Running Head: laryngectomy



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Running Head: LARYNGECTOMY

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Laryngectomy

Sara Tandy

Ivy Tech Community College

SURG 211

Prof. Susan Sheets

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Abstract


“A laryngectomy is the removal of the larynx, usually with wide excision and tissue grafting.” (Fuller, J.K. (2013)) When it comes to a Laryngectomy the patient can either have a total laryngectomy, supragiottic laryngectomy, or partial laryngectomy. A laryngectomy is normally performed to remove tumors or cancerous tissue. The Laryngectomy is only performed after cancer of the larynx has been diagnosed by a series of tests that allow the otolaryngologist to look into the throat and take tissue samples to confirm and stage the cancer. In this paper I will go through what a Laryngectomy is, why this procedure is done, what is necessary for surgery and what test are performed, what instrumentation is needed, the various steps of the surgical procedure, and the postoperative care for the patient.

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A laryngectomy is the partial or complete surgical removal of the larynx. A laryngectomy can be performed for many reasons such as; cancer of the larynx, diversion for total separation of the respiratory and digestive tracts, chondroradionecrosis, and major trauma such as a larynx that is badly damaged by a gunshot, automobile injuries, or similar violent accidents. A laryngectomy can be totally or partially removed. If the patient has a total laryngectomy it is because the cancer is advanced and the entire larynx will be removed. “Often if the cancer has spread, other surrounding structures in the neck, such as lymph nodes, are removed at the same time.” ((2015) LARYNGECTOMY) If the cancer is limited to one spot, a partial laryngectomy will be performed. Which means that only the spot with the tumor is removed. The patient may also have to have a laryngectomy when other cancer treatments such as radiation and chemotherapy have failed.



“The larynx is located slightly below the point where the throat divides into the esophagus, which takes food to the stomach, and the trachea (windpipe), which takes air to the lungs.” ((N.d.) Laryngectomy-definition of laryngectomy) Because of the location of the larynx, it plays a critical role in normal breathing, swallowing, and speaking. Located within the larynx, there are vocal folds (often called vocal cords) that vibrate as air is exhaled past them, thus creating speech. The epiglottis protects the trachea by making sure only air gets into the lungs. Once the larynx has been removed, all these functions will be lost. Air can no longer flow into the lungs once the larynx is removed.

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“The following definitions outline the scope and purpose of the surgery:” ((2015) Medcom, Inc.)



  • Total laryngectomy: Removal of the larynx, hyoid bone, strap muscles, cricoid cartilage, 2-3 rings of the trachea, and possible removal of the pre-epiglottic space. Indications for total laryngectomy are advanced stage cancers of the larynx and hypopharynx. Although the patient will lose their voice, they may be taught to talk by using esophageal speech or an artificial larynx. ((2015) Medcom, Inc.)

  • Supraglottic laryngectomy: the excision of the laryngeal structures above the true vocal cords (hyoid bone, epiglottis, and false vocal cords). Indications for supraglottic laryngectomy are cancer of the epiglottis and false vocal cords. The patient will retain the phonatory, respiratory and sphincteric functions of the larynx. ((2015) Medcom, Inc.)

  • Partial laryngectomy: the removal of a portion of the larynx. Indications for partial laryngectomy include tumors involving only one vocal cord or other cancers confined to the intrinsic larynx. ((2015) Medcom, Inc.)

The laryngectomy is often successful in curing early stage cancer, however it does cause lifestyle changes for the patient. Laryngectomies must learn new ways of speaking and they must be continually concerned with the care of their stoma. “Serious infections can occur if water or other foreign materials enters the lungs through an unprotected stoma.” ((N.d.) Laryngectomy-definition of laryngectomy) For women who undergo partial laryngectomy or

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who learn some types of artificial speech will have a deep voice which is similar to that of a man. For many of these women this will present with psychological challenges.



