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PubMed1997

The techniques of nonmuscular closure of hypopharyngeal defect following total laryngectomy: the assessment of complication and pharyngoesophageal segment.

The usual method of reconstructing a hypopharyngeal defect during total laryngectomy includes pharyngeal muscle layer closure, which may result in high pharyngoesophageal pressure. We hypothesize that nonclosure of the pharyngeal muscle can reduce the pressure of the pharyngoesophageal segment which can reduce the chances of the formation of pharyngocutaneous fistulae. A technique of nonmuscular closure of a hypopharyngeal defect is presented. The differences in the rate of fistula formation and swallowing function between patients with usual and nonmuscular closure were also studied. Sixty consecutive laryngectomees were enrolled in this study. Thirty patients received usual closure after total laryngectomy, whereas the other 30 patients underwent non closure of their pharyngeal muscles. One patient (3.3 per cent) in the nonmuscular closure group and three patients (10 per cent) in the usual closure group developed a pharyngocutaneous fistula. The pharyngoesophageal pressures of the nonmuscular closure group were significantly lower than those of the usual closure group. We conclude that the technique of nonclosure of the pharyngeal constrictor muscle after total laryngectomy is relatively more simple and is not associated with a higher rate of fistula formation. Furthermore, nonclosure of the pharyngeal constrictor muscle is preferable to muscular closure because it reduces the spasm of the pharyngoesophageal segment which limits voice rehabilitation.

Cutaneous Fistula↗
PubMed1997

Management of the thyroid gland with laryngectomy for cT3 glottic carcinomas.

Is routine hemithyroidectomy justified in laryngectomy for laryngeal carcinoma? Hemithyroidectomy with laryngectomy causes hypothyroidism in up to 25% of patients, and if combined with radiotherapy, in up to 70%. In this review of 102 total laryngectomies with routine hemithyroidectomy for cT3 glottic carcinoma, laryngeal carcinoma involved the thyroid gland in two. Both had subglottic tumour extension. The tumour approached within 3 mm of the thyroid capsule in seven. It is proposed that thyroidectomy should be performed only in selected laryngeal carcinomas. Intraoperative assessment of the thyroid gland should determine the need for thyroidectomy in glottic and transglottic carcinomas. Carcinoma invasion of the thyroid gland should be confirmed by frozen section before proceeding to thyroidectomy. In the absence of thyroid gland involvement, both thyroid lobes may be preserved. Total thyroidectomy should be performed if the thyroid gland has been invaded. Total thyroidectomy should be routinely performed with subglottic carcinomas.

Adult↗
PubMed1999

Pulmonary function pre- and post-total laryngectomy.

Pulmonary function pre- and post-total laryngectomy was assessed in 16 patients without overt inspiratory stridor preoperatively. It could be shown that total laryngectomy is associated with a significant decrease in vital capacity and in an increase in inspiratory flow-volume values 9 days postoperatively. The inspiratory values tended to increase slightly over the next half year. The measured expiratory flow-volume values were preoperatively already significantly lower than the predicted values, and no significant changes could be observed immediately after the operation nor after 6 months. These alterations have to be taken into account when judging the pulmonary function after total laryngectomy.

Adult↗
PubMed2001

[Voice restoration with voice prosthesis after total laryngectomy. Assessment of survival time of 378 Provox-1, Provox-2 and Blom-Singer voice prosthesis].

UNLABELLED: Voice Restoration with Voice Prosthesis after Total Laryngectomy. Assessment of Survival Time of 378 Provox-1, Provox-2 and Blom-Singer Voice Prosthesis. BACKGROUND: Indwelling voice prosthesis are used in Trier for voice restoration after total laryngectomy since 1991. OBJECTIVE AND METHOD: To assess the voice prosthesis survival times the patients of the years 1993-1999 are assessed retrospectively. PARTICIPANTS: 58 patients provided with indwelling voice prosthesis were seen regularly at follow-up. 378 prosthesis were changed. Provox 1, Provox 2 and Blom-Singer-Prostheses were used. RESULTS: The average survival lifetime of the prosthesis was 224 days for Provox-1, 96 days for Provox-2 and 107 days for Blom-Singer respectively. There is no significant difference found between Provox-2 and Blom-Singer Prosthesis. The survival times of the Provox-1 Prosthesis is significant longer. CONCLUSION: Using indwelling voice prosthesis for voice restoration after total laryngectomy an average survival time of the prosthesis of three months can be expected. There are relevant individual differences. Provox-1 Prosthesis have a significantly longer survival time, but as they are more difficult to handle they are not suitable for routine use. The indication for the choice between Blom-Singer or Provox-2 Prosthesis should be influenced by the surgeons' experience.

