Analysis of Factors Affecting the Longevity of Voice Prosthesis Following Total Laryngectomy with a Review of Literature

A double-blind randomized clinical trial of inflammatory cytokine and pepsin levels in the saliva of patients with voice prostheses

BACKGROUND

Tracheoesophageal speech is one of the most effective method used for voice rehabilitation after laryngectomy. The main limitation is the need for periodic voice prothesis (VP) replacements. The process of developing VP usage complications is still unexplored. The aim of this study was to assess the level of cytokines (IL-1β, IL-6, IL-8, IL-10, TNFα) and pepsin in saliva as potential factors reducing VP longevity.

METHODS

Prospective double-blind randomized clinical trial was conducted (NCT04268459). Patients were randomly divided into two groups depending on VP replacement regimen (regular-every 3 months, or irregular-when complications occur). Levels of IL-1β, IL-6, IL-8, IL-10, TNFα, and pepsin in saliva samples (fasting and after eating) of laryngectomized patients were measured using ELISA tests.

RESULTS

Fifty-two patients (26 in both groups) with control group (7 patients) participated in the study. The level of IL-1β, IL-6, IL-8, IL-10, TNFα, and pepsin did not differ according to regularity of VP replacements (p = 0.301-0.801). IL-6 levels were significantly higher when VP complications occurs (p = 0.012).

CONCLUSIONS

The saliva components were not significantly different depending on the frequency of VP replacements. IL-6 plays an important role in the development of VP use complications.

Analysis of durability and replacement of vocal prostheses in total laryngectomy patients at a head and neck surgery referral center

PURPOSE

The use of tracheoesophageal prostheses has become the gold standard in vocal rehabilitation of patients undergoing total laryngectomy. However, this method also has limitations, such as the need for frequent replacement of prostheses due to leakage or other complications. We have designed a study to access the clinical profile of patients using tracheoesophageal prostheses as vocal rehabilitation after total laryngectomy and to determine the average rate of changes, as well as the main causes of prostheses replacement.

METHODS

A retrospective cohort study was performed based on patients who underwent rehabilitation with voice prostheses after total laryngectomy between 2008 and 2017.

RESULTS

The sample consisted of 93 patients and 432 vocal prostheses replacement events. The median change of prostheses per patient was 210.25 days, (range 57.33 to 651.50). The most frequent cause of prostheses replacement was leakage through the prostheses, 218 (50.46%). Lower level of education was associated to higher prostheses replacement rate.

CONCLUSION

The results of this study show that the median of prostheses durability is higher than that presented in the literature, the main cause of replacement was protheses leakage and that low educational level is associated to higher replacement rate.

Does Prophylactic Replacement of Voice Prosthesis Make Sense? A Study to Predict Prosthesis Lifetime

OBJECTIVE

Voice prosthesis leakage significantly affects the quality of life of patients undergoing laryngectomy, causing insecurity and frequent unplanned hospital visits and costs. In this study, the concept of prophylactic voice prosthesis replacement was explored to prevent leakages.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary hospital.

METHODS

This study included all patients who underwent laryngectomy between 2000 and 2012 in the Netherlands Cancer Institute. Device lifetimes and voice prosthesis replacements of a retrospective cohort were used to calculate the number of needed voice prostheses per patient per year to prevent 70% of the leakages by prophylactic replacement. Various strategies for the timing of prophylactic replacement were considered: adaptive strategies based on the individual patient's history of replacement and fixed strategies based on the results of patients with similar voice prosthesis or treatment characteristics.

RESULTS

Patients used a median 3.4 voice prostheses per year (range, 0.1-48.1). We found high inter- and intrapatient variability in device lifetime. When prophylactic replacement is applied, this would become a median 9.4 voice prostheses per year, which means replacement every 38 days, implying >6 additional voice prostheses per patient per year. The individual adaptive model showed that preventing 70% of the leakages was impossible for most patients and only a median 25% can be prevented. Monte-Carlo simulations showed that prophylactic replacement is not feasible due to the high coefficient of variation (SD/mean) in device lifetime.

