FAQ 2: Why is the "stoma" necessary after a laryngectomy?
by Carla Gress, SLP, UCSF
Someone asked a question about laryngectomy surgeries, why they haven't changed much in 40 years, and why you couldn't reconstruct to avoid a stoma. Good questions!
Actually things HAVE changed a lot in the last 40 years. The last 40 years has seen more aggressive attempts at using non-surgical treatments, such as radiation or combination radiation and chemotherapy to avoid surgery completely. Also, there are now partial surgeries available by which they can remove only a single vocal cord (hemilaryngectomy) or by which they remove only the epiglottis and other structures above the vocal cords (supraglottic laryngectomy). Both of these procedures are designed to avoid having a stoma, if all heals well and the patient learns how to swallow safely with the reconstructed mechanism.
If we have a little anatomy/physiology tutorial, maybe it will help to understand what the surgeon faces when trying to develop a viable alternative to total laryngectomy. Essentially what you have in the throat is two long tubes, or pipes running in parallel. The tube in the back is the esophagus that leads to the stomach for the passage of food. The tube in the front is the windpipe or trachea, which leads to the lungs for transport of air. The larynx or "voicebox" sits at the top of the windpipe and works as a valve. It is open to let air move from the mouth or nose down into the windpipe and to the lungs and then back out. But the larynx (the valve) has to be closed to keep food and liquid out of the windpipe when you swallow. (If you look at any of the BEFORE surgery anatomy drawings on the WebWhispers site or the InHealth site, it will help your understanding of what I'm talking about.) If the valve doesn't close properly and food or liquid falls into the larynx or the windpipe (aspiration), usually a person starts coughing or "choking". If too much food or liquid gets into the lungs you will develop pneumonia, airway obstruction, or you could "drown". For voice production, the vocal cords close, the air comes up from underneath them as you exhale and that sets the vocal cords into vibration. The vibration then makes the voice. So for the various functions of breathing, swallowing, and voice production, the larynx has to open and close.
When the total laryngectomy is performed, the larynx is "cut off" from the top of the windpipe. But they can't just let it as an open passageway to the mouth or nose. You have to have a valve at the top of the windpipe to replace the valving action of the larynx - otherwise food or liquid would just fall into the airway. As you might now imagine, it is very difficult to reconstruct or rebuild the valve. It has to be open for breathing, completely closed to prevent aspiration of food or liquid, and closure to produce voice.
The first concern is always to remove enough so there is the best chance for cure of the disease, and this is done at the sacrifice of the voice and creation of a stoma. If they can perform a partial removal safely, maintain safe swallowing and a decent voice, and avoid the stoma, that's great. But if the entire larynx must be removed, the only way (currently) to allow you to safely swallow again, is to disconnect the windpipe from the mouth by taking the windpipe and ending it in the neck (stoma). That way you can never "choke", because there is no connection between the mouth and the windpipe.
I hope that this (lengthy) explanation helps you to understand why the surgery is performed the way it is. There are many bright minds around the world who are trying to find a better way, but the complexities of the larynx and conflicting demands for respiration, swallowing and speech make it an extremely difficult organ to rebuild or replace.