Questionnaire analysis of the swallowing-related outcomes following total laryngectomy

Diagnosis and treatment of oropharyngeal dysphagia after total laryngectomy with or without pharyngoesophageal reconstruction: Systematic review

Background

This systematic review qualitatively summarizes the current literature on diagnosis and treatment of oropharyngeal dysphagia (OD) after total laryngectomy (TLE).

Methods

Electronic databases PubMed, Embase, and the Cochrane Library were used. Two independent reviewers carried out the literature search and assessed the methodological quality of the included studies using a critical appraisal tool.

Results

Forty‐four articles met the inclusion criteria. Of these, 35 studies were on diagnosis, four on therapy, and five on both diagnosis and treatment of OD following TLE. Study aims, swallowing‐assessment methods, and main findings of the included studies were summarized and presented.

Conclusions

The reviewers found heterogeneous outcomes and serious methodological limitations, which prevented us from pooling data to identify trends that would assist in designing best clinical practice protocols for OD following TLE. Further research should focus on several remaining gaps in our knowledge on diagnosis and treatment interventions for OD following TLE.

Standard or individualized quality of life for larynx cancer patients?

Locally advanced larynx cancer benefits from curative surgery therapy. Clinical trials have been proposed for assessing the quality of life for patients with larynx malignant neoplasia who underwent radical surgery. The removal of the “voice box” is known to have great impact on the social reintegration of these patients as well as psychological distress. The presence of tracheostomy and voice impairment are two of the major issues that need to be thought of by patients that will have a total laryngectomy. The quality of life is a multi-dimensional subjective and personal concept which includes normal physical activity, looks, psychological status, somatic symptoms and, non the less, sexual activity. Cancer free survival intervals for patients with larynx cancer must be evaluated physical and psychological modifications with particular considerations to stress, anxiety and depression related symptoms and to functional rehabilitation adaptation regarding swallowing and speech. Oncology surgeons must consider that QoL is impaired in all patients with larynx cancer that benefit from total laryngectomy. However, there is evidence presented below that the difference in QoL parameters is small when comparing radical surgery, total laryngectomy, and larynx conservation by radio and chemotherapy.

How do voice restoration methods affect the psychological status of patients after total laryngectomy?

OBJECTIVE

This study investigated the relationship between psychological well-being and different voice rehabilitation methods in total laryngectomy patients.

METHODS

The study enrolled 96 patients who underwent total laryngectomy. The patients were divided into three groups according to the voice rehabilitation method used: esophageal speech (24 patients); a tracheoesophageal fistula and Provox 2 voice prosthesis (57 patients); or an electrolarynx (15 patients). The participants were asked to complete the Turkish version of the Voice Handicap Index-10 (VHI-10) to assess voice problems. They were also asked to complete the Turkish version of the Perceived Stress Scale (PSS), and the Hospital Anxiety and Depression Scale (HADS). The test scores of the three groups were compared statistically.

RESULTS

Patients who used esophageal speech had a mean VHI-10 score of 10.25 ± 3.22 versus 19.42 ± 5.56 and 17.60 ± 1.92 for the tracheoesophageal fistula and Provox 2 and electrolarynx groups respectively, reflecting better perception of their voice. They also had a PSS score of 11.38 ± 3.92, indicating that they felt less stressed in comparison with the tracheoesophageal fistula and Provox 2 and electrolarynx groups, which scored 18.84 ± 5.50 and 16.20 ± 3.49 respectively. The HADS scores of the groups were not different, indicating that the patients' anxiety and depression status did not vary.

CONCLUSION

Patients who used esophageal speech perceived less stress and were less handicapped by their voice.

'Endoflip® evaluation of pharyngo-oesophageal segment tone and swallowing in a clinical population: a total laryngectomy case series'

OBJECTIVES

To evaluate safety of positioning and distending the functional lumen imaging probe in the pharyngo-oesophageal segment in adults with known pharyngo-oesophageal segment dysfunction and to obtain preliminary measurements of pharyngo-oesophageal segment distensibility and opening during swallowing in a clinical group.