Adult↗
PubMed1995

[Examination technique of ultrasound follow-up of pharyngeal closure after laryngectomy].

BACKGROUND: The pharyngocutaneous fistula presents the most common complication after laryngectomy. Despite applying methods of pharyngeal closure, local factors such as irradiation may cause healing disturbances and the development of pharyngeal fistula. Before the nasogastric feeding tube is removed, an additional radiologic control with water-soluble contrast medium is recommended in literature in case of normal clinical healing. METHODS: The radiologic method was compared with a newly developed sonographic examination technique. Using the so-called "aerophagia maneuver" in sonography, an arising of peripharyngeal air before the "aerophagia maneuver" or a peripharyngeal mass lesion was an uncertain criterion for a pharyngeal fistula. Peripharyngeal air may be seen also due to infection with anaerobic bacteria, and peripharyngeal mass lesion may be caused by seroma or hematoma. In sonography, tissular air is seen typically, in a hyperechoic reflex with distal repetitions. RESULTS: Radiologic examination of the pharynx in 18 laryngectomy patients revealed fistulas in three cases. CONCLUSIONS: Our experiences have shown so far that sonographic examination in combination with the so-called "aerophagia maneuver" prove to be reliable or ascertaining pharyngeal closure after laryngectomy.

Cutaneous Fistula↗
PubMed2001

Aquatic activities after total laryngectomy.

OBJECTIVE: To assess the techniques used by patients who have undergone laryngectomies to enable them to participate in aquatic activities. STUDY DESIGN: Unstructured interviews. METHODS: The case histories of 4 patients who have returned to swimming and other aquatic activities after total laryngectomy were obtained by nonstructured interviews emphasizing techniques used to swim, safety precautions taken, any accidents or near accidents, and perceived effect of aquatic activities on sense of well being and quality of life. RESULTS: All 4 of the interviewed subjects swim regularly using commercial breathing aids or manual tracheostomal occlusion. One of the four is a regular surfer, who uses a homemade breathing aid. All were active swimmers prior to the development of laryngeal cancer. A single aquatic-related accident was reported by 1 of the 4 swimmers. All subjects describe feeling an enhanced quality of life resulting from their participation in aquatic activities. CONCLUSION: Despite recommendations of most clinicians, a small number of highly motivated patients will return to aquatic activities after laryngectomy.

Aged↗
PubMed2002

Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx.

OBJECTIVE: Stomal recurrence after total laryngectomy is one of the most serious issues in the management of laryngeal carcinoma. The management of stomal recurrence, including chemotherapy, radiotherapy, and surgery, has been reported as unsatisfactory. STUDY DESIGN AND SETTING: From 1985 to 1995, 69 patients underwent total laryngectomy for the treatment of laryngeal cancer at the University of Tokyo Hospital. To identify the risk factors for stomal recurrence, we analyzed these patients according to various clinicopathological factors. RESULTS: Stomal recurrence developed in 6 of 69 patients who underwent total laryngectomy for laryngeal carcinoma. Statistical analysis reveals that primary site, preoperative tracheotomy, and paratracheal lymph node metastasis are significant risk factors for stomal recurrence. CONCLUSION: Intensive follow-up should be performed for patients with glottic carcinoma who had preoperative tracheotomy, paratracheal lymph node metastasis, or both to detect stomal recurrence at an early stage.

Adult↗
PubMed2005

Supracricoid laryngectomy with cricohyoidopexy for recurrence of early-stage glottic carcinoma after irradiation. Long-term oncological and functional results.

