Practice Matters

Preoperative education for patients undergoing total laryngectomy

Patients undergoing a total laryngectomy can expect to experience significant lifestyle changes after surgery. Preoperative education is essential in helping them cope with these changes and to recover quickly after surgery. Research shows that surgical patients who perceive they did not receive proper preoperative education experience more dissatisfaction after surgery and have greater difficulty understanding the changes they face. This article focuses on essential aspects of preoperative education for patients undergoing a total laryngectomy.

Treatment for cancer

A total laryngectomy is performed for patients with laryngeal cancer. In the United States, this comprises about 1% of all newly diagnosed cancers, with an estimated 12,500 new cases per year. The most common type is squamous cell carcinoma. The main cause of laryngeal cancer is smoking, and alcohol consumption combined with smoking can increase the risk of laryngeal cancer by more than 50%.

In a total laryngectomy, the entire larynx, which houses the vocal folds, is removed. The lower airway is detached from the upper airway and the upper digestive tract. The trachea is then brought out to the surface of the neck and a permanent opening (stoma) is created. (See Laryngectomy.) This surgery is generally used for patients who have not had results with radiation and chemotherapy or who have very large tumors that cannot be treated with radiation and chemotherapy.

Benefits of preoperative education

A patient with a total laryngectomy faces a life-changing event, so it’s important to begin the education process early, preferably in the ambulatory setting during the preoperative visits. This will help the patient begin to process and prepare for these major life changes before hospitalization, rather than postoperatively while experiencing pain and anxiety.

In addition to the physician explaining the diagnosis and procedure, the patient needs a pre-operative visit with a nurse to discuss important information concerning the surgical process, what to expect in the hospital, equipment that will be used, skills to be learned, and appropriate resources. This can help improve patient outcomes and satisfaction.

When giving preoperative education, first assess what the patient already knows and information the patient wants to learn so that education can be individualized and mutual goals can be set. Remember to include the patient’s family in education as indicated and based on patient preferences.


Self-management

The ultimate goal for patients undergoing total laryngectomy is self-management. Several topics need to be covered to help patients achieve this goal. (See Preoperative education for patients undergoing total laryngectomy.)

Hospital experience

Patients undergoing a total laryngectomy generally go to a step-down unit postoperatively, and hospitalization usually lasts 7 to 10 days. The caregiver team includes physicians, nurses, dietician, speech-language pathologist, case manager, and/or social worker. Explaining the roles of the team members usually helps ease patients’ anxiety.

Airway maintenance

A priority for patients who have undergone a total laryngectomy is for them to learn how to care for their new airway. The lower airway is no longer connected to the upper airway, so patients must pay critical attention their only source of breathing—the stoma.

Stoma care comprises cleaning, including the removal of crusting, and frequent suctioning while in the hospital. The nurse will suction the patient, but patients need to know what to expect.

Typically, hydrogen peroxide and water is used to clean the incision during the hospital stay, with soap and tap water used after discharge. Patients lose the humidification, filtration, and warmth that the nose and mouth provide, so they will need artificial humidification with a cool mist machine in the hospital. (At home patients may use a different form of artificial humidification, such as a heat/moisture exchange device.)

Communication

Hospitalization and having major life-altering surgery can be a frightening experience, so patients need to know what outcomes to expect well before the surgery. The larynx will be removed and at first the patient will not be able to talk.

A preoperative consult with a speech-language pathologist is essential to begin communication education. Patients will need to know how to communicate with the staff. During hospitalization, they may use pen and paper, picture charts, gestures, and sometimes an electrolarynx. An electrolarynx is a medical device that facilitates speech by generating sound when held on the neck or at times intraorally. Some patients receive a tracheoesophageal puncture (TEP) during surgery and a voice prosthesis is placed in the newly created fistula between the trachea and esophagus. After the throat has healed, which usually takes about a month, a speech language pathologist will work with patients to teach them how to use the prosthesis to speak. 

Nutrition

Immediately after a total laryngectomy, patients will be unable to eat due to swelling of the throat as a result of trauma from the surgery. Tube feedings will be administered through a nasogastric tube.

Tell patients that they will have the tube until they pass a swallowing evaluation, usually in a few days to a few weeks. Patients who will continue tube feedings at home will need to learn how to administer them.

Management at home

A common and serious challenge for patients with a laryngectomy is interaction with emergency personnel who are unfamiliar with their history. A permanent stoma is easily confused with a temporary stoma on first glance. Tell patients they need to wear a medical alert bracelet and alert local emergency personnel of their status. Emergency personnel need to be aware that the patient cannot be intubated orally.

Patients have to be careful not to get water in their stoma, so let them know that swimming and boating are not recommended. They may shower with a special device that protects the stoma; patients may also benefit from tucking their chin when showering. The inability to inhale through the mouth and nose may cause patients to have an altered sense of taste, which can lead to decreased intake of food and liquids. Be sure patients know to monitor their weight and follow instructions from the dietician.

Other areas that are important to cover include their inability to voluntarily blow their nose and the need to abstain from smoking and excessive alcohol intake. The removal of the vocal folds and creation of a stoma causes patients to lose their ability to create pressure on the lower airway from the upper airway. This change can make it difficult for patients to bear down during a bowel movement, which can lead to constipation. Let patients know that they may need to increase fiber intake in their diet and possibly use medication such as stool softeners to prevent constipation.

Resources

Support groups and informational resources are important for the patient undergoing the life-changing experience of a total laryngectomy. These tools, which should be shared with the patient and the patient’s family before surgery, can help to reduce stress and anxiety. For example, patients can obtain more information and support by meeting people who have already undergone a laryngectomy and who are coping well. (See Resources for patients undergoing a total laryngectomy.)

Early education

Individuals undergoing a total laryngectomy will experience major life changes and will need much education to begin their journey. Patients will no longer be able to talk or breathe through their mouth and nose, and will need to learn how to take care of the permanent stoma, administer tube feedings, and perform wound care. It’s vital to begin the education process preoperatively to help patients and their families/caregivers prepare for life changes, decrease their anxiety, and ensure a successful recovery.

At the time this article was written, Kaleelah Branche was a patient educator and care coordinator at the Cleveland Clinic Head and Neck Institute in Cleveland, Ohio. She is now a clinical instructor for the department of nursing education and professional development at Cleveland Clinic.

Selected references

Baehring E, Mccorkle R. Postoperative complications in head and neck cancer. Clin J Oncol Nurs. 2012;16(6):E203-9.

Brook I. The laryngectomee guide. CreateSpace Independent Publishing Platform; 2013.

Diamond L. Laryngectomy: the silent unknowns and challenges of surgical treatment. J Am Acad Phys Assist. 2011;24(8):38-42.

Gilbert R, Devries-Aboud M, Winquist E, et al; Head and Neck Disease Site Group. The management of head and neck cancer in Ontario: organizational and clinical practice guideline recommendations. Cancer Care Ontario. 2009.

Pritchard MJ. Using targeted information to meet the needs of surgical patients. Nurs Stand. 2011;25(51):35-9.

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