Long-term results of the Blom-Singer speech rehabilitation procedure

Stricture associated with primary tracheoesophageal puncture after pharyngolaryngectomy and free jejunal interposition

BACKGROUND

Free jejunal interposition has been one of the standard reconstructive options for patients undergoing total laryngopharyngoesophagectomy. Tracheoesophageal puncture (TEP) done primarily is a well-accepted means of voice restoration. The rapid recovery of swallowing and communication in patients who have advanced cancer of the upper aerodigestive tract is a valid goal. The objective of this study was to evaluate the functionality and complications of primary TEP in patients with a free jejunal interposition graft.

METHODS

Twenty-four consecutive patients who had free jejunal interposition were studied. Thirteen of these patients had a primary TEP. Stricture was assessed through barium swallow, laryngoscopy, and CT scan.

RESULTS

A statistically significant greater number of patients had stricture develop after primary TEP (p < .0325). All these patients had stricture develop at the distal anastomosis. These patients also tended to have a poorer quality of diet. Moreover, speech with a TEP prosthesis in patients with a free jejunal interposition was less intelligible and functional than speech with a TEP prosthesis after simple laryngectomy.

CONCLUSIONS

This article recognizes an increased incidence of stricture formation after primary TEP as compared with non-TEP in patients undergoing pharyngolaryngectomy with free jejunal interposition. The morbidity and possible etiology of this complication are discussed. This clinical data have been translated into a change in clinical practice.

Organ preservation with radiotherapy for T1-T2 carcinoma of the pyriform sinus

PURPOSE

To report long-term results using radiotherapy with or without a planned neck dissection for T1-T2 carcinoma of the pyriform sinus.

METHODS

An analysis of 101 patients treated at the University of Florida with RT with or without a planned neck dissection for organ preservation.

RESULTS

The 5-year local control rates after RT were 90% for T1 cancers and 80% for T2 lesions. The only parameter that significantly influenced local control in univariate analyses was apex involvement for T1 tumors. Multivariate analysis revealed no parameter that significantly affected local control. Cause-specific survival rates at 5 years were as follows: stage I-II, 96%; stage III, 62%; stage IVA, 49%; and stage IVB, 33%. The absolute survival rates were as follows: stage I, 57%; stage II, 61%; stage III, 41%; stage IVA, 29%; and stage IVB, 25%. Moderate to severe long-term complications developed in 12% of patients.

CONCLUSIONS

RT alone or combined with a planned neck dissection resulted in local control with larynx preservation in a high proportion of patients. The chance of cure is comparable to that observed after conservation surgery, and the risk of major complications is lower. The addition of adjuvant chemotherapy is unlikely to improve the probability of organ preservation, but might improve locoregional control for patients with advanced nodal disease.

Radiotherapy alone or combined with neck dissection for T1-T2 carcinoma of the pyriform sinus: an alternative to conservation surgery

PURPOSE

We present our experience with irradiation alone or combined with neck dissection for AJCC T1-T2 pyriform sinus carcinoma and compare our results to those obtained with conservation surgery.

METHODS AND MATERIALS

Seventy-three patients were treated between 1964 and 1990. All patients had a minimum of 2 years of follow-up; no patient was lost to follow-up.

RESULTS

The 5-year rates of local control and ultimate local control were, for Stage T1 (17 patients), 88% and 94%; and for Stage T2 (56 patients), 79% and 91%. Patients with T2 lesions had a significantly higher rate of local control after twice-daily, compared with once-daily, irradiation (p = .04). However, a multivariate analysis of various parameters revealed that none of the variables tested significantly influenced this end point: vocal cord mobility (p = .15), once- vs. twice-daily fractionation (p = .33), T1 vs. T2 (p = .32), apex invasion (p = .58), and pretreatment CT scan (p = .67). Local control with laryngeal voice preservation was obtained in 88% of patients with T1 cancers and 80% of those with T2 cancers. Ultimate control above the clavicles at 5 years according to AJCC stage was as follows: I and II, 100%; III, 78%; IVA, 75%; and IVB, 60%. The probability of cause-specific survival at 5 years was as follows: I and II, 100%; III, 83%; and IVA and IVB, 51%. Overall, nine patients (12%) developed severe complications, one of which was fatal.

