Secondary tracheoesophageal puncture: factors predictive of voice quality and prosthesis use

Current Therapeutic Strategies for Patients with Hypopharyngeal Carcinoma: Oncologic and Functional Outcomes

Hypopharyngeal cancer is usually diagnosed at an advanced stage and is associated with a high risk of recurrence and poor survival rates. Although they differ greatly in terms of prognosis, hypopharyngeal cancers are usually treated together with laryngeal cancers in clinical trials. Therefore, there are very few studies that focus specifically on patients with hypopharyngeal carcinoma. As a result, the therapeutic management of these patients is highly debated, and their clinical outcomes are poorly reported. The aim of this review is therefore to discuss the current therapeutic options in patients with hypopharyngeal carcinoma and their oncologic and functional outcomes. Patients with early-stage tumors can be treated either by conservative surgery (including transoral robot-assisted surgery) or by RT alone. However, most patients are diagnosed with locally advanced tumors that cannot be treated surgically without total laryngectomy. In this situation, the critical issue is to select the patients eligible for a larynx preservation therapeutic program. However, radical surgery with total laryngectomy still plays an important role in the management of patients with hypopharyngeal carcinoma, either as the primary treatment modality (T4 resectable primary tumor, contraindication to larynx preservation therapies) or, more commonly, as salvage treatment.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Importance

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures.

Objective

To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP.

Design, Setting, and Participants

This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019.

Main Outcomes and Measures

Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed.

Results

Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type.

Conclusions and Relevance

This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Endoscopic visualization for tracheoesophageal puncture tract sizing

BACKGROUND

Accurate tracheoesophageal prosthesis (TEP) size is essential for optimal functioning. Current sizing techniques do not afford direct visualization. The clinical utility of direct visualization with unsedated transnasal esophagoscopy (TNE) to improve TEP sizing accuracy has not been established.

AIMS/OBJECTIVES

The purpose of this investigation was to determine if endoscopic visualization with TNE during TEP fitting improves sizing accuracy.

MATERIAL AND METHODS

Participants undergoing secondary TEP placement had their TEP sized without visualization and with visualization during TNE. The effect of endoscopic visualization on TEP sizing was assessed.

RESULTS

The mean age (SD) of the cohort (N = 15) was 61.20 (±10.19) years. The percent disagreement between non-visualized and endoscopic-visualized puncture tract measurement was 60%. The mean difference in puncture tract length with visualization compared to without visualization was 1.75 mm (±1.91). Discordance between non-visualized and endoscopic-visualized puncture tract length was worse for persons with a history of radiation (66.7%) than without radiation (33.3%) (p < .05). The overall test agreement between endoscopic and non-endoscopic sizing techniques was moderate (Cohen's kappa coefficient = 0.254; (p < .05).

CONCLUSION AND SIGNIFICANCE

The percent disagreement between non-visualized and endoscopic-visualized TEP sizing is high (60%). The data suggest that endoscopic visualization with TNE improves sizing accuracy during TEP placement.

Assessment of Factors Impacting Long-Term Utilization of Tracheoesophageal Speech Among Laryngectomees

OBJECTIVE(S)

To evaluate complication rate and abandonment rate after tracheoesophageal puncture and to assess factors associated with these outcome measures.

METHODS

Retrospective review of laryngectomy patients seen at a single academic institution between 1/1/2003 and 12/1/2018. Charts reviewed for demographics, medical comorbidities, tumor characteristics, surgical data, adjuvant treatment history, and complications related to laryngectomy or tracheoesophageal puncture. Complications were divided into minor and major.

RESULTS

A total of 293 laryngectomees met inclusion criteria. Of these, 69 patients (23.5%) underwent tracheoesophageal puncture. Average follow up was 64.6 months (SD 58.3). Overall laryngectomy complication rate was 43.3%. Overall tracheoesophageal puncture complication rate was 73.9%, with 39.1% of patients having major complications and 34.8% having minor complications only. Total abandonment rate for tracheoesophageal puncture was 34.8%. No associations were seen between tracheoesophageal puncture complication or abandonment rates based on age, gender, race, or insurance status. An increased rate of laryngectomy complications was seen after primary tracheoesophageal puncture (76.5% vs 41.3%, P = .005).

