"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

Order a paperback or Kindle Edition or e-book of "The Laryngectomee Guide," the 170 page practical guide for laryngectomees. To obtain a free paperback copy fill this form and mail it to J. Harrison 11390 W. Theo W. Allis, WI 53214, or fax it to 414 227 9033. The Guide can also be requested by emailing to customersupport.us@atosmedical.com

Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Having surgery: types of laryngectomy and reconstruction, outcome, recovery, survival, pain management and seeking a second opinion.

Types of surgery including laryngectomy 

Treatment of laryngeal cancer often includes surgery. The surgeon can use either scalpel or laser. Laser surgery is performed using a device that generates an intense beam of light that cuts or destroys tissues.

There are two types of surgery for removal of laryngeal cancer:

  • Removal of part of the larynx (partial laryngectomy): The surgeon takes out only the part of the larynx harboring the tumor.
  • Removal of the entire larynx (total laryngectomy): The surgeon removes the whole larynx and some adjacent tissues.
Total laryngectomy ( also called laryngectomie, laryngektomie, laringectomia, laryngektomii, Laringektomija, laringektomiya, and larenjektomi) is generally performed for these reasons:

  • A large laryngeal untreated cancer that has eroded through cartilage and other structures.
  • Laryngeal cancer that came back after previous treatment, (i.e., radiation with/without chemotherapy).
  • Prevention of aspiration pneumonia resulting from prior head and neck cancer surgery at sites other the larynx (i.e,. hypopharynx, tongue base).
  • Nonfunctional larynx, or inability to eat or drink because of pharyngeal or esophageal strictures. 

Lymph nodes that are close or drain the cancerous site may also be taken out during either type of surgery.

The patient may need to undergo reconstructive or plastic surgery to rebuild the affected tissues. The surgeon may obtain tissues from other parts of the body to repair the site of the surgery in the throat and/or neck. The reconstructive or plastic surgery may take place at the same time when the cancer is removed, or it can be performed later on.

Healing after surgery sometimes, and the length of time needed to recover varies among individuals.

Side neck view before and after laryngectomy

Surgical reconstruction in total laryngectomy

Total laryngectomy is an effective and reliable operation used to remove advanced cancer of the larynx, especially when conservative approaches were unsuccessful. The defect created after the larynx is removed is generally easy to close using sutures or staples. However, when the tumor has spread beyond the larynx and also involves the pharynx or esophagus, such closure is no longer possible and more complex reconstructive options have to be used.

The purpose of reconstruction is the recreate an effective passage through which swallowing as well as esophageal or tracheoesophageal speech are possible. Surgical reconstruction increases surgical time, cost, and postsurgical risks.

When additional tissue is needed to correct the defect, the reconstructive method is affected by the size of the defect, which determines the amount of tissue needed to repair it. The tissue used is called a “flap”. Flaps can be regional (close to the defect) or distal (some distance away from the defect). The blood supply to the flap can either be kept intact (in the regional), or the artery and vein serving it need to be connected to the blood supply at the location where it is required. These types of flaps as called “free flaps”. 

The types of available flaps are:

Regional flaps
·  Pectoralis myocutaneous (PMC) flap. 
·  Deltopectoral (DP) flap.

Free flaps
           ·   Radial forearm free flap (RFFF)
           ·   Jejunal free flap (JFF)

Pectoralis myocutaneous. This flap has been used for many years and originates from the muscle of the chest and the skin above it. Its  advantages are: the excellent and reliable blood supply, availability of sufficient amount of tissue, and proximity to the neck. Its disadvantages include: its large size, the cosmetic deformity it creates by transposing it under the neck skin, and the weakness of the arm it may create.

Deltopectoral flap. Tissues for this flap are taken from deltopectoral muscles region. It  is thinner and more closely fits the thin tissue of the pharynx. DP creates minimal donor site problems, but installation of the flap may need to be completed in several stages, and the amount of tissue that can be obtained maybe limited.

Radial forearm free flap. A larger more pliable flap is needed when parts the pharynx or esophagus are removed. This may require using a radial forearm which is obtained from the inside surface of the arm near the wrist. The artery and vein that serve the flap have to be sewn to an artery and vein in the neck (a microvascular anastomosis). The donor site is covered with a skin graft taken from another site. This procedure can compromise the blood supply to the hand in individuals with poor hand circulation, and this risk is evaluated prior to considering the RFFF. The first two weeks following surgery are the most vulnerable to blood supply interruption as the new blood supply may clot of. Such interruption has to be addressed promptly to prevent the flap from dying.

