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omy the individual breathes mainly through the stoma but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose the extent of breathing through the upper airways in these individuals varies and a tracheostomy tube is present in many of them ventilation and resuscitation of total and partial neck breathers is performed through the stoma however for these individuals the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation 16 complications edit different types of complications can follow total laryngectomy the most frequent postoperative complication is pharyngocutaneous fistula pcf characterized by an abnormal opening between the pharynx and the trachea or the skin resulting in the leaking of saliva outside of the throat 17 18 this complication which requires feeding to be completed via nasogastric tube increases morbidity length of hospitalization and level of discomfort and may delay rehabilitation 19 up to 29 of persons who undergo total laryngectomy will be affected by pcf 17 various factors have been associated with an increased risk of experiencing this type of complication these factors include anaemia hypoalbuminaemia poor nutrition hepatic and renal dysfunction preoperative tracheostomy smoking alcohol use older age chronic obstructive pulmonary disease and localization and stage of cancer 17 18 however the installation of a free flap has been shown to significantly reduce the risks of pcf 17 other complications such as wound infection dehiscence and necrosis bleeding pharyngeal and stomal stenosis and dysphagia have also been reported in fewer cases 17 18 rehabilitation edit voice restoration edit total laryngectomy results in the removal of the larynx an organ essential for natural sound production 20 the loss of voice and of normal and efficient verbal communication is a negative consequence associated with this type of surgery and can have significant impacts on the quality of life of these individuals 20 21 voice rehabilitation is an important component of the recovery process following the surgery technological and scientific advances over the years have led to the development of different techniques and devices specialized in voice restoration citation needed the desired method of voice restoration should be selected based on each individual s abilities needs and lifestyle 22 factors that affect success and candidacy for any chosen voice restoration method could include cognitive ability individual physiology motivation physical ability and pre existing medical conditions 23 24 pre and post operative sessions with a speech language pathologist slp are often part of the treatment plan for people undergoing a total laryngectomy 25 pre operative sessions would likely involve counselling on the function of the larynx the options for post op voice restoration and managing expectations for outcomes and rehabilitation 23 post operative therapy sessions with an slp would aim to help individuals learn to vocalize and care for their new voice prosthesis as well as refine their use of speech depending on the chosen method of voice restoration 25 voice prosthesis available methods for voice restoration for tracheoesophageal speech a voice prosthesis is placed in the tracheo oesophageal puncture tep created by the surgeon the voice prosthesis is a one way air valve that allows air to pass from the lungs trachea to the esophagus when the stoma is covered where the redirected air vibrates the esophageal tissue to produce a hoarse voice 26 the tep and voice prosthesis combination allows individuals post laryngectomy to have a voice to speak while also avoiding aspiration of saliva food or other liquids 21 tracheoesophageal speech is considered more natural sounding than esophageal speech but voice quality differs from person to person 1 for speech using an electrolarynx an electrolarynx is an external device that is placed against the neck and creates vibration that the speaker then articulates the sound has been characterized as mechanical and robotic for esophageal speech the speaker pushes air into the esophagus and then pushes it back up articulating speech sounds to speak this method is time consuming and difficult to learn and is less frequently used by laryngectomees 27 for larynx transplants a larynx from a cadaver donor is used as a replacement this option is the most recent and is still very rare 28 for individuals using tracheoesophageal or esophageal speech botulinum toxin may be injected to improve voice quality when spasms or increased tone hypertonicity is present at the level of the pharyngoesophageal segment muscles 29 the amount of botulinum toxin administered unilaterally into two or three sites along the pharyngoesophageal segment varies from 15 to 100 units per injection positive voice improvements are possible after a single injection however outcomes are variable dosages may need to be re administered individual dependent after a number of months where effective results are expected to last for about 6 to 9 months 29 oral feeding edit the laryngectomy surgery results in anatomical and physiological changes in the larynx and surrounding structures consequently swallowing function can undergo changes as well compromising the patient s oral feeding ability and nutrition 30 patients may experience distress frustration and reluctance to eat out due to swallowing difficulties 31 despite the high prevalence of post operative