Interaction of functional and participation issues on quality of life after total laryngectomy

Quality of Life and Respiratory Performance in the Laryngectomized Patient: Role of the HME Filters during Physical Activity

Background: Permanent tracheostomy because of total laryngectomy surgery entails significant consequences for patients regarding respiratory physiopathology, such as the loss of the filtering, humidifying, and heating of air by the nose. The use of special stomal filters can provide adequate protection of the tracheal-bronchopulmonary system with a reduction in respiratory pathologies. In fact, in most cases, laryngectomy patients are first cigarette smokers who for this reason also already have respiratory diseases such as chronic obstructive pulmonary disease (COPD). Despite the availability of tracheal filters, as reported in the literature, patients often tend to limit their use due to reported breathing difficulties, especially in conditions of intense breathing. Methods: The objective of this clinical study was to evaluate the most suitable stomal filter for laryngectomy patients during physical activity. The filters studied were an INHEALTH device (Blom-Singer SpeakFree HME); two ATOS devices (Provox® Life™ Energy HME and Provox® Life™ Home HME); and an FAHL device (Laryvox HME Sport). Results: For this purpose, the performances of 31 laryngectomy patients, subjected to medium-high physical effort, were analyzed through a standardized pneumological test, the Six Minute Walking Test (6MWT), which involves a sustained walk lasting six minutes, with an evaluation of heart rate, oxygen saturation, and meters traveled every 60 s; furthermore, we examined two subjective indices, namely, the basal and final dyspnea index and the initial and final muscular fatigue index. Conclusions: The multidisciplinary approach of the laryngectomee patient must also take pulmonary rehabilitation into consideration. It is the task of the medical team and speech therapy support to help the patient in the correct choice of HME filters taking into account daily needs.

Anxiety, depression and quality of life in patients with head and neck cancer undergoing laryngectomy: A long-term prospective evaluation

BACKGROUND

This study aimed to assess anxiety, depression and quality of life (QoL) in patients with head and neck cancer undergoing laryngectomy using comprehensive self-reported questionnaires for a period of up to 5 years.

METHODS

This prospective observational study enrolled 150 consecutive patients with locally advanced head and neck cancer who underwent laryngectomy at Nagoya University Hospital between 2007 and 2020. Anxiety, depression and QoL were assessed at baseline (preoperative) and at 3, 6, 12, 24, 36, 48 and 60 months after surgery using two brief self-reported questionnaires, such as the eight-item Short Form Health Survey (SF-8) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The surgical procedures were total laryngectomy, pharyngo-laryngectomy and pharyngo-laryngo-oesophagectomy in 97 (65%), 41 (27%) and 12 (8%) patients, respectively. All eight items of the SF-8 were significantly worse than those of the normal population at baseline and at 3 months after surgery. However, general health, vitality, mental health and bodily pain improved to normal levels within 1 year after surgery and were maintained for 5 years. In this study, 35% of patients were categorised as potential cases of depression, and 35% were potential cases of anxiety. During the follow-up period, the proportion of patients with anxiety gradually decreased after surgery. Further analysis revealed that the SF-8 and HADS scores and trends in 89 patients without tumour recurrence were similar to those in the total enrolled 150 patients.

CONCLUSION

Anxiety, depression and QoL in laryngectomised patients improved at 1 year after surgery and were maintained for up to 5 years.

WHAT THIS PAPER ADDS

What is already known on the subject Laryngectomy is associated with prolonged functional and psychological effects and has a major impact on patient quality of life (QoL). Several prospective studies evaluating the QoL in laryngectomised patients have been reported, in which significant deterioration in social functioning was found even 1 year after surgery. What this paper adds to existing knowledge One year is not a sufficient period for laryngectomised patients to return to normal life and spend their time in a social community. A recent review showed that most studies on QoL in laryngectomised patients were conducted under 1 year after the procedure, and there were not enough studies of sufficient quality. This is the first long-term prospective observational study of Japanese patients with head and neck cancer who underwent laryngectomy up to 5 years after surgery. What are the potential or actual clinical implications of this work? Our long-term observational study showed that the scores for anxiety, depression and QoL in laryngectomised patients improved at 1 year after surgery and were maintained for up to 5 years. Clinicians should recognize the importance of psychosocial risk factors in their QoL and multidisciplinary management, including social and psychological support, is essential for long-term laryngectomised survivors.