METHODS

Prospective case series of ten adults post total laryngectomy (61-75 years) recruited from an outpatient ENT clinic. Functional lumen imaging probe was inserted trans-nasally, and the balloon was positioned in the pharyngo-oesophageal segment. Two 20-mL ramp distensions were completed, and subjects performed two dry and two 5-mL and 10-mL liquid swallows at a 12-mL balloon volume. Pharyngo-oesophageal segment distensibility was calculated from cross-sectional area (mm(2) ) and intraballoon pressure (mmHg) measures. During swallowing, extent (mm) and duration (secs) of pharyngo-oesophageal segment opening and intraballoon pressure drop (mmHg) were evaluated.

RESULTS

Functional lumen imaging probe could be passed through the pharyngo-oesophageal segment in seven subjects, all of whom completed the protocol. During distensions, pharyngo-oesophageal segment cross-sectional area increased significantly (19.47-148.3 mm(2) , P < 0.001), and intraballoon pressure increased significantly (15- to 20-mL balloon volume, P = 0.005). Pharyngo-oesophageal segment diameter (5.1 mm) increased during dry (7.4 mm), 5-mL (7.3 mm) and 10-mL (7.7 mm) liquid swallows (P = 0.018). Pharyngo-oesophageal segment opening duration varied across dry (1 s), 5-mL (0.8 s) and 10-mL (1.6 s) liquid swallows. Resting intraballoon pressure (25.5 mmHg) did not alter significantly during swallowing (P = 0.656).

CONCLUSION

Functional lumen imaging probe provides novel quantitative information regarding pharyngo-oesophageal segment distensibility and opening during swallowing in adults post total laryngectomy. No adverse events were observed in this first clinical study. Data were easy to acquire, and measures may direct candidacy for and establish effectiveness of interventions to alter pharyngo-oesophageal segment tone.

Injection of botulinum toxin for the treatment of post-laryngectomy pharyngoesophageal spasm-related disorders

Introduction Pharyngoesophageal spasm (PES) can cause dysphagia, central valve leak (CVL), and dypshonia in post-laryngectomy patients. Botulinum toxin has been used effectively for the treatment of PES, but data regarding patient-reported outcomes and efficacy for CVL are limited. We evaluated the results of botox injection for PES spasm using subjective and objective measures. Methods Data were collected prospectively (February 2010 to August 2013) on 13 patients undergoing botox injection for PES as identified by video fluoroscopy. We collected digital voice recordings, air-pressure measurements (APMs) for speech, and quality of life (QoL) data before and after the procedure: University of Washington QoL questionnaire (UW-QoL), MD Anderson Swallowing Inventory (MDADI) and the Voice Handicap Index (VHI-30). Results APMs for a sustained vowel decreased by 18% after botox injection, whereas maximum phonatory times increased by 63% (mean increase, 8 to 13 seconds). Sustained vowel amplitude decreased (mean, 87db to 83db) with an associated reduction in sustained vowel frequency (117Hz to 77Hz). MDADI scores improved by 10.2% overall, and UW-QoL scores showed an improvement in score of 7.6%. Mean scores for VHI-30 deteriorated by 2% overall but, when considering only those patients experiencing dysphonia, an improvement of 9.4% was seen. There was an overall net reduction for the CVL cohort of 12 speech valves in the year after injection. Conclusions Our series confirm the safety and objective efficacy of botox injection for PES. QoL measurements were less convincing, and this disparity between subjective and objective measurements must be considered when treating such patients.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire)

OBJECTIVES

To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation.

DESIGN

This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS).

SETTING

Large urban teaching hospital.

PARTICIPANTS

Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients.

MAIN OUTCOME MEASURE

Preliminary validation of SOAL questionnaire.

RESULTS

Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03).

CONCLUSIONS

The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

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.

