Many patients have reported it is harder to swallow following their laryngectomy surgery. That may be true. How the swallow works after a laryngectomy is very different from how someone with a larynx will swallow.
With the larynx in place, there are several structures in the throat that assist in the swallowing process. Many of these are removed during the laryngectomy surgery, which means how you swallow really is different. In some cases, this can take some time to adjust. In order to better understand why swallowing is different after laryngectomy surgery, it is important to understand how we swallow before surgery.
With the larynx in place, there are several structures in the throat that assist in the swallowing process. Many of these are removed during the laryngectomy surgery, which means how you swallow really is different. In some cases, this can take some time to adjust. In order to better understand why swallowing is different after laryngectomy surgery, it is important to understand how we swallow before surgery.
Swallowing with a larynx
Swallowing is a complex and coordinated activity that requires various muscle groups and other structures, including the larynx, to function in a swift and coordinated manner. When this doesn’t happen, often this can result in food or liquid falling into the trachea, known as “aspiration.” This is what happens when a person chokes.
|
To briefly describe how people with a larynx swallow, of course it begins in the mouth. This is referred to as the oral phase of swallowing. A standard laryngectomy surgery should not impact this phase of swallowing. During this phase, you chew any solid food and your tongue works in coordination with your lips and cheeks to organize the material in your mouth and move it, all together, to the back of the mouth, or the oropharynx (where the mouth joins the throat).
|
|
Once this happens, the pharyngeal phase of swallowing occurs. During this phase is when much of the work of swallowing is accomplished. (This is usually what most laryngectomee patients notice has changed following their surgery.)
The tongue base pushes backward and downward, making contact with the superior pharyngeal constrictors. These are the highest muscles in the throat. This begins the downward movement of the food material toward the esophagus. As this happens, material fills the vallecula. This is a “pocket” in your throat which is created on one side by the tongue base and by the epiglottis on the other side.
As the tongue base pushes downward, the pharyngeal constrictors begin to contract, like a purse string, from the top of your throat downward in a wavelike manner. At the same time, muscles connected to the larynx and hyoid bone, pull the larynx upward and slightly forward. The vocal cords also close during this to protect the windpipe from food going in.
The closing of the vocal cords also plays a very important role in the swallow process. By closing, they prevent any air from leaving the lungs during the swallow. This subglottic pressure is important for driving a strong swallow.
As the larynx moves upward, two other very important things happen. The epiglottis flips backward or retroflexes over the opening to the larynx, like a lid covering the larynx and trachea during the swallow. While this helps to protect the airway from food material entering, it also allows for the tongue base to now clear the food out of the vallecula. As the epiglottis flips backward, the vallecular pocket turns into a smooth slide, deflecting the food material past the protected larynx and downward toward the esophagus.
Another important action happens when the larynx moves upward and forward during the swallow. This action also pulls open the cricopharyngeus, or “upper esophageal sphincter” which remains closed except during swallowing, burping or vomiting. This is a small muscle at the top of the esophagus that opens to allow food and liquid to pass, then closes to prevent reflux or regurgitation back into the throat. At rest, the cricopharyngeus is closed.
The pharyngeal constrictors work in conjunction with these other actions, squeezing in a purse string manner from top to bottom. The middle pharyngeal constrictors are active when moving the food past the larynx. The inferior pharyngeal constrictors help to squeeze the food material past the cricopharyngeus and into the esophagus.
Once into the esophagus, the Esophageal Phase of swallowing begins. It is not uncommon for laryngectomee patients to experience problems in the esophageal phase, especially affecting the uppermost portion of the esophagus exposed to radiation.
The esophagus is a tube like muscular structure that squeezes from the top downward in a wavelike manner called peristalsis. This action is what moves the food into your stomach. Although problems may arise in the lower esophagus and duodenum, this is not impacted by the laryngectomy surgery.