The laryngectomy is done after cancer of the larynx has been diagnosed by a series of test that have allowed the otolaryngologist (specialist often called the ear, nose, and throat doctor) to look down into the throat and take tissue samples (biopsies) to confirm and stage the patient’s cancer. The patient must be in good general health to undergo the laryngectomy procedure. The patient may also have blood and urine test done and chest X rays and EKG may be ordered as the doctor deems necessary. If a complete laryngectomy is planned, it may be helpful for the patient to meet with a speech pathologist and/or an established larygectomee for discussion of post-operative expectations and support.

Risk of any surgery include allergic reaction, breathing problems, heart problems, bleeding and infection. Risks for the laryngectomy surgery include hematoma (a buildup of blood outside the blood vessels), wound infection, Fistula (tissue connections that form between the pharynx and the skin that are not normally there), the stoma opening may become too small or tight (called stoma stenosis), leaking around the tracheoesophageal puncture (TEP) and prosthesis, damage to other areas of the esophagus or trachea, problems swallowing and eating, and problems speaking.



General instrumentation and specific instruments as stated in ((2015) Medcom, Inc.)

  • Laryngectomy I and II trays

  • Small, curved hemostats- for dissection and to obtain hemostasis.

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  • Fine tipped hemostats- smaller grasping tips than regular hemostats. Used for fine dissection.

  • Kelly clamps- to clamp and divide vessels used for dissecting tissue.

  • Allis clamps- to grasp tissue for retraction in order to provide exposure.

  • Right angled clamp- for dissection around vessels.

  • Straight Mayo scissors- for cutting suture.

  • Metzenbaum scissors- for dissecting tissue.

  • Jamison scissors- for fine dissection.

  • Cooley clamps- angled and straight to clamp vessles.

  • Thyroid tenaculum- to grasp tissue for retraction.

  • Kocher clamps- to secure tubing and electrocautery to drape. May also be used to grasp tissue for retraction.

  • Halsted clamps- straight clamps used to attach the suture from the flap to the drape in order to increase exposure.

  • Gerald forceps (toothed forceps) - to grasp thick or slippery tissues.

  • DeBakey forceps (smooth forceps) - to grasp vessels, and delicate tissue.

  • Adson forceps (small toothed forceps) - to grasp skin and tissue edges during closure.

  • Skin hooks (double and single prong) - to retract tissue to provide exposure.

  • Hand held retractors: Army-Navy, Richardson, Rakes, Thyroid, Deaver- to provide exposure.

  • Nerve hook- to retract a nerve.

  • Joseph periosteal elevator Freer elevator- for elevation of mucosa.

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  • Cricoid hook- to pull the trachea anteriorly for exposure.

  • Tracheal dilator- for expanding the trachea to facilitate insertion of tracheostomy tube.

    • Additional equipment: ((2015) Medcom, Inc.)

  • Cummings retractors- to provide exposure.

  • Bipolar cautery- to obtain hemostasis.

  • Nerve stimulator- to test nerve function during the procedure.

  • Tracheal punch- used to remove tracheal tissue.

  • Oscillating saw for partial laryngectomy (Rongeurs or Bone Cutters)- to separate cricoid cartilage.

    • Additional supplies: ((2015) Medcom, Inc.)

  • Tracheostomy/laryngectomy tube/reinforced ETT – A variety of sizes should be available.

  • 10cc syringe- used to inflate tracheostomy tube cuff.

  • Nasogastric feeding tube- used postoperatively to provide nutrition.

  • Closed suction drains- used to promote drainage of the wound.

Surgical procedure is performed as follows as it is stated in (Fuller, J.K. (2013))

  • The patient is placed in the supine position on a doughnut or Mayfield headrest with arms tucked at the side.

  • A shoulder roll may be placed to hyperextend the neck.

  • General anesthesia is used.

  • The patient is prepped from the level of the nose to the level of the umbilicus and draped for a head and neck procedure, including face, neck, and chest.

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  • Using a #15 blade, the surgeon begins by making an apron incision, either from mastoid to mastoid (for laryngectomy with neck dissection) or from midsternocleidomastoid muscle to midsternocleidomastoid muscle ( for laryngectomy alone).

