Laryngectomy – Information & Assessment Pack

Name of Patient:                     ………..………………………………………………

Date of Laryngectomy:           ……….………………………………………………

Size of Laryngectomy tube:  ……………………………………………………….

Voice prosthesis type and length/size (If appropriate) ……………………………………………………………………………………….

Diagram of a Laryngectomy:

(With permission from InHealth Technologies and Severn Healthcare)

What is a Laryngectomy?
A laryngectomy is the complete surgical removal of the voice box (larynx).

This means that your mouth and nose are permanently disconnected from your windpipe and your lungs. The windpipe (trachea) is cut and then the open end is stitched onto the front of the neck making a stoma, which will be your only route for breathing.

This is an irreversible operation and once it has been performed, you will never be able to breathe through your mouth or nose again.

Your mouth and nose are still connected to your food pipe (oesophagus) and stomach, however you may experience difficulties in swallowing food initially after your surgery.

Although this is a major operation, many laryngectomy patients, with a few alterations, and support from healthcare professionals, go back to living their normal lives/routines.

Changes in function of your nose, mouth and vocal cords:
When a laryngectomy is performed it bypasses some of our normal structures in your head and neck which would have provided humidification for your lungs and speech. This means that they no longer provide this function.

These structures include:

• Nose – as we breathe through our nose the air that we breathe is warmed, moistened and filtered – with a laryngectomy the air is taken in directly to trachea/windpipe so is cold, dry and unfiltered which can lead to drying of secretions and difficulty clearing them. Reduced flow of air around the nose can also cause an altered sense of smell. It may also be hard for you to ‘blow your nose’.
  Because of this it is essential that you have some form of adding ‘moisture and filtering’ for your airway, this may be in the form of small foam filled laryngectomy cassettes (Heat Moisture Exchange – HME) that fit into your laryngectomy tube or onto a baseplate, or you may wear a stoma bib. The relevant equipment and its use will be discussed with you prior to discharge.

• Mouth – Your mouth no longer is connected to your wind pipe/lungs. It is now primarily for the passage of food to your oesophagus/food pipe and then stomach – with a laryngectomy swallowing food may be more difficult, but you will have support and advice to help you with this. As you no longer have air from your lungs passing through your mouth you will have a reduced sense of smell which can also cause altered taste.
• Vocal cords – These have now been removed, which means that you will no longer be able to talk in your usual manner.  There are many ways that ‘artificial’ voice can be generated and these options will be discussed with you.
  Initially it is important that you have a way of attracting attention if you need help, for example have a bell by your bed or emergency pendant.
  Communication is encouraged in the form of writing things down, and mouthing words whilst in hospital as it is essential that you communicate how you are feeling to the hospital staff, thus avoiding the sensation of isolation.
  If you have a primary tracheo-oesphageal puncture to aid communication at the back of your stoma, the Speech and Language therapist will teach you how to manage this.

Laryngectomy tubes and baseplates
Laryngectomy tubes come in different lengths and diameters. They are normally initially worn while the stoma is healing to avoid any shrinkage of your stoma. After the stoma has healed fully then baseplates can be worn. You will be advised on what is appropriate for you prior to being discharged home.

Caring for a laryngectomy:

1. Laryngectomy Tubes and tape holders:

• Check the tube at least three times a day. This is essential daily care to ensure you are keeping your stoma free from secretions enabling you to breathe. We suggest:
  • when you wake up,
  • in the middle of the day
  • before you go to bed.
• Clean it/change it if you see any secretions (phlegm) inside. (see procedure below)
• You may need to check and clean the tube more frequently if you are producing a lot of secretions or if you have a chest infection.
• Always have a clean tube ready to put in, when you are removing/cleaning the dirty one.
• The Tape holders securing the tube in place need changing at least once a week or more often if they become soiled.

Procedure:

• Wash hands.
• Ensure all equipment is present: a clean tube, clean tape holder, lubricating gel, pot to put the soiled tube in once removed, tissues.
• Undo the tape holder via the velcro,
• Remove the tube and place in pot
• Dispose of soiled tape holder.
• Clear any secretions with a cough and clear method using tissues
• Assess the stoma site – if red, inflamed, sloughy /showing signs of infection, then contact GP/ district nurse.
• Clean area with cooled boiled water and dry with sterile gauze.
• Barrier cream can be applied if prescribed/required
• Insert clean tube with use of lubricating gel to ease passage
• Ensure the new tube is secure using a tape holder, baseplate or clips
• If using tapes ensure the new tape is securely fastened around the neck, and only 2 fingers can be passed between your neck and the tapes.

2. Laryngectomy cassette or stoma bib:

• Always wear a cassette (via a tube or a baseplate) or a Stoma Bib over the laryngectomy Stoma, to ensure the air you breathe is warm, moist and filtered.
• This is especially important at night, to help keep the secretions loose.
• This should be removed when coughing and clearing secretions, so that it doesn’t become blocked.
• The cassette should be changed once daily or more often if it becomes soiled.
• The stoma bib should be changed and washed if soiled. It can be washed and air-dried as per manufacturer’s recommendations before needing a new one.

