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Laryngectomy: care and emergency management

Evidence‐based approaches

Rationale

The aim of routine and emergency laryngectomy care is to (Everitt [76], NTSP [206]):
  • maintain the patency of the laryngectomy stoma
  • provide humidification
  • keep the stoma clean and free from infection
  • aid voice restoration.

Indications

The patient's laryngectomy stoma should be cleaned regularly and any crusts removed to ensure they are not aspirated and to ensure that the stoma remains unobstructed and patent. An HME or humidification bib should be used to heat and humidify inspired air.

Contraindications

There are no contraindications to providing laryngectomy care, especially in the initial post‐operative phase, when the patient may not yet be able to care for their stoma independently.
Procedure guideline 12.15

Laryngectomy care

Table 12.16  Prevention and resolution (Procedure guideline 12.15)
ProblemCausePreventionAction
Breathing difficulties
Mucus plug or reduced airflow due to secretions
Reduction in stoma size
Regularly check and clean the stoma.
Ensure adequate humidification over the stoma.
Regularly administer nebulizers.
Encourage the patient to carry out steam inhalation if the secretions are tenacious.
Encourage regular mobilization to assist in the clearing of secretions.
Regularly measure the stoma's size.
Check the stoma and clean it if mucus plugs or crusts have formed.
If a laryngectomy tube is in place, remove it and clean the tube.
Administer normal saline 0.9% nebulizer.
Measure the stoma and consider insertion of a stoma button or laryngectomy tube (refer to SLT if required).
Seek expert help if the patient is deteriorating and the above interventions have not helped with their breathing difficulties.
Bleeding from stoma
Bleeding may be caused by trauma to the trachea from cleaning or suctioning, or a lack of humidification
Check and clean the stoma as required.
Suction the patient only when absolutely necessary.
Encourage the patient to cough and wipe away secretions.
Ensure humidification of the laryngectomy stoma.
Regularly administer nebulizers.
If the bleeding is profuse and there is a risk of aspiration of blood into the lungs, a small tracheostomy tube should be inserted and the cuff inflated to protect the airway.
Seek expert help and ask for an urgent review.
Chest infectionPossible aspiration if the patient has a transoesophageal puncture
Monitor for signs and symptoms of chest infection.
Monitor the speaking valve for patency and size.
Clean the speaking valve to reduce the risk of secretions accumulating.
Check for leakage from the voice prosthesis (see ‘Voice prosthesis falls out accidentally’ below).
Contact the team or SLT for an urgent assessment if leakage is suspected.
Keep the patient nil by mouth until reviewed.
Stoma shrinkageLaryngectomy stoma reduced in size
Regularly measure the stoma's size.
Insert a laryngectomy tube or stoma button.
Escalate to the team and SLT and ask for a patient review.
Voice prosthesis falls out accidentallyVoice prosthesis not adequately secured or accidentally removed
Ensure that care is taken when cleaning the stoma and valve to reduce the risk of it falling out.
Insert a red rubber tube (Figure 12.55) (14 Fr catheter) or dilator.
If using a red rubber tube, tie a knot in the end of the tube and secure the end onto the neck or chest wall using tape.
Check for leakage around the tube or dilator (encourage several sips of coloured liquid or milk and watch for leakage; use a good torch or light to see clearly).
If leakage is noted, commence thickened drinks to reduce the risk of a chest infection.
Contact the SLT for an urgent review.
If unable to insert the red rubber tube or dilator, contact ENT team immediately.
Check the patient has removed the voice prosthesis from the airway; if not, the patient should be seen by the ENT team to check the prosthesis is not still in the airway.
Voice difficultiesVoice prosthesis blocked or not working
Clean the voice prosthesis regularly
Clean the voice prosthesis with a brush.
If this does not help, contact the SLT.
ENT, ear, nose and throat; SLT, speech and language therapist.
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