  • The flaps are elevated about ½ to 1 inch (1 to 2 cm) above the sternal notch from below and ½ to 1 inch (1 to 2 cm) below the hyoid bone.

  • The flaps generally are secured back with fishhook retractors or suture.

  • The surgeon detaches the strap muscles from the sternum using the ESU or Mayo scissors and retracts them laterally with Army-Navy retractors.

  • This exposes the carotid sheath, the thyroid, and a portion of the trachea.

  • The carotid sheath is dissected laterally and retracted with a Cushing vein retractor.

  • The thyroid veins may be ligated with hemostat clamps and 2-0 silk ties.

  • The surgeon removes the thyroid lobe on the affected side by dividing the isthmus of the thyroid down the middle with the ESU or scissors.

  • The thyroid lobe then is dissected free.

  • Scissors are used to remove the fat and lymph tissue from the gland.

  • The inferior thyroid artery is ligated and transected, and the recurrent laryngeal nerve is transected.

  • The dissection of the thyroid continues with blunt dissection to the level of the trachea.

  • The remaining portion of the gland is grasped with a Kocher clamp and divided from the trachea with the ESU.

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  • A cricoid hook is placed in the right side larynx to allow rotation of the larynx and exposure of the constrictor muscles on the thyroid cartilage.

  • These muscles are detached from the cartilage with the ESU.

  • A periosteal elevator then is used to remove the soft tissue from the underside of the thyroid cartilage.

  • The larynx is rotated to the left with a cricoid hook to free the larynx from the remaining muscle and soft tissue of the thyroid.

  • The surgeon then uses Metzenbaum scissors or a hemostat clamp to dissect the thyroid cartilage from the hyoid bone.

  • Any vessels and nerves that are exposed at this point in the dissection are ligated.

  • All muscular attachments between the tongue base and hyoid bone are separated with the ESU.

  • With the hyoid bone exposed and free, the surgeon uses heavy Mayo scissors to sever the attachments of the hyoid bone.

  • The tracheotomy is performed at this point because the surgeon is ready to enter the airway. ( Tracheotomy procedure to follow)

  • The surgeon sews the anterior tracheal wall to the posterior skin flap to secure it in place.

  • The ET tube then is removed and the anesthesia circuit is switched to the tracheotomy tube.

  • The surgeon then uses scissors or the ESU to make an incision into the hypopharynx in the midline over the hyoid bone.

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  • The hypopharynx is opened with a hemostat, and the epiglottis is grasped with an Allis clamp and rotated out of the larynx.

  • The lateral pharyngeal walls are incised with heavy Mayo scissors, with as much mucosa as possible spared.

  • The larynx then is opened out.

  • The tracheal tube is removed and the posterior membranous trachea is incised with a #15 blade.

  • The trachea is dissected from the anterior esophageal wall with Metzenbaum scissors.

  • The surgeon also transects any fibrous attachments to the larynx at this point.

  • The larynx is removed, and the tracheal tube is replaced.

  • With the larynx removed, the pharyngeal mucosa is closed with or without a PMC flap in two layers.

  • The first layer is closed with a long 3-0 absorbable suture on a tapered needle, and the second layer is closed with 3-0 absorbable horizontal mattress sutures.

  • With the pharynx closed, the surgeon creates a stoma by closing the anterior tracheal wall to the inferior skin flap and the posterior tracheal wall to the superior skin flap, using either absorbable or nonabsorbable sutures, depending on the surgeon’s preference.

  • The wound is irrigated with normal saline.

  • Drains are placed, and the skin is closed in layers with absorbable suture.

  • The patient is transferred to the intensive care unit.

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  • Chemotherapy and radiation are initiated as soon as the wound is sufficiently healed to tolerate them.

    • The tracheotomy procedure as stated in (Fuller, J.K. (2013)) (this procedure is also listed because this is also a part of the laryngectomy procedure)

  • An incision is made over the anterior tracheal wall.

  • The tracheal wall is visualized.

