A Modified Technique for Secondary Tracheo-Esophageal Puncture- An Affordable Option

Secondary TEP insertion in a patient who has had laryngectomy with adjuvant radiotherapy is challenging as the neck mobility and neck extension is restricted. Following laryngectomy, as our patient was unable to develop esophageal speech a secondary TEP was planned for him. A simple and cost-effective method of secondary tracheo-esophageal puncture (TEP) for voice rehabilitation following laryngectomy can be performed using routine equipment and instruments available in almost all operating rooms. A detailed description of the procedure performed is documented here.

Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Chest Tube Placement of Secondary Tracheoesophageal Voice Prosthesis: Overcoming Challenging Anatomy in the Laryngectomy Patient

Introduction: Total laryngectomy is used to cure advanced larynx cancer in many patients. The removal of the larynx requires the rehabilitation of the patient's ability to communicate, and one common method is to place a tracheoesophageal voice prosthesis (TEP) as a secondary procedure after the patient has completed cancer treatment. The traditional technique utilizes a rigid esophagoscope for access, but this can prove difficult in many patients who have kyphosis, scarring of the neck, or trismus. We describe a technique to allow TEP placement in these challenging patients that does not utilize rigid esophagoscopy to access the tracheoesophageal puncture site. Methods: For more than 15 years, the senior authors of this study have used this technique in patients in whom traditional methods of TEP with rigid esophagoscope were unsuccessful or not attempted due to the anticipated high probability of failure. The ease of this technique has prompted its use for all patients undergoing secondary TEP placement in their practice. The technique is described in detail in the Methods section below. Results: The described method has been successfully utilized to place TEPs in many patients with challenging anatomy. There have been no failed placements, including a patient with severe trismus who was able to have a TEP placed by placing the chest tube and flexible endoscope transnasally. Further, because of precise visualization and ease of the technique, there have been no observed complications of injury to the pharyngoesophageal lumen or creation of a false passage. Conclusion: The use of a chest tube and flexible scope allows for the protection of the pharyngoesophageal lumen, precise visualization and placement of the puncture, and avoidance of a false tracheoesophageal passage, all while minimizing the need for extension of the patient's neck. This has proven ideal for patients suffering the consequences of cancer treatment such as cervical scarring, fibrosis, kyphosis, and trismus.

Quality of Life and Respiratory Performance in the Laryngectomized Patient: Role of the HME Filters during Physical Activity

Background: Permanent tracheostomy because of total laryngectomy surgery entails significant consequences for patients regarding respiratory physiopathology, such as the loss of the filtering, humidifying, and heating of air by the nose. The use of special stomal filters can provide adequate protection of the tracheal-bronchopulmonary system with a reduction in respiratory pathologies. In fact, in most cases, laryngectomy patients are first cigarette smokers who for this reason also already have respiratory diseases such as chronic obstructive pulmonary disease (COPD). Despite the availability of tracheal filters, as reported in the literature, patients often tend to limit their use due to reported breathing difficulties, especially in conditions of intense breathing. Methods: The objective of this clinical study was to evaluate the most suitable stomal filter for laryngectomy patients during physical activity. The filters studied were an INHEALTH device (Blom-Singer SpeakFree HME); two ATOS devices (Provox® Life™ Energy HME and Provox® Life™ Home HME); and an FAHL device (Laryvox HME Sport). Results: For this purpose, the performances of 31 laryngectomy patients, subjected to medium-high physical effort, were analyzed through a standardized pneumological test, the Six Minute Walking Test (6MWT), which involves a sustained walk lasting six minutes, with an evaluation of heart rate, oxygen saturation, and meters traveled every 60 s; furthermore, we examined two subjective indices, namely, the basal and final dyspnea index and the initial and final muscular fatigue index. Conclusions: The multidisciplinary approach of the laryngectomee patient must also take pulmonary rehabilitation into consideration. It is the task of the medical team and speech therapy support to help the patient in the correct choice of HME filters taking into account daily needs.

Primary mode of communication for people with total laryngectomy in the UK: a cross-sectional survey

OBJECTIVE

This study aimed to report on the UK rate of surgical voice restoration usage and investigate the factors that influence its uptake.

METHOD

A national multicentre audit of people with total laryngectomy was completed over a six-month period (March to September 2020) in response to the coronavirus disease 2019 pandemic. This study is a secondary analysis of the data collected, focusing on the primary communication methods used by people with total laryngectomy.

RESULTS

Data on surgical voice restoration were available for 1196 people with total laryngectomy; a total of 852 people with total laryngectomy (71 per cent) used surgical voice restoration. Another type of communication method was used by 344 people. The factors associated with surgical voice restoration in the multiple regression analysis were sex (p = 0.003), employment (employed vs not employed, p < 0.001) and time post-laryngectomy (p < 0.001).

CONCLUSION

This study provides an important benchmark for the current status of surgical voice restoration usage across the UK. It found that 71 per cent of people with total laryngectomy used surgical voice restoration as their primary communication method.