Acupuncture for dysphagia after chemoradiation in head and neck cancer: rationale and design of a randomized, sham-controlled trial

INTRODUCTION

Dysphagia is a common side effect following chemoradiation therapy (CRT) in head and neck cancer (HNC) patients. Current dysphagia management includes swallowing therapy and dilation procedures, but these treatments have limitations. While acupuncture has been reported to positively impact swallowing function and quality of life (QOL) in patients with dysphagia, current evidence is inconclusive.

MATERIAL AND METHODS

In an ongoing trial, 42 squamous cell carcinoma HNC patients, who are receiving platinum-based CRT with curative intent, are being recruited from a comprehensive cancer center. They are randomized to 12 sessions of either active acupuncture or to sham acupuncture during and following CRT over a 24-week period. Blinded research staff assesses outcomes at baseline, 20 weeks post-CRT (end of acupuncture), and 12 months after baseline (6-month follow-up). The primary outcome is change in M.D. Anderson Dysphagia Inventory score from baseline to 12 months. Secondary outcomes include QOL measures pertaining to HNC patients. In addition, a subset of study patients are tested for salivary flow rates and cytokines, including plasma transforming growth factor-β1 and interleukin 6 (n=10 per arm), to preliminarily explore the biological mechanisms of acupuncture for dysphagia.

DISCUSSION

This paper addresses unique challenges related to study design in nonpharmacological, sham-controlled acupuncture trials including development of evidence-based credible verum and sham treatment protocols, blinding, and assuring fidelity of treatment. Results of this study will inform the feasibility of conducting a large scale trial and will provide preliminary evidence regarding the value of acupuncture for dysphagia in HNC patients.

Quality of life after treatment of laryngeal carcinoma: a single centre cross-sectional study

INTRODUCTION

Laryngeal cancer treatment inherently affects life's most basic functions and significantly affects quality of life (QOL). We aimed to identify which aspects of QOL and which patients are most affected by the various treatment options.

METHODS

The University of Washington Quality of Life (UW-QOL) questionnaire was administered to all patients with laryngeal cancer treated at a single institution over a seven-year period (2003-2010).

RESULTS

In total, 41 patients responded. All had been treated for squamous cell carcinoma of the larynx. Questionnaires were completed at a median of 18.5 months after treatment. The overall quality of life was 81.1/100 as assessed by the UW-QOL scale, with only 4.9% reporting 'poor' or worse QOL. Neither patient age nor time after treatment significantly affected any aspect of QOL. Patients undergoing primary radiotherapy reported the best QOL. Those undergoing chemoradiotherapy or combined surgical treatment and chemoradiotherapy reported the worst QOL, particularly in terms of social eating, taste and saliva production. Patients with a T stage ≥2 and those with nodal metastases reported a significantly worse QOL.

CONCLUSIONS

Overall, QOL in our patients was good. This study highlights the aspects of QOL most affected by various treatments for laryngeal cancer and identifies areas in which therapeutic intervention may be focused. It also provides information to guide clinicians when assisting patients to make informed decisions regarding treatment of their head and neck cancer.

Functional status after total laryngectomy: cross-sectional survey of 79 laryngectomees using the Performance Status Scale for Head and Neck Cancer

Introduction:

Total laryngectomy affects patients' post-operative speech and swallowing functions. We aimed to assess these outcomes.

Materials and methods:

Patients' normalcy of diet, ability to eat in public and speech comprehensibility were assessed using the Performance Status Scale for Head and Neck Cancer, in a cross-sectional survey of disease-free laryngectomees.

Results and analysis:

Seventy-nine laryngectomees (72 men and seven women), with a mean age of 64 years (range 37 to 96), were included. Mean scores were 81.6 (standard deviation 29.2) for normalcy of diet, 77.8 (standard deviation 30.2) for eating in public and 65.2 (standard deviation 23.5) for speech. Normalcy of diet achieved higher scores within six months of laryngectomy and remained stable. There was a statistically significant difference between scores for the speech and public eating domains, comparing patients less and more than six months post-laryngectomy. This trend was maintained beyond 12 months.

