Reflux as a cause of tracheoesophageal puncture failure

Patient factors associated with tracheoesophageal prosthesis complications: A retrospective TriNetX study

INTRODUCTION

Tracheoesophageal puncture (TEP) with voice prothesis placement is a common method for voice restoration following total laryngectomy (TL). This study aims to determine patient factors associated with the need for more frequent TEP changes and maintenance in addition to TEP-associated complications.

METHODS

Patients who underwent TEP procedure were identified in the TriNetX Research Network. Cohorts were stratified by comorbidities, including diabetes, GERD, esophageal stricture, hypo/hyperthyroidism, tobacco and alcohol use, radiation history, and primary versus secondary TEP. Kaplan-Meier analyses assessed time to prosthesis change, and risks of complications, including fistula formation, local infection, prosthesis leak, aspiration pneumonia, and dysphagia, were calculated.

RESULTS

Among 4145 patients identified, diabetes was associated with increased risk of prosthesis leak and dysphagia. Hypothyroidism, GERD, and esophageal strictures were linked to higher rates of fistula formation, infection, prosthesis leak, aspiration pneumonia, and dysphagia. Primary TEP was associated with increased fistula and infection rates compared to secondary TEP. Radiation and tobacco use were significantly associated with dysphagia, and tobacco and alcohol use with higher infection and aspiration risks. Average time to TEP change was 72 days. Patients with GERD (HR 1.17, 95 % CI [1.06-1.29]) and esophageal stricture (HR 1.13, 95 % CI [1.02-1.26]) required more frequent prosthesis changes.

CONCLUSIONS

Understanding factors that affect TEP function and longevity can help optimize patient selection for TEP following TL. Patients at increased risk for complications resulting in the need for more frequent TEP changes should be carefully counseled during the discussion of voicing options following TL.

Retrospective Exploration of Botulinum Toxin Injection for Pharyngoesophageal Segment Dysfunction Post-laryngectomy

Objective

To assess our institution's experience with botulinum toxin A injection management of pharyngoesophageal (PE) segment dysfunction after laryngectomy in tracheoesophageal voice and swallowing restoration.

Study Design

A retrospective review of 43 patients who had Botox as treatment for PE dysfunction.

Setting

Tertiary academic center with fellowship-trained otolaryngologists.

Methods

Pre- and post-injection outcomes were evaluated using chart review, and the severity of symptoms was recorded based on the subjective assessment by the patient, speech language pathologists, and the treating surgeon.

Results

Forty-three patients were treated for PE dysfunction with botulinum toxin A injection. Most patients were male (n = 35, 81.4%), underwent primary cricopharnygeal myotomy (n = 36, 83.7%), and 37 (86%) had both dysphagia and speech concerns. Our injection methods included percutaneous injection by videofluoroscopy (n = 19, 44.2%), transnasal esophagoscopy (17, 40.5%), electromyography (n = 3, 7%), ultrasound (n = 1, 2.3%), or in the operating room (n = 3,7%). We found that 37 (86%) patients had subjective improvement in their symptoms, with 16 (38.1%) improving in both swallow and voice. There were no significant complications, or subjective difference in speech and swallowing outcomes by method of injection.

Conclusion

Botulinum toxin A injection appears to be safe and effective for treating difficulty with speech and swallowing due to PE dysfunction after laryngectomy. Institutions should develop standard protocols for treatment and assessment.

The formulation of an enhanced recovery programme for patients undergoing laryngectomy

Objective

Enhanced recovery programmes have been widely adopted in other surgical disciplines but are not commonplace in head and neck surgery. The authors of this study created a pathway for post-operative laryngectomy patients.

Method

A multidisciplinary working group reviewed the literature and agreed standards of care. A retrospective audit was conducted to measure current practice against our new pathway; after programme implementation our performance was reaudited in two prospective cycles, with an education programme and review after the first prospective cycle.

Results

Statistically significant improvement in performance was realised in catheter and surgical drain removal, opiate analgesia use, mobilisation, and timeliness of swallow assessment. The rate of hospital acquired pneumonia reduced from 23.1 to 9.5 per cent and length of stay reduced by a median of 5.2 days to 14.8 days (non-significant).

Conclusion

The programme improved consistency of patient care across most areas that were measured. Improving patient stoma training needs to be prioritised.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Importance

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures.

Objective

To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP.

Design, Setting, and Participants

This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019.

Main Outcomes and Measures

Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed.

Results

Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type.

Conclusions and Relevance

This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Assessment of Factors Impacting Long-Term Utilization of Tracheoesophageal Speech Among Laryngectomees

OBJECTIVE(S)

To evaluate complication rate and abandonment rate after tracheoesophageal puncture and to assess factors associated with these outcome measures.

