The senile functional evolution of the larynx after supracricoid reconstructive surgery

Effect of Aging on Long-Term Functional Outcomes After Open Partial Laryngectomy

OBJECTIVE

Open partial horizontal laryngectomies (OPHLs) represent a comparable alternative to total laryngectomy and nonsurgical protocols in selected cases. While short-term functional outcomes of OPHLs have been widely investigated, few have focused on the effect of aging on residual laryngeal structures.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic center.

METHODS

Patients who underwent OPHLs after at least 1 year follow-up and optimal functional rehabilitation were included in the study. Swallowing function was assessed according to PAS (Penetration aspiration scale) and Pooling scores. Spectrogram analysis of voice was conducted according to Yanagihara classification and acoustic parameters were also recorded. Subjective questionnaire data about phonation and swallowing were also recorded. Data obtained were compared among patients according to age at time of surgery, evaluation and duration of follow-up.

RESULTS

Ninety-seven patients were enrolled with a mean age at surgery and evaluation of 63 and 70 years old, respectively. Median follow-up length was 5 years. OPHL type II was mostly performed. No significant correlation was observed between most of the analyzed variables and patient's age at the time of surgery and at the time of evaluation. Some acoustic parameters were negatively correlated with follow-up length, while Jitter, NHR (Noise-Harmonic Ratio), and Global grade and Roughness were significantly higher in patients >65 years old.

CONCLUSION

Patients who complete rehabilitation reach equally good results as their younger peers with stability over time. Finally, the effects of aging on residual larynx are of minor entity compared to the nonoperated patients.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Nurse-Led Counseling Intervention of Postoperative Home-Based Exercise Training Improves Shoulder Pain, Shoulder Disability, and Quality of Life in Newly Diagnosed Head and Neck Cancer Patients

This randomized controlled trial investigated the effectiveness of the nurse-led counseling intervention (NLCI) of postoperative home-based exercise training (HBET) on functional outcomes in patients with newly diagnosed head and neck cancer (NDHNC). Forty NDHNC patients were randomly and equally divided into the control and intervention groups. Both groups received routine care, and were instructed to undergo a HBET program with 40 min moderate-intensity exercise 3–4 times per day for 12 weeks after their surgery. Only the intervention group received the NLCI with a bedside demonstration, coaching, consultation, and a weekly telephone follow-up. Shoulder pain (SP), shoulder disability (SD), and quality of life (QOL) scores were assessed using questionnaires at 2 weeks presurgery and at several timepoints postsurgery. Over the 12-week study period, all three scores remained relatively stable in the control group. By contrast, the SP, SD, and QOL scores significantly improved in the intervention group. The generalized estimating equation analysis revealed a significant time effect, group effect, and group–time interaction. The analysis of covariance revealed that all three scores significantly improved in the intervention group compared with those in the control group at 12 weeks postsurgery. We concluded that the NLCI of postoperative HBET improved the SP, SD, and QOL of NDHNC patients.

Cognitive Impairment and Mild to Moderate Dysphagia in Elderly Patients: A Retrospective Controlled Study

Background: To investigate whether cognitive impairment in elderly patients could correlate with the severity of swallowing disorders detectable through the endoscopic fiber optic evaluation. Methods: Elderly patients (≥65 years) performing a swallowing evaluation were included and divided according to the Dysphagia outcome and severity scale (DOSS). Neurological evaluation and Mini-Mental test examination (MMET) were administered to detect cognitive impairment. Results: Significantly worse swallowing function was reported in the cognitive impairment group than the control one (40% vs 19%; P = .001). A different significant distribution of swallowing performance was detected according to the patient's MMET score (P < .001; P < .001; P = .01). At the ANOVA test among dependent variables assessed, only age>65 and MMET<10 were significantly correlated with swallowing function (F = 3.862, P = .028; F = 17.49, P = .000). Conclusions: The elderly patient has an increased risk for unrecognized swallowing disorders, with a prevalence of mild to moderate forms. Assessment of cognitive performance could facilitate the identification of swallowing disorders by providing a higher level of suspicion for silent aspiration in subjects with poor MMET scores.

