Laryngectomy Rehabilitation Guide — Voice, Stoma & Smell | HN Oncology

Specialist Rehabilitation Module

Laryngectomy Rehabilitation Guide

Voice restoration, stoma care, smell retraining and daily rehabilitation schedules — designed specifically for patients who have had a total laryngectomy.

Important: Total laryngectomy changes breathing, voice, and smell permanently. This guide supports your rehabilitation — but all voice restoration techniques must be started under the supervision of a specialist speech and language therapist (SLT). Do not attempt TE voice or oesophageal voice exercises without SLT guidance.

Select your recovery phase

🗣️

Voice Restoration Options

Three methods — select the one relevant to you

TE voice via a tracheoesophageal prosthesis (TEP) gives the most natural voice after laryngectomy — most patients can achieve functional speech within 2–4 weeks of prosthesis fitting.

How TE Voice Works

A small one-way valve (voice prosthesis) sits in a puncture between the trachea and oesophagus. Covering the stoma and exhaling redirects air through the prosthesis into the oesophagus — vibrating the pharyngo-oesophageal (PE) segment to produce voice. You then articulate with lips, tongue and palate to form words.

Stoma occlusion: Place the pad of your thumb or index finger firmly and completely over the stoma. The seal must be airtight — any air escaping around the finger reduces voice. Some patients use a Provox HME with a speaking valve for hands-free speaking.

Exhale with moderate effort: Breathe out steadily through the prosthesis — moderate, even pressure. Do not exhale too forcefully (voice becomes strained) or too gently (no voice produced). Find the "sweet spot" — your SLT will help you identify it.

Articulate normally: While exhaling with the stoma covered, move your lips, tongue and jaw as if speaking normally. The TE voice replaces the larynx — your articulation determines the words.

Phrase length: Begin with single vowels ("ah", "ee", "oo"), then single syllables ("pa", "ba", "ma"), then short words (2–3 syllables), then short phrases on one breath.

Prosthesis care: Flush the prosthesis daily with water using the cleaning brush provided. Check for leakage (liquid from trachea into oesophagus, or liquid through the prosthesis) — this indicates the prosthesis needs replacement. Most prostheses last 3–6 months.

TE Voice Practice Exercises

Oesophageal voice (OV) requires no device — air is injected into the oesophagus and expelled to vibrate the PE segment. It takes months to develop and requires intensive SLT support. Fewer patients achieve OV compared to TE voice, but it is a fully independent technique with no device maintenance.

Air injection — consonant press method: Form a voiceless plosive consonant (p, t, k) and as you release it, simultaneously press a small amount of air from the mouth into the oesophagus. The air is trapped above the upper oesophageal sphincter (UOS).

Immediate release: Immediately after injection, relax the UOS to allow air to escape upward — producing a short oesophageal tone. The sequence is: press → trap → release → tone. Aim for a clear, controlled single tone.

Air swallow method: Swallow a small amount of air (not a gulp). Immediately open the throat and allow the air to return upward — producing a sustained tone. This method produces longer phonation than injection.

Syllable practice: Once consistent tones are achieved, attach consonants: "pa", "ta", "ka", "da", "ba", "ma". Aim for 1 syllable per air charge initially, then 2–3 syllables as control improves.

Words and phrases: Build from single words to short phrases. Maximum phonation time on oesophageal voice rarely exceeds 2–3 seconds — phrase length is dictated by your injection frequency and efficiency.

Realistic expectations: Functional oesophageal voice for daily communication typically takes 6–12 months of intensive daily practice. Not all patients achieve it — anatomy and surgical technique affect the PE segment's ability to vibrate. Your SLT will assess your PE segment vibratory potential early in training.

The electrolarynx (EL) provides immediate communication from day one after surgery — before any TE or oesophageal voice is possible. The voice is electronic and robotic in quality, but fully functional for communication.

Device placement: Hold the EL firmly against the soft tissue of the neck or cheek (not over bony or hard areas). Experiment with position — the area that transmits best varies by anatomy. A 45° angle against the neck usually works well. The device must make firm contact with the skin.

Activate before speaking: Press the button and hold it pressed throughout the phrase. Begin articulating immediately as you press — there is no need to wait after activation.

Articulation is critical: The EL provides the voicing — you provide 100% of the speech intelligibility through clear lip, tongue and jaw movements. Exaggerate articulation compared to normal speech. Over-articulate until clear speech is habitual.

Pause between phrases: Release the button between phrases and take a breath. Running the device continuously when not speaking tires listeners and produces noise between words.

