Variation in surgical methods used for total laryngectomy in Australia

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

INTRODUCTION

The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario.

METHODS

A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included.

RESULTS

A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce.

CONCLUSION

We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.

An experimental model of the pharyngoesophageal segment in tracheoesophageal phonation

Tracheoesophageal (TE) speech is an important method of speech rehabilitation for those who undergo a total laryngectomy. Despite the many advantages over other methods, there is still room for improvement in terms of the overall quality of the TE voice as well as its success rate. These points could be greatly assisted by an improved knowledge on the mechanics of TE speech. Here, an experimental model of the pharyngoesophageal segment (PES), based on the idea of a collapsible tube, is proposed. To implement the model, considerable simplifications had to be made, most notably in the use of a thin flexible tube to represent the PES. The model was used to assess the minimum amount of tonicity required for the onset of phonation in terms of the flow rate and longitudinal tension. Additionally, comparisons with a mathematical model [Tourinho, da Silva, dos Santos, Thomaz, and Vieira, J. Acoust. Soc. Am. 149, 1979-1988 (2021)] have been made, yielding similar trends for sufficiently large flow rates. The measurements also suggest that the phonation frequency is most affected by the tonicity of the PES, which highlights the question of which physiological mechanism is responsible for the control of the fundamental frequency of phonation.

The effect of salivary bypass tube use on the prevention of pharyngo-cutaneous fistulas after total laryngectomy

INTRODUCTION

The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL).

METHODS

A consecutive series of 133 patients who underwent total laryngectomy between 1997 and 2019 was reviewed. The incidence of PCF was compared between patients who did not receive SBT (nSBT group; n = 55) and those preventively receiving SBT (SBT group; n = 78) in both primary and salvage TL. Risk factors for PCF were evaluated in a univariate and multivariate analyses.

RESULTS

The overall PCF rate was 30%. Preoperative characteristics were similar between the nSBT and SBT groups, except for older age (p = 0.016), lower preoperative hemoglobin (p = 0.043), and lesser neoadjuvant chemotherapy (p = 0.015) in the SBT group. The rate of PCF the nSBT group, was 41.5%, compared to 21.8% in the SBT group (p = 0.020). In multivariate analysis, only the use of SBT was associated with lower risk of PCF (OR = 0.41 (95% CI 0.19-0.89), p = 0.026). This effect was verified only in the subgroup of patient operated for salvage TL (OR = 0.225; 95% CI 0.09-0.7; p = 0.008).

CONCLUSION

The use of SBT in our series in salvage TL, appears to be associated with a decreased risk of PCF.

Influence of position and angulation of a voice prosthesis on the aerodynamics of the pseudo-glottis

The use of a tracheoesophageal valve, also known as voice prosthesis, is currently the most appealing solution for recovering the ability to speak in subjects who have undergone a total laryngectomy. The prosthesis allows the passage of air from the trachea to the esophagus, thereby promoting the flow-induced vibration of the subject's pharyngoesophageal segment. In turn, the pharyngoesophageal segment modulates the air flow from the lungs into the subject's vocal tract, acting as an alternative source of acoustic energy to generate voice. The vibration of the pharyngoesophageal segment will likely depend on the aerodynamic forces acting on its wall, which will be defined by the flow characteristics downstream from the valve's outlet. Previous works have investigated the pressure drop across different prosthesis designs with both in-vitro and in-vivo experiments. Nevertheless, the aerodynamic aspects of the flow in the tracheoesophageal region have only been investigated experimentally in an idealized geometry. This work investigates the influence of the prosthesis position on the aerodynamic behavior of the pharyngoesophageal segment in terms of wall pressure distribution and characteristics of the velocity field. The investigations were carried out with a static model of the tracheoesophageal region based on the finite volume method and a Reynolds-averaged Navier-Stokes solver. The geometry of the system was based on computed tomography images obtained from laryngectomized subjects during phonation at different voice registers and included the geometry of a commercially available voice prosthesis. The results suggest that the position and angulation of the voice prosthesis have a minor influence on the pressure loss along the tracheoesophageal segment and on the pressure distribution on the pharyngoesophageal segment's wall.