swallowing difficulties in the first days following the laryngectomy most patients recover swallowing function within 3 months 32 laryngectomy patients do not aspirate due to the structural changes in the larynx but they may experience difficulty swallowing solid food they may also experience changes in appetite due to a significant loss in their senses of taste and smell 33 in order to prevent the development of pharyngocutaneous fistula it is common practice to reintroduce oral feeding as of the seventh to tenth day post surgery although the ideal timeline remains controversial 34 pharyngocutaneous fistula typically develops before the reintroduction of oral feeding as the ph level and presence of amylase in saliva is more harmful to tissues than other liquids or food whether the reintroduction of oral feeding at an earlier post operative date decreases the risk of fistula remains unclear however early oral feeding within 7 days of the operation can be conducive to reduced length of hospital stay and earlier discharge from the hospital entailing a decrease in costs and psychological distress 35 smell and taste rehabilitation edit a total laryngectomy causes the separation of the upper air respiratory tract pharyn nose mouth and lower air respiratory tract lungs lower trachea 36 breathing is no longer done through the nose nasal airflow which causes a loss decrease of the sense of smell leading to a decrease in the sense of taste 36 the nasal airflow inducing manoeuvre naim also known as the polite yawning manoeuvre was created in 2000 and is widely accepted and used by speech language pathologists in the netherlands while also becoming more widely used in europe 37 this technique consists of increasing the space in the oral cavity while keeping the lips closed simulating a yawn with a closed mouth by lowering the jaw tongue and floor of the mouth 37 this causes a negative pressure in the oral cavity leading to nasal airflow 38 the naim has been recognized as an effective rehabilitation technique to improve the sense of smell 37 quality of life edit people with a partial laryngectomy are more likely to have a higher quality of life than individuals with a total laryngectomy 36 people having undergone total laryngectomy have been found to be more prone to depression and anxiety and often experience a decrease in the quality of their social life and physical health 39 voice quality swallowing and reflux are affected in both types with the sense of smell and taste hyposmia anosmia and dysgeusia also being affected in total laryngectomies a complaint which is given very little attention by medical professionals 36 40 partial or total laryngectomy can lead to swallowing difficulties known as dysphagia 1 dysphagia can have a significant effect on some patients quality of life following surgery 1 dysphagia poses challenges in eating and social involvement often causing patients to experience increased levels of distress 1 this effect holds true even after the acute phase of recovery 1 more than half of patients who received total laryngectomy were found to experience restrictions in their food intake specifically in what they can eat and how they can eat it 1 the diet limitations imposed by dysphagia can negatively impact a patient s quality of life as it can be perceived as a form of participation restriction 1 accordingly these perceived restrictions are more commonly experienced by dysphasic laryngectomy patients compared to non dysphasic laryngectomy patients 1 therefore it is important to consider dysphagia in short and long term outcomes post laryngectomy in order for patients to uphold a higher quality of life 41 often speech language pathologists are involved in the process of prioritizing swallowing outcomes 41 people receiving voice rehabilitation report best voice quality and overall quality of life when using a voice prosthesis as compared to esophageal speech or electrolarynx 39 furthermore individuals going through non surgical therapy report a higher quality of life than those having undergone a total laryngectomy 39 lastly it is much more difficult for those using alaryngeal speech to vary their pitch 42 which particularly affects the social functioning of those speaking a tonal language 42 references edit 1 2 3 4 5 6 7 8 9 10 11 12 13 ward elizabeth c van as brooks corina j 2014 head and neck cancer treatment rehabilitation and outcomes second ed san diego ca isbn 9781597566599 oclc 891328651 cite book cs1 maint location missing publisher link acs speech after laryngectomy archived from the original on 2007 11 05 retrieved 2007 12 05 brook i february 2009 neck cancer a physician s personal experience arch otolaryngol head neck surg 135 2 118 doi 10 1001 archoto 2008 529 pmid 19221236 gussenbauer karl 1874 über die erste durch th billroth am ausgeführte kehlkopf extirpation und die anwendung eines künstlichen kehlkopfes archiv für klinische chirurgie 17 343 356 stell p m april 1975 the first laryngectomy journal of laryngology otology 89 4 353 358 doi 10 1017 s0022215100080488 issn 0022 2151 pmid 1092780 s2cid 21325883 1 2 3 rosenberg p j 1971 total laryngectomy and cancer of the larynx a historical review arch otolaryngol 94 4 313 316 doi 10 1001 archotol 1971 00770070505005 issn 0007 9235 pmid 4938614 delavan d bryson february 1933 a history of thyrotomy and laryngectomy laryngoscope 43 2 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rehabilitation state of the art at the mil...