Caring for a laryngeal stoma and voice prosthesis after a laryngectomy

What is its aim?

The aim of this leaflet is to provide general information about the care of all types of laryngectomy. The information is only a guide; your surgery may be slightly different and your clinical team can discuss this with you. Please discuss with them any other worries or questions you may have.

• Introduction
• Cleaning your laryngeal stoma and tube
• Humidification
• General advice
• Communication

Introduction

After a laryngectomy operation, the top of the trachea (windpipe) is stitched to an opening in the neck. This hole or opening is called a laryngeal stoma. You will now fully breathe via this laryngeal stoma and no longer through your mouth and nose (see Figure 1).

The laryngeal stoma is permanent and will not close over, but occasionally it can shrink in size, affecting breathing and valve care. Therefore it is important to monitor the size of your laryngeal stoma and report changes to your clinical nurse specialist (CNS) or speech and language therapist (SLT). The team will assess your laryngeal stoma and decide if you need to wear a patency device such as a laryngectomy tube to keep your laryngeal stoma size stable.

The trachea connects your lungs to the laryngeal stoma and can produce lots of mucus initially after the operation. This will reduce over a few months, although sometimes radiotherapy can also make the mucus worse for a while.

The following sections will show you how to care for your laryngeal stoma and voice prosthesis, including cleaning, humidification, troubleshooting common problems and emergency procedures.

Cleaning your laryngeal stoma

Before you leave hospital you will be taught how to care for your laryngeal stoma. Initially, you will need to clean your laryngeal stoma more often - this will become easier as you get into a routine and will become less frequent over time as your secretions settle. You will need to ensure your laryngeal stoma is free of secretions and crusting, in order to keep your airway clear as they could affect your ability to breathe.

Remember – your laryngeal stoma is your airway. Look after it.

We advise you to clear your secretions regularly by taking a deep breath, holding a disposable tissue near to your laryngeal stoma and then coughing any secretions into it.

To clean your laryngeal stoma you will need:

• clean hands
• a good light source, such as a torch
• mirror
• tweezers
• water
• gauze swabs
• waste bag

1. Remove laryngectomy tube (if you use one) and clean around the laryngeal stoma with dampened (not dripping) gauze swabs.
2. Wipe away any secretions, working from the laryngeal stoma outwards. You may need to gently remove some with the tweezers – be careful not to cause any trauma to the laryngeal stoma or trachea.
3. Using a good light, check inside the laryngeal stoma to ensure the trachea is free of crusting.
4. If the secretions are excessive, thick or dried on, use a nebuliser to soften them and use the tweezers to remove them – taking care not to let any debris fall into the airway. Do not probe too deeply down into your stoma.
5. Let the area around your laryngeal stoma air dry, or use a clean piece of gauze to dry it off. If your skin appears sore, dry or irritated you can apply a barrier cream
6. If you have a voice prosthesis (VP), be careful not to catch this or accidentally pull it out.
7. If you wear a laryngectomy tube, it is important to keep this clean and free of secretions as well.

It is very important that you become familiar with your laryngeal stoma and know what it looks like. This way you can monitor things like secretions, the size, shape and colour of your laryngeal stoma.

Laryngectomy tubes and studs

A tube or stud device may have been recommended if your laryngeal stoma has reduced in size, or is at risk of this. This device will prevent your laryngeal stoma from becoming smaller and can sometimes be used to increase its size, over time.

Having an undersized laryngeal stoma can lead to increased breathlessness and also difficulty with access for laryngeal stoma cleaning and any voice prosthesis changes.

You will be shown how to insert the device. You may find that you cough when you insert it. This usually settles after a few minutes; however if coughing persists, try the following:

• Insert the device when you are sitting quietly, as this will help to reduce the urge to cough.
• If necessary, introduce the device gradually as this will allow your trachea to get used to the device
• Ensure you lubricate the outside of the tube/stud lightly to help with insertion.

Specialist staff will recommend how often you should wear the device. Once agreed, try and follow this plan. It is important that you inform your SLT or CNS if you stop using the device for any reason.

Cleaning and care of the device

We recommend that the device should be cleaned at least twice a day, but more frequently if secretions are collecting in it. The device and any brushes need to be washed in hot soapy water and rinsed with hot tap water. They should be left to dry naturally before being reused.

Do not use the device if it looks discoloured or scratched, or if it is splitting or perishing. Never try to alter or adapt any device. Please contact a member of the SLT or CNS if you feel that the device needs altering or replacing. You will need to contact us at least every six months for a new tube.