Dysphagia After Total Laryngectomy: An Exploratory Study and Clinical Phase II Rehabilitation Trial with the Novel Swallowing Exercise Aid (SEA 2.0)

The aims of this exploratory study and clinical phase II trial were to assess the specific nature and extent of dysphagia in laryngectomized patients with self-reported dysphagia, and its rehabilitation potential using the novel Swallowing Exercise Aid (SEA 2.0). Twenty laryngectomized patients participated in a six-week exercise program with the SEA 2.0. Exercises consisted of Chin Tuck Against Resistance (CTAR), Jaw Opening Against Resistance (JOAR), and Effortful Swallow Against Resistance, conducted three times per day. Swallowing was assessed at baseline (T0), six (T1) and 14 (T2) weeks, consisting of patient-reported outcomes, BMI, videofluoroscopy, swallowing capacity, and muscle strength measurements. Dysphagia significantly impacts quality of life, with impaired swallowing speed and bolus propulsion as main reported issues. Subjective dysphagia parameters, swallowing capacity, and pharyngeal residue clearance were reduced, but BMI was normal. Muscle and tongue strength were within normal ranges. All participants managed to use the SEA 2.0. Adherence was 95%. At T1, subjective swallowing parameters (MDADI and EAT-10) showed clinically relevant improvements. Objectively, CTAR and JOAR strength increased with 27.4 and 20.1 Newton, respectively. Also, swallowing capacity (from 2.4 g/s to 3.8 g/s) and pharyngeal residue clearance improved. At T2, results were slightly lower than at T1, but still better than at baseline. Dysphagia in laryngectomized patients affects quality of life, but swallowing can be improved with a six-week rehabilitation program using the novel SEA 2.0. Adherence was excellent and several subjective and objective swallowing parameters improved.

Maximal cardiopulmonary exercise testing in laryngectomised patients using different heat and moisture exchangers - feasibility and exercise responses

OBJECTIVE

After laryngectomy, the breathing resistance of heat and moisture exchangers may limit exercise capacity. Breathing gas analysis during cardiopulmonary exercise testing is not possible using regular masks. This study tested the feasibility of cardiopulmonary exercise testing with a heat and moisture exchanger in situ, using an in-house designed connector. Additionally, we explored the effect of different heat and moisture exchanger resistances on exercise capacity in this group.

METHODS

Ten participants underwent two cardiopulmonary exercise tests using their daily life heat and moisture exchanger (0.3 hPa or 0.6 hPa) and one specifically developed for activity (0.15 hPa). Heat and moisture exchanger order was randomised and blinded.

RESULTS

All participants completed both tests. No (serious) adverse events occurred. Only four subjects reached a respiratory exchange ratio of more than 1.1 in at least one test. Maximum exercise levels using heat and moisture exchangers with different resistances did not differ.

CONCLUSION

Cardiopulmonary exercise testing in laryngectomees with a heat and moisture exchanger is feasible; however, the protocol does not seem appropriate to reach this group's maximal exercise capacity. Lowering heat and moisture exchanger resistance does not increase exercise capacity in this sample.

Temporal and Spectral Models as Correlates to Auditory-Perceptual Judgments of Overall Severity and Listener Comfort in Tracheoesophageal Voice

INTRODUCTION

This study pursued two objectives: (1) to determine the potential association between listener (n = 51) judgments of 20 male tracheoesophageal speaker samples for two auditory-perceptual dimensions of voice, overall severity (OS) and listener comfort (LC); and (2) to assess the temporal and spectral acoustic correlates for these auditory-perceptual dimensions.

METHODOLOGY

Three separate correlation analyses were performed to evaluate the association between OS and LC. First, scores of OS and LC from all listeners were pooled together, and then the correlation between OS and LC was computed. Second, scores of OS and LC were averaged over all listeners to derive a single estimate of OS and LC for each TE speaker sample; the correlation between the average OS and LC was then computed. Third, listener-to-listener variability in the association between OS and LC was evaluated by computing the correlation between OS and LC scores from each listener across all TE samples. Finally, two stepwise multiple regression models were created to relate the average LC score to spectral and temporal variation in the acoustic signal.

