CANCER OF THE LARYNX 185 SOCIAL AND PSYCHOLOGICAL EFFECTS OF LARYNGECTOMY If laryngectomy is advised there must be a very good reason for doing it. This means that the patient has to be told in some way that he has cancer. In this country the word 'cancer' is interpreted by the patient as a fatal disease that spreads all over the body and kills. Thus if the word 'cancer' is used it must be explained to the patient that it is unlikely to have spread anywhere else and that if local control can be obtained then the outlook is good. The distant metastasis rate is 2 per cent. This will mean that the larynx and possibly the neck glands must be removed. Most patients will be relieved when the diagnosis is discussed openly since the fear of the unknown is removed and if his doctor talks to him about it he is less apprehensive than if he feels that his doctor is avoiding the issue. During the discussion, however, the doctor must have an optimistic outlook. To lose the larynx and voice conjures various emotive words in the layman's mind such as 'dumb' and 'dummy'. If the loss of voice is compared to loss of sight or loss of hearing it may take on a different perspective. Learning to speak again after a laryngectomy depends upon the teaching skill of the speech therapist. In the best hands about 25 per cent of patients never learn to speak again, but in areas where there are no skilled speech therapists then about 60 per cent of patients will never learn to vocalize. The basis of the new voice is oesophageal speech. Air is swallowed, belched up again and the sound made is converted into language by the lips, tongue, teeth and palate. If the patient cannot learn oesophageal speech he will have to use an electronic larynx. These are vibrators that make a 'buzz' like an electric razor, they are placed under the chin and by mouthing the words the patient can convert the 'buzz' to intelligible speech. In recent years various operations have been designed to remake speaking tubes by joining the tracheal stump to the base of the tongue by means of skin flaps. These operations, however, have not realized the potential initially hoped for. A laryngectomee will have a permanent tracheostomy but will soon be able to do without a tube. He will be able to wear a collar and tie or cravat with no embarrassment to respiration. He will not, however, be able to swim and must take care while bathing or showering. Most laryngectomees can return to their work especially if they learn oesophageal speech. Since most of those who fail to learn oesophageal speech are over 60 years of age they may prefer to accept an early retirement in which they may enjoy reasonable health. To someone with a larynx the thought of losing it may represent an intolerable mutilation. The author has performed over 100 such procedures and only 1 patient has committed suicide and another 2 have suffered severe reactive depression in response to what they consider an unacceptable change.