If you have a tube type device, we will provide you with a brush so that you are able to clean the inside of it. Cleaning brushes will need to be discarded and replaced after ten uses or if you have had an infection in the trachea, voice prosthesis or laryngeal stoma. These can then be ordered from the prescription service you have been registered with – Fittleworth or Countrywide supplies.

If you have been given a stud type device, you will need to insert this carefully to ensure that it does not enter the airway too deeply. Some studs need securing with thread. If this is the case, we will show you how to do this safely.

Humidification

Due to the change in how you breathe and the loss of the body’s natural air filtering system, it is important to ensure that you maintain a safe and healthy respiratory system. The team will recommend a regime which will include daily nebulising or steaming to help loosen and clear secretions. In the beginning, you will need to do this more frequently compared with someone who had their surgery months or years ago.

As a minimum, you should nebulise in the morning, lunchtime and at night.

What should I do for extra humidification?

Sometimes you might require extra humidification, especially when the air is dry or in extreme temperatures (cold and hot). Humidification will help keep your secretions thin, easy to expel and prevent crusting.

• Increase the frequency of your nebulising
• Ensure you drink plenty of fluids
• Inhale steam through the stoma. For example – hover your stoma over a basin of hot water or run a hot shower and stand in the bathroom

NB: Never use boiling water

Use of heat moisture exchange (HME) systems

There are various HME systems available, most commonly after surgery we use a ‘bib’ which ties around the neck and tend to move onto an adhesive baseplate with a HME cassette filter once your surgical site has healed.

It is important that you wear a HME system 24/7. The HME ensures that the air you breathe is warmed and filtered. This will in turn help to minimise the mucus you produce and reduce coughing and mucus plugs.

Wearing an HME over your stoma will also help to reduce the risk of particles, such as dust, pollen, sand, aerosol fumes, and insects entering the stoma.

A wide-brimmed hat will help to prevent sun burn around the laryngeal stoma / neck. This is especially important after radiotherapy when the skin is more sensitive to the sun.

Laryngectomy bibs

Laryngectomy bibs are particularly useful when your skin is sore or wet. They can be tied or fixed around the neck and can be easily placed and removed. They come in both small and large sizes and a range of colours. If you suffer from a chronic chest condition, you may find a bib easier to use than other types of filter, as they do not restrict your breathing.

Cleaning and care of the bibs

Bibs should be changed every 24 hours or sooner if they get secretions on them, as this will impede your breathing.

‘Sofshield’ bibs can be washed in the washing machine up to ten times. ‘Buchanan Lite’ bibs can be washed three times. After this they should be discarded and replaced with a new one.

Laryngectomy baseplate and filter cassette systems

The baseplate and cassette system come in two parts. There is an adhesive baseplate with a hole in the centre that fixes around your laryngeal stoma. A filter cassette button then clips into the hole and thereafter air breathed in and out passes through this cassette.

The cassette has been designed to filter, warm and moisturise the air that is breathed through it. It also has a button over it that can be used to aid voicing when a voice prosthesis is in place. However, the button should not be used at any other time as it will stop you from being able to breathe through the cassette whenever it is pressed.

This system can be worn 24 hours a day, or in combination with another system, such as a bib. However, it is important, that some sort of HME system is worn at all times.

The baseplates are manufactured in several different materials and shapes and the cassettes come with different filtering strengths. You may need to trial several products to find the one that best suits you and the hospital team will also advise you. We can see you in our laryngectomy support clinic to review and make suggestions.

Baseplates

It can take several days or weeks of practice to learn the best way to place your baseplate. Be patient and give yourself plenty of time.

Always make sure that the skin around your laryngeal stoma is clean and dry before applying the baseplate. If you find that your skin is naturally oily, the use of a skin preparation can also help. There are a range of skin preparation wipes available; your team will suggest which may be suitable for you. These help to protect your skin and prepare it for the baseplate adhesive.

The stickiness of the base plate can be improved if you warm it before placing it on your skin. To do this, keep the backing paper on and warm in-between your hands for several minutes. Then peel off the backing paper and apply the baseplate to your skin.

When placing the baseplate to your skin, try to ensure that the lower rim of the inner hole of the base plate sits slightly lower than your laryngeal stoma. This will discourage secretions from collecting behind it.

Try to get as much adhesion to your skin as you can with the sticky part of the baseplate. This can be helped by pressing down from the centre of the baseplate first and then moving out to the outer edges.

You only need to change the baseplate every 24 hours or if you wish to clean and care for the skin underneath it, or when it loses its stickiness.