CONCLUSIONS: These results suggest that, in selected cases, SCL-CHP may be used to treat laryngeal carcinomas after radiation failure, with good oncological and functional results. OBJECTIVES: Radiotherapy and surgery are believed to be equally effective and highly successful in the management of T1-staged glottic carcinomas. An almost normal post-therapy voice is considered the main advantage of irradiation over the surgical approach. On the other hand, when a tumour recurs after radiotherapy, it is more likely to extend beyond its original site, making total laryngectomy necessary in most cases. However, in selected cases, conservative laryngeal surgery is possible. At present only a few reports in the literature have documented the oncological and functional outcome of supracricoid laryngectomy with cricohyoidopexy (SCL-CHP) in the treatment of laryngeal recurrence after irradiation. MATERIAL AND METHODS: We describe seven cases of rT2-T3 laryngeal squamous cell carcinomas that recurred after radiotherapy and were treated with salvage SCL-CHP between 1989 and 1997 at the Department of Otolaryngology, University of Ferrara. The disease-free interval following initial radiotherapy ranged from 13 to 132 months (mean 54 months) in 6 patients; 1 patient underwent 2 courses of irradiation treatment 103 and 8 months prior to surgery. RESULTS: The mean post-SCL-CHP follow-up period exceeded 10 years (range 72-173 months). Only the patient who underwent 2 courses of radiation therapy before surgery experienced laryngeal recurrence 48 months after surgery. All patients were decannulated and recovered the ability to swallow. Vocal quality was significantly rough and breathy but was satisfactorily intelligible in all patients. Four patients had wound healing problems; 1 of them developed a laryngotracheocutaneous fistula 15 months after SCL-CHP as a consequence of chondronecrosis, prompting total laryngectomy.

Aged↗
PubMed2002

Rehabilitation after laryngectomy: a practical approach and guidelines for patients.

BACKGROUND: Laryngectomy causes irreversible loss or distortion in basic human habits, such as speech, swallowing, smelling, tasting, coughing and kissing. Rehabilitation can help a patient to reach the maximal potential within the context of his or her social milieu. Learning and adapting the lifestyle of living after laryngectomy is a challenge that faces the patient and the doctor. METHOD: The authors' Head and Neck Cancer Center treated more than 100 laryngeal carcinomas with laryngectomy during a five-year period. A multidisciplinary group was established for the education and rehabilitation of laryngectomized patients in order to provide them with the best possible overall quality of life. The group's rehabilitation program is described.

Home Care Services↗
PubMed2005

Some characteristics of voice in near-total laryngectomy.

Some vocal characteristics were compared in two groups of examinees: patients after near-total laryngectomy and a control group of healthy examinees. Acoustic analysis was carried out using Multi Dimensional Voice Program and Spectra LAB program. Analyzed parameters were: fundamental frequency, the range of fundamental frequency, maximum phonation time, jitter, shimmer, noise to harmonic ratio, voice turbulence index, degree of voice breaks and intensity of voice. We found that voice after near-total laryngectomy had normal mean fundamental frequency, larger range of fundamental frequency, jitter and shimmer were high, as were noise to harmonic ratio and voice turbulence index. Maximum phonation time was short and intensity was lower compared to control group. Degree of voice breaks was significant in near-total laryngectomy group.

Adult↗
PubMed2002

Olfactory acuity after total laryngectomy.

The olfactory acuity of 29 patients receiving laryngectomy was prospectively studied. The olfactory acuity was evaluated by Jet Stream Olfactometer (JSO) and Alinamin test preoperatively and at 3, 6 and 12 months postoperatively. The findings of nasal/olfactory mucosae were also observed by rigid endoscope. Based on the results of JSO, the averages of detection/recognition thresholds tended to increase 3 months postoperatively, then the averaged thresholds tended to decrease thereafter. There were significant differences between preoperative values and those 3 months after surgery, but there were no significant differences between preoperative values and these 6/12 months after surgery. Nasal respiratory mucosae observed 12 months after laryngectomy showed atrophic nasal mucosa in 11/14 patients. However, olfactory mucosae appeared normal in all of the patients observed. These results suggested that the function of the olfactory epithelium remained intact after laryngectomy.

Aged↗
PubMed1999

The difference between delayed extubation and tracheostomy in post-operative sleep apnea after glossectomy or laryngectomy.