METHODS

Retrospective review of laryngectomy patients seen at a single academic institution between 1/1/2003 and 12/1/2018. Charts reviewed for demographics, medical comorbidities, tumor characteristics, surgical data, adjuvant treatment history, and complications related to laryngectomy or tracheoesophageal puncture. Complications were divided into minor and major.

RESULTS

A total of 293 laryngectomees met inclusion criteria. Of these, 69 patients (23.5%) underwent tracheoesophageal puncture. Average follow up was 64.6 months (SD 58.3). Overall laryngectomy complication rate was 43.3%. Overall tracheoesophageal puncture complication rate was 73.9%, with 39.1% of patients having major complications and 34.8% having minor complications only. Total abandonment rate for tracheoesophageal puncture was 34.8%. No associations were seen between tracheoesophageal puncture complication or abandonment rates based on age, gender, race, or insurance status. An increased rate of laryngectomy complications was seen after primary tracheoesophageal puncture (76.5% vs 41.3%, P = .005).

CONCLUSION

Tracheoesophageal puncture outcomes were similar in patients with varied demographic, medical, and treatment backgrounds. When considering timing, our findings suggest that patients should be counseled on the possibility of increased complication risk after primary tracheoesophageal puncture. In those in whom the surgeon already has concerns about wound healing, it may be prudent to avoid primary tracheoesophageal puncture. The relatively high abandonment rate emphasizes the value of this measure of tracheoesophageal puncture outcome and highlights the need for appropriate patient counseling and prospective studies assessing the decision to abandon.

Tracheoesophageal Voice Prosthesis Use and Maintenance in Laryngectomees

Tracheoesophageal speech is the most common voicing method used by laryngectomees. This method requires the installation of tracheoesophageal prosthesis (TEP), which requires continuous maintenance to achieve optimal speaking abilities and prevent fluid leakage from the esophagus to the trachea. The present manuscript describes the available types of TEPs, the procedures used to maintain them, the causes for their failure due to fluid leakage, and the methods used for their prevention. Knowledge and understanding of these issues can assist the otolaryngologist in caring for laryngectomees who use tracheoesophageal speech.

Influence of proton pump inhibitor therapy on occurrence of voice prosthesis complications

PURPOSE

It has been shown that the reflux of the gastric content to the proximal oesophagus influences incidence of voice prosthesis (VP) complications in laryngectomized patients. We conducted prospective randomised study to investigate the relationship between pepsin concentration in saliva and occurrence of VP complications before and after 3 months of proton pump inhibitor (PPI) therapy.

METHODS

60 laryngectomized patients with VP and 30 controls were included in the study. Saliva samples were collected in the morning and concentration of pepsin were measured by Human Pepsin (PG) ELISA kit. Thirty-Four (57%) patients reported one or more VP complication and were randomised in two groups, with and without PPI therapy, 40 mg pantoprazole per day for 3 months.

RESULTS

Patients who had longer time since last VP change had higher incidence of periprosthetic and transprosthetic leakage and Candida colonisation. Pepsin was found in all saliva samples. Median saliva pepsin concentration level did not significantly differ between laryngectomized patients and control subjects, or between patients with and without VP complications, and there was no correlation between saliva pepsin concentration levels and type of VP complication. After 3 months therapy, there was no difference in median saliva pepsin level or incidence of VP complication between patients with and without PPI therapy.

CONCLUSION

Although reflux was proposed to be associated with VP complications and pepsin was proven as a most sensitive and specific marker of EER, we did not find any statistically significant correlation between pepsin levels and occurrence of VP complications. A 3 months 40 mg pantoprazole therapy was ineffective in reduction of VP complications in our study group.

Role of Reflux in Tracheoesophageal Fistula Problems after Laryngectomy

Objectives

The purpose of this 2-year prospective nonrandomized study was to investigate the relationship between pathological supraesophageal reflux and the occurrence of speech fistula complications, especially severe fistula enlargement, in patients who underwent total laryngectomy and prosthetic voice restoration.

Methods

We objectively assessed the presence of reflux disease using 24-hour dual-probe pH monitoring in 60 laryngectomized patients, correlated the incidence of tracheoesophageal fistula complications with the severity of reflux, and assessed the risk of problems by determining the absolute number of reflux events at the level of the speech fistula, the reflux area index score, and the DeMeester score.

Results

All patients with fistula enlargement showed highly pathological results in the diagnostic tests for reflux disease. Depending on reflux severity, the relative risk of developing fistula complications was up to 10 times higher for these patients.

Conclusions

We found a significant correlation between the occurrence of tracheoesophageal fistula complications and the severity of supraesophageal reflux. Potential chronic irritation of the esophageal and tracheal mucosa can possibly contribute to the development of these problems. If the presence of reflux disease has been confirmed by 24-hour dual-probe pH monitoring, patients with fistula complications should be treated with proton pump inhibitors.

