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PubMed1979

Manometry of the normal upper esophageal sphincter and its alterations in laryngectomy.

Rapid pull-through pressure profiles of the normal human upper esophageal sphincter (UES) were simultaneously studied with a conventional three-orifice Honeywell solid-state probe, an eight lumen radially perfused (RP) probe, and a circumferentially sensitive (CS) probe designed to measure UES pressure (UESP) without regard to probe orientation. Pressure curves were digitized and analyzed by computer. The Honeywell probe recorded significantly lower peak pressures than the other two methods, and had wide intrasubject pressure variations (average coefficient of variation, 53%). In contrast, UESP measured with the CS probe was constant for each subject (mean peak UESP, 121 mm Hg; average coefficient of variation, 15%). Anteroposterior RP probe UESP were identical to CS probe pressures. Thus, peak perfused anteroposterior UESP correlates with circumferentially measured sphincter squeeze.Computer programs were written that allowed RP probe pressures to be mapped in three dimensions. Normal three-dimensional maps were characterized by anteroposterior accentuation of peak pressures and also by consistent axial asymmetry with anterior peak pressures occurring 0.8+/-0.2 cm closer to the pharynx. After defining the normal two- and three-dimensional UESP configuration, patients who had undergone laryngectomy were studied. Peak pressures measured with the RP probe decreased to congruent with50 mm Hg and radial pressure asymmetry vanished. Like normals, CS probe pressures corresponded to peak RP probe pressures. UES length did not change significantly. Three-dimensional mapping showed that axial asymmetry also vanished. It therefore appears that the anatomic alterations produced by laryngectomy abolishes UESP asymmetry.

Adult↗
PubMed2004

Use of a "hands-free" tracheostoma valve in patients with laryngectomy and tracheoesophageal puncture.

The goals of the study were 1) to investigate the relationship between tracheal air pressure and the tracheostoma valve seal in patients with laryngectomy and tracheoesophageal puncture (TEP) and 2) to assess whether tracheal pressure contributes to the duration of the valve seal. Ten patients with TEP after laryngectomy underwent training with an outer Blom-Singer tracheostoma valve and a 30-day trial with this "hands-free" speaking valve. We found that tracheal pressure was not a significant predictor variable in assessing the duration of the outer tracheostoma valve seal achieved by the patients with TEP. Factors other than tracheal pressure appeared to affect the duration of the tracheostoma valve seal. Mastery of use of the tracheostoma valve, the subject's neck anatomy, and the amount of time, training, and experience that was given to each subject were significant predictors of the valve seal. Tracheal pressure measurements might be of use in deciding between a standard or a low-pressure outer tracheostoma valve for an individual patient.

Aged↗
PubMed2005

Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience.

On the basis of an inception cohort of 270 patients with a previously untreated invasive squamous cell carcinoma of the true vocal cord (232 T N0M0, 35 T2N0M0, and 3 T3N0M0) and a minimum of 3 years of follow-up, the authors analyze the oncological and functional outcomes following frontolateral vertical partial laryngectomy without tracheotomy. The 5-year Kaplan-Meier actuarial survival estimate ranged from 83.1% for T1 tumors to 67.2% for T2 tumors (p = .005). On univariate analysis, a significant statistical relationship was noted between reduced survival and the following variables: increased age, increased Charlson comorbidity index score over grade 0, increased tobacco intake, increased alcohol intake, increased T stage, local failure, nodal failure, and development of a metachronous second primary cancer. The hospital mortality rate was 0.4%. A significant postoperative surgical complication was noted in 49 patients (18.1%). The predominant significant surgical complication was wound infection (19 patients; 7%), followed by seroma and major subcutaneous emphysema. No significant statistical relationship was noted in a comparison of each, significant postoperative complication (including postoperative death) with the variables under analysis. The incidence of secondary tracheotomy was 0.4%. The incidence of completion laryngectomy due to functional problems was 0%. The 5-year Kaplan-Meier actuarial local control estimate was 91% for T1 tumors and 68.7% for T2 tumors (p <.0001). Within the T1 tumors, the 5-year Kaplan-Meier actuarial local control estimate ranged from 96.2% for tumors without anterior commissure involvement to 74.7% for tumors with anterior commissure involvement (p = .0002). On univariate analysis, a significant statistical relationship was noted between an increase in local recurrence and the following variables: increased T stage, anterior commissure involvement, and pathological margin involvement. The overall disease control rate and laryngeal preservation rate were 92.9% and 93.3%, respectively.

Age Factors↗
PubMed2006

Comparison of the glottic closure reflex in traditional "open" versus endoscopic laser supraglottic laryngectomy.

