Surgical voice restoration with the Blom-Singer prosthesis following laryngopharyngoesophagectomy and pharyngogastric anastomosis

Interdisciplinary plastic and reconstructive surgery of head and neck squamous cell carcinomas

Squamous cell carcinomas are the most common malignancies in the oral cavity, pharynx, and larynx. Even in the age of the most modern drug treatment methods, radical resection of these tumors is and currently remains the therapeutic gold standard. The loss of anatomical structures associated with surgery inevitably increases the functional deficits caused by the tumor itself. In this context, the extent of functional deficits is largely determined by the extent of resection. Complete organ resections, such as glossectomy, complete palate resection, laryngectomy, or transverse pharyngo-laryngectomy, lead to severe functional deficits, such as swallowing disturbances with life-threatening aspiration and articulation disorders up to the inability to speak. With the help of plastic reconstructive surgery, the lost tissue can be replaced and the specific functions of the upper aerodigestive tract can be preserved or restored.In recent decades, reconstructive surgical procedures have developed enormously in the treatment of malignant tumors of the head and neck. In order to make optimal use of them, a comprehensive, interdisciplinary therapy concept is a prerequisite for positive oncological and functional outcome. In addition to general medical and social parameters, surgical parameters play a crucial role in the choice of the reconstruction method. The extent to which the surgical measures must be interdisciplinary depends on the localization of the defects in the head and neck region and on the type of replacement tissue required. Here, the expertise of plastic surgery, oral and maxillofacial surgery, and abdominal surgery comes into play in particular. The use of different tissues, the combination of different grafts and flaps, or the preforming of donor regions allow reconstructions far beyond the level of simply restoring surface integrity. The functional results and thus the quality of life of patients after surgical therapy of extensive tumors of the mentioned localizations depend decisively on the type of reconstruction. Therefore, in the following review, special emphasis 1 be placed on the choice of reconstruction method and reconstruction technique for tissue loss after resections of HNSCC.

Prosthetic voice rehabilitation after laryngoesophagectomy: surgical and functional outcomes

PURPOSE

Quality of Life (QoL) after extensive head and neck resections is of paramount importance, especially after pharyngolaryngectomy or pharyngolaryngoesophagectomy where complex digestive tract reconstruction is required (with gastric pull-up or colon transposition). Tracheodigestive puncture (TDP) is the only vocal restoration option in this group of patients. The aim of this study is to evaluate postoperative complications, vocal outcomes, voice-related and swallowing-related QoL after secondary TDP in this cohort of patients.

METHODS

A retrospective study was conducted in the tertiary referral center of Verona Hospital between June 2014 and June 2020. Patient demographics, clinical and surgical data were assessed. Speech objective and subjective evaluation was performed. QoL was assessed with Voice Handicap Index-10 (VHI-10) and M.D. Anderson Dysphagia Inventory (MDADI) questionnaires.

RESULTS

Seven patients met the inclusion criteria, but two had died before questionnaires were administered. No intraoperative complications were noted after TDP surgery. There were delayed complications in four cases (57.1%) and all were treated with restoration. Intelligible voice was restored in all patients. Maximum phonation time and maximal voice intensity recorded were 5.42 ± 3.27 s and 65.20 ± 5.45 dB, respectively. Acceptable average VHI-10 and MDADI scores were obtained in all patients.

CONCLUSIONS

Secondary TDP performed after gastric pull-up or colon transposition reconstructions are feasible and effective procedures. An intelligible voice was restored in all patients, with satisfactory patient-perceived voice-related and dysphagia-related quality-of-life outcomes.

Prospective cohort study of voice outcomes following secondary tracheoesophageal puncture in gastric pull-up reconstruction after total laryngopharyngoesophagectomy

Background

Gastric pull-up is a reconstructive option for circumferential defects after resection of advanced laryngopharyngeal malignancy. Voice loss is expected and vocal rehabilitation remains a challenge. Our study objectives were to investigate the feasibility of secondary tracheoesophageal puncture following gastric pull-up and to analyze voice outcomes.

Methods

This was a prospective cohort study of patients with advanced laryngopharyngeal malignancies who underwent gastric pull-up and secondary tracheoesophageal puncture between 1988 and 2017 at a tertiary-care academic institution. Objective acoustic measures included fundamental frequency and vocal intensity. Perceptual analysis was performed using voice recordings (“Rainbow Passage”) randomly presented in a blinded fashion to four clinicians using the validated GRBAS scale. Speech intelligibility was assessed in a blinded fashion using a validated 7-point scale. Additionally, the Voice Handicap Index-10 was administered as a validated patient self-reporting tool.

