Total laryngectomy is a surgical procedure to remove the larynx. Located in the neck, where it is commonly referred to as the Adam's apple, the larynx contains the vocal folds for production of voice for speech. Additionally, the larynx serves as a valve during swallowing to prevent food and liquids from entering the airway and lungs. When a total laryngectomy is performed, the patient loses his or her voice and must breathe through an opening created in the neck called a tracheostoma.

Total laryngectomy is usually performed to remove advanced cancers of the larynx, most of which arise from prolonged smoking or a combination of tobacco use and alcohol consumption. Laryngeal cancers account for less than 1% of all cancers. About 10,000 new cases of laryngeal cancer are diagnosed each year in the United States, with a male-female ratio approximately 4 to 1 (American Cancer Society, 2000). The Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute (Ries et al., 2000) reports that laryngeal cancer rates rise sharply in the fifth, sixth, and first half of the seventh decades of life (Casper and Colton, 1998). The typical person diagnosed with cancer of the larynx is a 60-year-old man who is a heavy smoker with moderate to heavy alcohol intake (Casper and Colton, 1998). Symptoms of laryngeal cancer vary, depending on the exact site of the disease, but persistent hoarseness is common. Other signs include lowered pitch, sore throat, a lump in the throat, a lump in the neck, earache, difficulty swallowing, coughing, difficulty breathing, and audible breathing (National Cancer Institute, 1995). It is estimated that there are 50,000 laryngectomees (laryngectomized people) living in the United States today.

As a treatment of laryngeal cancer, total laryngectomy is a proven technique to control disease. The primary disadvantages of total laryngectomy are the loss of the vocal folds that produce voice for speech and the need for a permanent tracheostomy for breathing. Before the introduction of the extended partial laryngectomy, patients with cancer of the larynx were treated primarily with total laryngectomy (Weber, 1998). Today, early and intermediate laryngeal cancers can be cured with conservation operations that preserve voice, swallowing, and nasal breathing, and total laryngectomy is performed only in cases of very advanced cancers that are bilateral, extensive, and deeply invasive (Pearson, 1998). Radiation therapy is often administered before or after total laryngectomy. In addition, radiation therapy alone and sometimes in combination with chemotherapy has proved to be curative treatment for laryngeal cancer, depending on the site and stage of the disease (Chyle, 1998). Controversy and research continue over nonsurgical versus surgical intervention or a combination of these for advanced laryngeal cancer, weighing the issues of survival, preservation of function, and quality of life (Weber, 1998).

A person with laryngeal cancer and the family members have many questions about survival, treatment options, and the long-term consequences and outcomes of various treatments. An otolaryngologist is the physician who usually diagnoses cancer of the larynx and provides information about possible surgical interventions. A radiation oncologist is a physician consulted for opinions about radiation and chemotherapy approaches to management. If the patient decides to have a total laryngectomy, a speech pathologist meets with the patient and family before the operation to provide information on basic anatomy and physiology of normal breathing, swallowing, and speaking, and how these will change after removal of the larynx (Keith, 1995). Also, the patient is informed that, after a period of recovery and rehabilitation, and with a few modifications, most laryngectomized people return to the same vocational, home, and recreational activities they participated in prior to the laryngectomy.

Besides voicelessness, laryngectomized persons experience other changes. Since the nasal and oral tracts filter the air as well as provide moisture and warmth in normal breathing, laryngectomees often require an environment with increased humidity, and they may wear heat-and moisture-exchanging filters over their tracheostoma to replicate the functions of nasal and oral breathing (Grolman and Schouwenberg, 1998). There is no concern for aspiration of food and liquids into the lungs after total laryngectomy, because the respiratory and digestive tracts are completely separated and no longer share the pharynx as a common tract. Unless the tongue is surgically altered or extensive pharyngeal or esophageal reconstruction beyond total laryngectomy is performed, most laryngectomees return to a normal diet and have few complaints about swallowing other than that it may require additional effort (Logemann, Pauloski, and Rademaker, 1997).

There are nonspeech methods of communicating that can be used immediately after total laryngectomy. These include writing on paper or on a slate, pointing to letters or words or pictures on a speech or communication board, gesturing with pantomimes that are universally recognizable, using e-mail, typing on portable keyboards or speech-generating devices, and using life-line emergency telephone monitoring systems. None of these methods of communicating is as efficient or as personal as one's own speech.

A common fear of the laryngectomee is that he or she will never be able to speak without vocal folds. There are several methods of alaryngeal (without a larynx) speech. Immediately or soon after surgery, a laryngectomized person can make speech movements with the tongue and lips as before the surgery, but without voice. This silent speech is commonly referred to as “mouthing words” or “whispering”; however, unlike a normal whisper, air from the lungs does not move through the mouth after a laryngectomy. The effectiveness of the technique is variable and depends largely on the laryngectomee's ability to precisely articulate speech movements and the ability of others to recognize or “read” them.