If the skin under the baseplate becomes sore, rest the area by using a bib and contact us so that we can offer you further advice. Use of a skin barrier cream or the trial of an alternative baseplate at a later stage, can sometimes help.

Filter cassette buttons

Always start with ‘Xtra-flow’ or ‘active’ cassettes. There are cassettes that can provide more resistance; however, ‘Xtraflow’ or ‘active’ cassettes allow you to get used to the resistance provided by the cassette in the early stages.

You will need to remove the cassette to cough any secretions out of your laryngeal stoma. Any secretions left around the baseplate will then need cleaning with a tissue.

You need to use a new cassette every 24 hours or sooner if secretions are accidentally coughed into it. Do not allow secretions to collect on the filter cassette, as these can interfere with your breathing.

Most manufacturers supply a shower aid. This can be used with the baseplate to provide your laryngeal stoma with protection from water when you want a shower. Please ask one of the specialist team if you have not been supplied with this device.

Avoid trialling the system at night until you have become used to it.

How often should I change the baseplate and filter?

The filter cartridge should be changed daily as least, but more frequently if it becomes covered with mucus.

The baseplate should be changed every 24 hours; however there are some baseplates that are licensed to remain in place for up to 48 hours. Please check manufacturer’s guidance. There are specialist baseplate adhesive removal wipes available on prescription. You can wipe over the top of the baseplate to help break the adhesive bonds, and then wipe the skin as you remove the baseplate.

Remove the baseplate if it becomes soiled with secretions/mucus, otherwise your skin could become very sore and irritated.

Applying and removing the baseplate and cassette

1. Wash your hands.
2. Clean and dry the skin around the stoma.
3. Use a skin barrier wipe to protect the skin and allow to dry.
4. Warm up the baseplate in your hands, this helps it to seal to the skin better.
5. Peel the backing off the baseplate and line up the hole with your laryngeal stoma, gently stick it down and smooth out the sides, working from the inside outwards.
6. Avoid creating air bubbles or creases as these will reduce the adhesiveness
7. Place the cassette into the baseplate.
8. When you need to remove the cassette, place your fingers either side on the baseplate to stabilise it and use your other hand to lift and gentle pull the cassette out.
9. To remove the baseplate gently wipe over with an adhesive remover wipe, and also use this wipe to clean the skin as you gently peel the baseplate off.

When you remove baseplates, be gentle so that you do not pull or damage your skin.

If you have a voice prosthesis with a tab, ensure you secure the tab of the valve with your other hand to prevent accidentally pulling out the valve.

General advice

Showering and bathing after laryngectomy

It is important to ensure that water and soap do not enter the laryngeal stoma when you are bathing or showering as it will go straight into your lungs. If possible, use a shower hose rather than a fixed shower head. Alternatively redirect the shower head so that the water falls below the chest level. Stand with your back to the direction of the water spray. Shampoo and rinse your hair while bending over.

You are able to wear special devices that can help protect your airway whilst showering. These are available on prescription.

Please note only certain baseplates are suitable to be used in the shower. Please check the manufacturer’s guidance.

If water was to accidentally enter the lungs, bend over from the waist as low as possible, to ensure the laryngeal stoma is lower than the lungs. This will assist the water to flow back out through the laryngeal stoma.

Do not go swimming unless you have the correct breathing equipment. You must have been taught how to use this. Please contact the National Association of Laryngectomee Clubs (NALC) if this is something that interests you.

Lifestyle

Constipation can be troublesome with a laryngeal stoma, as it reduces your ability to ‘bear down’. Try to avoid becoming constipated by eating a varied diet with a good intake of fibre and by drinking plenty of water/squash to stay well hydrated. If you do find yourself constipated, report this to your GP for advice.

Once healed from the surgery, you will be able to resume many aspects of life you previously enjoyed. Once able to look over your shoulder and complete an emergency stop, - if your insurance company is happy – you can return to driving. You can also resume sexual activity once feeling physically and psychologically able.

It is normally for your mood to fluctuate after such large surgery and you may find you have good days and bad days. However, if your mood remains low, we encourage you to discuss this with your GP.

Smoke alarms

Your sense of smell can be affected after this operation, so we advise you to ensure your smoke alarms are tested regularly.

Resuscitation

Due to the anatomical changes post-surgery, mouth-to-mouth resuscitation would prove useless in an emergency situation.

In the event of an emergency, mouth-to- laryngeal stoma resuscitation is required.

For further information, please consult the ‘National Association of Laryngectomee Clubs’ emergency resuscitation leaflet.

Communication options after laryngectomy

Surgical Voice Restoration (SVR)?