Results

Ten patients (7 male, 3 female) were included, all of whom preferentially used tracheoesophageal puncture for communication. These patients had abnormal median fundamental frequency of 250 (interquartile range (IQR) 214–265) Hz and a limited median vocal intensity of 65.8 (IQR 64.1–68.3) dB. Perceptual analysis (GRBAS) revealed a median ‘moderate’ degree of impairment [grade 2 (IQR 2–3), roughness 2 (IQR 2–3), breathiness 3 (IQR 2–3), asthenia 2 (IQR 1–2), strain 2 (IQR 1–2)] as did median intelligibility scores [median 5 (IQR 4–7)]. Most patients self-reported an abnormal voice handicap-10 [median 26.5 (IQR 22.8–35.0)].

Conclusion

Secondary tracheoesophageal puncture is a safe and feasible option for voice rehabilitation after gastric pull-up. Although analyses demonstrated moderate subjective and objective impairment, tracheoesophageal puncture provided patients with a self-reported means of functional verbal communication and was their preferred method of communication.

Graphical abstract

Rehabilitation program for prosthetic tracheojejunal voice production and swallowing function following circumferential pharyngolaryngectomy and neopharyngeal reconstruction with a jejunal free flap

The case of a 68-year-old woman with postoperative speech and swallowing problems following a circumferential pharyngolaryngectomy and neopharyngeal reconstruction with a jejunal free flap is presented. The primary tumor was an extended papillary thyroid carcinoma (pT4N0M0). For vocal restoration, an indwelling Provox^® 1 voice prosthesis was inserted secondarily. The patient received speech and swallowing therapy, including digital maneuvers at the level of the proximal (cervical) part of the jejunal graft to improve speech and swallowing function. Pre- and/ or post-treatment data on speech and swallowing function were gathered using the following assessment methods: esophageal insufflation test, Voice Handicap Index (VHI), videofluoroscopy of phonation (VFSph), digital high-speed endoscopy of jejunal vibration during voice production, fiber-optic endoscopic evaluation of swallowing (FEES), and videofluoroscopy of swallowing (VFSs). This case clearly demonstrates that even after extensive laryngopharyngectomy with jejunal free flap reconstruction, a tailored rehabilitation program can improve both voice and swallowing function, and that these results clearly can be objectified/visualized, underlining the validity of this approach.

Swallowing and speech therapy after definitive treatment for laryngeal cancer

As the trend in laryngeal cancer treatment shifts towards organ-conservation surgeries and organ-preservation protocols, patients will more often retain anatomy vital to communication and swallowing. Despite a conservative approach, results of treatment may have debilitating effects. Rehabilitation efforts are directed towards a return to functional, if not normal, status. Although there are predictable trends in voice and swallowing disorders of patients with laryngeal cancer, posttreatment dysphonia and dysphagia are diverse in presentation. Considering the significant diversity of this population, speech pathologists should work closely with otolaryngologists to determine the most appropriate treatment for each patient. As this article demonstrates, voice and swallowing therapy are necessary components of the rehabilitation process following treatment for head and neck cancers. As always, treatment is tailored to the specific individual and based on information obtained during a thorough evaluation by a speech pathologist. Fortunately, with the help of voice and swallowing therapy, many patients return to functional communication and oral feeding.

Reconstruction of the pharynx and cervical esophagus using ileocolic free autograft

BACKGROUND

Advanced stage hypopharyngeal cancer is commonly treated by surgery and radiotherapy. This report presents a technique using ileocolic free autograft as a single-stage procedure for voice and swallowing rehabilitation after pharyngolaryngoesophagectomy.

METHODS

Digestive tract restoration is obtained by using the cecum and ascending colon, while the last ileal loop, protected by the ileocecal valve for food and liquid inhalation, is anastomized to the cervical trachea. After abdominal harvesting, the ileocolic complex is transected, transposed, and then revascularized in the cervical field.

RESULTS

Six patients underwent this operation successfully with recovery of swallowing function and vocal performance within a short period of time, varying from 18 to 38 days.

CONCLUSION

On the basis of achieved results, the ileocolic free autograft can be considered a good option for pharyngoesophageal reconstruction, offering as it does an immediate restoration of swallowing and voice function.

Primary placement of a voice prosthesis on transposed colon after total pharyngolaryngoesophagectomy

BACKGROUND

Primary placement of a voice prosthesis may aid rehabilitation after total laryngectomy.

METHODS

We present a rare clinical situation of a T4 NO MO squamous cell carcinoma of the hypopharynx and esophagus in a patient who had previously undergone a transmesocolic Billroth II gastrectomy.