The tongue base pushes backward and downward, making contact with the superior pharyngeal constrictors. These are the highest muscles in the throat. This begins the downward movement of the food material toward the esophagus. As this happens, material fills the vallecula. This is a “pocket” in your throat which is created on one side by the tongue base and by the epiglottis on the other side.
As the tongue base pushes downward, the pharyngeal constrictors begin to contract, like a purse string, from the top of your throat downward in a wavelike manner. At the same time, muscles connected to the larynx and hyoid bone, pull the larynx upward and slightly forward. The vocal cords also close during this to protect the windpipe from food going in.
The closing of the vocal cords also plays a very important role in the swallow process. By closing, they prevent any air from leaving the lungs during the swallow. This subglottic pressure is important for driving a strong swallow.
As the larynx moves upward, two other very important things happen. The epiglottis flips backward or retroflexes over the opening to the larynx, like a lid covering the larynx and trachea during the swallow. While this helps to protect the airway from food material entering, it also allows for the tongue base to now clear the food out of the vallecula. As the epiglottis flips backward, the vallecular pocket turns into a smooth slide, deflecting the food material past the protected larynx and downward toward the esophagus.
Another important action happens when the larynx moves upward and forward during the swallow. This action also pulls open the cricopharyngeus, or “upper esophageal sphincter” which remains closed except during swallowing, burping or vomiting. This is a small muscle at the top of the esophagus that opens to allow food and liquid to pass, then closes to prevent reflux or regurgitation back into the throat. At rest, the cricopharyngeus is closed.
The pharyngeal constrictors work in conjunction with these other actions, squeezing in a purse string manner from top to bottom. The middle pharyngeal constrictors are active when moving the food past the larynx. The inferior pharyngeal constrictors help to squeeze the food material past the cricopharyngeus and into the esophagus.
Once into the esophagus, the Esophageal Phase of swallowing begins. It is not uncommon for laryngectomee patients to experience problems in the esophageal phase, especially affecting the uppermost portion of the esophagus exposed to radiation.
The esophagus is a tube like muscular structure that squeezes from the top downward in a wavelike manner called peristalsis. This action is what moves the food into your stomach. Although problems may arise in the lower esophagus and duodenum, this is not impacted by the laryngectomy surgery.
Swallowing after a laryngectomy
|
During the laryngectomy surgery, many of the structures in the throat, useful in swallowing before the surgery, are removed. This does not mean a laryngectomee cannot swallow but the process of swallowing is certainly different.
In addition to the vocal cords and “voice box” being removed during the laryngectomy surgery, the epiglottis and hyoid bone are also removed. The muscles are also reconstructed in a way that changes what happens when they contract. |
|
After learning how the movement of the larynx and hyoid assist in the pharyngeal phase of swallowing, it becomes easier to understand why swallowing feels so different after the laryngectomy surgery. Also keep in mind that the movement of these structures also helps to open the cricopharyngeus to allow food into the esophagus. As these structures are removed, the mechanical help to open the cricopharyngeus is also lost.
All of this contributes to why the trachea or “windpipe” is diverted, sewn to the neck, creating the stoma a laryngectomee breathes through. Without all the structures to drive the swallow and protect the trachea from food entering, it would become impossible to swallow anything, including saliva, without it entering your lungs, creating a very dangerous situation.
This is also, however, why a laryngectomee can no longer choke during meals.
This is very important to remember. A laryngectomee will not choke or strangle, even if it feels as if the food is “stuck” in the throat. Anxiety over a fear of choking may create more tension in the throat and make it even more difficult for the food material to pass.
Many patients and family members are often questioning how a laryngectomee can swallow once all the “parts” have been removed. Its important to understand that swallowing is very different following a laryngectomy, but it can also be very effective.
Practice and proper instruction can often speed the process of returning to a more normal diet and way of eating. Essentially, the oral phase will be unchanged in a standard laryngectomee patient. It is the pharyngeal phase of swallowing that is most disrupted, as well as the cricopharyngeal opening.