A study on tracheoesophageal phonation based on a collapsible channel model

Laryngeal cancer afflicts a large number of people worldwide, and some will need surgery to contain the disease. Currently, tracheoesophageal (TE) speech is a common method of voice rehabilitation for patients who have had their larynges excised. However, despite the relatively high success rate, not everyone is capable of producing the TE voice, usually due to the tonicity of the pharyngoesophageal segment (PES). The present work studies how the tonicity of the muscles of the PES affects TE phonation, focusing mainly on hypotonicity. A simplified collapsible channel model is used. Steady-state solutions are obtained and a linear stability analysis is performed. It is then shown that the steady-state solutions of the model are similar to the wide variety of possible PES configurations that are reported in the literature. The linear stability analysis results provide a simple expression for the estimation of the minimum tonicity required for self-sustained oscillations of the PES.

Is It Important Which Suturing Technique Used for Pharyngeal Mucosal Closure in Total Laryngectomy? Modified Continuous Connell Suture May Decrease Pharyngocutaneous Fistula

OBJECTIVE

The aim of this study is to research the correlation between pharyngeal mucosal suture techniques and pharyngocutaneous fistula (PCF) development after total laryngectomy. We also aimed to investigate other risk factor for fistula development.

METHODS

Medical charts of 85 patients who had total laryngectomy during August 2016 and February 2020 were reviewed. Sixteen patients were excluded due to exclusion criteria. Patients were grouped according to pharyngeal mucosal suture technique. Group 1 had modified continuous Connell suture and group 2 had interrupted submucosal suture for mucosal closure of pharynx. Demographic, medical, and surgical records reviewed for comparison.

RESULTS

Overall PCF rate was 28%;PCF rates were 16% (5/31) in group 1 and 39% (15/38) in group 2. This difference was significant (Pearson χ² P = .033). There was no difference between groups due to age, gender, smoking history, tumor stage preoperative albumin levels, preoperative hemoglobin levels, radiotherapy status, chronic obstructive pulmonary disorder and diabetes mellitus history of patients, previous tracheostomy, neck dissection. But correlation analysis revealed that PCF formation significantly related with suture technique (P = .032), preoperative albumin level <3.5 g/dL (P = .028), preoperative hemoglobin level <12.5 g/dL (P = .041), and previous radiotherapy status (P = .012) of the patients. We also showed that suture technique is an independent predictive factor for PCF formation when other factors were controlled by univariate analysis.

CONCLUSION

The suture technique used for pharyngeal mucosal closure, preoperative albumin level <3.5 g/dL, preoperative hemoglobin levels<12.5 g/dL, and previous radiotherapy to the head and neck are risk factors for PCF development. Modified continuous Connell suture is a good option for pharyngeal closure.

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.

Factors affecting swallowing outcomes after total laryngectomy: Participant self-report using the swallowing outcomes after laryngectomy questionnaire

BACKGROUND

Little is known about what factors affect patient-reported swallowing outcome after total laryngectomy. We explored whether patient demographics, surgical variables, use of adjuvant treatment, and time since surgery were associated with patient-reported swallowing outcome.

METHODS

Cross-sectional study of laryngectomees in eight UK hospitals. Demographic, treatment, and surgical variables were drawn from medical notes. The swallowing outcomes after laryngectomy (SOAL) questionnaire captured perceived swallowing outcome.

RESULTS

Two hundred and twenty one participants had complete data on treatment-related variables. In regression analysis, having a free jejunum flap repair and requiring chemoradiation were the only two variables that added significantly to the model of worse self-reported swallowing outcome (R² adjusted = .23, P < .001).

CONCLUSION

The SOAL is a sensitive measure of self-reported swallowing outcome after laryngectomy. Type of surgical closure and the type of additional treatment influenced the swallowing outcome reported by patients. Changes in perceived swallowing function need to be routinely evaluated to inform clinical decision-making and intervention.