RESULTS

While the pooled OS and LC scores had a moderate positive correlation (r = 0.66, p < 0.00001), the averaged OS and LC exhibited a near perfect positive correlation (r = 0.99, p < 0.00001). The significant differences between the pooled and averaged scores were explained by significant listener-to-listener variability in the association between OS and LC. OS and LC scores from 5 listeners had non-significant correlations, 10 had moderate correlations (r < 0.7), 35 listeners had high correlations (0.7 < r < 0.9), and 1 listener had a very high correlation (r < 0.9 < 1). Finally, the acoustic models created based on the spectral and temporal variations in the signal were able to account for 87.7% and 61.8% of variation in the average LC score.

CONCLUSIONS

The strong correlations between OS and LC suggest that LC may, in fact, provide a more comprehensive auditory-perceptual surrogate for the voice quality of TE speakers. Although OS and LC are distinct conceptual dimensions, LC appears to have the advantage of assessing the social impact and potential communication disability that may exist in interactions between TE speakers and listeners.

Improving Hands-Free Speech Rehabilitation in Laryngectomized Patients with a Moldable Adhesive

OBJECTIVE

This study aims to assess the product performance of a new moldable peristomal adhesive with corresponding heating pad designed to facilitate and improve automatic speaking valve (ASV) fixation for hands-free speech in laryngectomized patients.

METHODS

Twenty laryngectomized patients, all regular adhesive users with prior ASV experience, were included. Study-specific questionnaires were used for data collection at baseline and after two weeks of moldable adhesive use. The primary outcome parameters were adhesive lifetime during hands-free speech, use and duration of hands-free speech, and patient preference. Additional outcome parameters were satisfaction, comfort, fit, and usability.

RESULTS

The moldable adhesive enabled ASV fixation adequate for hands-free speech in the majority of participants. Overall, the moldable adhesive significantly increased adhesive lifetime and duration of hands-free speech compared to participants' baseline adhesives (p < 0.05), regardless of stoma depth, skin irritation, or regular use of hands-free speech at baseline. The participants who preferred the moldable adhesive (55% of participants) experienced a significant increase in the adhesive lifetime (median of 24 h, range 8-144 h) and improved comfort, fit, and ease of speech.

CONCLUSION

The moldable adhesive's lifetime and functional aspects, including the ease of use and custom fit, are encouraging outcomes and enable more laryngectomized patients to use hands-free speech more regularly.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2965-2970, 2023.

Self-management of patients with tracheostomy in the home setting: a scoping review

PURPOSE

The aim of this study was to create a model of patient-centered outcomes with respect to self-management tasks and skills of patients with a tracheostomy in their home setting.

METHODS

A scoping review using four search engines was undertaken (Medline, CINAHL, PsycINFO, Cochrane Library) to identify studies relevant to this issue and published since 2000. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statements for Scoping Reviews (PRISMA-ScR), the Joanna Briggs Institute (JBI) approach of conducting and reporting a scoping review, and the Participants, Concept, Context (PCC) scheme were employed. The following elements of the framework synthesis study data were screened, and presented based on the self-management model of Lorig and Holman.

RESULTS

34 publications from 17 countries met the criteria for study inclusion: 24 quantitative, 8 qualitative and 2 mixed methods designs. Regarding the dimensions of self-management, 28 articles reported on "managing the therapeutic regimen", 27 articles discussed "managing role and behavior changes", and 16 articles explored "managing emotions". A model of self-management of patients with tracheostomy was developed, which placed the patient in the center, since it is this individual who is completing the tasks and carrying out his or her skill sets.

CONCLUSION

This scoping review represents the first comprehensive overview and modeling of the complex self-management tasks and skills required of patients with tracheostomy in their home setting. The theoretical model can serve as a cornerstone for empirical intervention studies to better support this patient-centered outcome for this population in the future.

Surviving cancer following total laryngectomy: a phenomenological study

PURPOSE

Total laryngectomy followed by radiotherapy is a life-preserving treatment for patients with locally advanced laryngeal cancer. This study explored how persons who had undergone total laryngectomy perceived themselves as cancer survivors in the follow-up phase.

METHODS

A descriptive phenomenological approach was adopted. We employed a purposive sampling strategy to collect data through interviews at the otorhinolaryngology outpatient clinics of two research hospitals in northern Italy. The interviews were transcribed verbatim and analysed, following the seven analytical steps of Colaizzi's descriptive analysis.

