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Surgeries to Aid Breathing and Eating

Some head and neck cancer patients will need surgical procedures to help them with breathing and swallowing. If a tumor compromises your ability to breathe or eat, or if your cancer removal surgery or recovery causes you to have temporary or permanent difficulties, you may need a feeding tube or a tracheotomy.

Feeding tubes

A feeding tube is a tube that enters your stomach to deliver nutrition, replacing the function of your mouth. The decision to insert a feeding tube should not be taken lightly. It is important for you to know that in many cases a feeding tube is only temporary. Once you are through with treatment and you begin eating enough by mouth, the tube can be easily removed in the office without any surgery.

The following are specific situations in which a feeding tube might be recommended:

  • Tumor blocking swallowing: If you have a tumor in your throat or esophagus preventing you from getting enough nutrition by mouth, your doctors might recommend a feeding tube as the diagnostic work-up is completed and treatment is planned. You need to be as healthy as possible to withstand treatment, and getting enough nutrition is important.
  • Side effects of treatment: Some side effects of chemotherapy and radiation that might lead you to have a feeding tube placed include strictures as well as mucositis and resultant pain with swallowing.
  • Aspiration: If, when you eat by mouth, some of the food and/or liquids make you cough or if it enters your lungs, you are at risk of developing aspiration pneumonia—infection in your lungs. If the problem remains after sufficient swallow therapy and adjustment of what you eat, your doctors might recommend you refrain from eating by mouth. In this case, a feeding tube will be required.
  • Salivary leak: A complication of surgery, especially after being treated with chemotherapy and radiation, is a leak of saliva from your mouth or throat into your neck. This can lead to infection in the neck as well as a host of other problems. If this occurs, it is important to take nothing to eat or drink by mouth until the leak is healed up.
  • After surgery: After a surgery in the mouth and/or throat, your surgeon will want you to maintain nothing by mouth until everything heals. There is a risk of saliva and liquids leaking out into the neck and causing an infection after surgery, and eating by mouth increases that risk. To get nutrition as the wounds heal, you will most likely have a feeding tube placed.

There are a number of different types of feeding tubes:

    • Nasogastric feeding tube (NG tube):
      This is a long, thin tube placed through one of your nostrils, into your throat and esophagus and passed down into your stomach. This type of tube is typically used immediately after surgery when a feeding tube might be required for only one or two weeks until your surgeon clears you for taking food and liquids by mouth. It can stay in longer, but it is a little uncomfortable and cannot be hidden like a gastric feeding tube.

NG_tube

An NG tube is placed either while you are asleep during the initial surgery or in some cases while you are awake after the surgery. If done while you are awake, it is a little uncomfortable going in, but it only takes a few minutes. It is helpful if you swallow as it goes down your throat to get it into the esophagus and then the stomach. The position is best confirmed with an X-ray or by listening to the stomach with a stethoscope while injecting air into the tube.

    • Gastric feeding tube (G-tube):
      This type of tube is placed directly through the abdominal wall into your stomach. It is typically used if you will require a feeding tube for more than two or three weeks. In some cases, your doctor might have you eat a little by mouth but use the gastric tube for additional nutritional intake. A few days after the initial placement, it is not particularly uncomfortable and can be hidden underneath your clothes.

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A G-tube can be placed in a number of ways.

 

Endoscopic G-tube

 

 

Radiologic G-tube

 