Artificial larynges have been used since the first recorded laryngectomy in 1873 (Billroth and Gussenbauer, 1874). Speech with an artificial larynx, also known as an electrolarynx, can be an effective method of communicating after laryngectomy, and many people can use one of these instruments as early as a day or two after surgery. Most modern instruments are battery powered and produce a mechanical tone. Usually the device is pressed against the neck or under the chin at a location where it produces the best sound, and the person articulates this “voice” into speech. If the neck is too swollen after surgery or the skin is hard as a result of radiation therapy, the tone of the artificial larynx may not be conducted into the throat sufficiently for production of speech. In this circumstance it may be possible to use an oral artificial larynx with a plastic tube to place the tone directly into the mouth, where it is articulated into speech. Speech with an artificial larynx has a sound quality that is mechanical, yet a person who uses an artificial larynx well can produce intelligible speech in practically all communication situations, including over the telephone. Most laryngectomized people require training by a speech pathologist to use an artificial larynx optimally.

A laryngectomized person may be able to learn to use esophageal voice, also known as esophageal speech. For this method, commonly known as “burp speech,” the person learns to use the esophagus (food tube) to produce voice. First the laryngectomee pumps or sucks air into the esophagus. Sound or “voice” is generated as the air trapped in the upper esophagus moves back up through the narrow junction of the pharynx and esophagus known as the PE segment. Then the voice is articulated into speech by the tongue and lips.

A key to producing successful esophageal speech is getting air into the esophagus consistently and efficiently, followed by immediate sound production for speech. Esophageal speech has distinct advantages over other alaryngeal speech techniques. The esophageal speaker requires no special equipment or devices, and the speaker's hands are not monopolized during conversation. A significant disadvantage of esophageal speech is that it takes a relatively long time to learn to produce voice that is adequate for everyday speech purposes. Additionally, insufficient loudness and a speaking rate that is usually slower than before laryngectomy are common concerns of esophageal speakers. Although some become excellent esophageal speakers, many do not attain a level of fluent speech sufficient for all communicative situations.

Tracheoesophageal puncture with a voice prosthesis is another method of alaryngeal voice production (Singer and Blom, 1980; Blom, 1998). During the surgery to remove the larynx or at a later time, the surgeon makes an opening (puncture) just inside and inferior to the superior edge of the tracheostoma. The opening is a tract through the posterior wall of the trachea and the anterior wall of the esophagus. Usually a catheter is placed in the opening and a prosthesis is placed a few days later. A speech pathologist specially trained in tracheoesophageal voice restoration measures the length of the tract between the trachea and the esophagus, and a silicone tube with a one-way valve—a voice prosthesis—is placed in the puncture site. The prosthesis is nonpermanent and must be replaced periodically. It does not generate voice itself. When the person exhales and the tracheostoma is covered with a thumb, finger, or special valve, air from the lungs moves up the trachea, through the prosthesis, into the upper esophagus, and through the PE segment to produce voice. Because lung air is used to produce voice with a tracheoesophageal puncture, the speech characteristics of pitch and loudness, rate, phrasing, and timing more closely resemble the laryngectomee's presurgical speech qualities than can be achieved with other forms of alaryngeal speech. For many laryngectomees, fluent speech can be achieved soon after placement of a voice prosthesis.

There are disadvantages associated with tracheoesophageal puncture. The laryngectomee may dislike using a thumb or finger to cover the tracheostoma when speaking, and use of a tracheostoma valve for hands-free speaking may not be possible. Expenses associated with tracheoesophageal puncture include those for initial training in the use and maintenance of the prosthesis with a speech pathologist and subsequent clinical visits for modification or replacement of the voice prosthesis, and ongoing costs of prosthesis-related supplies. If the PE segment is hypertonic and the tracheoesophageal voice is not satisfactorily fluent for conversation, or if it requires considerable effort to produce, injection of botulinum neurotoxin, commonly known as Botox, may be required (Hoffman and McCulloch, 1998; Lewin et al., 2001), or myotomy of the pharyngeal constrictor muscles may be considered (Hamaker and Chessman, 1998).

Historically, laryngectomees and speech pathologists have felt strongly about one form of alaryngeal speech being superior to others. In the 1960s, newly laryngectomized persons were discouraged from using artificial larynges, which were thought to delay or interfere with the learning of esophageal speech (Lauder, 1968). Today some think tracheoesophageal speech is superior because many laryngectomees are able to speak fluently and fairly naturally with this method only a few weeks after surgery. Others maintain that esophageal speech, with no reliance on a prosthesis or other devices, is the gold standard against which all other methods should be compared (Stone, 1998). Most believe any form of speech after laryngectomy is acceptable and should be encouraged, since speaking is a fundamental and essential part of being human.

People who undergo total laryngectomy experience the same emotions of shock, fear, stress, loss, depression, and grief as others with life-threatening illnesses. Along with regular medical follow-up to monitor for possible recurrence of cancer and to review all the body systems, laryngectomized persons may benefit from referral to other professionals and resources for psychological, marital, nutritional, rehabilitation, and financial concerns.

The International Association of Laryngectomees and the American Cancer Society provide services to laryngectomized persons. They sponsor peer support groups, provide speech therapy, and distribute educational materials on topics of interest, such as cardiopulmonary resuscitation for neck breathers, smoking cessation, and specialized products and equipment for laryngectomized persons.

See also alaryngeal voice and speech rehabilitation.