Emergency Department Care of a Patient After a Total Laryngectomy Richard B

Review article 1

Emergency department care of a patient after a total laryngectomy Richard B. Townsley, David E.C. Baring and Louise J. Clark

Patients who have undergone a total laryngectomy have the most appropriate to convey our objective were included altered anatomy and physiology. This results in unique and in our review. European Journal of Emergency Medicine specific issues that must be recognized in order to ensure 00:000–000 c 2013 Wolters Kluwer Health | Lippincott that this group of patients experience appropriate care. Williams & Wilkins. This article looks at the current literature and attempts European Journal of Emergency Medicine 2013, 00:000–000 to highlight specific areas of concern, so that emergency care providers can deliver an equally high standard of Keywords: emergency care, laryngeal neoplasms, laryngectomy, postoperative complications care to this patient group as they do to others. A Medline and Google scholar search was conducted using phrases Department of Otolaryngology, Southern General Hospital, Glasgow, UK associated with the complications of total laryngectomy. Correspondence to Richard B. Townsley, BSc, MBBS, DOHNS, MRCS, The results were analyzed to identify the most relevant Department of Otolaryngology, Royal Hospital for Sick Children, Glasgow, UK Tel: + 44 7 79 169 066 3; fax: + 44 141 201 0865; articles that meet our objective. Articles were then e-mail: [email protected] organized into the different subheadings used Received Accepted within the article and reviewed. The most up-to-date 21 November 2011 10 January 2013 articles or those that were in the opinion of the authors

Emergency department care of the After surgery, protection of the lungs and a safe airway are laryngectomee maintained through the complete separation of the According to the estimates of the European Union, in pharynx from the trachea. Therefore, the alimentary 2008 there were 29 000 new cases of laryngeal cancer [1]. and respiratory pathways are independent of one another. The trachea is sutured to the skin of the anterior neck, Early laryngeal cancer can be treated with radiotherapy, creating an end stoma (Fig. 1). chemoradiotherapy, organ preservation surgery including the use of a laser or a multimodal treatment regime. Postoperatively, voice is most commonly restored through Recurrent tumour after radiotherapy or more advanced a tracheo-oesphageal puncture (TOP) and placement disease often necessitates total laryngectomy with the of a speech valve (Fig. 1, 4) [4,5]. This allows passage possible inclusion of radiotherapy and chemotherapy. of air from the trachea into the neopharynx on occlusion of the end stoma. The speech valve prevents passage of There are an estimated 5000 laryngectomy patients living foodstuff from the neopharynx into the airway. Other in the UK [2]. methods of voice restoration or communication are People who have undergone a total laryngectomy pro- through the use of an electronic larynx, oesophageal cedure for laryngeal cancer have altered anatomy and speech, silent articulation and written communication. physiology. This results in specific issues that must be Laryngectomy patients can present to emergency care recognized to ensure that this unique patient group is services either with specific complications secondary to provided appropriate, good-quality emergency care. their treatment or with unrelated conditions. However because of the fact they have undergone a total A survey of members of the National Association of laryngectomy, certain factors must be kept in mind. Laryngectomy Clubs in the UK highlighted concerns regarding emergency care received [2]. It has also been shown that the requirements of neck breathers (tracheo- Laryngectomy or tracheostomy stomy and laryngectomy patients) are not consistently In most cases a patient will be able to inform you included in local resuscitation programs [3]. on whether he/she has undergone a laryngectomy Total laryngectomy involves surgically removing the or tracheostomy. In a tracheostomy, there may be larynx, with the creation of an end tracheal stoma and a patent airway above the level of the stoma, which reconstruction of the pharynx. in cases of tube obstruction or decannulation could possibly be intubated transorally. After a laryngectomy, Functions of the larynx include breathing, protection there is no connection between the trachea and of the lungs and voice production. oropharynx.

0969-9546 c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MEJ.0b013e32835ed735

Fig. 1 Fig. 2

Side tracheostomy showing no separation of respiratory and digestive End tracheostomy after laryngectomy. (1) Separate respiratory tract, tracts. (a) Larynx, (b) cricopharyngeus, (c) oesophagus, (d) common (2) separate digestive tract, (3) laryngectomy tube, (4) tracheo- upper aerodigestive tract, (e) tracheostomy tube, (f) trachea. oesophageal speech valve.