Long-Term Complications of Tracheoesophageal Voice Prosthesis

Background: The aim of our multicenter retrospective study was to evaluate the long-term complications associated with primary and secondary tracheoesophageal puncture (TEP) in patients who underwent total laryngectomy (TL) for laryngeal cancer and were subsequently rehabilitated to phonatory function with tracheoesophageal speech (TES). Materials and Methods: To evaluate the long-term outcomes and complications of TEP, the following data were collected: mean time of prosthesis replacement, mean time of onset of complications, type of complications, and type of failure. Results: Complications occurred in 18 out of 46 patients (39.2%) with primary TEP and in 10 out of 30 patients (33.4%) with secondary TEP, out of a total of 76 enrolled patients. Common complications included prosthesis leakage, fistula leakage, granulation, and prosthesis extrusion. Prosthesis replacement due to fistula leakage or prosthesis extrusion was observed exclusively in the group of patients with primary TEP. Among the 28 patients (35.7%) who experienced complications, rehabilitation with TEP failed in 10 cases, primarily due to abandonment and spontaneous fistula closure. Conclusions: TEP, both primary and secondary, represents a valid option for vocal rehabilitation in patients undergoing TL. However, identifying prognostic factors that could influence the success of TEP would be beneficial to allow a targeted rehabilitation process.

Procalcitonin for Early Detection of Pharyngocutaneous Fistula after Total Laryngectomy: A Pilot Study

OBJECTIVES

The aim of this prospective study was to investigate the role of procalcitonin as an early diagnostic marker of pharyngocutaneous fistula (PCF) in a cohort of head and neck patients treated with total laryngectomy for squamous cell carcinoma.

METHODS

This prospective study was conducted on a sample of patients enrolled from January 2019 to March 2022. All patients were subjected to a "protocol" of blood chemistry investigations, scheduled as follows: complete blood count with formula, ESR dosage, CPR, and PCT. PCT was also dosed by salivary sampling and a pharyngo-cutaneous swab in patients who presented with PCF. The dosage scheme was systematically repeated: the day before the intervention (t0); the 5th day postoperative (t1); the 20th day postoperative (t2); and at time X, the day of the eventual appearance of the pharyngocutaneous fistula.

RESULTS

A total of 36 patients met the inclusion criteria. The patients enrolled in the study were subsequently divided into two groups: 27 patients underwent total laryngectomy (TL) for laryngeal cancer without postoperative complications, and 9 patients were undergoing TL with postoperative PCF. Using the Cochran's Q test, statistical significance was found for PCT among T0, T1, Tx, and T2 (p-value < 0.001) between the PCF and non-PCF groups. The Z test demonstrated that there is a difference in PCT levels at T1 and T2 and that this difference is statistically significant (p < 0.001).

CONCLUSIONS

PCT could be considered an early marker of complications in open laryngeal surgery. According to our results, it could be useful in the precocious detection of pharyngocutaneous fistulas and in the management of antibiotic therapy.

Surgical closure of enlarged tracheoesophageal fistula after laryngectomy: A systematic review of techniques

OBJECTIVES

The objectives of the study were (1) systematically review the data on surgical closure of enlarged tracheoesophageal fistula after laryngectomy and (2) to perform a comparison of reconstruction of surgical techniques.

METHODS

Systematic review was performed using PRISMA methodology. Cumulative patient data were compared between patients reconstructed with vascularized tissue (sternocleidomastoid fascia and muscle, pectoralis major, deltopectoral, radial forearm) and those closed primarily (two-layer, three-layer, and tracheal transposition).

RESULTS

Fourteen studies reported outcomes for the reconstruction of tracheoesophageal fistula. Primary closure was used in 98 patients, vascularized flap in 74, and occlusive device in 8. Vascularized flap resulted in successful closure of the fistula in 89 % of cases compared to primary closure in 62 % (p = 0.0003).

CONCLUSION

Systematic review of the literature supports an improved surgical closure rate with vascularized flap interposed between the esophageal and tracheal lumens compared to primary closure.

Analysis of durability and replacement of vocal prostheses in total laryngectomy patients at a head and neck surgery referral center

PURPOSE

The use of tracheoesophageal prostheses has become the gold standard in vocal rehabilitation of patients undergoing total laryngectomy. However, this method also has limitations, such as the need for frequent replacement of prostheses due to leakage or other complications. We have designed a study to access the clinical profile of patients using tracheoesophageal prostheses as vocal rehabilitation after total laryngectomy and to determine the average rate of changes, as well as the main causes of prostheses replacement.

METHODS

A retrospective cohort study was performed based on patients who underwent rehabilitation with voice prostheses after total laryngectomy between 2008 and 2017.

RESULTS

The sample consisted of 93 patients and 432 vocal prostheses replacement events. The median change of prostheses per patient was 210.25 days, (range 57.33 to 651.50). The most frequent cause of prostheses replacement was leakage through the prostheses, 218 (50.46%). Lower level of education was associated to higher prostheses replacement rate.

CONCLUSION

The results of this study show that the median of prostheses durability is higher than that presented in the literature, the main cause of replacement was protheses leakage and that low educational level is associated to higher replacement rate.

Management of Enlarging Tracheoesophageal Fistula with Voice Prosthesis in Laryngectomized Patients

Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients.