Intraoral adaptor: If neck placement is difficult (e.g. due to radiation fibrosis), an intraoral adaptor (a flexible tube that channels EL sound into the mouth) is an effective alternative — discuss with your SLT.

Settings: Most electrolarynx devices have pitch and volume controls. Start with mid pitch. Volume should be similar to normal conversational voice — louder is not clearer. Adjust to the environment (louder in noisy settings).

Electrolarynx Practice Drills

🫁

Stoma Care

Daily management of your permanent breathing stoma

Emergency: If your stoma becomes blocked and you cannot breathe — call emergency services immediately. Inform them you breathe through your neck. Standard mouth-to-mouth resuscitation does NOT apply to laryngectomees.

Morning cleaning (twice daily): Wash your hands. Using saline or prescribed solution on gauze, gently clean around the stoma in circular motions — outward from centre. Remove any dried secretions or crusting. Never use cotton wool (fibres enter the airway).

Inspect the stoma: Look for redness, swelling, discharge, or granulation tissue. A small amount of clear mucus is normal. Yellow/green or foul-smelling discharge, bleeding, or narrowing of the stoma requires medical review.

Suction if needed: If secretions are thick or excessive, use a suction catheter as instructed by your nurse. Insert no more than 5cm — suction only on withdrawal. Limit suction to 5–10 seconds per pass.

Humidification is essential: The nose and throat no longer humidify inhaled air — all humidification now occurs through the stoma. Always wear an HME (Heat and Moisture Exchanger) over the stoma — even at home. This prevents crusting, reduces infections, and improves lung function.

Skin care: Keep the skin around the stoma clean and dry. Apply barrier cream if instructed. Stoma button/housing adhesive should be changed as directed — skin breakdown under adhesive is common and must be addressed promptly.

Signs requiring urgent review: Stoma narrowing, bleeding, inability to insert the tracheal tube, shortness of breath, fever, or foul-smelling discharge — contact your clinical team same day.

The HME (Heat and Moisture Exchanger) is a small foam filter worn over the stoma. It is the most important device a laryngectomee uses — it replaces the humidifying function of the nose and throat.

Wear 24 hours a day: The HME should be worn at all times — sleeping, eating, outdoors, indoors. Remove only for cleaning and replacement. Going without an HME for more than a few hours causes significant mucus crusting and increased infection risk.

Change daily: Replace the HME foam insert daily (or as directed by your SLT). The housing/cassette is changed according to manufacturer instructions. Do not wash and reuse — this damages the hygroscopic filter.

Speaking valve HME: An HME with an integrated speaking valve (e.g. Provox Vega with FreeHands) allows hands-free TE voice. The valve opens to allow inhalation and closes during exhalation, directing air through the TE prosthesis.

Night use: During sleep, wear a baseplate without a speaking valve — the speaking valve should not be worn overnight as it can occlude during sleep. Use a simple breathing filter for night-time.

Adhesive baseplates: The HME housing attaches to the skin around the stoma using an adhesive baseplate. Change every 1–3 days or when edges lift. Proper adhesion is critical — a loose baseplate allows unfiltered air into the trachea.

⚠️ Emergency Information for Laryngectomees

You breathe through your neck — not your mouth or nose. In any medical emergency, inform rescuers immediately.

Mouth-to-mouth resuscitation will NOT work. Rescue breathing must be applied to the stoma — not the mouth.

Always carry a Laryngectomee Emergency Card — available from your SLT. Keep one in your wallet, one at home, one in your car.

Wear a MedicAlert bracelet stating "Neck Breather — Laryngectomee". This is critical if you are unconscious.

Stoma occlusion emergency: If the stoma becomes blocked — remove the HME and any tracheal tube immediately. Attempt to clear visible mucus plugs with a suction catheter or by coughing. If breathing does not improve — call emergency services.

Swimming and bathing: Never swim without a stoma cover. Shower using a stoma shower guard or handheld shower directed below neck level. Never submerge the neck in water.

Emergency card wording: "I am a laryngectomee. I breathe ONLY through a hole in my neck (stoma). DO NOT put anything over my mouth or nose to help me breathe. Artificial ventilation must be applied to the neck stoma." — Show this to any first responder.

Some patients wear a tracheal tube (laryngectomy tube) inside the stoma — particularly in the early post-operative period when the stoma may be prone to narrowing.

Inner tube cleaning: Remove the inner tube (cannula) every 4–6 hours or more if secretions are heavy. Clean with a dedicated tracheal tube brush under running water. Rinse thoroughly before reinserting.