Comparison of Pharyngoesophageal Segment Biomechanics Between Persons with Total Laryngectomy With and Without Dysphagia Using sEMG: A Multicentric Swallow Study

Total laryngectomy (TL) is the surgical treatment option for advanced stage of laryngeal cancer, involving the removal of larynx along with several muscles attached to it. Several anatomical changes occur following the surgery which will in turn affect the swallowing mechanism. The severing of the cricopharyngeus muscle, which is an important muscle of the pharyngoesophageal segment (PES), may lead to dysphagia. Several other causes have also been explained in the literature. Several invasive instruments have been used to identify dysphagia in this population. The present study aimed to identify the differences in the biomechanics of the PES during dry and wet swallow tasks in persons with TL with and without dysphagia. Amplitude and duration of movement of PES was analysed using a non-invasive instrumental method surface electromyography. The results indicate that amplitude of PES movement was significantly higher in dysphagic group for solids and semisolids. A significantly longer duration was observed for solid consistency for dysphagic group when compared to non-dysphagic group. sEMG evidences suggestive of differences in amplitude and duration between the TL with and without dysphagia groups. Findings also revealed that TL with dysphagia group require more effort to swallow solids and semisolid consistencies when compared to the effort exerted by them during liquid and dry swallow.

Horizontal (vs. vertical) closure of the neo-pharynx is associated with superior postoperative swallowing after total laryngectomy

We conducted a cross-sectional study to compare the horizontal and vertical methods used in the surgical closure of the neo-pharynx after total laryngectomy in terms of their effect on swallowing function, swallowing-related quality of life (QOL), and overall QOL. We also assessed the potential influence of age (≤64 vs. ≥65 yr) and the type of treatment modality (primary, salvage, or total laryngectomy with radiotherapy) on outcomes. Our final study population was made up of 34 patients-31 men and 3 women, aged 49 to 89 years (mean: 66.8)-who had undergone a total laryngectomy. One year after surgery, all patients were asked to complete the M.D. Anderson dysphagia inventory (MDADI), which quantifies swallowing function and swallowing-related QOL, and the University of Washington quality-of-life questionnaire (UW-QOL), which quantifies overall QOL. Of the 34 patients, 16 had undergone a horizontal surgical closure of their neo-pharynx and 18 a vertical closure. According to the MDADI, patients in the horizontal group experienced significantly better swallowing function/QOL; the mean composite MDADI scores were 91.5 in the horizontal group and 68.3 in the vertical group (p = 0.005). We found no significant difference in terms of overall QOL, as the respective mean UW-QOL scores were 81.0 and 80.8 (p = 0.93). The population correlation coefficient was positive in both groups, but more so in the horizontal group (ρ_horizontal = 0.876 and ρ_vertical = 0.676). Neither age nor the type of treatment modality employed influenced swallowing function/QOL (p_age = 0.10, p_{treatment modality} = 0.78) or overall QOL (p_age = 0.08, p_{treatment modality} = 0.59). We conclude that horizontal closure of the neo-pharynx is superior to vertical closure in terms postoperative swallowing function/QOL but not overall QOL.

Defining the low-risk salvage laryngectomy-A single-center retrospective analysis of pharyngocutaneous fistula

Objectives

Salvage total laryngectomies (STL) are not a homogeneous group. Most will fall into two groups: i) Patients with previous AJCC stage I/II larynx cancer who have had radiotherapy to the larynx only (STL‐LOR), or ii) Patients who have had previous AJCC stage III/IV larynx cancer and subsequent radiotherapy to the larynx and draining nodal basins with concurrent cisplatin chemotherapy (STL‐CRT). We aimed to compare PCF rates following STL in these two groups.

Methods

A retrospective review of the department's cohort between January 2010 and August 2015 was conducted.