Postlaryngectomy prosthetic voice rehabilitation outcomes in a consecutive cohort of 232 patients over a 13-year period

Background

With the increasing necessity for total laryngectomy (TL) after prior (chemo)radiotherapy, prosthetic vocal rehabilitation outcomes might have changed.

Methods

Retrospective cohort study including all patients laryngectomized between 2000 and 2012 with a voice prosthesis (VP) in the Netherlands Cancer Institute.

Results

Median device lifetimes of the standard Provox2 and Vega VPs are 63 and 66 days, respectively, and for the problem‐solving ActiValve Light and Strong VPs 143 and 186 days, respectively. In multivariable analysis, salvage TL and TL for a dysfunctional larynx (compared to primary TL) were associated with a shorter device lifetime. Almost half of the patients (48%) experienced tracheoesophageal puncture tract‐related problems, and this concerned 12% of all VP replacements.

Conclusions

Compared to historical cohorts, device lifetimes of regular Provox2 and Vega voice prostheses have decreased. Complications are not occurring more frequently but affect more patients. Nevertheless, the clinical reliability and validity of prosthetic voice rehabilitation is still sound.

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

Tracheoesophageal voice puncture (TEP) coupled with the use of voice prosthesis has been considered as the gold standard for speech rehabilitation in patients of advanced laryngeal/hypopharyngeal carcinomas, who have undergone a total laryngectomy with or without partial pharyngectomy. Although prosthetic voice rehabilitation is commonly practiced worldwide including India, there is a paucity of published Indian data, more so in the current era of organ conservation. This study included 60 laryngectomized patients with a prosthetic voice rehabilitation at a tertiary cancer center in South India between January 1, 2010 and December 31, 2013. Among the 60 patients, the primary site of cancer was the larynx in 43 patients and hypopharynx in the remaining 17. All patients had undergone a primary TEP insertion, 55 in the upfront setting and five in the salvage (post-radiation/chemo-radiation) setting. The ability to retain a successful trachea-esophageal speech on follow-up (median 15.5 months) in our series was around 82%. The mean device life of voice prosthesis in our patient cohort was 16 months. There was surprisingly no significant difference in the prosthesis device life on correlation with age, co-morbidities, habitat, literacy status, pre-operative tracheostomy, setting of surgery, and the extent of surgery. Our series has successfully demonstrated the safety and feasibility of using primary TEP coupled with the use of voice prosthesis for voice rehabilitation in properly selected and motivated patients of advanced laryngeal and hypopharyngeal carcinomas across all clinical settings. A mean device life of 16 months makes prosthetic voice rehabilitation, an attractive as well as a financially viable option for patients in a resource constrained setting.

Post-laryngectomy voice rehabilitation with voice prosthesis: 15 years experience of the ENT Clinic of University of Catania. Retrospective data analysis and literature review

This study reports our 15-year experience, in Sicily, with the use of voice prostheses, analysing the different variables that have influenced the success or failure of speech rehabilitation. The retrospective clinical analysis was carried out by reviewing the clinical histories of 95 patients with laryngeal cancer, in whom a voice prosthesis had been placed by trachea-oesophageal puncture between 1998 and 2013. Age, type of tumour, type of surgery, use of prior radiation therapy, type of puncture, prosthesis used and its duration, number of replacements, complications and causes for prosthetic success or failure were analysed. The results showed a mean of Harrison-Robillard-Schultz (HRS) TEP rating scale of 11.8 in primary TEP and 12.6 in secondary TEP (P =0.613). PORT did not affect overall rehabilitation success. In these patients, the mean HRS rating scale was 11.2, with long-term success of 85% (P =0.582). In patients over 70 years old, long-term success was 82.5%, with 78% in primary and 86% in secondary TEP, the mean HRS was 11.2 in primary and 12 in secondary TEP (P =0.648). In total, long-term success was 87.5%, with 84% in primary and 91% in secondary TEP. The results obtained by retrospective analysis of 15 years of prosthetic rehabilitation in the Sicilian territory highlighted standard rehabilitation, in terms of intra and postoperative complications, fistula related pathology and overall success.

Device Life of Two Generations of Provox Voice Prostheses

Background:

Tracheoesophageal voice prostheses are invaluable for speech rehabilitation in patients who have received total laryngectomy, but device failure impedes communication and creates psychosocial and financial burdens. This study compares the Provox 2 and Provox Vega voice prostheses on the parameter of device life.

Methods:

This was a retrospective observational study of 21 patients with 181 device replacements at an academic tertiary care medical center. Disparity in device life and factors that may influence device life were analyzed.

Results:

The mean device life for Provox 2, at 115.6 days (SE = 5.8), was longer than for Provox Vega, at 65.1 days (SE = 7.5) ( P < .001).

Conclusions:

Device longevity was greater for Provox 2 over Provox Vega. These results will facilitate the design of prospective studies to assess reasons for variations in device life between patients and device types.