In the beginning of the pharyngeal phase in a laryngectomee, the tongue base serves to push the food downward toward the esophagus. Many reconstruction techniques may limit the tongue base movement to some degree. If the tongue base is not able to contact the posterior pharyngeal wall, the downward movement of the food material becomes less effective. In these cases, gravity will help quite a bit in getting the food to the base of the throat. For this reason, it is important that a laryngectomee eat and drink in an upright posture.
During the pharyngeal phase, the pharyngeal constrictors, squeeze from the top down in a purse string, wavelike manner. This serves as the driving force for how a laryngectomee moves food from the throat into the esophagus. BUT, there is no longer a pressurization of the swallow as the lungs are now open to the outside air or “atmospheric pressure.” The negative pressure that usually exists to help, like a vacuum, to pull air into the esophagus, is lost. This means the throat muscles must do the work of driving the food past the cricopharyngeus.
Radiation, as well as flap reconstruction, can both negatively impact the strength and effectiveness of the pharyngeal constriction. In many cases, therapy can help improve the overall strength and effectiveness of the swallow, although this will first need to be evaluated by the speech pathologist.
The cricopharyngeus is also impacted as a result of the laryngectomy surgery. The structures used to pull this muscle open, allowing food to pass into the esophagus, have been removed. Many times, a myotomy is performed during the laryngectomy surgery, which serves to relax the uppermost region of the esophagus, including the cricopharyngeus and thus, eases the passage of food through this region.
All of this contributes to why the trachea or “windpipe” is diverted, sewn to the neck, creating the stoma a laryngectomee breathes through. Without all the structures to drive the swallow and protect the trachea from food entering, it would become impossible to swallow anything, including saliva, without it entering your lungs, creating a very dangerous situation.
This is also, however, why a laryngectomee can no longer choke during meals.
This is very important to remember. A laryngectomee will not choke or strangle, even if it feels as if the food is “stuck” in the throat. Anxiety over a fear of choking may create more tension in the throat and make it even more difficult for the food material to pass.
Many patients and family members are often questioning how a laryngectomee can swallow once all the “parts” have been removed. Its important to understand that swallowing is very different following a laryngectomy, but it can also be very effective.
Practice and proper instruction can often speed the process of returning to a more normal diet and way of eating. Essentially, the oral phase will be unchanged in a standard laryngectomee patient. It is the pharyngeal phase of swallowing that is most disrupted, as well as the cricopharyngeal opening.
In the beginning of the pharyngeal phase in a laryngectomee, the tongue base serves to push the food downward toward the esophagus. Many reconstruction techniques may limit the tongue base movement to some degree. If the tongue base is not able to contact the posterior pharyngeal wall, the downward movement of the food material becomes less effective. In these cases, gravity will help quite a bit in getting the food to the base of the throat. For this reason, it is important that a laryngectomee eat and drink in an upright posture.
During the pharyngeal phase, the pharyngeal constrictors, squeeze from the top down in a purse string, wavelike manner. This serves as the driving force for how a laryngectomee moves food from the throat into the esophagus. BUT, there is no longer a pressurization of the swallow as the lungs are now open to the outside air or “atmospheric pressure.” The negative pressure that usually exists to help, like a vacuum, to pull air into the esophagus, is lost. This means the throat muscles must do the work of driving the food past the cricopharyngeus.
Radiation, as well as flap reconstruction, can both negatively impact the strength and effectiveness of the pharyngeal constriction. In many cases, therapy can help improve the overall strength and effectiveness of the swallow, although this will first need to be evaluated by the speech pathologist.
The cricopharyngeus is also impacted as a result of the laryngectomy surgery. The structures used to pull this muscle open, allowing food to pass into the esophagus, have been removed. Many times, a myotomy is performed during the laryngectomy surgery, which serves to relax the uppermost region of the esophagus, including the cricopharyngeus and thus, eases the passage of food through this region.