Results

Seventy‐seven patients underwent total laryngectomy for larynx cancer between January 2010 and August 2015. There were 10 post‐laryngectomy fistulas (13.0%). Three of these occurred in the 38 patients undergoing primary total laryngectomy (PTL), and seven in the 39 patients undergoing STL, rates of 7.9% and 17.9%, respectively. Twenty‐two patients had received radiation to the larynx alone without chemotherapy (STL‐LOR) for initial Stage I/II disease. Eleven patients had received laryngeal and neck irradiation plus cisplatin chemotherapy (STL‐CRT) for initial stage III/IV disease. Of the 22 STL‐LOR patients, two developed PCF (9.1%). Of the 11 STL‐CRT patients, five developed PCF. There was no difference in the rate of PCF between PTL and STL‐LOR. There was a statistically significant increase in PCF in STL‐CRT versus PTL (p = .009) and in PCF in STL‐CRT versus STL‐LOR (p = .027).

Conclusion

Salvage laryngectomies are often treated as a homogenous group. We demonstrate that PCF rates vary significantly depending on preoperative radiation fields and the use of chemotherapy.

Level of Evidence

2b.

Post-Laryngectomy stricture and pharyngocutaneous fistula: Review of techniques in primary pharyngeal reconstruction in laryngectomy

OBJECTIVE

The purpose of this study was to find a correlation between closure technique in pharyngeal closure and outcomes of both pharyngocutaneous fistula and post-laryngectomy stricture after laryngectomy.

STUDY DESIGN

Retrospective Chart Review.

METHODS

We retrospectively reviewed a total of 151 patients over a 20-year period from January 1994 to December of 2013 who underwent primary pharyngeal reconstruction after total laryngectomy specifically looking at the closure technique in relation to pharyngo-cutaneous fistula (PCF) and post-laryngectomy stricture postoperatively. Patients were excluded based on secondary pharyngeal closure. Using logistic regression modelling, we performed univariate and multivariate analyses of our data.

RESULTS

The overall PCF and post-laryngectomy stricture rates were 19.1% and 15.8%. When salvage laryngectomy was excluded, t-type closure had a significantly lower risk of fistula rate (P=.038) compared to vertical closure. In multivariate analysis, this statistical significance was lost (P=.23); however, non-salvage t-type closure remained significantly better than both salvage laryngectomy groups (t-type, P=.033, vertical, P=.037), while non-salvage vertical closure had no significant difference from other groups. There was no difference in stricture rate between the two closure techniques (P=.63).

CONCLUSION

Our study supports the role of t-type closure decreasing fistula rates in primary pharyngeal reconstruction. Orientation of the pharyngeal closure does not appear to change the risk of post-laryngectomy stricture formation after total laryngectomy. Salvage laryngectomy with primary pharyngeal reconstruction remains an independent risk factor for fistula formation.

Comparison of complication rates associated with stapling and traditional suture closure after total laryngectomy for advanced cancer

We conducted a retrospective, matched-cohort, case-control study to compare complication rates associated with two wound closure procedures-stapling vs. traditional hand suturing-following total laryngectomy. Our study population was made up of 42 consecutively presenting patients-38 men and 4 women, aged 34 to 92 years (mean: 60.3) whose pharyngotomies were amenable to primary closure. Of this group, 37 patients had active endolaryngeal squamous cell carcinoma (SCC), 2 patients had inactive endolaryngeal SCC, 2 patients had thyroid cancer, and 1 patient had been treated for chronic aspiration. A total of 26 patients (61.9%) had undergone traditional suture closure of the neopharynx (suture group) and 16 patients (38.1%) had undergone closure with a linear stapling device (staple group). Other than the fact that the patients in the staple group were significantly older than those in the suture group (median: 71.0 vs. 56.5 yr, p = 0.002), there were no significant differences between the two groups in terms of comorbidities or cricopharyngeal myotomy, tracheoesophageal puncture, or neck dissection. There was a total of 8 postoperative infections-5 in the staple group (31.3%) and 3 in the suture group (11.5%)-not a statistically significant difference. Fistulas occurred in 4 staple patients (25.0%) and 6 suture patients (23.1%)-again, not statistically significant. We conclude that in appropriately selected patients, primary closure of the neopharynx can be safely and effectively achieved with a linear stapling device.