RESULTS

The final sample included 19 patients. The following main themes were identified: (i) accepting a life with the "without" to survive; (ii) feeling unpleasant emotions; (iii) getting the hang of communication again; and (iv) reclaiming one's role. Together, they highlight the lived experiences of laryngectomised patients during the follow-up phase and how they perceived themselves as cancer survivors.

CONCLUSION

Laryngectomised patients are a uniquely vulnerable population. This study provides insights into how surgical procedures change and affect their lives over time to improve care models, patient education, and support systems. Survivors must be adequately prepared to transition from treatment and return to the community. This preparation should begin before treatment is started. Functional education, accurate information, and psychological support must be arranged and provided before surgery. Regarding the post-treatment phase, it is essential to support voice rehabilitation and peer support, and improve the family network, to ensure these patients' reintegration into society and social recognition.

Sport in the Laryngectomized Patient: A Literature Review and Single Case Presentation

BACKGROUND

Total laryngectomy is an operation that involves numerous problems for the patient, especially in daily life: loss of the fact, loss of voice, evident scars and persistence of the tracheostoma. Much is known about rehabilitation programs involving the voice, swallowing, shoulder girdle rehabilitation; less explored is the field of sport and sports rehabilitation in the laryngectomized patient.

METHODS

We conduced systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement in order to evaluate the possibilities of practicing sports for the patient after total laryngectomy.

RESULTS

From an initial search of 4191 papers, we have come to include six papers for this literature review. We have also reported one of our clinical cases referring to a laryngectomized patient who swims competitively at an amateur level even after surgery with a particular device. The purpose of this work is to understand the role and importance of sport in rehabilitation and the possibilities that a frail patient like the laryngectomized patient has in practicing sport. Surely the best results are obtained in subjects who practiced sports before surgery.

CONCLUSION

It is evident that sport is important in the psychological and motor recovery of the laryngectomized patient. There is still a lack of clear rehabilitation protocols, especially for water sports, which allow all laryngectomized patients to return to sports. We believe that early resumption of physical activity makes the experience of the disease less dramatic.

Understanding and predicting the performance of passive heat and moisture exchangers using a numerical model

BACKGROUND

To improve the understanding of the thermodynamics and performance of small passive hygroscopic Heat and Moisture Exchangers (HMEs), a computer model simulating HME function is required.

METHODS

We developed a numerical HME model to calculate the HME's water and heat exchange. The model was tuned and verified with experimental data and validated by applying it to HME design variations.

RESULTS

Verification of the model's results to the experimental data shows that the tuned model yields reliable results. The mass of the core, which determines the HME's total heat capacity, is the most important parameter influencing the performance of passive HMEs.

CONCLUSIONS

Increasing the HME's diameter is an effective way to improve an HME, as it yields higher performance and lowers breathing resistance. HMEs intended for use in warm or dry climates should contain more and those for use in cold humid climates should contain less hygroscopic salt.

New Heat and Moisture Exchangers for Laryngectomized Patients in Germany: Mixed Methods Study on the Expected Effectiveness

BACKGROUND

Notwithstanding the benefits of heat and moisture exchangers (HMEs) in both clinical research and practice, a gap exists between the optimal physiological humidification created through the nasal function and the humidification capacity of HMEs for patients after total laryngectomy. In this study, 5 new HMEs (Provox Life) specialized for situational use with improved humidification capacities were evaluated.

OBJECTIVE

This study aims to evaluate the effectiveness of the existing HMEs, assess the potential effectiveness of the new HMEs, and elicit expert judgments on the new HMEs' expected effectiveness and impact on health care use.

METHODS

First, a rapid literature review (RLR) was performed to identify evidence on the clinical outcomes, health outcomes, and complications of HMEs in patients who underwent laryngectomy. Second, semistructured interviews with German experts (n=4) were conducted to validate the findings of the RLR and identify reasonable expectations regarding the potential of the new HMEs. Third, a structured expert elicitation among German experts (n=19) was used to generate quantitative evidence on the expected effectiveness of the new HMEs in clinical and health outcomes.