[Importance of cellular tight junction complexes in the development of periprosthetic leakage after prosthetic voice rehabilitation]

BACKGROUND

The use of voice prostheses is currently the gold standard in voice rehabilitation after total laryngectomy. This method combines low complication rates and excellent rehabilitation results; however, approximately 30% of patients show periprosthetic leakage or severe fistula enlargement after laryngectomy and prosthetic voice restoration within the first 4 years. The development of this enlargement is controversially discussed in the literature but recently published studies have shown that high esophageal reflux plays a key role in this process, which leads to an inflammatory reaction and disturbs the intercellular tight junctions in the sense of an epithelial mesenchymal transition (EMT).

MATERIAL AND METHODS

A total of 44 patients underwent 24 h pH monitoring, a sample biopsy from the region of the fistula and a subsequent biomolecular examination for intracellular junction proteins as well as a correlation between the severity of reflux and tracheoesophageal fistula problems before and after antireflux therapy with proton pump inhibitors (PPI).

RESULTS

Immunohistochemical staining revealed decreases in membrane E-cadherin and β-catenin and a significant increase in the cytoplasmic fraction, depending on the severity of inflammation in the fistula tissue. In patients with an improvement of clinical fistula problems under oral PPI treatment an increase of membrane E-cadherin could be shown, whereas patients with persisting fistula enlargement demonstrated a further decrease of E-cadherin.

CONCLUSION

The data indicate a central role of EMT in the development of fistula enlargement after total laryngectomy. Patients with periprosthetic leakage showed a loss of membrane bound E-cadherin and β-catenin with an up-regulation of vimentin expression. In patients with mild or no leakage problems EMT could be resolved by aggressive antireflux treatment, whereas patients without any effect of PPI treatment on the fistula showed no reversal of EMT. These data contribute to the understanding of treatment resistant fistula enlargement after total laryngectomy.

Novel modification of voice prosthesis

The undesired dilatation of the tracheooesophageal shunt after surgical implantation of voice prosthesis is a typical complication of this procedure. Temporary removal of the prosthesis and reinsertion after a short period of time is a first-line therapeutical option aiming shrinkage of the shunt. Failure of this measure generally is an indication of revision surgery. We present first experiences treating leakage problems with novel modified voice prosthesis without surgical intervention in specified cases. 11 patients (1 female, 10 male) aging between 51 and 71 years were presented with shunt leakage between 11/2008 and 11/2012 in the ENT-Department of the University Hospital of Homburg/Saar after a custom built voice prosthesis had been used initially successfully. A "Provox 2"(®) voice prosthesis was modified with two discs made of silicone each on the tracheal and oesophageal side and additionally reinforcing the diameter of the prosthesis by a silicone tube. The modified prosthesis was inserted in a retrograde way under general anesthesia, analogical to the approach used with the "Provox 1"(®)-prosthesis. The period of observation ranged between 12 and 48 months. As a measure of control swallowing of methylene blue was used. In all cases leakage suspended. Durability of the modified prosthesis ranged between 2 and 6 months. Neither the patients' complained about, nor did the physicians notice subjectively an impairment of the voice quality. Modifications of "Provox 2"(®)-prosthesis should be regarded in individual cases and constitute a reasonable alternative to revision surgery. A surgical approach is more intricate and costly, more taxing for the patient and susceptible to failure. We regard the necessity of general anesthesia for the insertion of the modified prosthesis as a disadvantage.

Increased Pharyngeal Reflux in Patients Treated for Laryngeal Cancer

Objective

Laryngopharyngeal reflux may cause significant morbidity in the head and neck cancer population. The goal was to determine if pharyngeal reflux is increased as a result of treatment for laryngeal cancer.

Study Design

A prospective clinical trial.

Setting

Tertiary care center.

Subjects

Head and neck cancer patients treated at LSU Health–Shreveport with a plan for total laryngectomy.

Methods

Pharyngeal pH probes with resultant reflux scores were utilized in patients with laryngeal/pharyngeal cancer with a plan for total laryngectomy.

Results

Twenty-four patients were enrolled, of whom 10 underwent postlaryngectomy pH probe monitoring. The mean upright Ryan score for patients with prior radiotherapy was 238.4 (n = 8), compared with 22.0 (n = 16) in those without prior radiotherapy ( P = .02). The supine score was 12.7 in the radiotherapy group and 2.7 in those without radiotherapy ( P = .12). For those who completed the postlaryngectomy pH study (n = 10), the mean preoperative upright Ryan score was 106.32 ± 279.1 versus a postoperative score of 209.0 ± 352.6 ( P = .04). The mean supine preoperative Ryan score in this group was 3.9 ± 3.47, as opposed to 8.1 ± 9.6 postoperatively ( P = .13)

Conclusions

This study suggests that treatment of laryngeal cancer may increase the incidence of pharyngeal reflux. Consider screening for reflux in patients previously treated for laryngeal cancer.

