Laryngectomy Post Operation Care

Dr. Erami M.D.ENT Resident

Department Of ENTShahid Sadoghi Hospital

Yazd Iran

• Discharge:• Approximately 7-9 days after surgery

• Follow-up• 1st Visit:

• Approximately 1 week after discharge• Make arrangements for meeting with radiation oncologist• Radiation treatment should begin within 6 weeks of surgery

• 2nd Visit:• Approximately 1 month after surgery• Set-up appointment or meet with the Speech Therapist

• Long-term Follow-up Care

• Years 1-2: Every 6-8 weeks• Year 3: Every 3 months• Year 4: Every 4 months• Year 5: Every year

• POSTOPERATIVE MANAGEMENT AND COMPLICATIONS

• monitoring of systemic vital signs• fluid balance• Oxygenation• wound drain vacuum retention and output• neck flap viability• suture line

• care three times daily• nasogastric tube feeding

• once bowel sounds are present

• Airway care

• Frequently monitor airway patency and respiratory status, including :• respiratory rate and pattern• lung sounds• oxygen saturation• Excessive or retained respiratory secretions can impair gas exchange,

increase the work of breathing, and lead to complications such as pneumonia

• Encourage deep breathing and coughing :• Deep breathing helps ensure adequate ventilation of lower airways• coughing helps to move secretions out of airways• 10 deep breaths every hour

• Airway care

• The upright position:• promotes effective ventilation of the lungs• reduces edema and swelling of the neck

• tracheostomy tube care• Cleaning

• every 8 hours and as needed(The oral cavity may also need to be suctioned)

• provide good pulmonary hygiene• Safe, sterile suctioning

• Airway care

• Suctioning may be traumatic to the airway and is frightening to the patient(If the patient is able, allow him to cough)

• When suctioning airway• remember to do so gently• with the least amount of suction necessary

(so as not to cause trauma to the stoma or trachea)

• beneath the laryngectomy tube:• A sterile gauze dressing should be applied and changed

• Airway care

• cuff pressure checks• bronchodilator treatments• chest physical therapy• airway humidification

• Instillation of 3-5 ml of normal saline into the stomamaintain moisture in the stoma and upper airway

• bedside humidifierThe water in it needs to be changed daily to prevent pathogen growth

• Airway care

• Daily care of stoma:• Gently wipe with warm water to remove any dried secretions followed by

1% hydrocortisone ointment to prevent irritation• A few drops of normal saline drops down the stoma may help to facilitate

the removal of mucous plugs• A room humidifier also helps to keep the environmental relative humidity at

50 percent

• After clearance by speech therapy to take thin liquids by mouth, encourage 6-8 glasses of fluids per day

This also will help keep the mucous membrane secretions thin

•Drains assess drainage sites and collection receptacles often for proper functioningInadequate output from these drains may lead to:

• formation of hematomas or seromas• poor wound healing• Infection

• are removed output <25 mL/day for 2 consecutive days

• Oral feeding :

• Good oral hygiene with solutions :• important post-operatively to avoid infection and control odor

• Nasogastric tube:• Generally is inserted during laryngectomy• It usually remains in place for about 7 to 10 days

• (10 days in patients who have had radiation therapy)• tube feedings are started slowly

• When bowel sounds are present• Because the nasogastric tube lies near internal incision lines

• it should never be manipulated

• Oral feeding :

• patient is advanced to an oral diet:• When incisions are healed with no evidence of fistula formation

• Oral diet:• nonirradiated patient

• normally begun 7 days after surgery • Irradiated Patients

• 12 to 14 days in most cases

• Timing of feeding in total laryngectomy can be individualized depending on patient considerations

• Oral feeding :

• the tissues in the throat may take up to 2 weeks to heal• A speech therapist may be helpful when oral feedings are reinstituted to

assess swallowing safety and function • Gastrointestinal changes include alterations in eating and elimination • Normal bowel habits may be altered during hospitalization due to

• analgesic medication• decreased mobility

• patients should have a high fiber diet to keep stools soft or use stool softeners if necessary

• vitamins or minerals (during or post radiotherapy)

• Zinc at doses of 25mg tds taken during or post (chemo) radiotherapy • may reduce side effects (mucositis, taste changes)• interactions with chemotherapy and radiotherapy?!

