given help with these.
You will have some wound drains, which are thin tubes that drain fluid from your operation site and allow your wound to heal. Let your doctor or nurse know if these are uncomfortable. They are usually taken out 2–4 days after surgery.
A drip going into a vein in your arm will give you fluids for a few days. You will also have a feeding tube for liquid foods and medicines. You should be able to eat and drink again once your throat has healed, usually after 1–2 weeks. You will need to build up your eating gradually. The hospital dietitian can give you advice about this.
Some people are worried about the change in their appearance after a laryngectomy. You may feel embarrassed about your stoma. This can affect your confidence and may be distressing. It often takes time to adjust.
It can help to let your family and close friends know how you feel. Your doctor, nurse and speech and language therapist in the hospital can give you advice and support. They may put you in touch with someone in your area who has had a laryngectomy.
The National Association of Laryngectomee Clubs and the Cancer Laryngectomee Trust can put you in touch with the nearest group to you and give you information.
Living with a laryngectomy stoma
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You’ll be given lots of information and advice about your stoma, but getting used to it will take time. Try not to worry if it doesn’t make sense straight away.
When you breathe in through your stoma, the air will go directly down into your lungs. Because it isn’t warmed and moistened by your mouth and nose, this cooler, drier air can irritate your lungs. This can make you produce more mucus (phlegm) and you won’t be able to sniff or blow your nose to clear this. When you cough, the mucus is coughed up through your stoma, not your mouth.
It’s important to keep the laryngectomy stoma covered with stoma covers or filters. They’re also known as heat and moisture exchangers (HMEs). You attach them over the stoma to warm and moisten the air. These help to reduce the amount of sputum you produce and prevent coughing and chest infections. Your doctor, nurse or speech and language therapist can show you what to do with these.
Having a laryngectomy stoma makes you more likely to get chest infections. If you notice any change in the colour of your sputum, or have a cough that doesn’t go away, it’s important to tell your doctor straight away. They may prescribe antibiotics for you.
Reduced sense of smell and taste
Your sense of smell and taste may be affected because you no longer breathe through your mouth. This can improve after a few months, although some people may have long-term problems. You may be able to learn the ‘polite yawning technique’, where you yawn with closed lips. This draws air in through the nose, allowing you to smell. It can also improve your sense of taste. Your speech and language therapist may be able to teach you how to do this.
These help to prevent water going into your stoma when you shower. You can ask your specialist nurse or speech and language therapist about these.
You won’t be able to swim without using special equipment to stop water going into the stoma. The National Association of Laryngectomee Clubs can give you information about this. They also provide training to make sure you can use the equipment safely.