OBJECTIVES: Cancer of the supraglottic larynx may be surgically treated with either traditional "open" supraglottic laryngectomy (OSL) or endoscopic laser supraglottic laryngectomy (ELSL). Pharyngeal dysphagia is a well-documented consequence of traditional OSL from which near-normal swallowing characteristically recovers 14 to 40 days after surgery. Conversely, ELSL results in the resumption of serviceable swallowing within 2 to 7 days after surgery. METHODS: A prospective assessment of the glottic closure reflex in 6 consecutive patients who had ELSL was performed by fiberoptic endoscopic evaluation of swallowing with sensory testing. RESULTS: All 6 patients with ELSL demonstrated an intact glottic closure reflex both before surgery and 48 to 72 hours after surgery. In contrast, 7 of 8 historical control patients who had OSL demonstrated a persistent absence of the glottic closure reflex 3 weeks to 12 years later. CONCLUSIONS: Although a number of clinical factors influence swallowing recovery, one important factor separating our patient groups was the preservation of the glottic closure reflex in patients who underwent endoscopic laser resection. Because the loss of the glottic closure response persists for years after traditional OSL, it is concluded that the sensory field deficit caused by superior laryngeal nerve section is largely not recoverable; however, compensatory mechanisms remain important in serviceable recovery, even if delayed after operation. Indeed, preservation of the glottic closure response appears to enhance swallowing recovery when equivalent compensatory mechanisms are used.

Adult↗
PubMedDate not supplied

Neoglottic reconstruction after total laryngectomy: a preliminary report.

This paper is a preliminary report on neoglottic reconstruction of the larynx after total laryngectomy following the techniques described by Staffieri. Also included are general observations on the criteria for selecting candidates for this procedure. At the University of Texas Medical Branch in Galveston, this procedure has been attempted on eight candidates. Reconstruction was accomplished in six, of whom five achieved satisfactory speech, providing an 80% success rate. One of the five did not like the quality of his voice and refused to use it. The sixth produced speech with difficulty and is still undergoing speech therapy. One patient died from recurrence before a second stage could be carried out, and another patient did not have sufficient tissue for neoglottic reconstruction after total laryngectomy. Three patients developed salivary fistulas at the drain site, but all closed spontaneously with the application of pressure. From this data, one may conclude that this technique offers much potential and warrants further study.

Aged↗
PubMedDate not supplied

Stomal recurrence following laryngectomy: a critical evaluation.

Recurrent tumor in or around the tracheal stoma following laryngectomy almost always terminates in a fatal outcome. Several investigators have attempted to determine the factors that predispose a patient to stomal recurrence, but their conclusions are not entirely in agreement. The records of 251 consecutive laryngectomy patients treated at the UCLA Hospital between 1955 and 1977 were reviewed. The variables evaluated included type of operation, preoperative tracheostomy, interval from operation to recurrence, presence of neck metastases, performance of thyroidectomy, site of lesion, and control of tumor margins. While certain events, such as preoperative tracheostomy, appeared more frequently than others in the stomal recurrence patients, no single factor or group of factors could explain all the recurrences. It appears that stomal recurrences arise from heterogeneous causes. Good planning and utilization of the principles outlined should reduce the incidence of this dreaded complication.

Adult↗
PubMedDate not supplied

Neoglottic reconstruction following total laryngectomy. A reappraisal.

The purpose of this paper is to analyze the problems and complications which have resulted from neoglottic reconstruction at the University of Texas Medical Branch in Galveston. It has been performed as a primary procedure at the time of laryngectomy of 50 patients. Over 40% of these patients have required a second operative procedure to control major complications of their neoglottis. Aspiration is a nearly constant feature of the procedure, and a significant number of patients do not tolerate it well. Radiation therapy does not appear to increase the number of problems, but the complications are more severe when they do occur, and they are more difficult to control. The indications for surgical neoglottic reconstruction cannot be extended beyond those tumors which are within the confines of the larynx without an increased incidence of major complications. Other relative contraindications to this surgery are poor patient pulmonary reserve, reflux esophageal incompetence, and a "hyperactive" gag reflex. Nine patients with prior treatment which included a total laryngectomy underwent secondary neoglottic reconstruction. In our experience, all have had significant aspiration. About one half of these patients developed speech. The procedure of neoglottic reconstruction must be reviewed critically prior to popular introduction into the surgical armamentarium. A plea for careful study by a small number of experienced surgeons is now in order.

Glottis↗
PubMedDate not supplied

Total laryngectomy with tracheopharyngeal fistula (neoglottis).