CONCLUSION

Tracheoesophageal puncture outcomes were similar in patients with varied demographic, medical, and treatment backgrounds. When considering timing, our findings suggest that patients should be counseled on the possibility of increased complication risk after primary tracheoesophageal puncture. In those in whom the surgeon already has concerns about wound healing, it may be prudent to avoid primary tracheoesophageal puncture. The relatively high abandonment rate emphasizes the value of this measure of tracheoesophageal puncture outcome and highlights the need for appropriate patient counseling and prospective studies assessing the decision to abandon.

Routine use of salivary bypass tubes in laryngectomy patients: systematic review

BACKGROUND

Pharyngocutaneous fistula is a cause of significant morbidity following laryngectomy. Routine use of salivary bypass tubes during laryngectomy has been proposed to reduce the incidence of fistulae and neopharyngeal strictures.

METHOD

Following a systematic search of Embase, Medline and Cochrane databases (1946 - current), included articles were assessed for bias according to the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Three case-control trials showed reduced pharyngocutaneous fistula rates with the use of salivary bypass tubes; six case series reported widely varied fistula rates. With regards to stricture rates, the largest case-control trial found no improvement with salivary bypass tube use. No fatal adverse events were observed among the 204 patients who received a salivary bypass tube.

CONCLUSION

Low-level evidence suggests salivary bypass tubes may reduce the incidence of fistula in high-risk patient groups. A robust randomised controlled trial, or large, multicentre cohort studies, are needed to further examine this intervention.

Contemporary review: Impact of primary neopharyngoplasty on acoustic characteristics of alaryngeal tracheoesophageal voice

The physiology of the vibratory mechanism in alaryngeal tracheoesophageal speech depends on several factors. The structure and resulting function of the neoglottis (or neopharynx) varies from patient to patient depending on the individual details of the surgical procedure performed, as well as the patient's anatomy. In general, the vibratory segment is a blending of the pharyngeal constrictor muscles, cricopharyngeus, and upper circular fibers of the esophagus. Limited ability to visualize dynamically these three-dimensional structures during rapid events of voice and speech production impedes complete understanding of the vibratory function of the neopharynx. Acoustic studies have elucidated some general characteristics of the pharyngoesophagus and neoglottic vibratory mechanism in the laryngectomized population. A critical degree of tonicity is necessary for apposition of mucosal surfaces in the production of tracheoesophageal voice. Deficiencies in the vibratory segment can usually be managed with various surgical procedures (neopharyngoplasty), resulting in reduced intraesophageal pressure and corresponding increase in fluent, intelligible, effortless speech. The acoustic measures, when correlated with neopharyngoplasty variables, produce many significant associations. Some of them are paramount and deserve further attention.

Voice Rehabilitation after Laryngectomy

Improvements in voice rehabilitation over the past century have paralleled the surgical success of laryngectomy. The establishment of the tracheoesophageal puncture marked a turning point in the development of successful and dependable voice rehabilitation. Surgical options include both primary and secondary placement of a tracheoesophageal puncture. Though complications, such as pharyngoesophageal spasm or prosthesis leakage may occur, patients should expect functional voice restoration after laryngectomy.

Evaluation of voice prosthesis placement at the time of primary tracheoesophageal puncture with total laryngectomy

OBJECTIVES/HYPOTHESIS

Primary tracheoesophageal puncture (TEP) is a well-described and accepted method of surgical voice restoration and is standardly completed with a catheter placement intraoperatively, which is replaced with a prosthesis at a later date. This study evaluates the intraoperative placement of the voice prosthesis at the time of the primary TEP in an effort to understand the potential advantages and disadvantages of voice prosthesis placement at the time of primary TEP completed in conjunction with total laryngectomy.

STUDY DESIGN

Retrospective chart review within an academic medical center.

METHODS

After approval by the institutional review board of the Massachusetts Eye and Ear Infirmary, a retrospective chart review was completed of all cases of primary tracheoesophageal prosthesis placement completed in conjunction with primary tracheoesophageal puncture performed at the time of total laryngectomy.