CONCLUSION

Based on our simulations, prophylactic replacement of voice prostheses is not feasible due to high inter- and intrapatient variation in device lifetime.

Voice rehabilitation with voice prosthesis: Long term results, complications and risk factors

OBJECTIVES

Despite the advances in surgical and non-surgical organ preservation treatments, total laryngectomy (TL) remains the most effective treatment in advanced larynx cancer and as salvage procedure in chemoradiation failure. One of the most devastating sequel after TL is loss of voice. Voice prosthesis (VP) is currently the preferred choice for voice rehabilitation. The purpose of this study is to identify VP complications, its lifespan and factors that influence the longevity of the VP.

METHODS

We performed a retrospective study at a Tertiary University Hospital. Medical records of patients that underwent total laryngectomy, between January 1st of 2008 and 31st of December of 2017 were analyzed.

RESULTS

Of the 84 patients that underwent laryngectomy, 60 had VP. The average age at the time of surgery 60.2 years old and there was a male preponderance (57:3). The mean lifespan of the prosthesis was 7.53 months. Leakage through the prosthesis was the most common reason for replacement of the prosthesis, followed by leakage around the prosthesis. Follow up time and manual suture were associated with prosthesis replacement. There was no significant relationship between the staging, tumor location or adjuvant radiotherapy and number of prosthesis replacement or its lifespan.

CONCLUSIONS

Rehabilitation after TL is of major importance to improve quality of life after surgery. Tracheoesophageal puncture with voice prosthesis is a safe procedure for vocal rehabilitation and was performed in the majority of patients in our study. Follow-up time and type of suture were the main determinants of the lifespan of the prosthesis.

Factors Affecting the Lifetime of Third-Generation Voice Prosthesis After Total Laryngectomy

PURPOSE

The study aimed to evaluate the impact of different variables on the longevity of Voice Prosthesis (VP) in patients after total laryngectomy.

PATIENTS AND METHODS

This retrospective cohort study is based on data about a continuous series of 328 third-generation VP, which were implanted between 2016 and 2020. Data about the VP users' age, sex, place of residence, laryngeal tumor stage, neck irradiation, VP size, and the use of Heat and Moisture Exchanger (HME) were obtained and analyzed. The effect of these variables on VP lifetime was determined.

RESULTS

The median lifetime of VPs in patients 65 years old and above was 182 days (95% CI 168-196), versus 146 days (95% CI 130-162) (P = 0.033) in patients younger than 65. Neck irradiation was associated with a longer VP median lifetime of 161 days (95% CI 142-180) compared to 126 days (95% CI 100-152) with no prior neck irradiation (P = 0.046). HME usage was associated with significantly increased longevity of VPs: 182 days (95% CI 156-208) with HME and 149 days (95% CI 132-166) without HME usage (P = 0.039).

CONCLUSION

The results of the present study suggest that neck irradiation, and routine use of use of HME are positively associated with the longevity of VPs.

Tracheo Esophageal Prosthesis Insertion Under Endoscopic Guidance and Local Anaesthesia- Feasibility and Outcome

OBJECTIVES

Voice rehabilitation after laryngectomy is by tracheo esophageal puncture (TEP) and prosthesis insertion. Secondary TEP is very difficult due to neck fibrosis. Puncture under local anaesthesia with endoscopy guidance is a feasible option.

METHODS

Retrospective review of all laryngectomy patients from March 2009 till March 2019 was done and the methods of voice rehabilitation were assessed. The patients undergoing the procedure were classified according to the timing of insertion and type as primary insertion under general anaesthesia (Group P), secondary insertion under local anaesthesia (Group L), secondary insertion under general anaesthesia (Group G). The speech outcome and the procedure outcome were compared.

RESULTS

There were 148 patients who underwent laryngectomy, of which groups P, G, L were 12, 12 and 11. The rate of successful insertion was 100% in primary, 91.6% in secondary in general anaesthesia and 91% in secondary under local anaesthesia. All secondary TEP were done after surgery and radiotherapy. Complications related to the insertion techniques were minimal. Speech outcome were similar on intelligibility rating scale and longevity was not affected by the method.