  • A tracheal incision is made, usually between the third and fourth tracheal rings.

  • The endotracheal (ET) tube is partly removed to the point superior to the tracheal incision.

  • The tracheotomy tube is inserted.

  • Bleeding is controlled.

  • The tracheotomy tube is secured.

After a patient has underwent a laryngectomy, they spend several days in intensive care unit (ICU) and receives intravenous (IV) fluids and medication. As with any other major surgery, the patient’s blood pressure, pulse, and respirations are monitored regularly. The patient will be encouraged to turn, cough, and take deep breathes to help mobilize secretions in their lungs. After several days the drains that were placed in the patient’s neck to remove any fluids will be removed. It will take two to three weeks for the tissue of the throat to heal. Until that time, the laryngectomies cannot swallow food and must receive nutrition through a tube inserted though their nose and down their throat into the stomach. During this time, even the patients with partial laryngectomies are unable to speak.

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“When air is drawn in normally through the nose, it is warmed and moistened before it reaches the lungs.” ((2015) LARYNGECTOMY) When air is drawn through a stoma, it will not have that opportunity to be warmed and humidified. Laryngectomies are encouraged to breathe artificially humidified air in order to keep the stoma from drying out and becoming crusty. The stoma will usually be covered with a light cloth to keep it clean and to keep unwanted particles from entering the lungs. Caring for the stoma is very important since it is the only way for the patient to get air into their lungs. After the patient’s laryngectomy, a healthcare professional will teach the patient and their caregivers about how to care for the stoma. Immediately after the laryngectomy, the patient will need an alternate method of communication such as writing notes, gesturing, or pointing. A partial laryngectomy patient will gradually regain their speech just weeks after their operation. But with this, their voice may be hoarse, weak, and strained. There will be a speech pathologist that will work with a complete laryngectomies to establish new ways of communicating.



There are three main methods for the patient’s vocalizing after a total laryngectomy. “In esophageal speech the laryngectomies learn how to “swallow” air down into the esophagus and creates sounds by releasing the air.”((2015) LARYNGECTOMY) With this method, it requires quite a bit of sound. The tracheoesophageal speech diverts air through a hole in the trachea that is created by the surgeon. The air will then pass through an implanted artificial voice prosthesis (a small tube that makes a sound when air goes through it). In recent advances, the implanting voice prostheses has developed with good voice quality. “The third method of artificial sound communication involves using a hand-held electronic device that translates

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vibrations into sound.”((2015) LARYNGECTOMY) There are many different types of these devices, but all will require the patient to use at least one hand to hold the device to their throat. The choice on which method is best to use depends on many things including the health and age of the patient, and whether or not other parts such as the mouth, and tongue have also been removed.



Many laryngectomies will resume daily activities after surgery, but special precautions must be taken when showering or shaving. There are special instructions and equipment that is required for patient’s that wish to swim or water ski, as it is dangerous for water to enter the windpipe and lungs through their stoma. “Regular follow-up visits are important following treatment for cancer of the larynx because there is a higher-than-average risk of developing a new cancer in the mouth, throat, or other regions of the head or neck.”((N.d.) Laryngectomy-definition of laryngectomy) There are many support and self-help groups available to help patients meet other people who face similar problems.

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References



Fuller, J.K. (2013). Surgical technology principles and practice J. Armisted, (Ed.) (6th ed.). St Louis, MI: Elseveir.

(2015). LARYNGECTOMY: surgical removal of the larynx. Retrieved from http://www.auuuu.org/respiratory/laryngectomy

(2015). Memorial hospital excellence in care and technology. Retrieved from Medcom, Inc. website: http://www.medcomrn.com/mhsi

Kacker, Ashutosh (3/22/2013). Laryngectomy. Retrieved from Medline Plus website: http://nlm.nih.gov/medlineplus/ency/artice/007398.htm



(N.d.). Laryngectomy-definition of laryngectomy. Retrieved from http://medical-dictionary.thefreedictionary.com/larynectomy

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