LARYNGECTOMY FAQ'S

Why am I having swallowing difficulties?
(by William Carroll M.D., Otolaryngology,
Kirklin Clinic, Birmingham, AL)

Some degree of difficulty swallowing (dysphagia) is common after most types of laryngectomy, whether total or partial. In most cases, the swallowing problems are not severe and tend to improve over time. The causes of swallowing difficulty differ depending on whether the laryngectomy has been partial (hemi-laryngectomy, or supraglottic laryngectomy) or total.

Let’s discuss the partial laryngectomy situation first. As you know, the production of sound or voice is not the most basic function of the larynx. The most basic function is to separate the food and the air which are both taken in through the mouth. The larynx acts as a gate or door. It closes by reflex action when a swallow occurs. It opens when air is inhaled, closes when food or liquid is swallowed. It keeps air moving toward the lungs and food moving toward the esophagus. Part of the larynx is removed during surgery and part of the normal nerve supply is interrupted. The reflexes that direct the larynx to open and close are often disrupted. The main problem that develops is aspiration, or food going into the breathing passage (trachea) instead of the swallowing passage (esophagus). Aspiration may be minor and cause nothing more than a little cough with swallowing or may be severe and cause pneumonia. Early after surgery, almost every patient has some degree of aspiration. Typically this situation improves with swallowing therapy and oral intake can be resumed. Unfortunately, there are occasions when the protective reflexes can never be fully regained and oral intake remains unsafe due to the risk of aspiration. This is rare but can require long-term feeding tube dependence.

In contrast, aspiration almost never occurs after a total laryngectomy because the breathing and swallowing passages are surgically separated. To understand the swallowing changes that occur after total laryngectomy, a little anatomy review would be helpful. The back wall of the larynx actually makes up the front wall of the pharynx or upper esophagus. When the larynx is removed, part of the front wall of the pharynx / esophagus is removed also. When the remaining portion of the pharynx is closed with sutures, the circular opening becomes smaller. Imagine a string tied in a circle. Cut out a piece of the string and toss it out. Now tie the remaining two ends back together. The new circle will always be smaller than the original circle. Just how much smaller depends on how much string was removed. Those patients who start with tumors confined to the inside of the larynx usually have plenty of pharynx left to make a very adequate swallowing passage. Some, however, not only have their larynx removed, but also have part of their esophagus or pharynx removed as well. For these patients, the new "circle of string" can be quite tight. The extreme situation occurs when not only the larynx but also the entire pharynx or upper esophagus has to be removed. This is called a laryngo-pharngectomy. In these cases, the swallowing passage has to be completely reconstructed using small intestine, stomach or a ‘tubed’ skin flap.

Total laryngectomy also disrupts the nerve and muscle fibers that normally contract to help food move down the esophagus. Occasionally patients will have spasm of the remaining muscle, which makes the opening into the esophagus very tight. Plenty of tissue is present to allow easy swallowing, but the muscles are in spasm (hyper-contracted) and won’t allow food to pass. This situation can necessitate a surgical procedure called a myotomy (myo = muscle, tome = to cut) which divides the spastic muscle.

The other factors that can lead to difficult swallowing are radiation before or after surgery, or a wound infection or fistula occurring after surgery. Both make the tissues of the pharynx and esophagus more stiff and less stretchy when food is trying to pass. Both processes can actually narrow the caliber of the opening into the esophagus as well.

Many of the same factors that effect swallowing so dramatically after laryngectomy can also effect the ability to use a voice prosthesis (Blom-Singer valve) or esophageal speech. We’ll save that topic for next time...