CONCLUSION

TEP in local anaesthesia is feasible and has comparable outcome with TEP in general anaesthesia. Financial burden was very much less in group L compared to the other two groups.

Novel voice prosthesis after total laryngectomy with laryngoplasty reconstruction

BACKGROUND

Although many patients achieve serviceable speech after total laryngectomy (TL), others are limited by un-naturally low pitch. We describe a cadaveric study to provide proof of concept for a novel voice prosthesis after TL with free tissue laryngoplasty.

METHODS

Devices were implanted into fresh frozen cadavers after TL and free tissue laryngoplasty. Phonation pressures were measured using a custom Blom-Singer Manometer (InHealth Technologies, Carpinteria, CA) and acoustic files were analyzed using Praat, a speech analysis software.

RESULTS

Two fresh frozen cadavers were implanted with the voice prosthesis. Both prostheses demonstrated appropriate stenting of the laryngoplasty. Successful sound production was achieved after airflow generation at the proximal trachea. An average phonation pressure of 3.5 cmH₂ O (SD 1.7 cmH₂ O) was necessary to generate a sound intensity of 80.6 dB (SD 0.2 dB) at an average fundamental frequency of 299.5 Hz (SD 112.6 Hz).

CONCLUSIONS

The novel voice prosthesis described herein offers a feasible voice generation mechanism.

Voice Rehabilitation After Laryngectomy: A Regional Cancer Centre Experience and Review of Literature

Alaryngeal speech in laryngectomees has revolutionized the patient outlook toward the morbid procedure and the concept of permanent stoma unlike olden era when stigma of stoma with loss of voice was rampant. To analyse acceptance of voice rehabilitation options and their success and management of complications in a tertiary care centre. All patients who underwent laryngectomy from August 2014 to 2018 June at our institution were included in the study. The voice rehabilitation options like oesophageal speech, tracheao-oesophageal puncture and voice prosthesis insertion (TEP), and electrolarynx were explained to the patients. The options put forward to the patients, the importance of Taub test, Interval between treatment and secondary TEP insertion, life span of the prosthesis, Patients acceptance and success rates and the troubleshooting were noted. A total of 96 patients underwent total laryngectomy, 72 patients were willing for rehabilitation. 15% (11) patients had primary TEP, 22% (16) had secondary TEP insertion, esophageal speech in 36% (26) patients and 27% (19) patients opted for the electrolarynx. The rest 24 patients were not keen on any further interventions after laryngectomy. Speech rehabilitation is an integral part in surgical management of carcinoma of the larynx. Alaryngeal speech in laryngectomees have revolutionized the patient outlook towards the morbid procedure. Esophageal speech is the least successful method of rehabilitation but still the cheapest method and requires a lot of motivation. Primary and Secondary TEP insertions have similar success rates. Successful treatment for cancer of larynx ends with successful voice rehabilitation.

The Multidisciplinary Team (MDT) Approach and Quality of Care

The core function of a multidisciplinary team (MDT) is to bring together a group of healthcare professionals from different fields in order to determine patients' treatment plan. Most of head and neck cancer (HNC) units are currently led by MDTs that at least include ENT and maxillofacial surgeons, radiation and medical oncologists. HNC often compromise relevant structures of the upper aerodigestive tract involving functions such as speech, swallowing and breathing, among others. The impairment of these functions can significantly impact patients' quality of life and psychosocial status, and highlights the crucial role of specialized nurses, dietitians, psycho-oncologists, social workers, and onco-geriatricians, among others. Hence, these professionals should be integrated in HNC MDTs. In addition, involving translational research teams should also be considered, as it will help reducing the existing gap between basic research and the daily clinical practice. The aim of this comprehensive review is to assess the role of the different supportive disciplines integrated in an MDT and how they help providing a better care to HNC patients during diagnosis, treatment and follow up.