Incidence of severe tracheobronchitis and pneumonia in laryngectomized patients: a retrospective clinical study and a European-wide survey among head and neck surgeons

Post-laryngectomy pulmonary and related symptom changes following adoption of an optimal day-and-night heat and moisture exchanger (HME) regimen

BACKGROUND

This study examined post-laryngectomy pulmonary and related symptom changes following establishment of an optimal day/night regimen (all day/night wear of devices with improved humidification) using a new generation range of heat and moisture exchanger (HME) devices.

METHODS

In Phase 1 (6 weeks), 42 post-laryngectomy HME users transitioned from their usual HME regime to equivalent new device/s (i.e., "like-for-like"). In Phase 2 (6 weeks) participants used the full range of HMEs to achieve an optimal day/night regimen. Pulmonary symptoms, device use, sleep, skin integrity, quality of life and satisfaction were examined at baseline, and weeks 2 and 6 of each Phase.

RESULTS

From baseline to end of Phase 2, cough symptoms and impact significantly improved, as did sputum symptoms, sputum impact, duration and types of HMEs used, reasons for HME replacement, involuntary coughs, and sleep.

CONCLUSION

The new HME range supported improved HME use, with pulmonary and related symptom benefits.

Incidence and medical complications of COVID-19 in the total laryngectomy population: A population-based study

OBJECTIVES

Laryngeal and hypopharyngeal cancers treated with total laryngectomy (TL) may provide a unique avenue for COVID-19 to infect cancer patients. The objective of this investigation was to identify incidence of COVID-19 infection and potential complications in TL patients.

MATERIALS AND METHODS

Data was extracted from TriNetX COVID-19 research network from from 2019 to 2021 and ICD-10 codes were utilized to query for laryngeal or hypopharyngeal cancer, and outcomes of interest. Cohorts were propensity score-matched based on demographics and co-morbidities.

RESULTS

A query of active patients in TriNetX from January 1, 2019 to December 31, 2021 identified 36,414 patients with laryngeal or hypopharyngeal cancer out of the 50,474,648 active patients in the database. The overall COVID-19 incidence in the non-laryngeal or hypopharyngeal cancer population was 10.8% compared to 18.8% (p < 0.001) in the laryngeal and hypopharyngeal cancer group. Those who underwent TL had a statistically significant increased incidence of acquiring COVID-19 (24.0%) when compared to those without TL (17.7%) (p < 0.001). TL patients with COVID-19 had a higher risk of developing pneumonia RR (risk ratio) 1.80 (1.43, 2.26), death 1.74 (1.41, 2.14), ARDS 2.42 (1.16, 5.05), sepsis 1.77 (1.37, 2.29), shock 2.81 (1.88, 4.18), respiratory failure 2.34 (1.90, 2.88), and malnutrition 2.46 (2.01, 3.01) when matched with those COVID-19 positive cancer patients without TL.

CONCLUSIONS

Laryngeal and hypopharyngeal cancer patients had a higher rate of acquiring COVID-19 than patients without these cancers. TL patients have a higher rate of COVID-19 compared to those without TL and may be at a higher risk for sequalae of COVID-19.

New Heat and Moisture Exchangers for Laryngectomized Patients in Germany: Mixed Methods Study on the Expected Effectiveness

BACKGROUND

Notwithstanding the benefits of heat and moisture exchangers (HMEs) in both clinical research and practice, a gap exists between the optimal physiological humidification created through the nasal function and the humidification capacity of HMEs for patients after total laryngectomy. In this study, 5 new HMEs (Provox Life) specialized for situational use with improved humidification capacities were evaluated.

OBJECTIVE

This study aims to evaluate the effectiveness of the existing HMEs, assess the potential effectiveness of the new HMEs, and elicit expert judgments on the new HMEs' expected effectiveness and impact on health care use.

METHODS

First, a rapid literature review (RLR) was performed to identify evidence on the clinical outcomes, health outcomes, and complications of HMEs in patients who underwent laryngectomy. Second, semistructured interviews with German experts (n=4) were conducted to validate the findings of the RLR and identify reasonable expectations regarding the potential of the new HMEs. Third, a structured expert elicitation among German experts (n=19) was used to generate quantitative evidence on the expected effectiveness of the new HMEs in clinical and health outcomes.

RESULTS

The RLR (n=10) demonstrated that HME use by patients has advantages compared with no HME use concerning breathing resistance, tracheal dryness and irritation, mucus production and plugging, frequency of cough and forced expectorations, sleep quality, voice quality, use of physiotherapy, tracheobronchitis or pneumonia episodes, quality of life, and patient satisfaction. From the expert interviews and structured expert elicitation, it was found that, on average, experts expect that compared with the second-generation HMEs, the new HMEs will lead to a decrease in tracheal dryness or irritation (51%, SD 24%, of patients), mucus plug events (33%, SD 32%, of patients), mucus production (53%, SD 22%, of patients), physiotherapy (0.74, SD 0.70, days) and pulmonary infections (34%, SD 32%) and an increase or improvement in speech quality (25%, SD 23%, of patients), social contacts (13%, SD 18%), quality of life (33%, SD 30%), and patient satisfaction (44%, SD 30%). An improvement in breathing (53%, SD 28%, of patients) and shortness of breath (48%, SD 25%, of patients) was expected. The average number of daily cough periods and forced expectorations was expected to be 2.95 (SD 1.61) and 2.46 (SD 1.42), respectively. Experts expect that, on average, less than half of the patients will experience sleeping problems (48%, SD 22%) and psychosocial problems (24%, SD 20%).

