Swallowing: Before and After Laryngectomy

by Katrina M. Jensen, Fort Worth, Texas, USA

Swallowing. How we swallow is certainly not something a person considers in everyday life. That is, of course, until it becomes a problem. Anyone who has ever experienced a swallowing problem, or dysphagia, understands how something that previously was an ability taken for granted, can evolve into an issue that all but consumes your thoughts, especially during meals.

In the field of dysphagia, those treating and managing the disorder are trained predominantly from the standpoint of avoiding aspiration. That is the typical goal in a dysphagic population, although that does not apply to the patient who has undergone a total laryngectomy.

Swallowing difficulties in laryngectomees, therefore, can often be overlooked. Since there is no risk of aspiration during the swallowing process, there is no primary concern by traditional standards.  Add to that, the significant anatomical alterations of a laryngectomized patient and traditional treatment methods and practices no longer apply. This can leave many patients feeling as if, like many other factors related to their laryngectomy, their swallowing difficulties will be simply another thing to adjust to.

To some extent, this is true. Swallowing is different following a laryngectomy. The anatomy is changed in such a way that the physical actions of how swallowing is accomplished is different. In essence, a laryngectomee swallow is different. It will certainly feel different to swallow and there is a period of adjustment and learning as a laryngectomee discovers how this “new” throat works. This inherently implies there will be a degree of adjustment. It is suggested that this initial period of adjustment or adaptation to a new and different way of swallowing, accounts for some of the highest incidences of dysphagia reported in the newly laryngectomized population [1]. But in some cases, there is more than just a period of adjustment involved and true swallowing problems can arise. If this does occur, it should be treated appropriately to optimize the patient’s ability to eat as normally as possible.

So if we know swallowing will be different following a laryngectomy, and some adjustment will be required, how can a person determine if they or a loved one has a true dysphagia?

This can often be a perplexing proposition for patients, families and clinicians alike. Understanding what is considered to be normal can help.

Understanding Swallowing in a Laryngectomee

The first consideration is to understand what is different, both anatomically and physiologically. Essentially, what’s different and how it works.

Many patients find it very interesting to understand that the larynx, besides being the organ for voicing, is also very important in swallowing. Removing the larynx, therefore, changes how swallowing happens.

First, we understand that during the normal swallow, the vocal cords close, just after the initiation of an exhalation, trapping the air in nearly full lungs and providing what’s known as “subglottic pressurization” to the swallow [2]. The physics of swallowing, therefore, are altered quite a bit as laryngectomees are no longer capable to maintaining intrathoracic pressure. This is what is happening during subglottic pressurization in a non-laryngectomized person. Before the laryngectomy, with every swallow, there was a typical degree of pressurization that assisted in driving the food through the pharynx and into the esophagus.[3,4]

Additionally, the larynx was also a very large part of what is referred to as the “hyolaryngeal complex.” During a normal swallow, this complex moves up and forward. In addition to assisting in moving the food material through the throat, this upward/forward movement also helps to pull open the upper esophageal sphincter [6] (also referred to as the “cricopharyngeus” or “cricopharyngeal sphincter.” This is the muscular “valve” at the top of the esophagus that typically remains closed, except when food material is passing through. How it opens is a complex function that is both neurologic as well as mechanical [6]. The mechanical component is accomplished in large part by the hyolaryngeal complex pulling it open as it moves upward and forward during the height of the swallow. Following a laryngectomy, this is no longer the case, as the hyolaryngeal complex no longer exists as it did prior to surgery. The mechanical component of the cricopharyngeal sphincter opening, therefor, is lost.

Understanding how the larynx functions during a swallow can make it easier to understand why a laryngectomee may experience some difficulty swallowing, but there are additional changes that also come into play. Following the removal of the larynx, the throat, or “pharynx,” requires reconstruction that also changes how it will work during the swallow. We know that as a result of this reconstruction, the forces within the pharynx are changed drastically [1].  In many cases, the position of the tongue base may also change as this helps to close the anterior, or front portion of the throat. [7]. The main muscles within the throat, the pharyngeal constrictors, are pulled together in a cylindrical manner [7,8].

Following these changes, the dimensions, the actual size and volume of the throat are very different from before the laryngectomy surgery. Depending on the extent of the laryngectomy surgery, the length of the pharynx as well as the diameter are changed.