Taking one's pulse at the wrist is no longer possible after the surgery. It is important to notify one's medical providers about this.

Radial forearm free flap site after surgery (left) and 2 years later 

The jejunal free flap. The JFF is an alternative to the RFFF. It comes as a cylinder and is especially useful when parts of the esophagus are removed. Although swallowing is generally adequate, the voice is less good as with the RFFF.

In instances where all of the pharynx, larynx, and esophagus are taken out, the stomach can be connected directly to the throat.  Because of the potential for a serious infection in the mediastinum after this surgery it is generally used in the most advanced cases where no alternative for reconstruction is available.

The reconstructive options currently available allow for the treatment of more advanced cancer, with a higher likelihood of successful restoration of voicing and swallowing than has been possible in the past. The best option for the patient depends on the tumor’s extent, the risks of each reconstructive option, and the patient’s overall health. Discussion between the patients and surgeon of the risks and benefits of each option can assist in selecting the best one. Obtaining a second option can also assist in the process. 

Preparation of radial forearm free flap site

Preparing for surgery

Prior to surgery it is important to thoroughly discuss with the surgeon all available therapeutic and surgical options and their short and long term outcomes. Patients scheduled for surgery may be anxious and under a lot of stress. It is therefore important to have a patient advocate (such as a family member or friend) also attend the meetings with the surgeon. It is important to freely ask and discuss any concerns and request clarifications. It is necessary to repeatedly listen to explanations until they are understood. It is useful to prepare questions to ask the surgeon and write down the information obtained.

In addition to consultation with the surgeon, it is also important to see these medical providers:

  • Internist and/or family physician
  • Any specialist one sees for a specific medical problem (i.e., cardiologist, pulmonologis) 
  • Medical oncologist
  • Radiation oncologist
  • Anesthetist
  • Dentist
  • Speech and language pathologist (SLP)
  • Social worker or mental health counselor 
  • Nutritionist
Pre-operative counseling sessions with the patient and family are essential in clarifying a variety of aspects regarding what to expect regarding communication restoration. It is also very useful to meet other patients who have already undergone a laryngectomy. These individuals can guide the patient about future speech options, share some of their experiences and provide emotional support. 

The Speech and language pathologist (SLP) plays an important role in the care of the total laryngectomy patients from initiation of pre-operative counseling through acute care, home health and outpatient services. These includes the pre-laryngectomy evaluation and education; immediate post-operative care, post-surgical home care; and post-operative outpatient setting. A list of SLP that take care of laryngectomees can be found in the International Association of Laryngectomee website

Contacting a local laryngectomee club to meet other laryngectomees and find support before and after the surgery can be helpful. A list of local laryngectomee clubs in North America and throughout the world is available at the International Association of Laryngectomee website.

Getting a second opinion

When facing a new medical diagnosis that requires making a choice between several therapeutic options including surgery, it is important to get a second opinion. There may be different medical and surgical approaches and a second (or even third) opinion may be invaluable. Getting such an opinion from physicians experienced in the issues at hand is judicious. There are many situations when 
treatment cannot be reversed. This is why choosing the course of therapy after consulting with at least one more specialist is very important.

Some individuals may be reluctant to ask for a referral to see another physician for a second opinion. Some may be afraid that this will be interpreted as lack of confidence in their primary physician or doubts about their competence.  However, most clinicians welcome and encourage the practice and many medical insurers welcome it. Furthermore, many medical insurers welcome it. 

The second doctor may agree with the first doctor’s diagnosis and treatment plan. Conversely, the other physician may suggest a different approach. Either way, the patient ends up with more valuable information and also with a greater sense of control. Eventually one may feel more confident about the decisions he/she makes, knowing that  all options have been considered.

Gathering one's medical records and seeing another physician may take some time and effort. Generally, the delay in initiating treatment will not make the eventual treatment less effective. However, one should discuss any possible delay with the physician.

There are numerous ways to find an expert for a second opinion. One can request a referral to another specialist from the primary doctor, a local or state medical society, a nearby hospital, or a medical school.

Even though patients with cancer are often in a rush to get treated and remove the cancer as soon as possible-but waiting for another opinion may be worthwhile.