Open surgical G-tube

An endoscopically placed feeding tube is called a Percutaneous Endoscopic Gastrostomy (PEG).A PEG is placed by a surgeon or gastroenterologist and requires sedation or general anesthesia.This is considered to avoid an open surgical procedure. It should not be used if passing a camera through your mouth, down your throat and into your stomach is unsafe or impossible. A radiologically inserted G-tube is placed by an interventional radiologist with you sedated and numbing medicine on the skin of the abdominal wall.This is an alternative to a PEG and can be used in the same situations. It will be considered over a PEG if you already have a feeding tube in place and it is not safe or feasible to pass a camera through your mouth, down your throat and into your stomach. An open G-tube is done by a surgeon in the operating room with you completely asleep with general anesthesia.This will be considered if you don’t already have a nasogastric tube in place and one cannot safely be placed, or if passing a camera from your mouth, down into your throat and into the stomach cannot safely be done.The healing time and post-procedure discomfort increases with this procedure and requires general anesthesia. Therefore, this method is not preferred but is sometimes necessary.
How it’s done: In this method of G-tube insertion, a camera is placed through your mouth, down your throat, into your esophagus and down into your stomach. Gas is injected into your stomach to bring it closer to the abdominal wall. The light of the endoscope (camera) is seen shining from the stomach through to the skin of the abdominal wall. This light is the guide to place a needle through the skin of the abdomen and into the stomach.Once the needle is placed and seen inside the stomach using the endoscope, part of the feeding tube is passed into the stomach. A wire on the end of the feeding tube is grasped and pulled out from your mouth. Finally, the tube is passed through the wire and brought down the esophagus and out through the abdominal wall skin. How it’s done:In this method of G-tube insertion, contrast is injected through a previously placed nasogastric tube. The contrast lights up on a continuous X-ray known as fluoroscopy that is performed during the procedure to identify the location of the stomach. A gas is injected to inflate the stomach to bring it closer to the abdominal wall.Once the stomach is localized, a needle is placed through your skin, and the position inside the stomach is confirmed with a continuous X-ray (fluoroscopy). The opening on the abdominal wall on the skin is dilated, and the feeding tube is passed directly into the stomach. The position is confirmed using contrast with X-ray. The G-tube is then secured to the skin. How it’s done: In this procedure, a surgeon will make an incision through the abdominal wall and through the stomach.A laparoscopically inserted G-tube is a variation of the open G-tube. It is another surgical procedure to place the tube. In this method, a few small incisions are made in the abdominal wall to place a camera, gas and instruments. The stomach wall is identified with the camera, and an incision is made in the stomach. A feeding tube is placed directly into the stomach, just as in an open G-tube. 
  • A jejunal feeding tube (J-tube) is basically the same as a G-tube, but instead of a hole placed in the wall of the stomach, the opening is made in the second part of the small bowel called the jejunum. The J-tube can be placed using an endoscope just like a PEG, but when the tube goes into the jejunum it is called a PEJ. The procedure can be done with radiographic guidance or via surgery as an open J-tube or laparoscopically based J-tube.

J-tube

With a J-tube, you cannot give a large amount of tube feeds at once (bolus tube feeds). This means you will be connected to a pump providing you tube feeds over an extended period of time rather than just loading up four times a day.

A J-tube will be considered in the following circumstances:

    • Difficulty emptying the stomach (gastroparesis): Stomach remains full when feeds are placed.
    • Reflux of feeds from the stomach upwards: Placing feeds directly into the stomach results in reflux up the esophagus and into the throat.
    • Plans for a gastric pull-up: You require a stomach surgery, including something known as a gastric pull up, which can be used for esophageal or hypopharynx cancers.
    • Have disease of the pancreas: By bypassing the stomach and duodenum (first part of the small intestines), you are bypassing the need for the pancreas to aid in digestion.
    • Possibly improve feeding tolerance: You can’t tolerate feeds into your stomach; therefore your nutrition will go directly into the jejunum rather than the stomach.
  • Gastric and jejunal feeding tube (Moss tube, G-tube or J-tube): A variation of a J-tube is a tube that has one feeding tube in the jejunum for you to receive nutritional feeds and one tube in the stomach to remove stomach contents that might be refluxing upwards.

Risks of a feeding tube

With any procedure, there are risks to placing a feeding tube. Risks associated with nasogastric tubes are low; however, be mindful of the following:

  • If you have ever had a skull base surgery performed either endoscopically through the nose or as an open procedure, you should inform your doctors before having a nasal tube passed down into your stomach.
  • An NG tube should not be placed immediately after throat surgery for fear of breaking through one of the suture lines and causing a leak. There is a small risk of perforating the throat or esophagus as it is passed, which would result in an infection. It might take a few attempts to get the tube into the right area, which can be uncomfortable for you. You can help by swallowing the tube.
  • For a G-tube and J-tube, the risks of bleeding and infection are present as in any procedure in which the skin is cut. Placing it into a false passage can result in an infection of the belly. More so with an open procedure, you will probably be constipated for a while, and it is important you are placed on stool softeners.

Using your feeding tube

Once the position is confirmed and the insertion site has had sufficient time to heal from a few hours to an entire day, your feeding tube is ready for use.