General issues after laryngectomy If a patient is unable to inform you on which airway Airway he/she has, there are a number of things that could aid in Unlike in tracheostomy, in which a side stoma into the the differentiation between a tracheostomy and a trachea is created, there is no connection between the laryngectomy. Look for MedicAlert bracelets or emer- trachea and the oropharynx after a total laryngectomy gency cards that they may carry stating that they have (Fig. 2), meaning that total laryngectomy patients are undergone a laryngectomy. Some units provide patients obligate neck breathers. If a patient requires supplemen- with cards to carry in their wallets, which provide tary oxygen, it must be provided through the stoma. emergency advice on their airway status. In some regions A well-intended face mask, nasal cannula, nasal airway or ambulance services have a registry of telephone numbers oropharyngeal airway achieves nothing. and addresses of patients who have undergone a laryngectomy; this ensures that they respond to 999 In a resuscitation situation, the guiding principles should calls from these numbers even if there is no speech be to get the best available help as early as possible and to during the call. consider oxygenation a priority. Look, listen and feel for respiration at the mouth and the stoma. If the patient is The majority of laryngectomy patients attending the breathing, high-flow oxygen should be supplied. If special emergency department will have an open stoma (i.e. laryngectomy masks are not available, a paediatric mask is without a tube in situ). Examining the stoma will usually a useful alternative. If there is uncertainty as to whether a allow differentiation between a tracheostomy side stoma patient has an end stoma (total laryngectomy patients) or and the end stoma of a laryngectomy (Figs 1 and 2). a side stoma (tracheostomy patients), oxygen masks Examining superiorly through the stoma will allow you to should be applied to both the face and the neck. An visualize whether there is a patent passage superiorly. assessment of stomal and tracheal patency should be This will not be the case after a total laryngectomy. made. The humidification cover or button should be Laryngectomy patients will often have a TOP speech removed if in situ (Figs 3c and 4), and if there is a valve in situ (Fig. 1, 4), and if this is visible in the posterior laryngectomy tube in situ that has an inner tube, the inner tracheal wall it is indicative of a total laryngectomy. tube should be removed at this stage. It is not necessary

Fig. 3 to remove the TOP speech valve (Figs 1, 4 and 3g, h). Removal of a TOP speech valve may potentially be harmful because of the risks of aspiration and trauma. Ensure that the stoma is clear and none of the tubes blocked with secretions or mucus. Stomal patency can be checked by passing a suction catheter through the stoma into the trachea. If the catheter passes easily, tracheal suction should be performed. If the patient is not breathing he/she can be ventilated with a bag-valve mask through the stoma. If the stoma is blocked and a suction catheter cannot be passed, the next step would be to deflate any tube cuffs if present. Patients with a tube are unlikely to have a cuff, although it is possible. If the patient is not improving or is unstable, all laryngectomy tubes should be removed from the stoma, if present, and oxygen should be resupplied through the stoma. If ventilation is required, it can be achieved by bag-valve mask ventilation through the stoma by placing a paediatric face mask or applying a laryngeal mask airway over the stoma. The stoma can be intubated if required, and a small cuffed endotracheal tube of size 6 can be used, passing it over a bougie or fibre-optic scope if necessary. If not in a hospital setting, mouth to stoma resuscitation can be performed; however, transoral intubation cannot be performed. Suctioning of the airway should be performed using a suction catheter passed through the stoma into the trachea.

(a) Laryngectomy tube (plus HME device), lateral view (LAT); (b) laryngec- If the stoma is patent and the patient is distressed or tomy tube, anteroposterior (AP) view; (c) the HME device can be placed in breathless, a respiratory problem could be indicated, and thelaryngectomytubeorthroughtheadhesivebaseplate;(d)adhesive continued assessment along the ABCDE algorithm base plate for the HME device; (e) stoma button, lateral View; (f) stoma button, anteroposterior view; (g) provox speech valve, anteroposterior view; should be performed to identify a cause. (h) provox speech valve, lateral view. HME, heat moisture exchange. Algorithms for the emergency management of the laryngectomy airway are available from the National Tracheost- omy Safety Program website http://www.tracheostomy.org.uk/.