SVR is the method of using a tracheoesophageal voice prosthesis to produce voice after a total laryngectomy.

A small hole (puncture) is made in the back of the trachea creating a channel between your trachea and oesophagus through which air can pass. A tracheoesophageal voice prosthesis (TEP or “valve”) is inserted into the puncture. This procedure can be done at the same time as your laryngectomy (primary puncture) or after your laryngectomy (secondary puncture).

We aim for most people to have the option of SVR. In some cases this is not recommended. This may be due to the extent of the surgery or other factors which may affect the individual person’s ability to care for or achieve speech with this method.

Your surgeon will discuss this with you.

Routine care of the voice prosthesis

Make sure you have all the necessary equipment and wash your hands.

• a good light source (torch)
• mirror
• tweezers
• dilator / catheter
• voice prosthesis cleaning brush
• tape
• gauze / cotton swab
• water
• valve plug

The voice prosthesis will need to be cleaned and checked daily to ensure it is not leaking.

1. Clean mucus from around the voice prosthesis and stoma using gauze, cotton swab and/or tweezers.
2. Insert the brush into the centre of the voice prosthesis and gently rotate the brush in a clockwise motion into the voice prosthesis until you reach the stopper of the brush or to the point where you have been shown to insert it to.
3. Continue to rotate the brush in the same motion as you remove the brush. The voice prosthesis may twist around as you do this – this is normal. If the voice prosthesis has a tab on, you can place a finger on this to stabilise the valve whilst you are cleaning it.
4. If the voice prosthesis is particularly dirty (sticky mucus), you can dampen the cleaning brush with tap water and shake off the excess liquid before inserting it again as above, or try nebulising / steaming for a short period and then attempt to clean it again.
5. After use, wash the brush with plain soap and tap water, and dry it on a clean towel/ piece of gauze.

If you are still nil by mouth (NBM), look at the centre of the voice prosthesis and around the outside of the voice prosthesis to ensure there is no obvious saliva leaking from these areas. If there is saliva leaking from the centre of the voice prosthesis which is not resolved by cleaning (steps 1-5 above), then contact the SLT or ENT doctor at the hospital. If there is saliva leaking from the outside of the voice prosthesis, contact the SLT or ENT doctor at the hospital.

When you are able to eat and drink, monitor the valve to ensure that food/ drink doesn’t leak from the centre of the voice prosthesis or around it. If leaking through the centre, clean the voice prosthesis as above and check again. If the central leak continues insert your plug and contact the SLT or ENT doctor at the hospital. If there is leaking around the voice prosthesis, contact the SLT or ENT doctor for a review. Do not eat and drink until seen by the hospital team.

The voice prosthesis must remain in situ at all times. If for any reason the voice prosthesis comes out, a dilator or stent will need to be placed into the tracheoesophageal fistula to keep the tract open (as this can close in a matter of minutes and may require another surgical procedure to re-puncture the tract if fully closed). You should have a dilator by your bedside / in your laryngectomy bag. If not then a catheter (14-16fr) should be placed in to the tract. These should then be taped securely outside of the stoma onto the skin on your chest to keep them in place. The SLT/ENT doctor should be informed so that they can replace a voice prosthesis. You may be able to eat and drink with the catheter / dilator in place as long as there is no leak around it.

If you lose your voice or it deteriorates in quality, first try cleaning the voice prosthesis (steps 1-5 above) but if this does not resolve it, contact your SLT or ENT doctor at the hospital for advice. You may need an urgent review.

Out of hours arrangements

We advise for you to attend your regional hospital Accident & Emergency department, and ask for an ENT on-call doctor where possible.

Electrolarynx

An electronic larynx (electrolarynx), is a battery-operated machine that produces sound for you to create a voice. There are many different makes and types, but they are usually about the size of a small electric razor. This will be provided by your speech and language therapist.

The electrolarynx might be the best speech method for you in case:

• you cannot have a voice prosthesis for medical reasons
• you did not have a voice prosthesis put in at the time of your surgery, but you are waiting to have one put in at a later date

How to use it

You hold the machine against your neck or cheek, or fit a small tube into the corner of your mouth. When you press the button on the machine, it makes sound. If you move your tongue and mouth you can form the sounds into words.