Procedure for cassette:

• Wash hands
• Always keep one finger on the tube to avoid unnecessary movement/discomfort
• Using a pinching grip gently pull the soiled cassette from the tube/baseplate and dispose of
• Attach the clean cassette to the tube/base plate by gently pushing it on… ensure you give counter pressure with your other hand on the tube/ baseplate so not to just push the tube/baseplate into the neck and cause discomfort/coughing

Voice prosthesis care: Trans-oesophageal puncture (if appropriate)

In some, but not all cases, a voice prosthesis is placed at the time of surgery or after. This is a one-way valve that sits in the wall separating your airway and your food pipe. Air is redirected through the valve, causing the new throat surfaces to vibrate and produce a valve voice. It relies on regular cleaning through the centre of the valve so that the flap inside can close or open as needed.

Procedure for cleaning valve (at home):

• Wash hands
• Make sure you are sitting so that you can see your stoma clearly.
• Position yourself with a good light source & mirror
• Use a valve brush (provided by speech therapy) that is designed for your length of valve
• Relax your shoulders and place the brush to the centre of the valve, apply gentle pressure until it reaches the stopper and rotate one way.
• Gently remove the brush. Wipe on a dry towel, or if there are lots of secretions, run under warm water and dry. Repeat this process until the valve is clean.
• Do not force the brush through the centre. If there is a large crust, nebulising prior to cleaning the valve can be helpful.
• Wash hands

Chest clearance via your Laryngectomy stoma
Chest clearance is a way of removing excess mucus from your lungs using deep breathing exercises with a huff/cough. After a laryngectomy mucus can collect in the airway and clearing this will help you to breathe better. It is important that you keep your chest clear by regularly performing breathing exercises.

The ward Physiotherapist will visit you regularly and instruct you on this.

Things to consider if having difficulty clearing your chest:

• Could a nebuliser help to loosen your secretions
• Are you drinking enough/well hydrated – if you are dehydrated your secretions will be thicker.
• Regular laryngectomy tube change and clean, stoma care
• Activity – are you keeping as mobile as possible. Walking around regularly can help to loosen and move your secretions

Type of Secretions – looking out for chest infections:
Secretions can be an indicator that you may have a chest infection. It is important to keep an eye on what is normal for you

If you notice any changes in your secretions e.g.:

• Thicker/harder to clear secretions
• More secretions present – increased need for suction
• A change in colour – darker/green/orange/yellow
• Smelly secretions

Often coupled with other changes e.g.:

• Irritable
• Sleepy
• Feels hot/flushed has a high temperature
• Coughing more
• Difficulty breathing/ more short of breath

If there is any change in what is normal for you then this may mean that a chest infection is present and you should make an appointment to see your GP as soon as possible, to see if antibiotics are required.

What to do in an Emergency
What should I do if the tube becomes blocked?

1. Remove the tube and replace with a clean one.
2. If there are secretions present – cough and clear into tissues
3. If this relieves your symptoms, have a nebuliser immediately and repeat as above.
4. if you are still in difficulty, call 999 immediately ensuring you inform them you have a Laryngectomy.

Contact hospital outpatients department or specialist nurse if you are still concerned and they can advise or have a look at your stoma.

Useful contact numbers:
(Please add to this section prior to discharge)
Head and Neck Ward – 01905 760545
Head and Neck Clinical Nurse Specialist – 01905 761440

Laryngectomy equipment needed for home:
The ward nursing team will arrange this for you when you are ready for discharge.

1. One week’s supply of consumables to be sent home with patient from the ward. When home these then should be topped up by ordering through GP or prescription delivery company.
   • Spare Laryngectomy tube
   • Box of gloves
   • Nebulizer chamber and mask with tubing
   • Tube holders
   • Stoma bibs and /or baseplates and filter cassettes
   • Gauze
   • Water based gel
2. Non consumable Laryngectomy equipment sent home with patient from the ward
   Contact the Head & Neck ward at WRH if any issues with this equipment –  01905 760545.
   • Nebuliser unit
   • Tileys forceps

Adult Laryngectomy Assessment

• This assessment should be used in conjunction with the Trusts ‘Adult Altered Airway Patients – Discharge Guideline’ and ‘Altered Airways Discharge Pathway’.
• The Assessor should be an appropriately trained RGN with suction experience /Senior Physiotherapist.
• The Patient/Carer should complete both Theory and Practical Skills Assessment before signing off.

Theory Assessment – Laryngectomy

Practical Skills Assessment – Laryngectomy

On-going daily record of training – Patient Record

• Patient/Carer to fill in

Altered Airways Training – Final Assessment
Patients/Carers should have completed all aspects of Laryngectomy care as per the ‘Adult Altered Airway Patients – Discharge guideline’. 

This final assessment is to be filed in the patients’ medical notes.

Assessor/s – all Individuals involved in training programme:

Name _________________   Position held _____________ Signature _____________

Overall Assessment:
I certify that the below named person, has been instructed and observed in carrying out these procedures safely and effectively.

Name             _____________________ Initial _____ Signature ________________

Position held _______________________________________________________

Date                _____________________________

Parent/Carer
I the BELOW named CARER/PATIENT certify that I am happy to carry out the above procedures within the assessment detailed above.  I understand the scope of these skills.  I will only use this training in respect of the person specifically named on the front of this form and I will not carry out procedures, which are contrary to or not covered by this training.

I will seek further training if I have any concerns about my skills. In all other respects I will seek all necessary advice guidance and further training needed from time to time in order for me to continue to operate safely within these skills

Name        __________________________

Signature __________________________

Date          __________________________

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.  

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