Fig. 4

Communication As mentioned previously, communication following laryngectomy can be achieved in several ways. For the uninitiated, understanding some of these forms of communication can be difficult initially and this can cause frustration for all concerned. Be patient and look at the patient’s mouth when they communicate. In some cases, getting the patient to communicate by writing information down can help. In an emergency situation, time is often a luxury in short supply and in these cases a history can be taken from a partner, friend or caregiver. However, try to communicate as much as possible with the patient directly, as you would with a patient who had not undergone a laryngectomy. A common complaint among laryngectomy patients is that people assume they (a, b) An HME device to humidify and raise the temperature of inspired are deaf and talk loudly or shout. Hearing loss can occur air through a changeable insert (c) within an adhesive base plate placed around the stoma. AP, anteroposterior; HME, heat moisture exchange; in conjunction with laryngeal cancer and is a recognized LAT, lateral; post, posterior. complication following treatment with platinum-based chemotherapeutic agents.

Delivery of inhaled or nebulized medication Nutrition Patients who have undergone total laryngectomy and Many laryngectomy patients during their initial post- require nebulized drugs should have them delivered treatment period, and some for longer periods of time, through a tracheostomy mask placed over the stoma. The receive nutrition through a nasogastric tube. Tube skin surrounding the stoma should be washed and dried displacement and blockage is a common occurrence. when the drug has been delivered in order to prevent skin Replacement of a displaced or blocked tube can be reactions. As with airway emergencies, if a tracheostomy performed within the emergency department, with a mask is unavailable, a paediatric face mask placed over postprocedure pH aspirate to ensure correct positioning. the stoma can be used instead. Care should be taken when replacing a nasogastric tube during the initial postoperative period as there is the Psychosocial potential for pushing the tip of the tube through the A diagnosis of advanced head and neck cancer and its suture line in the pharynx. During the first 2 weeks after treatment has been shown to affect some of the most surgery, we feel that nasogastric tube replacement should fundamental and noticeable aspects of day-to-day life, be performed by an experienced ENT, head and neck or which can have a dramatic impact on a patient’s nutrition specialist. psychosocial well-being [6]. It has been reported in a number of studies that, after treatment, patients with head Stoma problems and neck cancer show some of the highest rates of Because of the separation of the respiratory and depression, anxiety states and suicidal tendencies com- alimentary systems, secretions from the respiratory pared with other groups of patients with cancer [7–9]. This system can no longer be swallowed and can therefore must be borne in mind when assessing risk in patients who build up and crust around the airway. This is further have undergone a total laryngectomy. exacerbated because of the loss of normal humidification In addition, there is a higher incidence of chronic alcohol and warming of air that occurs during normal nasal related problems in patients with head and neck cancer. inspiration. Some patients are provided with a ‘heat This can complicate psychosocial support [8] and can lead to moisture exchange device’ partly restore these functions medical problems related to excessive alcohol consumption. (Figs 3 and 4). The stoma should be kept clean and any crusting should be cleared away carefully using forceps. Crusts can be softened with nebulized saline, allowing Problems directly resulting from total laryngectomy easier removal. To reduce crust formation, humidified Dysphagia oxygen should also be used when possible. Many studies have shown a negative impact on swallowing after a total laryngectomy, with rates of dysphagia Stenosis of the stoma can occur postoperatively, with ranging from 10 to 62% [10,11]. After a total laryngect- published rates of tracheostomal stenosis varying from 4 omy, loss of laryngeal movement on swallowing increases to 42% [14,15]. The impact of stenosis on respiratory resistance to flow through the pharynx and oesophagus, function seems to have more to do with the general doubling pharyngeal transit time. Greater propulsive condition of the patient and lower airways and lungs, and forces are required to overcome increased pharyngeal this must be taken into account when assessing the resistance and achieve an effective swallow [12]. stoma. In some cases surgical correction of tracheostomal stenosis is required [16]. If the patient’s treatment regime included radiotherapy, swallowing can be further impaired secondary to xeros- A laryngectomy tube or silicone stoma button can be tomia, submucosal fibrosis, gastropharyngeal reflux and inserted if there are concerns with regard to the size lymphoedema. of the stoma (Fig. 3). Stricture formation in the neopharynx or oesophagus can occur at the site of surgical anastomosis or be a result of Tracheo-oesophageal puncture and speech valve trauma secondary to speech valve insertion or an elongated complications valve projecting into the oesophageal lumen [13]. The function of the TOP and speech valve is to allow voice rehabilitation and prevent aspiration (Figs 1 and 3). Dysphagia may be severe enough to warrant admission for Leakage can occur through the valve. This can be intravenous rehydration and maintenance of adequate secondary to colonization of the valve with Candida or nutrition. biofilm formation [17,18]. This necessitates a change of Careful examination of the postlaryngectomy patient the speech valve, which should be performed by a with swallowing complaints is critical to rule out practitioner who has experience with this procedure. recurrent or new disease and to determine the cause of Peripheral leakage can also occur; this is a result of the swallowing problem; therefore, these patients should enlargement of the TOP, which can be secondary to be referred to an ENT specialist to allow fibre-optic trauma, often following repeated valve change or tumour examination of the upper aerodigestive tract. recurrence. Accepted treatment for this is valve removal