RESULTS

Thirty patients were identified, 29 of whom underwent laryngectomy for advanced laryngeal carcinoma. Twenty-eight of 29 patients received preoperative full-dose radiation therapy. Twenty-nine of 30 patients had a 20F classic Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA) placed. One had placement of 16F Indwelling Blom-Singer prosthesis. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Twenty-nine of 30 subjects had initial success with tracheoesophageal voice production. At 1-year follow-up, 23/30 subjects (77%) had successful voice restoration. Five failed because of recurrent disease, one subject never achieved successful voice, and one subject wanted the prosthesis removed although successful voice was achieved. Twenty-three of 25 (92%) disease-free subjects had functional voice restoration at 1-year post-total laryngectomy and primary prosthesis placement.

CONCLUSIONS

This study demonstrates that the voice prosthesis can be safely and effectively placed intraoperatively at the time of primary TEP and laryngectomy. Initial voice acquisition rates were high and long-term success was well within the acceptable range.

Computerized manometry use to evaluate spasm in pharyngoesophageal segment in patients with poor tracheoesophageal speech before and after treatment with botulinum toxin

Tracheoesophageal voice (TEV) with voice prosthesis (VP) is an efficient and reproducible method used in vocal rehabilitation after total laryngectomy (TL), prevented by spasms in the pharyngoesophageal segment (PES). Computerized Manometry (CM) is a new, direct and objective method used to assess the PES.

Aim

to carry out an objective analysis of the PES, with CM, before and after the injection of botulinum toxin (BT).

Study design

clinical-prospective.

Materials and Methods

analysis of eight patients consecutively submitted to TL with TEV and VP, without vocal emission, with PES spasms seen through videofluoroscopy, considered the gold standard for spasm detection. All had their spasms treated with the injection of 100 units of BT in the PES. The assessment was based on PES videofluoroscopy and CM, before and after BT injection.

Results

There was a PES pressure reduction according to the CM after BT injection in all patients. The average pressure in the PES seen through the CM in eight patients before BT injection was 25.36 mmHg, and afterwards it dropped to 14.31 mmHg (p=0.004). There was vocal emission without stress and PES spasm improvement seen through the videolaryngoscopy after BT injection.

Conclusion

We observed a reduction in PES pressure after BT injection, seen through CM in all the patients, with spasms improvement seen through videofluoroscopy.

Use of computerized manometry for the detection of pharyngoesophageal spasm in tracheoesophageal speech

Objective

To evaluate the utility of computerized manometry (CM) to identify pharyngoesophageal segment (PES) spasm during tracheoesophageal speech.

Study Design

Prospective clinical, controlled study.

Subjects and Methods

Intraluminal pressures of the PES were collected in 12 tracheoesophageal speakers without spasm and 8 tracheoesophageal speakers with PES spasm before and after localized injection of botulinum toxin to the PES. All subjects underwent voice analysis and videofluoroscopy in addition to CM before and after treatment.

Results

All tracheoesphageal speakers with PES spasm presented with mean intraluminal pressures greater than 16 mmHg (mean, 25.36 mmHg). In contrast, mean intraluminal pressures of subjects without spasm was 11.76 mmHg ( P < 0.05). The negative predictive value associated with the use of 16 mmHg as a threshold value for spasm was 100%.

Conclusion

CM is a clinically useful tool to aid in speech rehabilitation for tracheoesophageal speakers. Intraluminal pressures of greater than 16 mmHg was highly predictive for PES spasm. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Botulinum toxin in speech rehabilitation with voice prosthesis after total laryngectomy

In tracheo esophageal puncture (TEP), we carry out a myotomy of the pharynx constrictor muscle; however, about 9 to 79% of patients need such procedure. The consequence of such procedure is an increase in salivary fistula rates in the postoperative. Botulin toxin is used in an outpatient basis.

Aim

analyzing the efficacy of botulin toxin (BT) use in the rehabilitation of totally laryngectomized patients with tracheoesophageal voice (TEV) with spasms (S) of the pharyngoesophageal segment (PES) without myotomy.

Materials and Methods

We analyzed eight patients submitted to total laryngectomy (TL), rehabilitated with TEV, with speech prosthesis (SP) and struggle to utter voice because of PES spasms. They were all submitted to treatment of such motor alteration with the injection of 100 units of BT in the PES. The evaluation was based on perceptive voice analysis, video fluoroscopy (VF) of the PES, acoustic voice analysis and computerized manometry (CM) of the PES, all before and after BT injection.