• Vitamin E, at high doses of 400IU/d, may be associated with reduced survival or recurrent disease

• Antioxidants should not be taken during chemotherapy or radiotherapy due to possible tumour protection and reduced survival

• Vitamin A, at high doses of 200 000IU/week, has no benefits and may have an adverse effect on survival and disease outcomes

• Nutritional recommendations

• More than 50% of patients with head and neck cancer are nutritionally compromised before diagnosis or treatment

• Daily weight and blood chemistries:• to monitor for any fluid or electrolyte imbalances

• Maintain BMI in range of 18.5–25 kg/m2• Consumption of alcoholic beverages is not recommended • Overall consumption of salt-preserved foods and salt should be moderate• Have a diet which includes at least 400 g/d of total fruit and vegetables • Those who are not vegetarian are advised to moderately consume of red

meat• Zinc supplementation 20 mg / day

• Sleeping & Positioning

• should have the head of the bed elevated 30 degrees to promote:• downward drainage of secretions and decrease the risk of aspiration,

particularly if the patient has coexisting COPD. • Because these patients also may have impaired mobility and range of

motion in their neck, propping with extra pillows may be helpful to not occlude the stoma

• Cancer pain management

• consider a regular oral opioid If pain is:• moderate or severe • continues despite treatment with paracetamol or NSAIDs

• For patients with normal renal and hepatic function:• start with a low dose

• morphine 20–30 mg per day• 10-15 mg sustained release every 12 hours

Or• 5 mg immediate release every 4 hours

• for breakthrough pain with 5 mg immediate release rescue doses 1 hourly as needed

• In elderly or frail patients, starting doses should be half the above doses

• Physical Recovery After Laryngectomy• patients move around to prevent blood clots and muscle tone during

recovery, while in bed:• stretch arms and legs• turn ankles and wrists in circles• bend elbows and knees

• Safety of thromboprophylaxis after oncologic head and neck surgery. Study of 1018 patients

(Departments of Surgical Oncology, Peter MacCallum Cancer Institute, Melbourne, Australia)

• analysis shows no benefit from chemoprophylaxis in oncologic head and neck surgery patients, with no VTE events

• analysis shows higher rates of morbid side effects from using chemoprophylaxis

• therefore conclude that chemoprophylaxis should not be routinely used

• Early Complications usually occur during the hospitalization• Drain Failure• Hematoma• Infection• Pharyngocutaneous Fistula• Wound Dehiscence

• Late Complications • Stomal Stenosis• Pharyngoesophageal Stenosis and Stricture• Hypothyroidism

• Drain Failure• a serious threat to the wound• a leak is present in :

• pharynx or the skin and stoma closure• needs to be promptly detected and sealed

• Hematoma• The patient is returned to the operating room• the clot is evacuated• any detectable bleeding is controlled• New drains are inserted

• because blockage of the original ones with clot is inevitable

• Infection • For smaller wounds:

• routine cleaning• application of antibiotic ointment

• A subcutaneous infection after total laryngectomy is recognized by: • skin flaps 3 to 5 days after surgery increasing:• erythema • edema• Odor• Fever• elevated leukocyte count

• If an infected collection is present• the wound is opened under sterile conditions• the pus is evacuated and cultured

• Infection

• Dead space between the neopharynx and skin flap:• managed with repeated antiseptic gauze packing until healed

• Antibiotic coverage is modified according to culture results• Wound infections usually respond to local care and appropriate antibiotic

therapy• Larger wounds and exposed vessels may require surgical flap closure

• if wound discharge continues or increases• a pharyngocutaneous fistula is suspected

• if neck dissection was performed• A chyle fistula should be ruled out

• Pharyngocutaneous Fistula

• may occur 1 to 6 weeks postoperatively• depending on the presence or absence of previous irradiation