The development and treatment of periprosthetic leakage after prosthetic voice restoration. A literature review and personal experience part I: the development of periprosthetic leakage

In the past 30 years, the use of a voice prosthesis has become the treatment of choice for the restoration of speech following laryngectomy. Not only is the placement of a voice prosthesis a simple surgical procedure, but it is also associated with a low rate of complications and an excellent success rate. Approximately, 20-30 % of all patients with voice prostheses, however, develop periprosthetic leakage with aspiration over time. Periprosthetic leakage is usually caused by an enlargement of the tracheo-oesophageal fistula and substantially affects the quality of life of the patients concerned. In a retrospective analysis of our patients, the incidence of periprosthetic leakage was 35.7 % in a total of 232 patients who underwent laryngectomy during a period of 20 years. Substantial enlargement of the tracheo-oesophageal fistula which required multiple treatments occurred in 12.5 % of the patients. In this review, the various causes of fistula enlargement are discussed on the basis of the literature and the experience that we have accumulated during the past 20 years in the management of patients with voice prostheses.

Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands

PURPOSE OF REVIEW

Total laryngectomy rehabilitation (TLR) in Europe is not uniform, with quite some differences in approach and infrastructure between various countries. In, for example, the Netherlands, Switzerland, Scandinavia, and more recently also in the UK, head and neck cancer (HNC) treatment and rehabilitation shows a high level of centralization in dedicated HNC centres. In other European countries, the level of centralization is lower, with more patients treated in low-volume hospitals. This article focusses on the situation in the Netherlands and, where applicable, will discuss the regional variations in Europe.

RECENT FINDINGS

Prosthetic surgical voice restoration (PSVR) presently is the method of choice in Europe, and use of oesophageal and electrolarynx voice has moved to the background. In most European countries (except the UK and Ireland), PSVR is physician driven, with an indispensable role for speech-language pathologists and increasingly for oncology nurses. Indwelling voice prostheses are mostly preferred, also because these devices can be implanted at the time of trachea-oesophageal puncture. Pulmonary rehabilitation is achieved with heat and moisture exchangers, which, based on extensive clinical and basic physiology research, are considered an obligatory therapy measure. In addition to PSVR, also issues such as smoking cessation, dysphagia/swallowing rehabilitation, and olfaction/taste rehabilitation are discussed. Especially, the latter has shown great progress over the last decade and is another example of increasing implementation of evidence-based practice in TLR.

SUMMARY

TLR has shown considerable progress over the last decades, and through the intensified collaboration between all clinicians involved, significantly has improved vocal, pulmonary, and olfactory rehabilitation after total laryngectomy.

Relationship between radiotherapy and gastroesophageal reflux disease in causing tracheoesophageal voice rehabilitation failure

OBJECTIVE

The objective was to analyze the association of radiotherapy with gastroesophageal reflux as determinant of fistula related pathology, in voice prosthesis patients.

STUDY DESIGN

Retrospective study.

METHODS

Sixty-one laryngectomy patients were enrolled between 2005 and 2012. All patients underwent phonatory rehabilitation with voice prosthesis, along with evidence of gastroesophageal reflux disease, for which proton pump inhibitors (PPIs) were prescribed. We analyzed the occurrence of fistula-related problems among patients who received postoperative radiotherapy and those patients who did not.

RESULTS

We observed a higher rate of failure of speech rehabilitation in laryngectomy patients with gastroesphageal reflux: this occurred when they had a history of postoperative radiotherapy (45%) compared with patients who did not (17%) (P < 0.05), although all patients were treated with PPIs.

CONCLUSION

Our results seem to confirm the importance of postoperative radiotherapy with gastroesophageal reflux for the determinism of fistula-related problems.

Transnasal esophagogastroduodenoscopy for evaluation of upper gastrointestinal non-neoplastic disorders in patients with fresh hypopharyngeal cancer

OBJECTIVES/HYPOTHESIS

Upper gastrointestinal (UGI) tract non-neoplastic disorders are detrimental to cancer treatment. This study is to evaluate the feasibility of transnasal esophagogastroduodenoscopy in the diagnosis of UGI disorders at the same time as the diagnosis of hypopharyngeal cancer and to provide the prevalence of UGI disorders in patients with fresh hypopharyngeal cancer.

STUDY DESIGN

A prospective cases series study.

METHODS

Patients with newly diagnosed hypopharyngeal cancer between 2007 and 2010 were enrolled. An endoscope (GIF-XP260N; Olympus Optical, Tokyo, Japan) without conscious sedation was transnasally used to evaluate from the pharynx to duodenum.

RESULTS

One hundred two patients were evaluated. Sixty-five patients had at least one UGI disorder: gastric/duodenal ulcers in 32; active Helicobacter pylori infection in 36; and erosive esophagitis in 20 patients, including Los Angeles classification grade A in eight patients, grade B in 10, grade C in one, and grade D in one. Of the abovementioned disorders, 45 patients had only one, 17 patients had two, and three patients had all of the above disorders. Neither age, sex, location, nor T classification of the hypopharyngeal tumor was associated with the presence of UGI disorders.