Study design

prospective

Results

There was a reduction in PES CM pressure after BT injection. Acoustic analysis showed an improvement in harmonics quality after treatment. There was smoother voice utterance and spasm improvement after BT.

Conclusion

all patients with PES spasms presented vocal improvement after BT injection in the PES.

Prothetische Stimmrehabilitation nach Laryngektomie

BACKGROUND

Indwelling voice prostheses are state of the art for post-laryngectomy voice rehabilitation. The aim of this study was to identify the impact of radiation prior to tracheoesophageal puncture on success rate and complications.

PATIENTS AND METHODS

We undertook a retrospective study of 145 patients who had undergone prosthetic voice restoration between 1990 and 2002 (Provox) and Provox2). Risks of functional failure and complications in 17 patients with previous radiation therapy were compared to those of 128 patients without such therapy.

RESULTS

Previous radiation increased not only the risk of functional failure by 2.9 (P=0.023), but also the risk of shunt-related complications such as aspiration around the prosthesis (1.51; P=0.046), widening of the shunt (2.32; P=0.014), esophageal (2.51; P=0.013) or tracheal (3.29; P=0.0023) dislocation of the prosthesis and spontaneous (2.51; P=0.047) or surgical closure (3.76; P=0.037) of the shunt.

CONCLUSION

Primary tracheoesophageal puncture during laryngectomy is recommended in cases without previous radiation therapy, especially when post-laryngectomy radiation is likely. In patients with previous radiation therapy, generally good success rates decrease, however, without absolute contraindication of tracheoesophageal puncture. These results may affect salvage surgery concepts.

Outcomes of Primary and Secondary Tracheoesophageal Puncture: A 16-year Retrospective Analysis

The current study retrospectively reviewed the cases of 68 patients who had undergone total laryngectomy and tracheoesophageal puncture (TEP) over a 16-year period. Fifty-one patients underwent primary TEP and 17 underwent secondary TEP. Nearly 80% of patients who received TEP at the time of laryngectomy achieved excellent voice quality perceptually. In contrast, only 50% of secondary TEP patients achieved excellent voice ratings. This difference was statistically robust (p = 0.03). Although both surgical and prosthesis-related complications occurred more frequently following primary TEP, statistically significant differences were not achieved. Neither pre- nor postoperative radiotherapy had any effect on voice restoration or complication rates. Based on these data, primary TEP may be preferable for several reasons, including a greater likelihood of successful voice restoration, a shorter duration of postoperative aphonia, and the elimination of the need for a second operation and interim tube feedings.

Reabilitação vocal pós-laringectomia total: resultados em longo prazo com prótese fonatória Blom-Singer® de longa permanência

Avaliar o uso em longo prazo de próteses fonatórias (PF) para reabilitação fonatória de pacientes submetidos à laringectomia total (LT). Foram estudados a influência do tempo de realização da punção tráqueo-esofágica (PTE), o uso de radioterapia pós-operatória (RTXpos-op), idade e seguimento do paciente, sobre a taxa de sucesso de uso da PF. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODOS: Setenta e um pacientes submetidos à LT e reabilitados com PF de longa permanência. Todos foram avaliados por otorrinolaringologista e fonoaudióloga, quanto aos aspectos funcionais vocais, durante o seguimento. Os dados relativos a tempo de colocação da PF, tempo de utilização da PF, uso de RTXpos-op, idade do paciente, tempo de seguimento e tempo de duração de cada PF foram anotados. RESULTADOS: Houve 87% de pacientes com PTE primária e 13% com secundária. O tempo de seguimento variou de 12 a 87 meses, com média de 38 meses para a PTE primária e 51 meses para a secundária. Houve 59% de pacientes submetidos a RTXpos-op. A taxa de sucesso geral foi de 94%. Na PTE primária foi de 97% e na secundária 78% (p=0,07) e, após dois anos, foi de 96% na PTE primária e 75% na secundária (p=0,07). Utilização de RTXpos-op e idade do paciente não influenciaram no sucesso de utilização de PF, independentemente do tempo de seguimento. CONCLUSÕES: Houve tendência de maior sucesso na reabilitação vocal de pacientes submetidos à LT com a PTE primária. O uso de RTXpos-op e idade não influenciou nesta taxa de sucesso.