Conclusions:

In post-laryngectomy patients, Performance Status Scale for Head and Neck Cancer scores improved over time, especially those for the speech and public eating domains, reflecting increasing confidence in social interactions and familiarity with surgical voice restoration.

The impact of radiotherapy on swallowing and speech in patients who undergo total laryngectomy

OBJECTIVES

Quality of life studies have shown no detrimental effect with radiotherapy (RT) in patients who have a total laryngectomy. We wished to determine the effect of RT (initial or postoperative) specifically on the swallowing and voice function in patients treated by total laryngectomy (TL) for carcinoma of the larynx.

DESIGN

Multicenter chart review.

SETTING

Multicenter study in the Greater Manchester and Lancashire area.

PARTICIPANTS

A total of 121 postlaryngectomy patients all of whom had completed definitive treatment at least 6 months before this study. Twenty-six patients had total laryngectomy as a single modality treatment and 95 had total laryngectomy and radiotherapy.

MAIN OUTCOME MEASURES

Swallowing (solid food, soft diet or fluid/PEG) and voice development.

RESULTS

Swallowing was better in the group who had no radiotherapy (P = 0.0037). There was no difference in voice function between the two groups. We also demonstrated that females had a worse swallowing outcome (P = 0.0101), as did advanced nodal stage (P = 0.001).

CONCLUSIONS

RT adversely affects the swallowing results but not the speech results after TL when given either as initial treatment or postoperatively. This should be kept in mind in the decision-making process in the treatment of patients with carcinoma of the larynx.

Changes and challenges to patients' lifestyle patterns following treatment for head and neck cancer

AIM

This paper is a report of a study to explore the changes and challenges to patients' lifestyles following treatment for head and neck cancer.

BACKGROUND

Head and neck cancer affects some of the most basic aspects of daily functioning, such as eating and speaking. There has been a rapid increase in the number of studies on the quality of life for people with head and neck cancer, but most studies have used quantitative methodology.

METHODS

Using a qualitative approach, data were collected in 2004 using semi-structured interviews with a purposive sample of 10 participants who had completed treatment 6-12 months earlier for head and neck cancer. A thematic analysis was employed to interpret the findings.

FINDINGS

Following thematic analysis seven broad themes were identified, five of which covered areas of changes and challenges to participants' lifestyles following treatment. These were: physical changes, concerns about cancer, work and day-to-day tasks, interpersonal relationships and social functioning. The concerns and challenges experienced following treatment were not limited to one aspect of an individual's lifestyle but spanned a number of the themes identified, highlighting the complexity of needs following treatment for head and neck cancer. The other two themes concerned personal attributes that facilitated or inhibited posttreatment coping and specific information needs in the posttreatment period.

CONCLUSION

Specific posttreatment concerns and challenges cannot be viewed as unitary or discrete aspects of life, but should be considered within a biopsychosocial context, to address patients' needs holistically.

Voice restoration following total laryngectomy by tracheoesophageal prosthesis: effect on patients' quality of life and voice handicap in Jordan

Background

Little has been reported about the impact of tracheoesophageal (TE) speech on individuals in the Middle East where the procedure has been gaining in popularity. After total laryngectomy, individuals in Europe and North America have rated their quality of life as being lower than non-laryngectomized individuals. The purpose of this study was to evaluate changes in quality of life and degree of voice handicap reported by laryngectomized speakers from Jordan before and after establishment of TE speech.

Methods

Twelve male Jordanian laryngectomees completed the University of Michigan Head & Neck Quality of Life instrument and the Voice Handicap Index pre- and post-TE puncture.

Results

All subjects showed significant improvements in their quality of life following successful prosthetic voice restoration. In addition, voice handicap scores were significantly reduced from pre- to post-TE puncture.

Conclusion

Tracheoesophageal speech significantly improved the quality of life and limited the voice handicap imposed by total laryngectomy. This method of voice restoration has been used for a number of years in other countries and now appears to be a viable alternative within Jordan.