Our experience with the so-called "neoglottis" (according to Staffieri) after total laryngectomy is presented. The technique, described in detail, aims at giving the patient good speech by creating a tracheoesophageal fistula through which air passes. In the period from 1973-1979, 63 patients underwent the procedure. The functional results were satisfactory in 68% of the cases. The patient's voice is much more agreeable than the esophageal voice and sounds louder and less monotonous than a laryngophone voice. The spectrographic analyses confirm its resemblance to natural voice. An occasional passage of liquids into the trachea may occur, but is not prejudicial to either speech or swallowing. Some dysfunctional problems may arise early or late after the operation: they are continuous aspiration during swallowing and lack of phonatory function. In most cases, these problems are due to incorrect surgical technique; the possibilities and procedures of correction are described. In conclusion, we maintain that the "neoglottis" which may be applied to nearly all cases of total laryngectomy, represents a worthwhile "phonatory" innovation in the field of mutilating surgery of laryngeal cancer.

Adult↗
PubMedDate not supplied

Surgical and radiological effects upon the development of speech after total laryngectomy.

The data presented examine the relationship between postlaryngectomy communication method, and the extent of total laryngectomy and the use of radiation therapy. The expectations of speech therapy providers were also examined. The author interviewed 60 laryngectomy patients who were six months to 3 1/2 years postsurgery. Surgeries were grouped into four categories and correlated with communication method. The relationship was statistically significant with the most apparent deterrent effect exhibited only for the most extreme surgical excisions. There was no relationship with the use of radiation therapy. In many cases speech therapy providers' expectations were not supported by the data.

Humans↗
PubMedDate not supplied

Imbrication reconstruction following partial laryngectomy.

Experience over a 16-year period with 38 patients who underwent partial laryngectomy with imbrication reconstruction is reviewed. We have found this technique to be an expeditious and highly successful means of eradicating T1 or T2 glottic cancer. The use of the patient's own full-thickness, adjacent normal tissue with imbrication of cartilage produces an adequate airway, an almost normal-appearing larynx, and a remarkable posttreatment voice quality, better results than from most cordectomies or vertical hemilaryngectomies. It is valuable as a salvage procedure after full-course radiation. Imbrication laryngoplasty is an alternative and a preferred modality for treatment of young people with early glottic carcinoma for whom the possible carcinogenic properties of radiation must be considered. The survival results are comparable with the more extensive vertical laryngectomies.

Glottis↗
PubMedDate not supplied

Long-term results of concurrent polychemotherapy and radiotherapy in patients with stomal recurrence after total laryngectomy.

From 1978 through 1985, eight patients with stomal recurrence after total laryngectomy were treated with a combination of a cytotoxic regimen (vincristin sulfate, bleomycin, and methotrexate [VBM]) and radiotherapy. The essential feature of this combination is the synchronous administration of pulses of VBM and fractionated doses of external radiotherapy in order to achieve potentiation of radiotherapy. On average, four to five pulses of VBM were given. Severe mucositis is the main problem during treatment. Two patients needed nasogastric tube feeding, and treatment was carried out as an inpatient procedure. Five patients are alive with complete local remission at 7 years, 3 years, 2 1/2 years, 14 months, and 8 months after treatment. These results appear to be spectacular, even though the number of patients is small. Of the three patients who died, only one had recurrent disease around the tracheostoma. The two other patients were free of disease in the neck when they died 6 and 16 months after treatment of, respectively, lung metastases and a second primary tumor in the lung. Patients with stomal recurrence after total laryngectomy are now routinely treated with synchronous VBM and radiotherapy.

Aged↗
PubMedDate not supplied

Deglutition following supraglottic horizontal laryngectomy.

In order to determine factors that may contribute to deglutition problems following supraglottic horizontal laryngectomy or its modified techniques, clinical records of 38 patients were studied. Contribution of the following factors was investigated: age; sex; tumor classification; radical neck dissection; extent of and symmetry in removal of the aryepiglottic folds, arytenoid cartilages, and false folds; removal of the base of the tongue, hyoid bone, and a part of the vocal folds; extent of removal of the epiglottis and thyroid cartilage; cricopharyngeal myotomy; and some complications and concomitant diseases. The results suggest that removal of the arytenoid cartilage and asymmetrical removal of the false folds contribute to deglutition problems. We conclude that the standard supraglottic horizontal laryngectomy associated with surgical approximation of the larynx to the base of the tongue and cricopharyngeal myotomy does not usually cause serious deglutition problems. When the arytenoid cartilage is removed, reconstruction of the structure is required for the prevention of severe aspiration.

Aged↗
PubMed1989

Applications of the voice prosthesis during laryngectomy.