Outer tube change: The outer tube is changed weekly or as directed by your nurse. This requires practice — your nurse will demonstrate the first several changes. Keep a spare outer tube of the same size at home at all times.

Weaning: Many patients are gradually weaned off the tube as the stoma stabilises and matures — typically over weeks to months. Discuss the weaning plan with your clinical team.

Cuff-free tubes: Most laryngectomy tubes are cuffless (unlike standard tracheostomy tubes). Do not inflate a cuff unless specifically instructed — it can occlude the trachea.

👃

Smell Retraining

Recovering the sense of smell with NAIM technique and olfactory training

Why laryngectomees lose smell: The sense of smell depends on airflow through the nose. After laryngectomy, air travels directly into the trachea through the stoma — bypassing the nose entirely. This means no air reaches the olfactory receptors, and smell is lost. Taste is also affected, as much of what we "taste" is actually retronasal olfaction (smell from the back of the mouth).

🧠 The NAIM Technique — Nasal Airflow Inducing Manoeuvre (Polite Yawn)

NAIM is the key technique that allows laryngectomees to redirect air through the nose and mouth — enabling smell and improving taste. It is sometimes called the "polite yawn" because the jaw movement resembles a suppressed yawn.

Close your lips and teeth lightly. Your mouth should appear closed from the outside.

Lower your jaw and floor of your mouth slowly — as if beginning a yawn — while keeping your lips closed. This creates a small negative pressure in the oral and nasal cavities.

Air is drawn in through the nose (and around the lips) into the mouth by this negative pressure. You should feel a cool airflow in the nostrils and back of the nose.

Hold the jaw lowered position for 2–3 seconds. During this time, any scent molecules in the air will reach the olfactory receptors in the upper nasal passages.

Return jaw to normal position. Repeat 5–10 times when you want to smell something. Practice the movement daily — it becomes easier and more effective with consistent use.

Hold duration

jaw lowered

Reps today

0/10

target 10

✓ 10 NAIM reps complete — excellent work!

4-Scent Olfactory Training Programme

Olfactory training involves smelling 4 specific scents twice daily using NAIM — the repeated stimulation encourages neuroplastic recovery of the olfactory system. This same approach has been used in COVID-related anosmia with significant success. Consistent practice for 3–6 months is required.

What you need: 4 small jars or cotton pads with: rose essential oil, eucalyptus essential oil, lemon essential oil or fresh lemon peel, and clove essential oil. Keep them labelled and replace monthly as scent fades.

How to do olfactory training with NAIM: Hold the scent jar 2–3cm below your nose. Perform the NAIM manoeuvre (lower jaw, draw air through nose). While air flows through the nose, concentrate on the scent. Hold 3 seconds. Rest 10 seconds. Repeat 3 times per scent. Record whether you detected anything — even faint awareness counts as progress.

Training progress tracker — 16 weeks

0 / 16 weeks complete

Tap to mark a week as complete. Full 16-week programme recommended minimum.

Most patients notice first improvement between weeks 6–10. Some see improvement beyond 6 months — continue as long as you are making progress.

👅

Taste Recovery

Linked to olfaction — what to expect

Up to 80% of what we experience as "taste" is actually retronasal olfaction — smell from the back of the mouth. After laryngectomy, this pathway is disrupted, making food taste bland. NAIM practice gradually restores retronasal airflow and with it, some taste recovery.

Practise NAIM while eating: Between mouthfuls, perform the NAIM manoeuvre — this draws flavour molecules retronasally, enhancing taste perception of the food you have just swallowed.

Strong-flavoured foods: Begin taste training with pungent, clearly-flavoured foods — strong spices, citrus, mint, fresh herbs. These give more olfactory stimulation for the recovering system to respond to.

Focus on basic tastes: The basic tastes (sweet, salty, sour, bitter, umami) are perceived by the tongue and are usually preserved after laryngectomy — it is complex flavour that is lost without smell. This means food remains palatable even with anosmia.

Be patient: Taste and smell recovery after laryngectomy is slower than post-COVID anosmia recovery. Improvement over 12–18 months of consistent NAIM practice is realistic for most patients.

Water safety: You breathe through your neck — water entering the stoma is a medical emergency. Never swim without a purpose-designed laryngectomy swim collar. Always use a shower guard or direct the shower below neck level. Never submerge your head or neck.

Daily Rehabilitation Schedule

Specialist Support

Laryngectomy rehabilitation is a long-term process. Our team provides ongoing SLT assessment, voice prosthesis fitting and management, stoma care reviews, and smell retraining guidance throughout your recovery journey.

WhatsApp +91 9150000542