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Emergency department care of a laryngectomee Townsley et al.5 and passage of a Foley catheter or nasogastric tube Radionecrosis usually manifests itself in the first year through the fistula to allow the puncture to narrow. This after treatment, although patients can present after allows the patient to be fed, prevents complete closure of longer periods of time. the fistula and reduces the risk of aspiration pneumonia, Osteoradionecrosis of the mandible has an incidence rate which, if it develops, could prove fatal [19]. Another valve of 0.4–56% after radiation therapy for head and neck can be reinserted later. malignancies [23]. The diagnosis is made on the basis of Displacement of the speech valve can result in aspiration continuing radiologic evidence of necrosis within the of the valve itself. If a patient presents with loss of their radiation field in the absence of recurrent cancer [24]. valve, the fistula should be made safe as described Clinical diagnosis is made on the basis of observation of previously, the respiratory system examined and a plain exposed bone that does not heal with conservative chest radiograph obtained to ensure that the valve is not management over a period of weeks to months. lodged in the airway. A referral to an ENT or speech and Conservative treatment involves improved oral hygiene language therapist should then be made so that a new with saline irrigations, antibiotics and, in some cases, use valve can be sized and inserted. of hyperbaric oxygen. Some patients require surgical treatment, which involves radical sequestrectomy and Pharyngocutaneous fistula sometimes mandibular resection [23]. Postoperatively, breakdown of the mucosal suture line after Osteoradionecrosis of the temporal and facial bones is laryngectomy can result in salivary leakage into the thankfully rare. This challenging complication of radio- surrounding soft tissue, resulting in a fistula [20]. This therapy can present as foul odour, epistaxis and headache, usually becomes apparent 7–11 days after surgery [21,22], and if not recognized and treated, it can lead to meningitis, and therefore, most patients are likely to still be inpatients. blindness and carotid artery haemorrhage [25]. However, some fistulas can present later, and the length of hospital stay can vary widely from centre to centre. Conclusion Initial clinical signs include wound erythema in conjunction Patients who have undergone a total laryngectomy can with facial and neck oedema. Although tenderness of the present to the emergency department with complications skin incision is the classic hallmark of soft-tissue infection, directly related to their previous surgery; however, they this may be reduced because of the neck paraesthesia, are also at risk for the same maladies and misfortune as which is inevitable after total laryngectomy [20]. Early the rest of the population. Understanding the treatment recognition of fistula formation can reduce the incidence of they have received and the unique needs that arise as catastrophic wound complications, such as wound break- a result of their treatment is paramount to ensuring that down, exposure of great vessels and carotid artery blowout. they are offered the same high-quality care as any other Antibiotic therapy should be commenced, the patient service user. should be assessed for aspiration pneumonia and then referred to the operating team. Adequate nutritional intake Acknowledgements needs to be maintained throughout to support healing. Conflicts of interest Fluid collections can be aspirated, and if necessary There are no conflicts of interest. exteriorized, allowing the diversion of the fistula from critical structures. A proportion of fistulas will heal without the need for surgical intervention [20]. References 1 Cancer Research UK. Laryngeal Cancer Statistics; 2010. Available at: Radionecrosis http://info.cancerresearchuk.org/cancerstats/types/larynx/Last [Accessed 5 July 2011]. Radiotherapy can be administered as part of a multi- 2 National Patient Safety Agency. Laryngectomy patients and emergency care; modality treatment combined with total laryngectomy, or 2004. Available at: www.npsa.nhs.uk/advice [Accessed 20 June 2011]. 3 Protecting patients who are neck breathers, National Patient Safety Agency, in other cases, total laryngectomy can be performed after Information, March 2005. 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