Practice of laryngectomy rehabilitation interventions: a perspective from Australia

PURPOSE OF REVIEW

To provide a perspective of contemporary practice in rehabilitation of speech and swallowing in patients undergoing total laryngectomy in Australia.

RECENT FINDINGS

In Australia, the preferred method of voice rehabilitation is by the use of tracheo-oesophageal voice prosthesis. Dysphagia is an ongoing problem and the use of adjuvant radiation and chemotherapy compounds this problem. There are difficulties associated with surgery because of the variation in disease involvement of pharyngeal mucosa and musculature, as well as difficulties associated with healing in previously chemoradiated surgical fields.

SUMMARY

This article demonstrates the need for careful consideration of surgical technique, particularly in closure of the neopharynx in the chemoradiated patient. It encourages further research into the problems of speech and particularly swallowing in this patient population, as these problems impact significantly on the quality of life.

Quality of life and deglutition after total laryngectomy

Introduction: Total laryngectomy creates deglutition disorders and causes a decrease in quality of life

Aim: To describe the impact of swallowing and quality of life of patients after total laryngectomy.

Method: A case series study. Patients completed a Swallowing and Quality of Life questionnaire composed of 44 questions assessing 11 domains related to quality of life (burden, eating duration, eating desire, frequency of symptoms, food selection, communication, fear, mental health, social functioning, sleep, and fatigue). The analysis was performed using descriptive statistics, including measures of central tendency and variability.

Results: The sample comprised 15 patients who underwent total laryngectomy and adjuvant radiotherapy. Of these, 66.7% classified their health as good and 73% reported no restrictions on food consistency. The domains “communication” and “fear” represented severe impact and “eating duration” represented moderate impact on quality of life. The items with lower scores were: longer time to eat than others (domain “eating duration”), cough and cough to remove the liquid or food of the mouth when they are stopped (domain “symptom frequency”), difficulties in understanding (domain “communication”) and fear of choking and having pneumonia (domain “fear”).

Conclusion: After total laryngectomy, patients report that swallowing issues have moderate to severe impact in “communication,” “fear,” and “eating duration” domains.

Impact of a Laryngectomy and Surgical Closure Technique on Swallow Biomechanics and Dysphagia Severity

Objective. The incidence of self-reported dysphagia following a laryngectomy is high (72%). The impact, if any, of a surgical closure technique on swallowing biomechanics and dysphagia severity is not known. To date, there is no recommended standard procedure for pharyngeal reconstruction during laryngectomy surgery. The aim of this study was to determine how laryngectomy surgery alters swallowing biomechanics, pharyngeal peak deglutitive pressure, and hypopharyngeal intrabolus pressures and whether these changes in pressure correlate with specific surgical closure after total laryngectomy or with dysphagia severity.

Study Design. Combined videoradiography and manometry was used to measure peak mid-pharyngeal, tongue, and intrabolus pressures; anatomical derangements; postswallow residue; and pharyngeal dimensions.

Setting. Radiology Department, St George Hospital, Sydney, Australia.

Subjects. Twenty-four patients following total laryngectomy surgery and age-matched control data.

Results. When compared to controls, peak mid-pharyngeal pressures were significantly reduced in laryngectomy patients ( P < .001). Hypopharyngeal intrabolus pressures were significantly higher in patients when compared to controls ( P < .001). Patients who had undergone mucosa-and-muscle pharyngeal reconstruction had higher peak mid-pharyngeal pressures compared to those who had mucosa-alone closure ( P ≤ .04). Combined mucosa-and-muscle closure was also associated with reduced postswallow residue, indicative of a more efficient swallow.

Conclusion. Following laryngectomy surgery, pharyngeal pro-pulsive contractile forces are impaired, and there is increased resistance to bolus flow across the pharyngoesophageal segment. These adverse biomechanical effects can be influenced by surgical techniques, providing surgeons with evidence for optimum pharyngeal closure following a laryngectomy to improve swallowing outcomes.