Tube feeds and/or water will be placed into the tube at a very slow rate. This will be ramped up slowly throughout the next day to avoid any nausea and to monitor your reaction to the feeds. The rate is increased toward a goal that is based upon the amount of calories and water you need for your body weight. A nutritionist can sometimes help make sure you are getting enough nutrition. You will receive water through the feeding tube. Medications can also go through the tube. Typically, liquid medications are used. If tablets are required, it is extremely important that they are crushed very well and the tube is flushed with a lot of water afterward to prevent it from getting clogged. Delayed or extended release tablets cannot be crushed and given through the feeding tube. Your doctors will need to convert the dosage and frequency to an immediate release form of your medication.

Tube feeds can go in as a continuous infusion (a feeding pump continuously providing tube feeds through the tube) or as a bolus (putting in a larger amount all at once, a few times per day at regular meal times). The advantage of a continuous infusion is that a little goes in at a time so you don’t feel full. However, a bolus is great because you only need to be hooked up a few times a day and are free from tubes and wires the rest of the day. Feeds cannot be given through a J-tube as a bolus because there is no reservoir for the tube feeds to sit in as your body digests the feeds. This is in contrast to a G-tube, in which a large bolus of feeds can sit in the stomach and slowly make its way through the GI tract just as a regular meal.

Caring for a feeding tube

When you go home with a feeding tube, you should check the skin around the tube for redness spreading from the tube or increased pain around the tube or in the abdomen. Fevers or chills associated with these problems should be discussed with your doctor.

Sometimes redness and irritation of the skin around the G-tube can be from acid irritation, small leaks or the tube rubbing against the skin. You should keep the skin area clean, and many people like to keep a little dressing around the tube to keep the skin clean.

If the tube falls out, you should call your doctor. You will probably need to have it reinserted or replaced quickly and then undergo a quick X-ray-type study to confirm it is placed correctly. The hole closes up after a few hours, so it is important to act quickly.

If the tube gets clogged up, try to flush it with water by pushing the water in and pulling the water out. Keep doing this back and fourth for about one hour. If it still doesn’t work, call your doctor to have it evaluated. This is not an emergency, but you should have it checked out soon. The best thing to do is to avoid it getting clogged by making sure you crush any medications really well and flush the tube regularly with water after using it for any purpose and on a regular basis if you are not using the tube very frequently.

Tracheotomy

A tracheotomy is a procedure in which a tube is placed directly into the windpipe, or trachea, through the neck to help with breathing as well as suctioning and cleaning the lungs.

In head and neck cancers, a tracheotomy might be considered in the following situations:

  • Upper airway obstruction: If breathing is blocked because of a large tumor or swelling in the mouth and/or throat, you might require an urgent tracheotomy so air can bypass that tumor by going directly into your lungs through the opening in the neck. In some cases you might even receive a tracheotomy during surgery in anticipation of significant swelling that might obstruct your breathing. These are reversible, and can easily be removed once the obstruction is treated. Prophylactic placement of a tracheostomy during surgery or prior to starting radiation can be a very important life-saving measure. It is always preferable to be cautious rather than to react after airway obstruction develops.
  • Cleaning the lungs: Some people have a lot of secretions in their lungs, possibly from chronic aspiration, or are too weak to effectively cough and clear their lungs of mucous and infection. If this is the case for you, you might require a tracheotomy for pulmonary toilet—suctioning and keeping the lungs clean.
  • Prolonged oral intubation: If you require a breathing tube for a prolonged period (more than a week), your doctors might recommend changing from a breathing tube placed through your mouth and into your trachea to a tracheotomy tube. A tracheotomy tube is more comfortable, so you don’t have to be sedated, and it avoids complications of a tube sitting in your voice box for a prolonged period.

There is a subtle difference between a tracheotomy and a tracheostomy. Whereas a tracheotomy is a hole through the skin and into the trachea through which a tube is passed, in a tracheostomy, the tracheal wall is sewn directly to skin to create a more permanent opening. The tracheotomy is completely and easily reversible. The tracheostomy is reversible, depending on the reason for the procedure. Following removal of the larynx, the top-most end of trachea (windpipe) is permanently sewn to the neck skin. There is no connection between the mouth and the lungs. Breathing is done completely through the tracheostomy via the neck, and this is not reversible.

How a tracheotomy is performed

A tracheotomy can be done in one of two ways: percutaneously or open.