CONCLUSION

Compared with available data from series using conservation surgery, radiotherapy alone or followed by neck dissection results in similar rates of local control and survival with a significantly lower risk of fatal complications.

Prosthetic voice restoration with the tracheostomal valve: a clinical experience

INTRODUCTION

Tracheoesophageal puncture (TEP) and use of a voice prosthesis is not a panacea for all laryngectomies. This report presents results of longitudinal treatment of 24 patients with secondary TEP followed longitudinally for 10 years in a private practice setting. Unique to this report is a focus on the use of the entire voice restoration system including both the voice prosthesis and the automatic tracheostomal valve.

METHODS

All patients referred for secondary TEP between 1982 and 1992 are included. Voice quality and the longevity of vocal restoration were ascertained. Clinical problems and their solutions are reported.

RESULTS

Immediate vocal restitution was achieved in 19 of 24 patients. Voicing was produced in two more patients within a few weeks. Four patients were not available for long-term follow-up because of death due to recurrent disease. Overall, 60% of patients were rated excellent and 5% rated fair in communication over a long-term period. Thirty-five percent were rated failure.

DISCUSSION

TEP and the use of the voice restoration system enabled both hands to be free during speaking and is achieved by many laryngectomies. Patient evaluation, training, and follow-up with team problem-solving may increase success rates using this approach.

Depression following laryngectomy. A pilot study

When a group of 10 patients who had received surgery for carcinoma of the larynx were compared with 10 control patients who had received radiotherapy for carcinoma of the larynx, four of the former but none of the latter were found to be suffering from depression, a statistically significant difference. Depression was associated with poor communication skills and geographical isolation. Psychiatric intervention is recommended for patients undergoing mutilating forms of surgery.

Communication status following laryngectomy: the Iowa experience 1984-1987

Data regarding treatment and outcome for a consecutive series of 73 total laryngectomy patients were collected from clinical records with a follow-up period of 30 to 78 months postoperatively. Notable findings were that 27% were women; 75% reported hoarseness or a voice change as an early symptom; and 22% reported combined heavy use of both cigarettes and alcohol. Of the 73 patients, 38 (52%) died during the follow-up period; 18 of the 38 died within 1 year postoperatively. Thirty-nine (53%) of the 73 had received a surgical tracheoesophageal fistula (TEF) for voice restoration, as either a primary or a secondary procedure. Of the 39, 75% were using the TEF at last examination, with no failures attributed to sphincter spasm. Of the total group, the primary communication modality was reported to be use of a TEF by 44% and use of an electrolarynx by 50%. Limitations of the study and directions for future investigations are discussed.

The acceptability of secondary tracheo-oesophageal fistula creation in long standing laryngectomees

The use of a tracheo-oesophageal voice prosthesis was introduced to the Glasgow Royal Infirmary Otolaryngology, Head and Neck Surgery unit in 1986. Although it was the authors' impression that most total laryngectomees since then had been offered this method of voice restoration, it was thought that long standing laryngectomees were seldom offered tracheo-oesophageal fistula (TOF) speech. Therefore all 58 total laryngectomees currently attending the combined head and neck surgery/radiotherapy clinic were assessed. Thirty-two had a tracheo-oesophageal fistula with voice prosthesis. All of these patients had undergone their total laryngectomy since 1986 and 83 per cent had achieved TOF speech. The remaining 26 patients (who mostly had their laryngectomy before 1986) had not been offered TOF speech. An outpatient consultation was arranged for these patients and 63 per cent of those offered, accepted TOF creation and a voice prosthesis. When compared to those who refused, it was found that good oesophageal speech, age or interval since laryngectomy were not good predictors of likely refusal. This study indicates that all fit long standing laryngectomees should be offered secondary TOF creation.