BACKGROUND: Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin. Post-operatively, it is possible that the patients have problems respiring comfortably. In addition to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the possible change in their post-operative respiration, we monitored the patient's respiratory pattern with an apnea monitor. METHODS: We attached an apnea monitor to the patients and recorded their respiratory pattern and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior to the operation, one day before the operation, the day of operation, two days after, and on the fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next morning. RESULTS: Sixteen patients completed this study. The patients whose tube was extubated after glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin graft after glossectomy and laryngectomy. CONCLUSION: Further studies are required to improve the patient's respiration during their sleep after tracheal extubation in glossectomy.

Aged↗
PubMed1991

Larynx preservation using induction chemotherapy plus radiation therapy as an alternative to laryngectomy in advanced head and neck cancer. A long-term follow-up report.

Since 1977, we have used induction chemotherapy (CT) plus radiation therapy (RT) with curative intent in 35 advanced head and neck cancer (Ca) patients who otherwise would have required total laryngectomy. Fourteen patients had advanced Ca of the larynx or supraglottic larynx (SGL); 21 patients had Ca of the hypopharynx. In six patients the Ca was Stage III; in 26 patients it was Stage IV. Three patients had Stage II disease--2 with cancer of the pyriform sinus and one patient with Stage II SGL Ca who refused surgery. Chemotherapy consisted of platinum (P) + bleomycin in 18 patients until 1982, then P + fluorouracil in the next 17 patients. Total response rate was 77%--complete (CR) in 26% and partial (PR) in 51%. There were two toxic deaths. Surgery was limited to tracheostomy in 4 patients prior to CT and to radical neck dissection after CT in 4 others. Two patients required salvage laryngectomy at 11 and 31 months, respectively. One patient underwent partial laryngectomy with voice preservation. Thirty-two patients were evaluable for overall response after RT. Final disease-free status was achieved in 20/34. One long-term survivor was lost to follow-up (44 months) and 8 patients remained alive at 13+ to 109+ months. Median failure-free survival for all patients was no less than 24 months. Not counting 4 early deaths free of disease, 2-year local control using only chemotherapy plus radiation was 52% (16:31). Overall, 33 of 35 patients retained their voices. Sixteen patients (46%) have survived 2 years or longer. Survival of patients who achieved CR after induction chemotherapy was 48 months versus 14 months for those with less than a CR (p = 0.001). Patients with a hypopharyngeal primary had only a 33% 2-year local control rate with chemotherapy and radiation and a median survival of only 12 months versus 77% control and a minimum 39-month survival for those whose tumor arose in the larynx (p = 0.009). Induction chemotherapy plus radiation therapy is an effective strategy which can produce a high rate of larynx preservation, local control, and long-term survival in patients with advanced cancer of the larynx. Patients with hypopharyngeal primaries have a lesser rate of long-term survival and local control, despite similar overall response rates.

Aged↗
PubMed1998

Supracricoid partial laryngectomies in the elderly: mortality, complications, and functional outcome.

A review of the postoperative course, complications, and functional outcome of 69 elderly patients (older than 65 years of age) consecutively managed with a supracricoid partial laryngectomy between 1977 and 1993 is presented. The tumors were glottic and supraglottic in origin in 53 and 16 patients, respectively. A cricohyoidoepiglottopexy, a tracheo-cricohyoidoepiglottopexy, and a cricohyoidopexy were performed in 48, five, and 16 patients, respectively. Immediate laryngeal, cervical, and medical complications were noted in 5.8%, 10.2%, and 10.2% of patients, respectively. Supracricoid partial laryngectomies never resulted in perioperative or postoperative death. The 5-year actuarial survival and local control estimates were 68%, and 93.9%, respectively. Late surgical complications included laryngocele, laryngeal stenosis, and pneumonia from aspiration-related death in 4.3%, 4.3%, and 1.4% of patients, respectively. Completion total laryngectomy, permanent gastrostomy, and permanent tracheostomy were requested in 1.4%, 1.4%, and 2.91% of patients, respectively. Overall a 92.8% laryngeal preservation rate was achieved. Univariate analysis of the potential correlation of different factors with the mortality incidence and causes, the incidence and type of the various complications, and the incidence for postoperative aspiration is presented.

Actuarial Analysis↗
PubMed1998

Local failure after supracricoid partial laryngectomy: symptoms, management, and outcome.