CONCLUSIONS

Transnasal esophagogastroduodenoscopy can be a single procedure to diagnose hypopharyngeal cancer and UGI disorders at one session. Approximately ⅔ of the patients with fresh hypopharyngeal cancer had either erosive esophagitis, active H. pylori infection, or gastric/duodenal ulcers.

Gastroesophageal reflux disease and postlaryngectomy tracheoesophageal fistula

The objective of this study is to evaluate the incidence of pathologic gastroesophageal reflux in laryngectomized patient with phonatory prosthesis, analyzing potential related problems and appraising, at the same time, the effectiveness of a therapeutic protocol. A retrospective study was conducted on 43 phonatory prosthesis patients who had problems with regard to recurrent tracheoesophageal granulations, the need of frequent prosthesis replacement, within a 3-month period, and unsatisfactory vocal results. Such patients underwent physical examination of the fistula region and of the neopharynx and were submitted to esophagogastroduodenoscopy. Moreover the group of patients underwent a therapeutic protocol and were re-evaluated posttreatment, examining fistula region both on the tracheal side and on the esophageal side through videolaryngostroboscopy. Of the 43 recruited patients 13 (30%) presented tracheoesophageal granulations, 20 (46.5%) unsatisfactory vocal results and 10 (23.5%) frequent prosthesis replacement, within a 3-month period, due to abnormal biofilm development. In particular, of the 13 patients who had recurrent granulations, the evaluation results revealed the presence of gastroesophageal reflux disease (GERD) in 6 cases (46%). In the group of patients presenting unsatisfactory vocal results GERD was shown in 13 cases (65%). In the third group of patients GERD was found in two cases (20%). The overall analysis of the data gathered, allowed to identify GERD in 21 (49%) of the 43 patients submitted to the study. The results posttreatment indicated, in the first group, the disappearance or a significant (>75%) volume reduction of such formation in five cases (38%, p = 0.002). In the second group an overall improvement in the quality of voice was displayed at least for 12 patients (60%, p = 0.0001). Finally in the last group an increase of the prosthesis life was recorded in four (40%, p = 0.05) of the ten patients who had the need of prosthesis replacement within 3 months. Also the 22 GERD negative cases (51%) underwent the treatment, therefore representing the control group, whose posttreatment results showed substantial modifications in just two cases (9%). The data obtained suggest a high degree of correlation between the presence of pathologic gastric reflux and the partial or total prosthesis failure. The introduction of a specific therapeutic protocol has allowed to improve the quality of prosthesis (QoP) in 22 of the 43 patients (p < 0.001) who had a pathologic condition of the fistula and of the prosthesis.

[A novel puncture instrument: the Provox-Vega® puncture set. Its use in voice prosthesis insertion following laryngectomy]

BACKGROUND

The use of voice prostheses has been considered the gold standard in voice rehabilitation following laryngectomy for the last 20 years. Insertion is generally performed as a primary procedure during laryngectomy or as a secondary procedure with a re-usable trocar or rigid esophagoscope, a guidewire and anatomic hemostatic forceps. The use of these instruments requires a certain level of experience on the one hand, while on the other use of a trocar and subsequent manipulation with the hemostatic forceps can lead to tissue trauma around the membranous wall or damage to the voice prosthesis. We present the results of a phase I/II study using a novel atraumatic puncture set for primary and secondary insertion of voice prostheses.

PATIENTS AND METHODS

Once patients had been fully informed and given their consent, the Provox-Vega® puncture set was used in 21 patients in either a primary (16) or a secondary (5) procedure. All procedures were documented on video, while approach, complications and surgical success were recorded using a questionnaire.

RESULTS

The average surgical time was 83.5 (± 19.12) s for primary voice prosthesis insertion and 212.57 (± 93.03) s in secondary procedures. The prosthesis could be inserted without complication in 19 patients, while a longer prosthesis needed to be selected intraoperatively in two patients due to a thick membranous wall. No serious complications were observed. One patient incurred a discrete injury to the mucosa of the esophageal posterior wall.

CONCLUSION

The Provox-Vega® puncture set proved itself to be a safe aid in the insertion of voice prostheses. It is significantly easier to use than other systems and tissue trauma is minimal. In most cases, no further instruments were required.