• Its existence often is heralded by:• increased turbid drain output• erythema and edema around part of the wound closure

• communication from the skin to the pharynx is confirmed:• methylene blue swallow test

or• Gastrografin swallow radiograph

• Persistent or recurrent tumor should always be ruled out

• Pharyngocutaneous Fistula

• Initial management is by:• regular antiseptic gauze fistula tract packing• Dressings• antibiotic therapy• giving the patient nothing by mouth

• If a fistula is present, the NG tube remains in place• Fix the NG tube and reduce movement, to decreas secretions

• An active drain can often be converted to a passive drain• to allow diversion of the saliva and to prevent salivary collection

• A pressure dressing is sometimes useful

• Pharyngocutaneous Fistula• A useful adjunct is to “sterilize” the fistula from within by administering :

• 10 mL of 0.25% acetic acid by mouthor

• an antibioticor

• other antiseptic• preparation 3-4 times daily

• If are unsuccessful in sealing off the pharynx from the neck• operative closure should be considered

• spontaneous closure may occur up to 6 weeks after onset• most patients prefer a more rapid resolution so that oral feeding may begin

• Pharyngocutaneous Fistula

• An excellent option for fistula closure:(before complete epithelialization)

• pedicled muscle flap slipped between the pharyngeal and skin defects• Pectoralis• Trapezius• latissimus dorsi

• Control of esophageal reflux(preventing and managing )

• Wound Dehiscence

• Wound dehiscence may accompany :• tensioned skin closure • post radiation state• wound infection• Fistula• poorly designed ischemic neck flaps

• Local wound care should suffice for:• healing by secondary intention

• but if the carotid becomes persistently exposed:• vascularized muscle flap coverage is advisable

• Stomal Stenosis (Late Complications)

• is uncommon If the stoma is created with true technique • Revision can be done with:

• V-Y advancement flaps• Z-plasties• a “fish-mouth” stomaplasty

• Pharyngoesophageal Stenosis and Stricture (Late Complications)

• tumor recurrence should be suspected• endoscopy and biopsy

• once this has been ruled out :• outpatient dilation is usually an effective treatment

• An adequate lumen (36 Fr) is necessary for:• swallowing and nutrition and tracheoesophageal speech production

• If dilation is unsuccessful:• flap reconstruction is preferable

• Hypothyroidism (Late Complications)

• Preoperative or postoperative RT + hemithyroidectomyis usually sufficient to induce a low-thyroid state

• after completion of all treatment when supplemental thyroid medication is required

• Thyroid function tests every 1 to 2 months indicate

• Vaccination

• Vaccination against the Influenza:• It is important for laryngectomees regardless of age• Influenza can be more difficult to manage• Because laryngectomees do not breathe through their noses, cold

viruses are less likely to infect them.• The influenza virus is capable of spreading by touching objects

• Vaccination against the pneumococcal bacteria:• It is one of the major causes of pneumonia

• Activity After discharge

• Plan frequent rest periods to avoid shortness of breath• deep breathing and controlled coughing exercises• Don’t drive until free of pain and off pain medicine

• This may take 2 to 4 weeks

• Break the smoking habit

• Don’t passive smoker• Patients who continue to smoke and drink are:

• less likely to be cured• more likely to develop a second tumor

• When smoking is continued both during and after RT• increase the severity and duration of mucosal reactions• worsen the dry mouth (xerostomia)• compromise the patient outcome

• Other home care

• This is a difficult surgery, and many people have serious emotional issues after it.

• sense of smell will be severely affected by the operation.• Patient may be at increased risk for things like food poisoning• Also double check smoke alarms to be sure they are working

• Due to the greater risk of drowning, new laryngectomy patients need to be extremely cautious near water

• The stoma should be protected during bathing and showering to prevent the entrance of large amounts of water

• When to seek medical care

• Fever of 100.4°F (38°C) or higher• Signs of infection around the stoma or incision

• These include redness, drainage, warmth, or pain.• Trouble breathing

• Shortness of breath without exertion• Trouble swallowing• Nausea or vomiting• Thoughts of self-harm