RESULTS

The patient benefited from a total pharyngolaryngoesophagectomy, with reconstruction using a transverse-descending colon transposition, and primary placement of a low-pressure voice prosthesis.

CONCLUSION

Primary placement of a voice prosthesis may be successful even in a patient who requires extensive pharyngoesophageal reconstruction using transposed colon. To our knowledge, there has been no previous report of primary placement of a voice prosthesis on a colon autograft.

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls (p > 0.05). No significant differences (p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences.

Vibratory segment function after free flap reconstruction of the pharyngoesophagus

Reconstructive options following total laryngopharyngectomy include thin, pliable free tissue segments, approximating the natural thickness of the pharyngeal wall. The authors have investigated outcomes in the following clinical series, emphasizing speech and swallowing. Twelve cancer patients underwent laryngopharyngectomy with or without glossectomy. Eight jejunal, 1 radial forearm, and 3 innervated latissimus dorsi flaps were used for vibratory segment (VS) reconstruction, and all 12 patients underwent tracheoesophageal puncture (TEP). Eleven patients achieved intelligible speech, with a median intelligibility of 93%. The vibrating segments showed fluttering of the free flap tissue when studied by videopharyngography. Vocal quality was lower pitched and softer than "conventional" TEP speech. All patients achieved oral intake as their primary mode of nutrition. Free flaps are a successful option for VS reconstruction in patients undergoing laryngopharyngectomy or glossopharyngolaryngectomy, obviating the need for written or electrolarynx communication.

Tracheoesophageal voice following tubed free radial forearm flap reconstruction of the neopharynx

Tracheoesophageal voice restoration after laryngectomy is possible with a variety of neopharyngeal reconstructions. We have used the tubed radial forearm free flap for neopharyngeal reconstruction since 1991. Six patients have undergone voice restoration with the Blom-Singer prosthesis and were available for quantitative and qualitative speech analysis. These patients were compared to five laryngectomy patients with standard pharyngeal closures and similar voice restorations. The free flap patients produced similar loudness levels compared to the standards with soft speech (52.06 dB and 47.19 dB, respectively) and loud speech (62.66 dB and 60.91 dB, respectively). The free flap patients demonstrated adequate intelligibility, with fundamental frequencies comparable to standards (124.82 Hz and 135.66 Hz, respectively), although with increased jitter (5.00% versus 1.96%). No differences were statistically significant, but evaluation by trained and naive listeners demonstrated significant differences in voice quality. This quantitative and qualitative and qualitative analysis of tracheoesophageal speech after radial forearm free flap reconstruction of the neopharynx demonstrates that acceptable voice can be achieved, but with limitations.

Long-term functional results after pharyngoesophageal reconstruction with the radial forearm free flap

For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free jejunal flap. Speech rehabilitation in patients secondarily reconstructed with the radial free flap was nearly equivalent to that of total laryngectomy patients who have primary closure of the pharynx and was superior to that reported with other popular PE reconstructions, including the gastric pull-up and the free jejunal flap.

Speech restoration following total laryngo-pharyngectomy with free jejunal repair

Nine patients who have undergone total laryngo-pharyngectomy with free jejunal reconstruction between 1984 and 1993, have had Blom-Singer valves inserted. All patients had little or no voice prior to valve insertion, compared with a good but gravelly voice after valve insertion. Tracheo-oesophageal puncture and valve insertion provides a safe and reliable means of restoring voice after laryngo-pharyngectomy with free jejunal repair.

Reconstruction with free jejunal autograft after pharyngolaryngoesophagectomy

Twenty-four patients with hypopharyngeal or cervical esophageal carcinoma were treated surgically. All had squamous cell carcinoma, and none had intrathoracic lymph node involvement by preoperative computed tomography. Endoscopy in 18 patients confirmed there was no intramural spread into the thoracic esophagus. The patients underwent pharyngolaryngoesophagectomy and bilateral modified radical neck dissection. Reconstruction of the cervical esophagus was performed with transplantation of a free jejunal autograft. Postoperative complications included anastomotic leak in 2 patients (8.3%), wound infection in 3 (12.5%), and intussusception in 4 (16.7%). Reconstruction of the cervical esophagus was successful in 23 (95.8%) of the 24 patients. The operative mortality rate was 4.2%, and the 5-year survival rate was 39.7%. We emphasize that pharyngolaryngoesophagectomy followed by transplantation of a free jejunal graft is suitable for cervical esophageal carcinoma or hypopharyngeal carcinoma when the disease is limited to the cervical region.