  • Percutaneous tracheotomy: A percutaneous tracheotomy is done in someone who is already intubated orally and sedated. It is not performed in individuals with a large neck, bleeding disorders or other obstacles that might increase the risk of this procedure. A small flexible camera is passed through the endotracheal tube via the mouth. A needle is then placed in the neck and through the trachea and seen via the camera to be in the right place. The needle hole is then dilated (made bigger) until it is large enough to pass the tracheotomy tube through it. All the while, everything is visualized by the camera to make sure it goes in the right place. This is a quick procedure and can be performed in an intensive care unit.
  • Open tracheotomy: An open tracheotomy is the standard method used in patients with head and neck cancer. If required, it is often part of the surgical resection of the cancer. An open tracheotomy can be performed as an “awake tracheotomy” in which local anesthesia is injected to numb the neck area, and the tracheotomy is performed while you are awake, or it can be performed with you completely asleep after an endotracheal tube is passed from your mouth or nose into your trachea. Your surgeon and anesthesiologist will decide what is safest for you, depending on a number of factors. In an open tracheotomy, an incision is made through the skin of the neck, and layer-by-layer tissue is moved to the side until the trachea is in view. A small incision is made in the tracheal wall, and the incision is dilated open. At this point, if you were intubated prior to the tracheotomy procedure, the endotracheal tube is withdrawn by the anesthesiologist, and then the tracheotomy tube is placed directly into the trachea. If this procedure is done as an awake tracheotomy, once the tube is in place, you are quickly sedated with medication and you typically forget the final moments of the procedure anyway.

When a tracheotomy tube is first inserted, there will be some irritation, constant coughing and secretions. Also, with a large tube or cuffed tube, you won’t be able to speak initially. After a few days, patients are often changed to smaller tubes with or without fenestrations and, with a cap or a special valve, will be able to speak even with the tube in place. The secretions and coughing settle down as your windpipe gets used to the tracheotomy tube.

Is the tracheotomy tube removable?

Yes. A tracheotomy is a temporary measure and can be removed when the time is right. A tracheostomy following a total laryngectomy cannot be reversed. When you are ready to have your tracheotomy tube removed—a fairly quick process—the hole in the neck is covered and should close within days. Remember to keep your finger over the hole anytime you speak or cough to help the hole mend more quickly. If the hole does not heal within days, you might need a minor procedure in the operating room to seal the opening.

To test if you are ready to have your tracheotomy tube removed, you will undergo a capping trial. A cap is placed over the tracheotomy tube, and you are required to breathe completely through your nose and mouth. This is a test to see if you are ready to have the tube removed. If you have to remove the cap for any reason, such as breathing difficulty or a need to suction, the tracheotomy tube is likely not ready to be removed. Once the cap is on for 24 to 48 hours continuously, you are ready to have the tube removed.

Can I speak with a tracheotomy tube in place?

People often ask if they can speak with a tracheotomy tube. The answer is yes. Your doctors will place an appropriate-size tube into your airway small enough for air to get around the edges, up through the vocal cords and out your mouth for you to speak with a tracheotomy tube in place. Alternatively, a fenestrated tracheotomy tube can be placed that allows air to pass up through the larynx and out the mouth, thereby giving you speech. In order to speak, the opening on the tracheotomy tube must be closed off when you breathe to speak. This can be accomplished with:

  • A cap placed over the end of the tube that blocks both breathing in and out from the tracheotomy tube, or
  • A one-way valve (Passy-Muir valve) that allows air to come in through the tracheotomy tube; but when you breathe out, all of the air moves up, past your vocal cords and out your mouth, thereby allowing you to speak.

Caring for a tracheotomy tube

You should keep your tracheotomy tube clean to prevent it from getting blocked and prevent infections. Almost all tracheotomy tubes have an inner cannula, which is a tube inside the main tracheotomy tube. If the inside tube gets blocked or dirty, it can simply be removed and cleaned. The inner cannula can be replaced.
If you have a tracheotomy, you and your caregivers should learn to suction the tube. In most cases, you will go home with a suction machine.

Humidified air is important when breathing through a tracheotomy tube. Humidification normally happens as air passes through your nose and throat on its way down to the trachea and lungs. Because a tracheotomy tube bypasses those humidification structures, you should have a humidifier in your house.

Call your doctor for any signs of infection including a lot of pain and redness around the tube site. Call if you have any bleeding from the tube. If the tube comes out and cannot be replaced, it is necessary to go to the emergency room.

Risks of a tracheotomy

In any procedure, there are risks. Risks of bleeding and infection are always present. Bleeding can be caused by many factors, from a little irritation along the wall of the trachea to a hole in a major blood vessel that runs just in front of the trachea. The risk of the tube getting clogged can be devastating if you require the tube to breathe because of an upper obstruction.