Post Laryngectomy Stoma Care

Introduction

The successful management of laryngeal cancer depends on a well rounded and comprehensive pre-treatment assessment of the respective patients and their disease factors to decide the accuratet staging, leading to appropriate treatment selection. Most cases require a laryngectomy. While laryngectomies are typically done as a curative cancer surgery, some patients will have recurrences and be seen in palliative care and hospice settings. Laryngectomy stomas differ from tracheostomies which drastically impacts patient’s well being. A practical knowledge of the basic management and equipment used in patients with a stoma after laryngectomy can avoid complications and improve a patient’s comfort and safety.

The treatement options include surgical modalities, including transoral laser microsurgery, open partial laryngectomy, and total laryngectomy, offer options, alone or in combination with radiation and chemotherapy. The treatment strategy for laryngeal cancer emphasizes for cure while maintaining the best quality of life possible for the patient. Achieving the goals of initial and salvage treatment for laryngeal cancer depends on executing a plan of care determined by the expertise of the multidisciplinary team.

Stoma care

Post-laryngectomy patients undergo significant anatomical changes which hamper the normal physiological processes. The management of a laryngectomy stoma depends to some degree on the type of surgical procedure used to create the tract. The aim of stoma care is to keep the area clean and dry, reducing the risk of skin irritation and infection. Any dressing placed around the tracheostomy site should always be designed for use specifically on a tracheostomy and pre-cut by manufacturers in order to prevent loose fibres entering the airway. Routine use of dressings around the stoma site are not recommended and should only be used when clinically indicated.

The basic equipment for a laryngectomy stoma includes:

• Suction device

• Humidified air device: The HME is a disposable small, round filter device, which inserts into the opening of the laryngectomy tube. Patients generally replace the HME every 24 hours
• Personal mirror: Patients with post-laryngectomy stomas will often use a small personal mirror to assist with crust removal at the stoma site
• Soft laryngectomy tube
• Voice Prosthesis: a tracheoesophageal puncture (TEP) prosthesis, which is a small circular device that is placed at the back wall of the stoma to allow for speech

Although most post-laryngectomy stomas, do not require a tube to keep them patent, some patients use a laryngectomy tube to assist with hygiene and minimize stenosis. Suctioning is performed to remove excess mucus or crusting near the opening of the stoma and to facilitate clearance of mucus from the lungs. Stomas require warm humidification to prevent buildup of thick mucus, and humidification can be achieved with saline nebulizers or a portable heat and moisture exchange (HME) device.

Taking care of your stoma

A post-laryngectomy stoma does not typically require any stenting and appears as a circular opening above the clavicles directly midline in the neck. Post-laryngectomy stomas, however, may have a moisture exchange device ​which is discussed below. If there is any question about a patient’s airway anatomy, consultation with an otolaryngologist is warranted.​

It is very important to always cover the stoma in order to prevent dirt, dust, smoke, micro-organisms, etc., from getting into the trachea and lungs. ​There are various kinds of stoma covers. ​The stoma often shrinks during the first weeks or months after it is created. To prevent it from closing completely, a tracheostomy or laryngectomy tube is initially left in the stoma 24 hours a day. ​Over time this duration is gradually reduced. It is often left overnight until there is no more shrinking.

HME

Total laryngectomy causes significant anatomical changes that interfere with normal physiological processes. Separating the alimentary and respiratory tracts with the creation of a permanent stoma at the base of the neck precludes normal pulmonary driven voice and speech, and lack of a nasal airflow leads to olfaction and pulmonary problems.1 To reduce pulmonary symptoms, such as involuntary coughing and excessive phlegm production, patients normally use a heat and moisture exchanger (HME).

• Heat and moisture exchanger (HME) serve as stoma covers and create a tight seal around the stoma.​
• Preserve some of the M & H inside the respiratory tract and prevents loss and adds resistance to the airflow. ​
• Restoring the temperature, moisture and cleanliness of the inhaled air.

• It also reduces the resistance and the effort needed for inhalation by removing air resistance and shortening the distance the air travels to the lung. ​
• An HME increases the resistance to inhaled air and therefore increases inhalation efforts, thus preserving previous lung capacity.

• HME captures the warm, moistened, and humidified air upon exhalation.​
• Decreasing risk of mucus plugs and re-instating the normal airway resistance to the inhaled air which preserves the lung capacity​
• Decreasing the viscosity of the airway secretions​
• Increasing the moisture within the lungs (subsequently leading to less mucus production).​

Complications Post- Laryngectomy Stoma Care

Early Complications