Post Laryngectomy Stoma Care

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (21/03/2023)

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 accurate 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 treatment 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 emphasises 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).

Role of 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

Complication rates of laryngectomy stomas are reported to be as high as 60%. Aside from a pharyngocutaneous fistula or stomal recurrence, which are early and late findings respectively, the variety of complications of laryngectomy stomas can occur at any stage throughout the post-operative period.

Bleeding

Bleeding from the stoma can be a common early presentation, and it should first be determined whether the patient is coughing up blood or simply identifying it at the stomal site. The patient and stoma should be examined closely for the presence of granulation tissue at the skin edge or any wound breakdown if the operation was recent. Insensate granulation tissue can be treated with the application of silver nitrate cautery in the GP setting or a short course of topical antibiotic and corticosteroid ointment. Granulation tissue can also commonly occur around the voice prosthesis, which is inserted into the posterior wall of the trachea; if this occurs, then review by a speech pathologist is required so the prosthesis can be replaced.

Pharyngocutaneous fistula

Pharyngocutaneous fistula is the most common, and normally early. It is an abnormal communication between the pharynx and cervical skin at the stoma or, more frequently, the surgical incision site. Examination will reveal a cutaneous defect, as shown in, with salivary output also potentially seen. Treatment is normally conservative, and patients may present to their GPs for regular dressing changes, which are required to maintain integrity of the skin and prevent aspiration of saliva per stoma.

Stomal stenosis

Patients may present with concerns regarding reduced patency of the laryngectomy stoma. Stenosis of the post-laryngectomy stoma remains an ongoing concern, with a reported incidence in up to 22% of patients.8 It is typically associated with the administration of post-operative radiotherapy and the surgical technique initially used to form the stoma.8 It can be distressing for the patient, and they should be instructed to keep a laryngectomy tube inserted into the stoma to ensure patency until a speech pathologist and surgical review is arranged.

Peri-stomal skin irritation

Patients with a laryngectomy stoma can experience significant skin irritation and consequently peristomal breakdown, as similarly occurs with an abdominal stoma. As with abdominal stomas, a stomal therapy nurse (STN) is an expert in managing these conditions and should be contacted for assistance with dressing choice and alteration if necessary. Aside from a fistula, a common cause of irritation is the use of a heat and moisture exchange (HME) cover that is applied to the stoma to create a tight seal, preserving some of the moisture within the lower respiratory tract. The repeated removal and application of these appliances, or the glue used to secure the baseplate, can cause skin breakdown. An STN can assist with alteration of the appliance to one more tolerated. Leaving the stoma uncovered for at least two days is recommended for the situations above.

Late Complications

• Voice prosthesis dislodgement/leakage

Most patients who have had a laryngectomy will be regularly reviewed by a speech pathologist and otolaryngologist in the post-operative period. While a speech pathologist would normally be patients’ first point of contact for any voice prosthesis complications, patients may present to their GPs out of hour. One of the more commonly encountered complications is leakage, either through or around the voice prosthesis. Leakage through the prosthesis can be addressed by brushing and flushing the prosthesis and then capping it if the leak persists. If leakage occurs around the prosthesis, follow-up with a speech pathologist is recommended. A common cause of leakage is chronic fungal overgrowth, so a trial of oral and systemic anti-fungals is also often useful. If the patient lives in a rural location and a speech pathologist is not available, the voice prosthesis should be removed and a catheter inserted; alternatively, a tracheostomy tube with a cuff can be inserted into the stoma to prevent leakage.

• Stomal crusting

Stomal crusting and mucous plugging are not only frustrating for the patient but can become life-threatening if acute airway obstruction develops. As shown in Figure 1, as a result of post-laryngectomy anatomy changes, patients lose the humidification effects of the upper airway, and inhaled air passes directly into the trachea. This can cause irritation to the trachea at the stomal site, leading to crusting and an over-production of mucous.9 If crusting and mucous plugging is a concern, the frequency of nebulise saline and tracheal suctioning should be increased or an HME considered, in consultation with a speech pathologist. If crusting is particularly bad at the stomal site itself, a laryngectomy tube coated in antibiotic and steroid ointment can be used and changed regularly.

• Stomal recurrence

Stomal recurrence after laryngectomy is a complication feared by both patient and clinician and typically presents as an enlarging nodule or soft tissue mass at the stomal site within 1–2 years post-operatively. Unfortunately, stomal recurrence has an incidence of 3–15% in patients who have had a laryngectomy. If the treating GP is comfortable, a simple punch biopsy of the cutaneous aspect of the mass can be performed; however, it is recommended that these patients are referred for surgical review.