Prevalence and associated factors of aspiration and severe dysphagia in asymptomatic patients in the late period after open partial laryngectomy: a videofluoroscopic evaluation

PURPOSE

This study aimed to evaluate late and asymptomatic patients after open partial horizontal laryngectomy (OPHL), investigating the clinical-surgical and socio-demographic factors associated with aspiration and severe dysphagia.

METHODS

One-thousand videofluoroscopic swallowing studies were performed in 100 asymptomatic patients in the late period after OPHL(median 6.5 years). Aspiration and severe dysphagia were, respectively, assessed by the Penetration-Aspiration scale (PAS) and by the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) classification. Associated factors were investigated by multivariate logistic regressions.

RESULTS

34% (95% CI 24.3-47.6%) of patients presented aspiration and 23% (95% CI 15.3-34.6%) had severe or life-threatening dysphagia (DIGEST grades 3-4). On logistic regression, the presence of aspiration was associated with lower preoperative serum albumin (odds ratio [OR]: 0.22; 95% CI 0.07-0.64; p = 0.005, for each 1 g/dL increment); a greater weight loss in early postoperative period (OR: 1.19, 95% CI 1.05-1.35; p = 0.008, for each 1 kg loss); older age at surgery (OR: 1.08; 95% CI 1.01-1.17, for each 1-year older); and with the presence of diabetes (OR: 5.16; 95% CI 1.09-27.47; p = 0.039).

CONCLUSION

Deglutition abnormalities are frequent in asymptomatic patients later after OPHL. Older patients, with lower preoperative serum albumin levels, with greater postoperative weight loss, and with diabetes compose the clinical profile at risk for having worse swallowing function in the late period after OPHL.

Upright epiglottis prevents aspiration in patients with nasopharyngeal carcinoma post-chemoradiation

NPC is the most widely found malignant tumor in the head and neck region in Indonesia. Chemoradiation therapy for NPC can induce swallowing disorders (dysphagia) that adversely affects a patients quality of life. This study aimed to assess the swallowing process by flexible endoscopic evaluation of swallowing in patients with nasopharyngeal carcinoma after chemoradiation. Thirty-nine patients with NPC who had chemoradiation therapy more than one month previously underwent flexible endoscopic evaluation of swallowing and were assessed for oral transport time, sensation, standing-secretion, pre-swallowing leakage, residue, penetration, aspiration, and silent aspiration. The most common structural abnormalities were an upright and swollen epiglottis (89.4%), poor oral hygiene, and velopharyngeal closure defects (56.4%). This examination also revealed a mild degree of standing secretion (38.5%) and aspiration (10.3%). No penetration was observed in 64.1% of the patients, and no silent aspiration was observed in any of the patients. A severe degree of residue (45.7%) was observed when administering oatmeal, while the residue was mild to moderate when administering gastric rice, crackers, and milk. The residue changed to a mild degree (32.3%-51.4%) in all food administrations after the watering maneuver. The highest penetration was noted after oatmeal administration (42.8%), and the highest aspiration was found after milk administration (8.6%). Standing secretion in almost all patients was caused by hyposensitivity of the hypopharynx. Persistent residue and hyposensitivity of the hypopharynx led to aspiration. The low percentage of aspiration and silent aspiration might have been caused by the upright and swollen epiglottis that prevented aspiration. Poor oral hygiene and a dry mouth led to prolonged oral transport. Therefore, most patients had hypopharyngeal abnormalities in the form of a swollen and upright epiglottis. Secretion and food residue were also detected. Drinking helps to expedite the swallowing process by facilitating oral phase transport and reducing residues.