OBJECTIVES

An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction.

METHODS

Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016-11/2022.

RESULTS

Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm-free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow-up was 400.4 days. Two required a second free flap for persistent fistula.

CONCLUSION

Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm-free flaps have the additional benefit of a long vascular pedicle to access more distant and less-irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:198-206, 2024.

Fatal Tracheoesophageal Puncture Leakage Associated With Lenvatinib

Tracheoesophageal puncture (TEP) is a voice restorative option adopted by many head and neck cancer patients following laryngectomy. Though generally safe, TEP may develop leakage. Lenvatinib is a tyrosine kinase inhibitor (TKI) with anti-tumoral activity against head and neck malignancies.TKIs, including lenvatinib, have been associated with organ perforation or fistula formation. There remains a paucity of literature on the association between lenvatinib and TEP leakage. In this report, we described a patient with adenoid cystic carcinoma of the larynx who had a TEP. After approximately two weeks of treatment with lenvatinib, the patient developed a leakage of TEP. Despite several interventions, the patient died three months afterward due to a retropharyngeal abscess secondary to Fusobacterium nucleatum. To our knowledge, this is the first report of fatal lenvatinib-associated TEP leakage. Clinicians should be cognizant of a potentially rapid development of this complication when prescribing TKI for patients with TEP.

Quality of Life with Voice Prosthesis after Total Laryngectomy

Introduction

The loss of voice after total laryngectomy is one of the main impairments in personal and social life. In order to prevent potential psycho-social consequences in the patient and his family, the restoration of phonatory function is the main objective of post-laryngectomy rehabilitation. The aim of this study was to assess quality of life in patients who received prosthetic voice after total laryngectomy.

Materials and Methods

Over a one-year period, 51 patients with voice prostheses after total laryngectomy were recruited. 32 patients (62.74%) were administered radiation therapy and 9 patients (17.64%) underwent to surgical reconstruction with flaps. Each patient was administered the VHI-10 and V-RQOL self-assessment questionnaires.

Results

The study showed that vocal restoration with voice prosthesis allows patients to recover a significant degree of quality of life after total laryngectomy. The average score on the V-RQOL questionnaire was 75.9 and on the VHI-10 questionnaire was 13.5. It has not been shown a statistically significant correlation between quality of life after tracheoesophageal prosthesis and radiation therapy, chemotherapy or reconstruction flaps. Younger patients showed, on average, a higher score at V-RQOL. These results allow to state that, after prosthetic rehabilitation, at least 75% of patients experienced an increase in quality of life. Moreover, the prosthetic technique (primary vs secondary) does not affect the long-term outcome and radiotherapy, chemotherapy or reconstruction flaps are not absolute contraindications to rehabilitation with voice prosthesis.

Conclusion

After total laryngectomy, rehabilitation with tracheoesophageal prosthesis is a satisfactory choice to restore the patient's ability to communicate verbally.

Perceptual Voice and Speech Analysis after Supraglottic Laryngeal Closure for Chronic Aspiration in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

To evaluate the voice and speech outcomes after tubed supraglottic laryngeal closure (TSLC) surgery to treat chronic aspiration after radiotherapy for head and neck cancer.

STUDY DESIGN

A retrospective case-control study.

METHODS

The data of patients who underwent radiotherapy for head and neck cancer and who later required total laryngectomy or TSLC for chronic aspiration between 2004 and 2017 were retrieved from a dysphagia clinic. Preoperative and postoperative voice and speech were assessed by the GRBAS and INFVo rating scales. Control subjects who underwent radiotherapy alone or total laryngectomy with a tracheoesophageal prosthesis for other indications were recruited for comparison.

RESULTS

Of 15 patients who underwent a TSLC with a mean age of 57.3 years (45-75 years), 13 were male and 2 female. All patients had a history of nasopharyngeal carcinoma. The success rate of speech production using their own larynx following an intact TSLC was 64%. There was no statistically significant difference in voice and speech ratings between preoperative and TSLC subjects on the GRBAS (P = .32) and INFVo scales (P = .57), although the quality of voice appeared to deteriorate after TSLC. However, the INFVo scale for impression, intelligibility and unsteadiness of the voice after TSLC was statistically significantly better than for laryngectomy with tracheoesophageal speech.

CONCLUSIONS

A tubed supraglottic laryngeal closure controls chronic aspiration while preserving the larynx for phonation, and results in a better voice and speech quality than a laryngectomy with a voice prosthesis.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1616-E1623, 2021.

[Surgical reconstruction in laryngeal carcinoma]

Tumors of the larynx can substantially impair vocal function, breathing and also swallowing. The primary goal of reconstructive surgical treatment of laryngeal tumors is to sufficiently resect the tumor while minimizing the effects of the treatment on the voice, breathing and swallowing. In general, primary reconstructions in primary laryngeal surgery have many advantages. The tissue at this point in time is soft because the scarring process has not yet been initiated. A better prerequisite for a sufficient glottic closure can also be expected through the immediate adjustment of the volume of the vocal folds; however, reconstructive treatment can also be carried out secondarily. Different methods of reconstructive surgery for laryngeal carcinoma are presented and discussed.