Speech rehabilitation after total laryngectomy: long-term results with indwelling voice prosthesis Blom-Singer®

To evaluate long-term use of indwelling Blom-Singer voice prosthesis (VP) for vocal rehabilitation of patients submitted to total laryngectomy (TL). We studied the influence of time of performance of tracheo-esophageal puncture (TEP), use of radiotherapy (XRT), patients' age and length of follow-up, on the rate of success of use of VP.

STUDY DESIGN

Clinical prospective.

MATERIAL AND METHOD

Seventy-one patients were submitted to TL and rehabilitated with indwelling VP. Both otolaryngologist and speech pathologist evaluated all patients for the vocal functional issues during the follow-up. The relative data on time of placement of VP, time of use of PF, use of XRT, age, length of follow-up and interval of duration of each VP were recorded during the follow-up.

RESULTS

There was 87% of patients with primary TEP and 13% with secondary. The follow-up varied from 12 to 87 months, with average of 38 months for primary and 51 months for secondary TEP. There were 59% of patients submitted to XRT. The general rate of success was of 94%. In primary TEP it was of 97% and in the secondary, it was 78% (p=0.07) and after two years, the success rate was of 96% in primary TEP and 75% in secondary TEP (p=0.07). The use of XRT and patient age did not influence the success of use of VP among primary and secondary TEP, independently of length of follow-up.

CONCLUSION

Tendency to greater success rate in voice rehabilitation after TL with primary TEP was observed. Postoperative XRT and age did not influence success rate.

Preoperative evaluation for tracheoesophageal voice restoration

Systematic preoperative assessment by the surgeon and speech pathologist reduces complications and increases the success rates of tracheoesophageal (TE) voice restoration by identifying unsuitable candidates for the procedure. Preselection criteria are based on the various medical, psychologic, structural, and physiologic factors that are contraindications to the procedure or are associated with failure of the TE method. Predictive testing as part of the preoperative evaluation for secondary voice restoration can identify patients with structural or physiologic abnormalities that will hinder the development of satisfactory TE speech. Early recognition and management of potential obstacles to TE voice production will shorten the recovery time to achieve functional communication,and allow more laryngectomees to benefit from the TE voice restoration method of alaryngeal communication.

Voice following laryngeal cancer surgery: troubleshooting common problems after tracheoesophageal voice restoration

The introduction of tracheoesophageal voice restoration by Blom and Singer has provided laryngectomy patients with a successful alternative to the use of artificial larynx and esophageal speech. Although this method of communication provides for the rapid acquisition of intelligible, functional speech, there are common problems that may occur in these patients. Close follow-up of patients postoperatively along with thorough patient education is beneficial to improving long-term success with tracheoesophageal speech. The purpose of this article is to discuss common problems encountered in the treatment of patients who have undergone tracheoesophageal puncture and to provide systematic assessment and treatment guidelines that are essential to maintaining functional tracheoesophageal speech.

Tracheoesophageal voice restoration with total laryngectomy

Tracheoesophageal voice restoration has gained worldwide acceptance over the past 24 years and is the preferred method of postlaryngectomy speech. Tracheoesophageal puncture is safe, reliable,and reproducible and should be considered in all patients undergoing total laryngectomy and in those who have failed to master other methods of alaryngeal speech. This article discusses patient selection, surgical technique and complications, quality of speech,and predictors of success. Improved prosthesis design has expanded the use of tracheoesophageal speech in laryngectomees.

Current indications and complications of tracheoesophageal puncture for voice restoration after laryngectomy

Surgical voice restoration by valved tracheoesophageal fistula is undoubtedly the most successful method of voice restoration for laryngectomy patients, is one of the most important developments in head and neck surgery, and has resulted in a greatly enhanced quality of life for most patients who have undergone this debilitating procedure. In developed countries, it is now unacceptable to perform laryngectomy without giving patients the opportunity to undergo surgical voice restoration. Successful voice acquisition should be achievable in approximately 80% of patients. Success rates will be highest and problems most effectively dealt with under the auspices of a properly organized surgical voice restoration program within a specialist head and neck cancer unit with a well structured specialist multidisciplinary team. This article reviews recent publications addressing indications for surgical voice restoration by tracheoesophageal puncture, expected success rates, and reasons for failure and complications and ways to manage them in the context of the author's own experience.