Recovery from surgery

The recovery course depends on the extent of the surgery and reconstruction. After some surgeries, it is possible to be discharged after several hours of observation in the recovery room, while other surgeries may require a hospital stay for 7 to 14 days. A longer stay may be needed because of post-operative complications.

Hospital recovery takes place in different parts of the medical center. Patients are first observed in the recovery room, than they are moved to the intensive care unit, and lastly to the regular surgical or otolaryngological ward. Each move is made when the time is right. With time the lines, tubes, catheters and drains are gradually removed, and the patient is eventually helped to get up and walk.

The post-surgical risks following laryngectomy include: local bleeding (including hematoma), infection, salivary fistula, low calcium levels (hypocalcemia), hypothyroidism, blood clots, and aspiration (after partial laryngectomee).

Patients are discharge from the hospital once the physician(s) determine that there is no longer a need for in-patient level care. Some patients can go home directly from the hospital with or without visiting nurses; others might need to be transferred to a rehabilitation or skilled nursing facility before going home. Selection of the best discharge location is made by the medical team that is made of physicians, social workers, nurses and physical therapists. It is made in conjunction with the patient and his/her family.

A speech and language pathologist is also involved to assisting the patient in learning about speaking options. Patients should be informed about the need for continued speech rehabilitation and communication options post-operatively. 

Further reconstructive and cosmetic procedures or treatments are generally done after discharge. This allows time for recovery from the initial surgery, get the pathology results of the surgery and make any arrangements needed for the next steps.

After surgery 

Surgery's outcome

The main results of the surgery can include all or some of the following:

  •   ·       Throat and neck swelling
  •   ·      Local pain
  •   ·       Tiredness
  •    ·     Increased mucus production
  •    ·       Changes in physical appearance 
  •   ·       Numbness, muscle stiffness and weakness
  •   ·       Tracheostomy

Most people feel weak or tired for some time after surgery, have a swollen neck, and experience pain and discomfort for the first few days. Pain medications can relieve some of these symptoms.

Surgery can alter the ability to swallow, eat, or talk. However, not all such effects are permanent, as discussed in the outcome of surgery page. Those who lose their ability to talk after surgery may find it useful to communicate by writing on a notepad, writing board (such as a magic slate), cell phone, or computer. Prior to the surgery it may be helpful to make a recording for one's answering machine or voicemail to inform callers about one's speaking difficulties.

An electrolarynx can be used to speak within a few days after the surgery. (See methods of speaking section chapter) Because of neck swelling and post surgical stitches, the intra-oral route of delivering vibrations using a straw-like tube is preferred.

Long term survival

The prognosis of head and neck squamous cell carcinoma depends on the cancer’s stage at diagnosis and its location. Survival rates represent the percentage of people who are alive within a certain period of time after treatment, but they should not be used to predict how cancer will affect a particular patient. Five-year overall survival in patients with stage I or stage II cancer is generally 70 - 90%. More advanced (stage III or IV) cancer and those who continue to smoke and consume alcohol have a poorer prognosis. Those with advanced laryngeal carcinoma have about 40 % five years survival.

The prognosis is better in HPV associated oropharyngeal cancers compared to non- HPV associated oropharyngeal cancers.

A tool that allows general calculation of the expected survival rates of head and neck cancer patients is available

In general, the frequency of follow-up is greatest in the first two to four years following diagnosis because about 80 to 90% of all recurrences occur within this period. However, follow-up beyond five years is warranted because of the risks of late complications, late recurrence, and second malignancies. This is especially important for patients with non-HPV associated oropharyngeal cancers.

Pain management after surgery

The degree of pain experienced after laryngecomy (or any other head and neck surgery) is very subjective, but as a general rule, the more extensive the surgery, the more likely the patient will experience pain. Certain types of reconstructive procedures, where tissue is transferred as a flap from the chest muscles, forearm, thigh, jejunum, or a stomach pull up are more likely to be associated with increased or prolonged pain.

Those who have a radical neck dissection as part of the surgery may experience additional pain. At present, most patients undergo a "modified radical neck dissection" when the spinal accessory nerve is not removed. If the spinal accessory nerve is cut or removed during surgery, the patient is more likely to have shoulder discomfort, stiffness, and 
long term loss of range of motion. Some of the attendant discomfort of this procedure can be prevented by exercise and physical therapy. 

For individuals who experience chronic pain as a result of laryngectomy or any other head and neck surgery, evaluation by a pain management specialist is usually be very helpful.

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