Total Laryngectomy

  1. General information: consists of removal of the entire larynx, hyoid bone, pre-epiglottic space, cricoid cartilage, and 3-4 rings of trachea. The pharyngeal opening to the trachea is closed and remaining trachea brought out to the neck to form a permanent tracheostomy. The result is loss of normal speech and breathing and loss of olfaction.
  2. Nursing care: preoperative
    1. Provide routine pre-op care.
    2. Explain expected procedures after surgery including suctioning, humidification, coughing and deep breathing, IV fluids, nasogastric tube feedings, tracheostomy or laryngectomy tube.
    3. Reinforce physician's teaching regarding loss of normal speech, breathing patterns, and sense of smell.
    4. Encourage client/significant others to talk about fears and hopes following surgery.
    5. Introduce client to changes in modes of communication (esophageal speech, artificial larynx).
    6. Establish method of communication to be used immediately post-op (Magic Slate, gestures).
  3. Nursing interventions: postoperative
    1. Promote optimum ventilatory status.
    2. Suction nose frequently because of rhinitis.
    3. Assess function of tracheostomy/laryngectomy tube and suction as needed.
    4. Promote pain relief.
      1. Elevate head of bed to decrease pressure on suture line.
      2. Administer analgesics as needed and monitor effects.
      3. Assist with moving head and turning by supporting back of neck with hands.
    5. Promote wound drainage.
      1. Elevate head of bed to promote lymphatic drainage from head.
      2. Monitor amount, characteristics of drainage.
    6. Promote nutrition.
      1. Institute and monitor tube feedings as ordered.
      2. Increase fluid intake as tolerated to improve hydration.
      3. Encourage self-feeding.
      4. Advance to normal diet as soon as client able to tolerate.
    7. Prevent infection.
      1. Assess WBC and report significant increases.
      2. Take temperature every 4 hours.
      3. Maintain sterile technique when suctioning and performing tracheostomy care.
      4. Observe stoma/suture lines for signs of infection.
      5. Provide frequent oral hygiene.
      6. Monitor sputum and drainage for changes in color, odor, characteristics.
    8. Enhance communication.
      1. Carry out modes of communication determined pre-op.
      2. Assess nonverbal behavior.
      3. Allow client time to ask questions and do not anticipate answers.
      4. Arrange for volunteer laryngectomee to visit client and assist with esophageal speech/artificial larynx.
      5. Consult with speech therapist if needed.
      6. Progress to normal diet as soon as possible to regain muscle tone of throat and abdomen.
    9. Support client during adaptation to altered physical status.
      1. Encourage client to discuss feelings about changes in appearance, body functioning, and life-style; be aware of nonverbal responses to the changes.
      2. Assist to identify and use coping techniques that have been helpful in past.
      3. Suggest flattering clothing styles that don't emphasize chest or neck configuration.
      4. Monitor for and support behaviors indicative of positive adaptation to changes (e.g., interest in appearance).
    10. Assess for respiratory complications (dyspnea, cyanosis, tachycardia, tachypnea, restlessness).
    11. Provide client teaching and discharge planning concerning
      1. Tracheostomy/laryngectomy and stomal care
      2. Proper administration of nasogastric tube feedings and maintenance of nasogastric tube (see Nasogastric (NG) Tubes)
      3. Control of dryness/crusting of tongue by brushing tongue regularly with soft toothbrush and toothpaste and using mouthwashes
      4. Need for humidified air at home
      5. Importance of protecting the stoma with a shield or towel while showering, directing shower nozzle away from stoma
      6. Need to use electric razors only for 6 months after surgery as facial area will be numb
      7. Need to lean forward when expectorating secretions and to cover stoma when coughing or sneezing
      8. Snorkle devices to enable swimming (caution is advised since drowning can occur rapidly in these clients)
      9. Need to wear an identification bracelet indicating that client is a neck breather
      10. Types of stoma guards available
      11. Necessity of installing smoke detectors since sense of smell is lost
      12. Information about prosthetic devices, speech therapy, and reconstructive surgery