Voice-Related Quality of Life in Post-Laryngectomy Rehabilitation: Tracheoesophageal Fistula's Wellness

(1) Introduction: Laryngeal cancer is one of the most common types of cancer affecting the upper aerodigestive tract. Despite ensuring good oncological outcome in many locoregionally advanced cases, total laryngectomy is associated with relevant physical and psychological sequelae. Treatment through tracheo-esophageal speech, if promising, can lead to very variable outcomes. Not all laryngectomee patients with vocal prosthesis benefit from the same level of rehabilitation mainly due to the development of prosthetic or fistula related problems. The relating sequelae in some cases are even more decisive in the patient quality of life, having a higher impact than communicational or verbal skills. (2) Material and Methods: A retrospective study was conducted on 63 patients initially enrolled with a history of total laryngectomy and voice rehabilitation, treated at the University Hospital of Catania from 1 January 2010 to 31 December 2018. Quality of life (QoL) evaluation through validated self-administrated questionnaires was performed. (3) Results: The Voice-Related Quality of Life questionnaire revealed significantly better outcomes in both socio-emotional and functional domains of the tracheoesophageal patient group compared to the esophageal group (p = 0.01; p = 0.01, respectively), whereas in the Voice Handicap Index assessment, statistically significant scores were not achieved (p = 0.33). (4) Discussion: The significant differences reported through the V-RQOL and Voice Handicap Index scales in the presence of fistula related problems and device lifetime reduction when compared to the oesophageal speech group have demonstrated, as supported by the literature, a crucial role in the rehabilitative prognosis. (5) Conclusions: The criteria of low resistance to airflow, optimal tracheoesophageal retention, prolonged device life, simple patient maintenance, and comfortable outpatient surgery are the reference standard for obtaining good QoL results, especially over time. Furthermore, the correct phenotyping of the patient based on the main outcomes achieved at clinical follow-up guarantees the primary objective of the identification of a better quality of life.

High-grade chondrosarcoma of the larynx: treatment and management

We present a case of an 88-year-old man with high-grade chondrosarcoma of the larynx. The patient presents with a history worsening dysphonia and dyspnoea treated with antibiotic and corticosteroid therapy as it was a bronchopneumonia. Thanks to fibrolaryngoscopy, radiological imaging and final biopsy with immunohistochemistry, we have done differential diagnosis with the others sarcomas of the larynx. The histological diagnosis and the correct grading are essential for treatment and management of the pathology. The best treatment is primary surgical resection with negative margins. Chemoradiotherapy may provide some benefit if there are margin positive resections or with palliative intent. In our case, we performed only surgery treatment and a close follow-up at 1-3-6 months and after every 6 months. After 18 months from surgery, there are no signs of recurrence of disease.

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy

Objectives

Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies.

Study Design

Retrospective observational study.

Setting

San Raffaele Hospital, Vita-Salute University, Milan, Italy.

Methods

A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017—clinically with the Pearson’s Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing.

Results

Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery ( P = .020). Type of surgical procedure, resection of 1 arytenoid cartilage, postoperative rehabilitation with a speech-language therapist, radiotherapy, age at consultation, and length of follow-up did not influence the prevalence of aspiration. Pulmonary complications affected 5 patients; incidence of pulmonary complications was related to aspiration and was favored by poor laryngeal sensation/cough reflex. Aspiration significantly affected quality of life.

Conclusions

Chronic aspiration is frequent and affects patients’ quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications.

Excessive anterior cervical muscle tone affects hyoid bone kinetics during swallowing in adults

Purpose

This study aimed to determine whether excessive neck muscle tone affects hyoid bone kinetics during swallowing using videofluorography (VF) in an unnatural posture in healthy individuals.

Subjects and methods

Subjects were 28 healthy adults (12 men, 16 women; mean age, 39.75±9.50 years) without any history or present complaints of swallowing disorders. We first established the participant’s posture a reclining wheelchair that was adjusted to a 30-degree angle with the headrest (without excessive neck muscle tone) or without headrest (with excessive neck muscle tone), used an electromyogram above the mylohyoid muscle to represent the suprahyoid muscles and above the sternohyoid muscle to represent the infrahyoid muscles to confirm neck muscle tone, and then conducted VF of swallowing measurements. Videofluorographic images were obtained when 5 mL of 50% (w/v) barium sulfate was being swallowed, and hyoid bone coordinate (the resting position and the elevated position), extent of horizontal and vertical hyoid bone elevation, as well as duration and velocity of hyoid bone elevation were evaluated (x-axis and y-axis coordinates for the resting position of hyoid bone are referred to as Xr and Yr, respectively; those for the elevated hyoid bone position induced during swallowing are referred to as Xs and Ys, respectively).

