By: Ronda Polansky M.S. CCC-SLP
Evaluation of the patient must take into account not only the structure and function of the swallowing mechanism, but also the side effects that the chosen medical interventions will impose. Assessment of unique patient characteristics, including medical history, nutritional status, cultural preferences, coping style, support systems, and communication and cognitive abilities, is crucial in developing a treatment plan.
Historically, the first total laryngectomy completed for cancer was performed by Dr. Billroth in 1873. Today, a laryngectomy typically is performed as a primary or secondary treatment for laryngeal carcinoma. When indicated for a primary, untreated tumor, it is usually for advanced disease that cannot be adequately managed in a more conservative manner.
It is important to understand that during the normal swallow, the vocal cords close, just after the initiation of an exhalation, trapping the air in nearly full lungs and providing what’s known as “subglottic pressurization” The physics of swallowing, therefore, are altered quite a bit as laryngectomees are no longer capable to maintaining this pressure. Before the laryngectomy, with every swallow, there was a typical degree of pressurization that assisted in driving the food through the pharynx and into the esophagus.
There are 2 types of Laryngectomies: 1) Supraglottic laryngectomy and 2) total laryngectomy
During a supraglottic laryngectomy (sooprah-GLOT-tik lair-un-JECT-uh-me), a surgeon removes the top part of your voice box (larynx), near your vocal cords. Your voice box (larynx) has two bands of muscle that form the vocal cords. The front of the voice box is made of cartilage and is sometimes called the Adam’s apple. Supraglottic laryngectomy can interfere with laryngeal elevation and sometimes vocal fold adduction. If a “laryngeal suspension procedure” is performed during reconstruction, laryngeal elevation is improved and swallowing is safety enhanced. If a supraglottic laryngectomy procedure encompasses more than the traditional procedure and includes portions of the hyoid bone, base of tongue, aryepiglottic folds, or false vocal folds, prognosis for swallowing recovery is more diminished.
A total laryngectomy requires separation of the airway from the esophagus. The trachea typically is brought forward below the level of the larynx and is sutured to the base of the neck just above the sternal notch, creating a permanent tracheostoma for breathing. Dysphagia after total in all likelihood, is underreported. Patients undergoing total laryngectomy have few swallowing problems following surgery due to the permanent separation of the trachea and esophagus. However, occasionally the laryngectomee may have problems propelling the bolus through the oral cavity and pharynx as a result of the loss of hyoid bone, which is the anchor for the tongue. Increased pressure in the pharyngoesophagus following laryngectomy requires the tongue to move with greater force. Stricture at the anastomosis may cause narrowing and reduced bolus flow through the pharynx. Pseudoepiglottis, a postsurgical fold of tissue from the pharynx at the level of the base of tongue, may serve as a mechanical barrier to efficient bolus flow and trap food in its pocket.
Tracheostomy – A patient will have a temporary tube placed in their throat/neck called a trachesostomy tube, which they will breathe through. A “Trach” is short for tracheostomy (TRAKE-e-os-toe-me) which is simply a surgical hole in your windpipe. A tracheostomy provides an air passage to help you breathe when the usual route for breathing is somehow obstructed or impaired. Breathing is done through the tracheostomy tube rather than through the nose and mouth. When a tracheostomy is no longer needed, it’s allowed to heal shut or is surgically closed. For some people, a tracheostomy is permanent.
Effects of Radiation on Swallowing – Radiation has both early and late side effects that can impact swallowing function.
Early effects include xerostomia (dry mouth), erythema superficial ulceration, bleeding, pain, and mucositis, which is a painful swelling of the mucous membranes lining the digestive tract. These usually result in oral pain that may cause only minimal diet alterations, require prescription of pain medications, or necessitate reliance on non-oral nutrition. Hypopharyngeal stricture (a narrowing of the pharyngeal structure as a side effect of the radiation) may require dilation or surgery. Xerostomia is a side effect of treatment that persists for years and may worsen over time.
Late effects may include osteoradionecrosis (a condition where irradiated bone and surrounding tissues lose their reserve repairative capacity and start to degenerate), trismus (lockjaw), reduced capillary flow, altered oral flora, dental caries, and altered taste sensation. The late effect of reduced blood supply to the muscle can result in fibrosis, reduced muscle size, and the need for replacement with collagen. This can dramatically affect swallowing years after treatment with a fixation of the hyolaryngeal complex, reduced tongue range of motion, reduced glottic closure, and cricopharyngeal/PES relaxation, resulting in potential for aspiration.
Goals of Swallowing Rehabilitation There are several goals in swallowing rehabilitation.
The primary goals are to prevent malnutrition and dehydration and reduce the risk of aspiration. Re-establishment of safe and efficient oral intake, prevention of dysphagia prior to medical treatment, and patient education regarding the specifics of their disorder are also important goals of intervention. Pretreatment counseling is beneficial in addressing the possibility that dysphagia may develop during or after the completion of the planned treatment. Poorly prepared patients may become frustrated when attempting to feed and thus may fail to ingest enough to maintain adequate nutrition and hydration. Individuals can be given strategies, recommendations, or exercises prophylactically to reduce the chances of developing a problem. Researchers are currently investigating the benefits of pre radiation exercise. Treatment for post-surgical cases usually begins once the surgeon indicates the patient has healed sufficiently, usually 5 to 10 days post-surgery
Diet alterations and food presentation strategies also can be use therapeutically to improve efficiency and safety of swallowing. Thickening liquids may slow the rate of bolus flow through the pharynx for patients with a delayed swallow. A puree diet can be used if surgical resection or trismus prevents chewing. Foods prepared with sauces and gravies may be useful for a xerostomic patient. Alternating solids and liquids can reduce pharyngeal stasis. Liquids can be presented by cup, straw, spoon, or syringe, depending on specific patient needs
Agrawal, N., & Goldenberg, D. (2008). Primary and salvage total laryngectomy. Otolaryngology Clinics of
North America, 41, 771-780.
Balfe, D. M., Koehler, R. E., Setzen, M., Weyman, P. J., Baron, R. L., & Ogura, J. H. (1982). Barium
examination of the esophagus after total laryngectomy. Radiology, 143, 501-508.
Bajaj, Y., Shayah, A., Sethi, N., Harris, A. T., Bhatti, I., Awobem, A., Loke, D., & Woodhead, C. J. (2009).
Clinical outcomes of total laryngectomy for laryngeal carcinoma. Kathmandu University Medical Journal,
Chu, E. A., & Kim, Y. J. (2008). Laryngeal cancer: Diagnosis and preoperative work-up. Otolaryngology
Clinics of North America, 41, 673-695.
Crary, M. A., & Glowasky, A. L. (1996).Using botulinum toxin A to improve speech and swallowing
function following total laryngectomy. Archives of Otolaryngology-Head and Neck Surgery, 122, 760-763.
The Department of Veterans Affairs Laryngeal Cancer Study Group. (1991). Induction chemotherapy plus
radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The New
England Journal of Medicine, 324, 1685-1690.
Eibling D. E.; Gross R. D. “Subglottic air pressure : A key component of swallowing efficiency”; The Annals of otology, rhinology & laryngology ISSN 0003-4894.
-See more at: http://www.oralcancerfoundation.org