The medical files of 15 patients with local recurrence after supracricoid partial laryngectomy consecutively managed at Laënnec Hospital were reviewed. The clinical symptoms and the laryngeal computed tomography appearance of local recurrence, as well as the salvage treatment performed, are presented. The main presenting symptom was dyspnea. None of the local recurrences was considered to be unresectable. One patient refused any form of salvage treatment. Radiation therapy and salvage total laryngectomy were the options retained for local salvage. A minimum 5-year follow-up was always achieved. In patients who underwent salvage total laryngectomy, perioperative or postoperative death and postoperative pharyngocutaneous fistula were not encountered. The 5-year survival was 33.3%. The local control rate was 66.6%. The percentage of patients who experienced nodal recurrence was 26.6%, and the distant metastasis estimate was 53.3%. The cause of death was distant metastasis in eight patients, local recurrence in two, and intercurrent disease in one. Peristomal recurrence was not encountered. Overall, 80% local control and 6.6% laryngeal preservation rates were achieved.

Adult↗
PubMed1999

Management of the N0 neck during salvage laryngectomy.

BACKGROUND: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated. OBJECTIVE: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy. STUDY DESIGN: Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection. METHODS: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y). RESULTS: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries). CONCLUSIONS: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Adult↗
PubMed1999

Three-dimensional imaging of the speaking shunt in patients with near-total laryngectomy.

OBJECTIVES: Near-total laryngectomy with creation of a speaking shunt is generally considered suitable treatment for most T3 and some T4 laryngopharyngeal cancers. In some patients, poor speech production by the shunt can be problematic and usually means that a shunt lumen is stenotic or too small. Conventional axial computed tomography (CT) of the neck is of little value in predicting the shunt function and the patency of the shunt lumen. Such defect, however, can be better overcome if the spiral CT is used. STUDY DESIGN: This study was designed to evaluate the dynamic speaking shunt by spiral CT and a three-dimensional (3-D) imaging model of the upper airway in 59 near-total laryngectomies. METHODS: During scanning, the patients were asked to make a single, 20-second phonation. A high-quality 3-D surface model was then rendered at an independent workstation. The 3-D model took on the appearance of the speaking shunt which could serve as a tracheopharyngeal fistulography. RESULTS: 3-D reconstruction of the images could clearly demonstrate the dynamic anatomy and patency of the speaking shunt. We found the 3-D model to be of diagnostic value, particularly in the near-total laryngectomy patients with stenotic shunts. The most common site of stenosis was at the top portion of the shunt. CONCLUSION: The 3-D image findings of the shunts significantly improved the assessment and therapies of the patients undergoing revision surgeries of the shunt stenoses.

Adult↗
PubMed1999

Vocal function after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap: durational and frequency measures.

OBJECTIVE: Compare vocal function following vertical partial laryngectomy (VPL) with or without glottic reconstruction by false vocal fold (FVF) mucosal flap. STUDY DESIGN: Twenty-seven patients with Tla squamous cell carcinoma (SCC) of the glottis were included in a prospective randomized clinical study. All patients were treated by frontolateral partial laryngectomy (FLPL). Glottic reconstruction with FVF mucosal flap was performed in 14 patients at the time of the FLPL, whereas 13 patients had standard FLPL. METHODS: Objective voice assessment was based on computerized acoustic recordings performed before and 1 year after surgery. When possible, additional recordings were performed at 3 months, 6 months, and 2 years postoperatively. Incidence of postoperative granuloma and anterior neoglottic web were noted. Repeated analysis of variance (ANOVA) was used to compare the durational (maximum phonation time, speech rate) and frequency measurements (average fundamental frequency [Fo], standard deviation of Fo, jitter, shimmer, noise-to-harmonics ratio, degree of voice breaks) between patients with or without glottic reconstruction, postoperative granuloma, and anterior neoglottic web. Linear regression was used to study the evolution over time of the durational and frequency measurements. RESULTS: Frequency measurements improved with time and were significantly better in patients treated with glottic reconstruction. In addition, glottic reconstruction decreased incidence of postoperative granuloma and anterior neoglottic web. CONCLUSIONS: The FVF mucosal flap technique can improve vocal results in selected cases of Tla SCC of the glottis when FLPL is the adequate surgical treatment. false vocal folds; glottic reconstruction; vertical partial laryngectomy; vocal function.

Adult↗