1. Place the electrolarynx on your neck.
2. Make sure it is “flush/flat” against the skin on your neck for the best sound.
3. Press the button on the side of the device and it will make a sound.
4. As you press and make a sound, mouth a word – it is good to start with something simple like counting, so press the button and say ‘one’.
5. Press the button as you start mouthing the word, and release your finger from the button at the end of the word. Holding the button down for too long will make the word ‘blurred’, not holding it down for long enough will cut some of the word off.
6. Talking slowly and exaggerating your mouth movements as you speak will help to make the sound clearer.
7. Make sure you have found the best spot on your neck where the sound is clearest (this is often just below the jaw, to either side of your neck). Practice moving the device to different spots on your neck to see which is best.
8. The use of the device does not require any breath work, so breathe in a relaxed way while you are using the device to talk.
9. Once you get used to the device you should be able to string together 2 or 3 words with one press (keeping the button held down and then releasing and pressing again for the next two to three words).
10. The device uses a battery which is inserted by unscrewing the bottom half of the device. The rechargeable batteries can be placed in the plug and charged overnight. Normal batteries can also be used and discarded when they run out.

Do not get the device wet. It can be wiped with a slightly damp cloth if you get it dirty.

Oesophageal speech (swallowing air)

This used to be the most common way that people learned to speak after a laryngectomy. If you use this method, your speech and language therapist will teach you this method after your surgery.

How you do it

To speak in this way, you move air down towards your food pipe (oesophagus) and then bring it back up again. The air passes through the muscles in your reconstructed or ‘new’ throat and causes vibrations. You learn to use these vibrations and turn them into speech by moving your mouth and lips as you would when speaking normally.

Some people are able to achieve this method of voicing more easily than others, but it often takes regular practice to try and get the hang of it.

The biggest difficulty is moving down enough air to be able to produce continuous speech. About 1 in 3 people manage this very well. Some people can even go back to jobs that require a lot of talking.

Sometimes using this method of oesophageal speech can cause an increase of air into the stomach. This will not cause damage, but you may find that you pass more wind through your mouth or bottom initially until your refine your technique.

Your SLT can be a great support during this time. They understand that you need a lot of practice and will assist you with this.

The advantages

Many people find it easier to use a voice prosthesis than oesophageal speech. But the advantage of oesophageal speech is that you don't need any equipment. This may be better for you than a speech valve if you have difficulty with fiddly things.

Oesophageal speech might also be a better option than an electrolarynx if you think you might have a problem holding something to your throat every time you need to speak.

Eating, swallowing and smelling after a laryngectomy

Eating, swallowing, and smelling are not the same after a laryngectomy.

Eating and swallowing difficulties can be generated by a decrease in saliva production and a narrowing of the oesophagus, plus a change in the way your food or drink is pushed down into the food pipe (oesophagus) as the some of the muscles that used to do this have been removed or changed during surgery. Smelling is also affected because inhaled air now bypasses the nose.

During a laryngectomy, the sphincter in the upper oesophageal sphincter (the cricopharyngeus) which normally prevents food from being regurgitated and returning to the mouth is removed. This leaves the upper part of the oesophagus flaccid and always open, which may result in the reflux of stomach contents up into the throat and mouth if you are not careful. Therefore, ensure you maintain a good upright posture,

especially in the first hour or so after eating, to reduce the chance of this happening.

Taking medications that reduce stomach acidity such as antacids and proton

pump inhibitors (PPI), can alleviate some of the side effects of reflux, such as

throat irritation, damage to the gums and bad taste. Eating small amounts of food multiple times causes less food reflux than eating large meals.

If you struggle to return to a normal diet after surgery your speech and language therapist can assess this and provide you with advice on how to improve things.

Patient Groups and Support

SLT and CNS teams host regular patient groups for laryngectomy patients. You and your partner / family / friend will be invited to attend these and patients are invited to identify areas and topics that they would like covered in these sessions.

One to one issues can be discussed in our regular Laryngectomy Support Clinics, please contact your CNS or SLT to request an appointment if you have any concerns or queries.

Contacts / further information

Head and neck clinical nurse specialist: 01223 217425

Head and neck speech and language therapists: 01223 216200

Head and neck dietitians: 01223 216655

Addenbrooke’s hospital: 01223 245151

M5: 01223 348527

Macmillan Cancer Support website (opens in a new tab)
Telephone: 0808 808 0000

National Association of Laryngectomee Clubs (NALC) (opens in a new tab)

Cancer Laryngectomee Trust (opens in a new tab) - This website gives access to travel information and a book written by a laryngectomee.
Telephone: 01422 205522

NHS 111 (opens in a new tab) – When you need medical help fast but it’s not a 999 emergency. NHS 111 is available 24hours a day, 365 days a year.

NHS Choices (opens in a new tab) – provides online information and guidance on all aspects of health and healthcare, to help you make decisions about your health.

Video from Greater Glasgow NHS about care of your laryngectomy (opens in a new tab)