Stage T3 squamous cell carcinoma of the glottic larynx: a comparison of laryngectomy and irradiation

One-hundred eighteen patients with previously untreated T3 squamous cell carcinoma of the glottic larynx were treated with curative intent between March 1965 and November 1988 at the University of Florida. All patients were observed for at least 2 years and 83% were observed for 5 or more years. Fifty-three patients were treated with irradiation alone and 65 patients were treated with surgery alone (32) or combined with irradiation (33). Thirty-two patients treated with irradiation alone had twice-daily fractionation and the remainder had once-daily fractionation. The local-regional control rates, including patients successfully salvaged after a local-regional recurrence, were 81% after irradiation alone and 81% after surgery alone or combined with adjuvant irradiation. The local control rates for patients treated with irradiation alone were 53% after once-daily fractionation and 71% after twice-daily fractionation. There was no relationship between vocal cord mobility at 5000 cGy, at the end of radiotherapy, or at 1 month after treatment and subsequent local control. The 5-year cause-specific survival rates were 74% for patients treated with irradiation alone and 63% for patients treated surgically. The incidence of severe complications, including those associated with salvage procedures, was 15% for both treatment groups. The rates of laryngeal voice preservation were 66% after irradiation alone and 2% after surgery. Irradiation alone for selected patients with T3 glottic cancer resulted in similar rates of local-regional control, survival, and severe complications, with a significantly higher likelihood of voice preservation, compared with surgery.

Italian experience of voice restoration after laryngectomy with tracheoesophageal puncture

This report concerns 102 cases of tracheoesophageal puncture performed as a means of secondary voice restoration after total laryngectomy, in 70 patients proving unable to learn esophageal speech and as a treatment of choice in a further 32 cases. Complications arose in 21 cases but were generally minor and could be overcome. Results were favorable in 45 of 70 and 29 of 32 cases, respectively. The method was considered effective, particularly when supported by the patient's determination to learn a verbal communication method.

Tracheogastric puncture for vocal rehabilitation following total pharyngolaryngoesophagectomy

Speech rehabilitation postpharyngolaryngoesophagectomy has not received significant emphasis. We describe our experience with five patients who underwent a delayed tracheogastric puncture (TGP) after pharyngogastric anastomosis. When compared to patients who had undergone tracheoesophageal puncture (TEP) after laryngectomy, speech intelligibility and fluency were adequate for conversational speech, but voice quality was characterized by lower pitch, reduced intensity, slower rate, and a "wet" quality. There were no complications related to the TGP. TGP is a safe and often useful procedure for voice and speech restoration in patients who have undergone total pharyngolaryngoesophagectomy and pharyngogastric anastomosis.

Voice restoration following laryngectomy: the role of primary versus secondary tracheoesophageal puncture

A protocol was established at our institution to compare a series of primary and secondary tracheoesophageal punctures using the Singer-Blom voice prosthesis. Over a 24-month period, 20 primary and 18 secondary punctures were performed. Voice production, fluency of voice, and functional use were graded. Our data support the use of both primary and secondary voice restoration following laryngectomy.

Voice restoration after total laryngopharyngectomy and cervical esophagectomy using the duckbill prosthesis

We have presented a series of 10 patients who were successfully rehabilitated using the tracheoesophageal puncture technique for voice restoration. These patients underwent total laryngopharyngectomy or laryngopharyngoesophagectomy and reconstruction with visceral transposition (five patients), myocutaneous flaps (four patients), and skin graft and cervical flaps (one patient). All patients were able to produce adequate voice and carry on a conversation. Clinical evaluation of voice quality and acoustic analysis of voice samples indicate that the voice obtained in these patients was intelligible, and had adequate intensity, low pitch, and limited pitch variation. There were no complications related to the voice restoration procedure. It appears from our data and the limited experience reported in the literature that the tracheoesophageal prosthesis can be used successfully and safely for the speech rehabilitation of patients who undergo total laryngopharyngectomy, cervical esophagectomy, or both, regardless of the reconstructive method used.