Double Blind Study Investigating the Effect of Different Voice Prostheses on Ease of Swallowing and Residue Post Laryngectomy

Swallowing after total laryngectomy surgery: where are we after 150 years?

Purpose of review

Recent findings

Dysphagia is a common sequela following total laryngectomy surgery; however, there is significant variability in its assessment and management. Manometry enables an accurate understanding of the underlying mechanism of dysphagia and precise assessment of any oesophageal dysfunction. EndoFLIP is a useful tool to better understand dysfunction of the upper oesophageal sphincter particularly to detect stricture.

Summary

Following total laryngectomy surgery, dysphagia is common; clinicians need to be alert to early indicators of dysfunction and understand the tools to comprehensively characterize swallow function. Accurate diagnosis of a stricture is important, as this aspect of dysfunction can be modified, and may alleviate surrogate problems such as a leaking voice prosthesis. Clinicians should have a low threshold to examine patients for oesophageal dysfunction due to the high prevalence of dysmotility following a laryngectomy.

The results of sequential swallowing assessments after total laryngectomy for laryngeal and hypopharyngeal malignancies

BACKGROUND

Swallowing after total laryngectomy (TL) is altered and the swallowing related issues are largely underreported. It is important to identify factors that may negatively influence swallowing after TL in order to rehabilitate these patients appropriately.

METHODS

The study included patients who underwent TL from June 2015 to November 2017 for laryngeal and hypopharyngeal malignancy. Sequential swallowing assessment was done in these patients over time. The assessments were done using the FOIS scale and the PSS-HN normalcy of diet scores and analysed to assess the presence of swallowing related issues, factors influencing swallowing and its recovery over time.

RESULTS

Sixty-seven who underwent total laryngectomy (TL) were included in the study. Swallowing assessments were done once in 3 months. Overall there was an improvement in swallowing over time. Both the FOIS (Median score of 3.82 in first to 5.77 in the fifth visit) and the PSS-HN scores (median score of 33.63 at first visit to 63.66 at fifth visit) improved over time. Patients undergoing TL after treatment failure with chemoradiotherapy (p value < 0.001) and those with advanced stage disease (p-value < 0.001) did poorly in terms of swallowing. At the last follow up only 8 patients were dependent on feeding tube; the rest of the patients were able to take food orally.

CONCLUSION

Following total laryngectomy swallowing gradually improves in the first 18 months after surgery. It is essential to identify factors influencing swallowing negatively so that these patients can get appropriate attention to improve swallowing.

Swallowing difficulties caused by a voice prosthesis in a laryngectomee

INTRODUCTION

The role of voice prosthesis (VP) in causing swallowing difficulties has not been thoroughly evaluated. A laryngectomee with dysphasia caused by a VP is presented.

CASE REPORT

A 77-year-old laryngectomee presented with dysphagia. He had hypo pharyngeal squamous cell carcinoma, which was treated with intensity-modulated radiotherapy 13 years earlier. Cancer recurrence 2 years later required laryngectomy and forearm free flap restoration. The patient used trachea-oesophageal speech for communication using Provox® Vega 22.5/Fr 6mm. Diagnostic endoscopy revealed significant oesophageal stenosis at the upper portion of the flap immediately below the VP. The VP was replaced with a 22.5 Fr/4mm Provox® Vega that was modified by cutting out its distal hood that protruded into the oesophageal lumen. The patient noted an immediate improvement in his dysphagia that persisted through the 14-month follow-up.

CONCLUSIONS

This report underscores the need to evaluate the role of VP in laryngectomees with swallowing difficulties. Obstruction generated by oesophageal protrusion of the VP can be alleviated by installing a thinner prosthesis and/or when possible by changing the location of the puncture to a new site.