Common head and neck surgery includes the removal of the voice box: largyngectomy and tracheostomy: making an incision on the anterior aspect of the neck and opening an airway through an incision in the trachea. The removal of the larynx occurs in cases of laryngeal cancer and in this case the airway is separated from the mouth, nose and oesophagus meaning that the patient will breathe through a stoma in the neck. In tracheostomy cases the resulting stoma can act as an airway and a tracheotomy tube is inserted, enabling the individual to breathe without the use of their nose and mouth.
Tracheostomys may be required for long term control of excessive bronchial secretions, particularly in those with reduced consciousness or to maintain an airway and protect the lungs in those with impaired pharyngeal and laryngeal reflexes (Clark & Kumar, 2009). They can be used for patients with an obstruction in the upper airway, for example trauma, infection, largyngeal tumour, and facial fractures. It can also be used when there is impaired respiratory function for example, head trauma.
They may be temporary to preserve the airway from post op oedema associated with oropharyngeal surgical procedures. Patients in intensive care will sometimes have a tracheostomy to assist weaning from ventilator support. There are different types of tracheostomy tubes that can be inserted into the stoma. These include plastic or silver tubes, silver tubes cannot stay in for more than a week and do not have an inner tube that can be removed, unlike plastic tubes which can stay in for up to 30 days.
There is also the option of the tube being cuffed or uncuffed, cuffed meaning that there is a small balloon around the far end that can be inflated tubes with air to protect the airway and they tend to be used in ventilated patients whereas when the balloon is deflated it allows air around the tube for vocalisation. There are also fenestrated tubes which have an opening in the tube that allows speech through the upper airway when the external opening is blocked or even if the tube is too big to allow airflow around it. Tubes can also be used in laryngectomy patients to prevent stenosis or narrowing soon after surgery.
Communcation becomes a problem for patients with both types of surgery, removal of the voice box prevents speech and patients with laryngectomys require rehabilitation such as speech therapy. At first patients will not be able to speak and so often use written communication. There are different ways in which speech can be achieved in these individuals depending on the extent of their surgery, the patients personal social and vocational needs and also their determination and opportunity for speech therapy support. The first is non verbal communication, often writing and picture charts are used.
The second is the oesophageal voice, which uses the air that has been pulled into the oesophagus, or by creation of a tracheoesophageal fistula which is the placement of a one way valve into an opening between the trachea and oesophagus for speech. Another option is the use of an electrolarynx, one type is an intraoral which consists of a battery powered unit which when activated produces a tone which is transmitted along a plastic tube in the mouth. This is useful for post-operative facial swelling, lymphoedema and skin reactions following radiotherapy.
The other type is a neck-type electrolarynx which is placed directly onto the skin under the chin/towards either side of the neck. As the button is depressed, sound is transmitted through the tissue and into the oral cavity to be articulated into speech. Most of these can be adapted into an intraoral type for early post-op use. They allow for rapid communication soon after surgery and they result in less frustration for the patient. It can be very frustrating for patients when they are not able to communicate easily with people and when others cannot understand them.
This type results in less likelihood of developing bad habits such as ‘stoma blast’ and ‘forced whisper’. With a tracheostomy, speech is also a challenge as after surgery the majority of people breathe through their stoma or tracheostomy tube. This means that air does not pass through the vocal cords and so speech is not possible. Sometimes patients can have a tracheostomy tube that allows some air to go through the vocal chords and out of the mouth. Patients can have this type of tube if they are able to swallow without difficulty and if they do not need a tracheostomy tube with an inflated cuff in order to get air into the lungs.
The last option is surgical voice restoration which was introduced by Singer & Blom in 1980(Blom,1995) Not all patients are suitable for this however, It involves a tracheoesophageal speaking valve, a small fistula is surgically created through the tracheal wall into the oesophagus. A small, one way valve is inserted into the fistula and it allows air to be shunted from the trachea to the oesophagus and up through the pharyngo-oesophageal segment creating an acoustic wave form and voice. A longer flow of voice can be achieved as pulmonary air is used as the initiator for voice.
Another problem that arises in head and neck patients is that of malnutrition and weight loss. They are particularly at risk of developing nutritional problems. Many patients with head and neck cancer have histories of high alcohol intake, tobacco use and poor dietary habits. Malnutrition often when alcohol is involved. Patients nutritional needs should be assessed and patients at high risk of malnutrition should be identified early. Cancer can lead to a reduced appetite; dysphagia also leads to a decreased intake. Supplements can be taken and foods can be fortified for these patients.
Nasogastric feeding is also often used; the tube is passed into the stomach through the nose. Fluids and feed can be passed through the tube to prevent dehydration and weight loss. Similarly Gastronomy feeding can be used; this is an opening in the wall of the stomach on the outside to the stomach on the inside, the abdominal cavity. A feeding tube is then inserted into the gastronomy and feed passed through. Pain is another factor that is important in nutrition, communication and social/psychological interactions. Pain can be caused by the disease process and also by oncological treatment.
Keefe et al(1986) report pain in head and neck patients to be mostly in the jaw, mouth, neck and shoulder. Many members of the multi-professional team are required to support a patient with these types of surgeries. Speech and language therapy is vital in reviewing patients knowledge of what to expect after the surgery and to give them knowledge and advice. They can assess the patient’s communication impairment post operatively and help them to solve any problems that they have along with concerns of the patient’s family or carer.
Other professionals often involved in supporting these patients are dietician, physiotherapists, head and neck specialist nurses, doctors, social services, homecare, day care, services for carers, voluntary schemes and charities. There are also self help and support groups that can help the patients locally and provide them with advice. It is often helpful for patients to meet former patients to help them get through difficult parts of living with a tracheostomy or laryngectomy. They can gain advice from people with experience and ask them any questions that they may have.
Overall there are many factors surrounding this type of surgery and head and neck cancer in general. These patients require support from a number of professionals as it can mean a huge change in their lives. Communication is a very important factor that is altered along with dealing with pain and maintaining nutritional intake. Rehab and support is needed and widely available to these patients.