Extra-Esophageal Reflux and Laryngeal Disease: Update From a Translational Research Team

Extraesophageal reflux (EER) has been implicated in a variety of different otorhinolaryngologic disorders including otitis media, chronic sinusitis, globus pharyngeus, laryngeal neoplasia, and many benign laryngeal disorders. New technologies such as multichannel intraluminal impedance studies have revolutionized our ability to detect the prevalence of EER, and the role of biomarker detection in diagnosing ongoing EER is evolving. Gastric refluxate contains not only hydrochloric acid, but also bile salts and digestive enzymes such as pepsin. Analysis of pepsin levels in both tissues and secretions is emerging as a useful adjunct in the diagnosis of EER and work to evaluate the role of pepsin in the promotion of laryngeal inflammation and neoplasia is ongoing. This review discusses the recent literature regarding the diagnosis and treatment of EER, and describes the controversies that can perhaps be further elucidated by ongoing clinical and translational research.

Does Prosthesis Diameter Matter?

Objective. To assess the impact of tracheoesophageal voice prosthesis diameter and treatment status on prosthesis-related complications.

Study Design. Historical cohort study.

Setting. Single academic medical institution.

Subjects and Methods. Patients who underwent total laryngectomy (TL) between 1996 and 2008 were divided into 2 subgroups according to prosthesis diameter: 16F (n = 19) and 20/22F (n = 71). Each patient only used 1 diameter of prosthesis. Time to leakage through the prosthesis, number of episodes of leakage around the prosthesis, number of prosthesis dislodgements, and length changes after the first 6 months were chosen as outcomes of interest.

Results. Analysis included 90 patients. Analysis of selected complications by prosthesis diameter revealed no significant differences for time to leakage through the prosthesis, number of leaks around the prosthesis, or dislodgement. Larger diameter prosthesis use was associated with a greater number of length changes ( P = .008). Multivariable regression analysis did not find any significant association between prosthesis-specific complications and prosthesis diameter when controlling for other variables. Prior radiation was associated with an increased number of size changes (β = 2.0, P = .004) and a decrease in time to leakage through the prosthesis (β = −4.4, P = .048), after controlling for other variables.

Conclusions. Prosthesis diameter is not associated with an increased prevalence of certain voice prosthesis complications in laryngectomy patients, regardless of initial treatment modality, whereas prior radiation or chemoradiation is associated with complications. These data suggest that factors affecting tissue health, rather than prosthesis size, may be more responsible for prosthesis complications.

[Prosthetic voice restoration after laryngectomy: the management of fistula complications with anti-reflux medications]

INTRODUCTION

Approximately 30% of all patients show periprosthetic leakage or severe fistula enlargement after laryngectomy and prosthetic voice restoration. In a prospective study, we investigated the role of aggressive anti-reflux therapy in fistula complications.

PATIENTS AND METHODS

A total of 48 patients were assigned to one of two groups. Group A consisted of 16 patients with recurrent periprosthetic leakage. Group B comprised 32 patients without periprosthetic leakage. The presence of reflux was objectively assessed using 24-h dual-probe pH monitoring. All patients with pathological reflux underwent proton pump inhibitor (PPI) therapy. After 6 months, patients were re-evaluated for fistula complications and objective reflux parameters.

RESULTS

The mean absolute number of reflux events was 202.8 (+/-44) before and 74.5 (+/-22.9) after PPI therapy (p=0.025). The reflux area index decreased from 419.5 (+/-112.5) before treatment to 105.8 (+/-54.7) after treatment (p=0.0005). The mean DeMeester score was 104.4 (+/-21.3) without PPIs and 43.5 (+/-9.3) after 6 months with PPIs (p=0.028). A risk analysis for patients with both periprosthetic leakage and pathological reflux (15 patients at the beginning of the study, four patients after therapy) showed that the relative risk of periprosthetic leakage decreased to 0.3 (p=0.0054) with PPI therapy.

CONCLUSION

Patients with recurrent periprosthetic leakage in the region of the fistula showed a significantly higher number of supra-oesophageal reflux episodes. Rigorous anti-reflux treatment can help manage or prevent leakage problems in a large proportion of patients.

[Laryngectomised patients with voice prostheses: influence of supra-esophageal reflux on voice quality and quality of life]

INTRODUCTION

We conducted a prospective study to assess the influence of supra-esophageal reflux on voice quality and quality of life in patients who had undergone laryngectomy and prosthetic voice rehabilitation.

PATIENTS AND METHODS

We investigated 60 laryngectomised patients using 24-h dual-probe pH monitoring before and 6 months after oral anti-reflux treatment with proton pump inhibitors (PPIs). Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30. Voice quality was quantified using the voice handicap index (VHI10). Quality of life and voice quality parameters were then correlated with the severity of reflux disease.

RESULTS

Patients with physiological reflux area index (RAI) scores had a mean VHI10 score of 46.4 (±11.4). VHI scores were found to increase to up to 64.1 (±9.6) with reflux severity (p=0.025). Total quality of life scores ranged from 115.8 (±24.7) in patients with physiological RAI scores to 131.0 (±33.1) in patients with highly pathological RAI scores (p=0.007). After 6 months of treatment with PPIs, VHI scores improved to a total score of 57.5 (±20.6, p=0.003). Quality of life scores improved to 123.3 (±29.0, p=0.045).