Results

In the resting position of the hyoid bone, the Yr coordinates in those with excessive neck muscle tone were significantly lower than in those without excessive neck muscle tone. Vertical hyoid bone elevation and hyoid bone elevation velocity were significantly higher with excessive neck muscle tone than without excessive neck muscle tone, whereas horizontal elevation showed no significant differences.

Conclusion

Our findings suggest that the generation of neck muscle tone due to inappropriate posture may encourage hyoid depression and increase the extent of hyoid bone elevation, thereby increasing the risk of aspiration.

Combined Vocal Exercises for Rehabilitation After Supracricoid Laryngectomy: Evaluation of Different Execution Times

INTRODUCTION

The supracricoid partial laryngectomy allows the preservation of laryngeal functions with good local cancer control.

OBJECTIVE

To assess laryngeal configuration and voice analysis data following the performance of a combination of two vocal exercises: the prolonged /b/vocal exercise combined with the vowel /e/ using chest and arm pushing with different durations among individuals who have undergone supracricoid laryngectomy.

METHODS

Eleven patients undergoing partial laryngectomy supracricoid with cricohyoidoepiglottopexy (CHEP) were evaluated using voice recording. Four judges performed separately a perceptive-vocal analysis of hearing voices, with random samples. For the analysis of intrajudge reliability, repetitions of 70% of the voices were done. Intraclass correlation coefficient was used to analyze the reliability of the judges. For an analysis of each judge to the comparison between zero time (time point 0), after the first series of exercises (time point 1), after the second series (time point 2), after the third series (time point 3), after the fourth series (time point 4), and after the fifth and final series (time point 5), the Friedman test was used with a significance level of 5%. The data relative to the configuration of the larynx were subjected to a descriptive analysis.

RESULTS

In the evaluation, were considered the judge results 1 which have greater reliability. There was an improvement in the general level of vocal, roughness, and breathiness deviations from time point 4 [T4].

CONCLUSION

The prolonged /b/vocal exercise, combined with the vowel /e/ using chest- and arm-pushing exercises, was associated with an improvement in the overall grade of vocal deviation, roughness, and breathiness starting at minute 4 among patients who had undergone supracricoid laryngectomy with CHEP reconstruction.

Objective and self-evaluation voice analysis after transoral laser cordectomy and radiotherapy in T1a-T1b glottic cancer

Voice quality outcome becomes an important factor in the choice of the therapeutic option. The differences between radiotherapy and laser cordectomy have been extensively debated in the literature. We analyzed the vocal outcomes after carbon dioxide (CO₂) laser cordectomy and radiotherapy treatment for T1a-b early glottic cancer by means of objective and subjective voice evaluation. A retrospective study was performed on 56 cancer patients, 30 treated with cordectomy and 26 with radiotherapy. All patients underwent laser cordectomy which was performed under general anesthesia using a surgical microscope in laryngeal suspension. The laser we used was an Ultrapulse one, 10.6-μm wavelength, and a power setting of 2 to 4 W in an Ultrapulse mode was selected. Two different sets of data were recorded: (a) voice acoustic analysis (jitter, shimmer, fundamental frequency and noise/harmonic ratio) and (b) voice handicap index (VHI). Data collected were statistically analyzed using SPSS 20.0 for Windows. Jitter, shimmer, and signal-to-noise ratio were significantly altered in both glottic cancer patient groups as compared to the control group. On the contrary, no statistically significant alteration of the fundamental frequency was found in both treatment groups. Interestingly, jitter and shimmer values were significantly more compromised in transoral laser surgery patients as compared with radiotherapy-treated patients. The VHI was also significantly altered in both cancer patient groups as compared to the control group. More importantly, however, the self-evaluation voice analysis was not significantly different between the two treatment groups, contrary to what we observed for two of the four parameters measured in the objective voice analysis. Given the importance of the self-perception of the voice quality, no treatment can be considered superior from the patients' point of view. Therefore, we suggest that priority should be given to the endoscopic surgery, due to lower costs, lower morbidity, and shorter hospitalization.