RESULTS

The RLR (n=10) demonstrated that HME use by patients has advantages compared with no HME use concerning breathing resistance, tracheal dryness and irritation, mucus production and plugging, frequency of cough and forced expectorations, sleep quality, voice quality, use of physiotherapy, tracheobronchitis or pneumonia episodes, quality of life, and patient satisfaction. From the expert interviews and structured expert elicitation, it was found that, on average, experts expect that compared with the second-generation HMEs, the new HMEs will lead to a decrease in tracheal dryness or irritation (51%, SD 24%, of patients), mucus plug events (33%, SD 32%, of patients), mucus production (53%, SD 22%, of patients), physiotherapy (0.74, SD 0.70, days) and pulmonary infections (34%, SD 32%) and an increase or improvement in speech quality (25%, SD 23%, of patients), social contacts (13%, SD 18%), quality of life (33%, SD 30%), and patient satisfaction (44%, SD 30%). An improvement in breathing (53%, SD 28%, of patients) and shortness of breath (48%, SD 25%, of patients) was expected. The average number of daily cough periods and forced expectorations was expected to be 2.95 (SD 1.61) and 2.46 (SD 1.42), respectively. Experts expect that, on average, less than half of the patients will experience sleeping problems (48%, SD 22%) and psychosocial problems (24%, SD 20%).

CONCLUSIONS

According to German experts, it is expected that the new HMEs with improved humidification levels will lead to additional (clinical) effectiveness on pulmonary health and an improved overall quality of life of patients compared with the currently available HMEs.

Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers

OBJECTIVE

To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy.

STUDY DESIGN

Prospective crossover study.

SETTING

Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery.

METHODS

Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).

RESULTS

Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D.

CONCLUSION

Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

Characteristics associated with communicative participation after total laryngectomy

PURPOSE

The purpose of this study was to identify individual characteristics that are associated with communicative participation after total laryngectomy (TL).

METHODS

This study was a single-institution investigation of individuals who had undergone TL. Data were collected at a single timepoint via patient self-report and medical record review. Thirty-five participants completed a questionnaire containing a communication survey as well as several published, validated instruments. Independent variables included characteristics related to demographics, health and medical history, social network composition, and communication. The dependent variable was communicative participation, which was assessed using the Communicative Participation Item Bank (CPIB). Correlations between the independent variables and CPIB scores were calculated to assess the influence of these characteristics on communicative participation. The study participants were subdivided into three distinct groups based on whether their primary method of communication was spoken or non-spoken and the frequency of using alternate methods of communication. Outcomes across the three groups were then compared. A follow-up survey was also conducted to examine the impact of "stay at home" orders during the COVID-19 pandemic of 2020-21.

RESULTS

There were significant correlations between communicative participation and some non-communication-related characteristics. Reduced communicative participation was associated with younger age, less time since TL, a history of reconstructive surgery, poorer self-rated health, more depressive symptoms, worse quality of life, and a weaker social network of friends. Several communication-related characteristics were also associated with CPIB scores. Increased communicative participation was associated with using fewer non-spoken communication methods, higher levels of satisfaction with speech and communication, and better communicative effectiveness. There were significant differences between the three groups for communicative effectiveness and satisfaction with speech. The three groups did not differ significantly for satisfaction with communication or communicative participation. There were no significant differences in CPIB scores measured before and during the pandemic.

CONCLUSIONS

Communicative participation is a complex measure that may be affected by a variety of factors related to demographics, health, social network status, and communication. Despite poorer communicative effectiveness and lower levels of satisfaction, individuals who use non-spoken methods of communication after TL did not demonstrate worse communicative participation than those using spoken methods. Surprisingly, CPIB scores did not decline as a result of social distancing.

Improving heat and moisture exchanger therapy with a hydrogel base adhesive in laryngectomised patients: an open, randomised, crossover trial

OBJECTIVE

This study aimed to assess individual preference, symptoms and compliance between habitual use of Provox XtraFlow and the combination of Provox XtraFlow during the day and Provox Luna during the night for heat and moisture exchanger therapy in laryngectomised patients.

METHOD

This was an open, randomised, crossover trial for 25 days. After this first study period and a 5-day wash-out period, treatments were switched for another 25 days.

RESULTS

A total of 28 patients were enrolled. Differences were found (p = 0.009) in the incidence of dermatological problems with XtraFlow (46.4 per cent) versus Provox Luna (14.3 per cent), as well as in the need to abandon the use of adhesives (46.4 per cent vs 10.7 per cent; p = 0.003). A total of 60.7 per cent of the patients preferred the Provox Luna system as their preference for heat and moisture exchanger therapy.

CONCLUSION

The Provox Luna system is a viable additive to heat and moisture exchanger therapy, especially in the setting of compliance concerns and in patients who desire dermatological relief overnight.