CONCLUSION

Supra-esophageal reflux influences voice quality and quality of life in laryngectomised patients with voice prostheses. This can be explained, for example, by an increased incidence of periprosthetic leakage, the presence of edema in the pharyngo-esophageal segment (where speech is produced), and general reflux symptoms. Rigorous treatment with anti-reflux medications leads to an improvement in reflux parameters that can be assessed objectively (RAI) and in correlated quality of life and voice quality parameters. For this reason, we recommend rigorous oral treatment with PPIs in laryngectomised patients with a confirmed diagnosis of supra-esophageal reflux.

Analysis of Pepsin in Tracheoesophageal Puncture Sites

Objectives:

Tracheoesophageal puncture (TEP) and prosthesis insertion is a well-established method of voice rehabilitation after laryngectomy. Maintenance of the prosthesis and tract can be challenging, and reflux to the TEP site has been proposed as a cause. The sites of TEP were evaluated for the presence of pepsin in tissue biopsy specimens and tract secretions to explore this association.

Methods:

Patients with TEP were interviewed for a history of symptoms related to reflux, medication use history, TEP voice quality, and incidence of TEP complications. Tissue biopsy specimens and tract secretions were obtained from TEP sites and analyzed for the presence of pepsin via sodium dodecyl sulfate–polyacrylamide gel electrophoresis Western blot analysis.

Results:

Twelve of 17 patients (47%) had some history of preoperative or postoperative symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux. Pepsin was present within the TEP site in a total of 10 of 17 patients (58%; 7 of 17 tissue biopsy specimens and 6 of 7 secretion samples). There were no statistically significant associations between the presence of pepsin and sex, reflux history, use of acid suppressive medicine, or time since laryngectomy.

Conclusions:

Reflux with subsequent pepsin deposition into the TEP tract occurs in a majority of laryngectomy patients. Further studies on the effect of reflux on the health and function of the TEP tract are warranted.

Clinical phase I/feasibility study of the next generation indwelling Provox voice prosthesis (Provox Vega)

CONCLUSIONS

Provox Vega prostheses demonstrate good short-term feasibility, and their optimized airflow-resistance design offers laryngectomy patients indwelling voice prostheses with more choices in outer diameters without sacrificing (too) much in voice quality.

OBJECTIVES

Technological progress enables improvement of in vitro airflow characteristics of voice prostheses and design of voice prostheses with smaller outer diameters. This could potentially improve voice quality in users of Provox2, and avoid diminished voice quality in users of prostheses with smaller outer diameters.

METHODS

This was a prospective clinical phase I/feasibility study of three newly designed indwelling voice prostheses (Provox Vega 22.5 (Provox2 successor), 20, and 17Fr). Assessments consisted of patients' self-reported voice and speech, perceptual evaluation, acoustic analysis, maximum phonation time, loudness, speech rate, pull-out force and adaptation of the tracheoesophageal (TE) puncture to smaller diameter voice prostheses. Vega 22.5 was assessed in 15 patients (all Provox ActiValve users, observation period 3 weeks), and 16 patients with Vega 20/17 (2 weeks each).

RESULTS

No voice prostheses problems were encountered. Half of the patients with Vega 22.5 preferred that for its better voice quality. Voice and speech were considered equal to Provox2 for Vega 20, but slightly less for Vega 17. Most TE punctures adapted well to the smaller diameter voice prostheses.

[Total voice prosthesis incarceration in the trachaeo-oesophageal mucosa. Report of a new complication when using phonatory prostheses]

We report the cases of three patients seen at the Otolaryngology Department after presenting a laryngeal carcinoma that required total laryngectomy, followed by trachaeo-oesophageal puncture and Provox voice prosthesis positioning. In all cases the growth of granulomatous tissue totally incarcerated the prosthesis in the trachaeo-oesophageal mucosa. In two of the cases the prosthesis could be extracted by oesophagoscopy and a new prosthesis was positioned in the same surgery. In the other case an external approach was performed using a peristomal wound to extract the prosthesis. In this case a new trachaeo-oesophageal puncture was performed 3 months after the extraction.

[Surgical treatment of enlarged trachoesophageal puncture with and without supraesophageal reflux : case report and review of literature]

Approximately a quarter of all patients who undergo prosthetic voice restoration develop periprosthetic leakage with aspiration symptoms within 1 to 4 years following surgery. Depending on the severity of fistula enlargement, treatment ranges from conservative approaches to surgical procedures. In some cases, however, these measures prove unsuccessful. The causes of treatment failure and fistula enlargement are not fully understood. There is growing evidence, however, that the presence of coexisting supraesophageal reflux can contribute to fistula complications. We report the case of two patients with voice prostheses and simultaneous severe reflux disease who underwent multiple failed attempts at fistula closure. After effective reflux therapy, the fistulas could eventually be closed successfully.