With the recent introduction of the voice prosthesis for alaryngeal speech rehabilitation, its application in the early postlaryngectomy period is gaining acceptance. One hundred twenty-eight patients received a tracheoesophageal puncture and adjunctive pharyngeal constrictor relaxation during laryngectomy. The voice prosthesis was applied as early as 10 days after surgery, and the results of a 9-year experience are presented. Eighty percent of the population achieved a durable voice, and the complications were infrequent. The results support the primary use of tracheoesophageal phonation as a relatively safe and reliable alternative to total laryngectomy alone.

Adult↗
PubMed1990

Jejunal interposition for repair of stricture or fistula after laryngectomy.

Complications following total laryngectomy may include pharyngocutaneous fistula or pharyngeal stricture. Traditional techniques of repair of fistula and stricture with local or regional flaps lead to a high rate of failure. In this study, we report 18 patients treated by secondary jejunal interposition (JI) to rehabilitate swallowing following recalcitrant postlaryngectomy stricture or fistula. All patients had undergone total laryngectomy with or without partial pharyngectomy for treatment of squamous cell carcinoma of the larynx (8) or hypopharynx (10). Four were stage II; 5, stage III; and 9, stage IV. Thirteen patients (72%) regained swallowing function. Complications of secondary JI included perioperative death (2), flap loss (1), and persistent fistulas (3). Jejunal interposition may be the best modality in the rehabilitation of swallowing in patients with persistent fistula or stricture that fails to respond to traditional management.

Aged↗
PubMed1990

Use of the nasogastric tube after total laryngectomy: is it truly necessary?

The nasogastric tube has been routinely used to feed the patient during the first postoperative days after a total laryngectomy. In the last 21 years the author has performed 625 total laryngectomies without using the feeding tube. With this procedure oral feeding could be started during the third postoperative day, making the patient more comfortable and confident. In addition, the hospital stay was shortened. It was also observed that the incidence of pharyngeal fistulas (9%) was comparable to that of other reports in the literature.

Evaluation Studies as Topic↗
PubMed1990

Medical complications in total laryngectomy: incidence and risk factors.

The prevention and management of medical complications are important components in the surgical treatment of head and neck malignancies. We retrospectively evaluated the postoperative medical complications in 414 patients who underwent total laryngectomy between 1973 and 1987. The mortality rate was 1.2% (five deaths); while major, nonfatal medical complications occurred in 6.3% (24 of 384 patients)--seven strokes, three myocardial infarctions, two pulmonary emboli, and 12 respiratory failures requiring mechanical ventilation. Elderly patients did not experience more frequent or more severe medical complications, and the overall pattern of complications was different from that of other surgical specialties. Only specific cardiovascular and pulmonary risk factors were associated with these complications. We conclude that medical complications are a significant cause of morbidity in total laryngectomy; a focused preanesthetic risk factor analysis by a medical team familiar with head and neck cancer patients assures prompt identification and management of these complications.

Adult↗
PubMed1994

Pharyngocutaneous fistula after total laryngectomy: incidence, cause, and treatment.

Postoperative pharyngocutaneous fistula is a major complication of total laryngectomy that prolongs the short hospitalization of 2 to 3 weeks to many weeks or even months. It is a common complication that increases the morbidity and mortality of the procedure. In the Department of Otolaryngology of the Red Cross Hospital of Athens, 310 patients underwent total laryngectomy from January 1980 through December 1989. Twenty-eight patients developed a fistula (incidence 9%). The incidence, predisposing factors, and methods of treatment of this complication are analyzed and discussed.

Carcinoma, Squamous Cell↗
PubMed1995

Nasotracheal airway-oropharyngeal alimentary canal: a microvascular technique for reconstruction of the upper airway after total laryngectomy.

Every patient who has to be laryngectomized because of a carcinoma is concerned with the loss of his or her voice and the presence of a permanent tracheostoma in his or her neck. While various methods for producing a substitute voice are available (esophageal voice, voice devices, voice-shunt operations with or without voice prosthesis), it is usually impossible after laryngectomy to reconstruct a complete upper airway so that the tracheostoma can be closed. One potential method for reconstruction of the airway is its division into a nasotracheal airway and an oropharyngeal alimentary canal. Ten Alsatian dogs were laryngectomized, and a microvascularly anastomosed jejunal autograft was inserted as a junction between the tracheal stump and the circularly exposed nasopharynx, while the pharynx was reconstructed separately. One week postoperatively, oral feeding could be started again; at the same time breathing was possible via the reconstructed nasotracheal airway, which was kept open by insertion of a silicone tube. By means of this microvascular technique, a complete nasal airway could be reconstructed surgically after laryngectomy.

Anastomosis, Surgical↗