Neoglottic formation from posterior pharyngeal wall conserved in surgery for hypopharyngeal cancer

OBJECTIVE

To describe a new treatment modality of hypopharyngeal cancer consisting of total laryngectomy plus partial pharyngectomy (TLPP) conserving the posterior wall of the pharynx vertically for voice restoration.

METHODS

Review of hospital charts, TLPP was undertaken in 15 of 54 patients. Surgical modalities of reconstruction subsequent to TLPP were indicated on the basis of the width of posterior pharyngeal wall conserved during surgery. Posterior pharyngeal walls of width 3 cm or larger were sutured in primary closure. If the width of posterior wall was less than 3 cm, a free forearm flap or free jejunal flap was patched to the wall. Tracheo-esophageal shunt with a voice prosthesis was performed 3 weeks after surgery.

RESULTS

The Kaplan-Meier method indicated no difference in survival rate between patients with TLPP (46.4%) and the remaining patients (47.4%). Nine of 15 patients with TLPP (two patients with primary closure, three with free forearm flap, and four with free jejunal flap) were examined for voice restoration and fluoroscopy of the neopharynx. Eight of the nine patients, in whom more than 2 cm of the posterior pharyngeal wall had been conserved, demonstrated a good speech rating, maximum phonation time and neoglottic formation by the posterior pharyngeal wall.

CONCLUSION

The combination of conservation of the posterior pharyngeal wall, patch graft and a voice prosthesis is a useful method that offers sufficient quality of phonation without deterioration of survival rate for patients with hypopharyngeal cancer.

Reconstruction of the pharynx and cervical esophagus using ileocolic free autograft

BACKGROUND

Advanced stage hypopharyngeal cancer is commonly treated by surgery and radiotherapy. This report presents a technique using ileocolic free autograft as a single-stage procedure for voice and swallowing rehabilitation after pharyngolaryngoesophagectomy.

METHODS

Digestive tract restoration is obtained by using the cecum and ascending colon, while the last ileal loop, protected by the ileocecal valve for food and liquid inhalation, is anastomized to the cervical trachea. After abdominal harvesting, the ileocolic complex is transected, transposed, and then revascularized in the cervical field.

RESULTS

Six patients underwent this operation successfully with recovery of swallowing function and vocal performance within a short period of time, varying from 18 to 38 days.

CONCLUSION

On the basis of achieved results, the ileocolic free autograft can be considered a good option for pharyngoesophageal reconstruction, offering as it does an immediate restoration of swallowing and voice function.

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture

OBJECTIVES/HYPOTHESIS

Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature.

STUDY DESIGN

Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996.

METHODS

Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y).

RESULTS

All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications.

CONCLUSIONS

Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Current trends in laryngectomy rehabilitation: a survey of speech-language pathologists

This study determined the perceptions of experienced speech-language pathologists regarding current practices in the speech rehabilitation of laryngectomy patients since the introduction of the tracheoesophageal puncture-voice prosthesis technique in 1980. The sample population consisted of 151 experienced speech-language pathologists, or 43% of those who were sent questionnaires. The speech-language pathologists ranked tracheoesophageal puncture-voice prosthesis as their most preferred speech rehabilitation method and the electrolarynx as their least preferred, even though the electrolarynx continues to be the most frequently used method. Variable use of the tracheoesophageal puncture procedure by otolaryngologists was reported, with only a small portion perceived as using it routinely. About 65% of the speech-language pathologists reported that more than half of the laryngectomy patients were being given choices among speech rehabilitation methods. Nearly 50% of the speech-language pathologists reported that fewer than six speech therapy sessions were necessary with tracheoesophageal puncture patients, whereas more than 20% reported the need for 10 sessions or more. Use of manual closure of the tracheostoma by tracheoesophageal puncture patients far outweighed their use of automatic speaking valves. Most speech-language pathologists reported that they were involved in teams with otolaryngologists to determine patient suitability for tracheoesophageal puncture and to troubleshoot problems. Eighteen different categories of medical and speech production problems were reported.