CONCLUSIONS

According to German experts, it is expected that the new HMEs with improved humidification levels will lead to additional (clinical) effectiveness on pulmonary health and an improved overall quality of life of patients compared with the currently available HMEs.

Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers

OBJECTIVE

To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy.

STUDY DESIGN

Prospective crossover study.

SETTING

Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery.

METHODS

Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).

RESULTS

Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D.

CONCLUSION

Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

Fragility and contagiousness of the total laryngectomy patient in the COVID-19 pandemic

OBJECTIVE

The Coronavirus disease 2019 (COVID-19) pandemic has posed significant problems for patients who have undergone total laryngectomy (TL). The lack of specific guidelines and paucity of information available to the public on this topic has clearly emerged during the ongoing pandemic. The aim of the present study is to investigate our personal experience in managing the stoma in TL patients during the COVID-19 pandemic.

METHODS

A questionnaire was administered by phone to laryngectomised patients who had previously been seen at the outpatient otolaryngology clinics of Vittorio Veneto and Barletta Hospitals from January to December 2020.

RESULTS

A total of 92 patients were included. Twenty-five patients (27%) had been tested for SARS-CoV-2. Among these, 19 (76%) had been investigated with a nasal swab, 5 (20%) with a tracheal swab and 1 with a serological assay. Five patients were positive for SARS-CoV-2 (in 4 cases as a result of the nasal swab, in one case with the bronchial aspirate). Eighty-four patients (91%) used a heat moisture exchanger over the stoma every day, but 6 patients (6.5%) were unaware of the importance of protecting the stoma.

CONCLUSIONS

We conclude that TL patients should always be adequately informed by healthcare staff about how to manage their stoma. Specific guidelines are needed for testing TL patients for SARS-CoV-2.

Surviving COVID-19 and multiple complications post total laryngectomy

The clinical manifestation of novel COVID-19 is variable. Pre-existing carcinoma and other comorbidities have been associated with increased COVID-19-related morbidity and mortality. Surgical intervention for advanced laryngeal carcinoma in old age during the COVID-19 pandemic may pose multiple challenges to the patient and the treatment team. We report a case of a 67-year-old elderly man who developed SARS-CoV-2 infection on the 21st day following total laryngectomy and neck dissection. The postoperative period was complicated by sequential development of pulmonary embolism, neck infection, pharyngeal leak and COVID-19 which were managed successfully. No close contacts were positive on the reverse transcription-PCR test for SARS-CoV-2. The patient is in follow-up for the past 7 months without any recurrence or COVID-19-related morbidity. The successful recovery and no cross-infection may be attributed to early diagnosis, immediate intervention and properly implemented institutional infection control policy.

Cost-effectiveness analysis of using the heat and moisture exchangers compared with alternative stoma covers in laryngectomy rehabilitation: US perspective

BACKGROUND

This study aims to evaluate the cost-effectiveness of using heat and moisture exchangers (HMEs) vs alternative stoma covers (ASCs) following laryngectomy in the United States.

METHODS

A cost-effectiveness and budget impact analysis were conducted including uncertainty analyses using real-world survey data with pulmonary events and productivity loss.

RESULTS

HME use was more effective and less costly compared with ASCs. Quality-adjusted life years were slightly higher for HME-users. Total costs per patient (lifetime) were $59 362 (HME) and $102 416 (ASC). Pulmonary events and productivity loss occurred more frequently in the ASC-users. Annual budget savings were up to $40 183 593. Costs per pulmonary event averted were $3770.

CONCLUSIONS

HME utilization in laryngectomy patients was cost-effective. Reimbursement of HME devices is thus recommended. Utilities may be underestimated due to the generic utility instrument used and sample size. Therefore, we recommend development of a disease-specific utility tool to incorporate in future analyses.

COVID-19 and Total Laryngectomy—A Report of Two Cases

Objective:

To date, no cases have been reported on the effects of COVID-19 in laryngectomees.

Case Presentation:

We herein presented two clinical cases of laryngectomized patients affected by COVID-19, detailing their clinical course and complications.

Discussion:

In our experience, permanent tracheostomy did not significantly affect the choice of treatment. However, dedicated devices and repeated tracheal toilettes may be needed to deal with oxygen-therapy-related tracheal crusting.

Conclusion:

In conclusion, laryngectomees should be considered a vulnerable population that may be at risk for worse outcomes of COVID-19 due to anatomical changes in their airways. The role of the ENT specialist is to guide airway management and inform the support-staff regarding specific needs of these patients.

The challenges of treating tracheobronchitis in a laryngectomee due to nontypeable Haemophilus influenzae: a case report

Background

Laryngectomees run the risk of developing severe respiratory tract infections especially during the winter and when they do not wear a stoma cover. A case of severe tracheobronchitis in a laryngectomee is presented that illustrates the risks and difficulties encountered in managing this infection in a neck breather.

Case presentation

A 76-year-old Caucasian man, a laryngectomee, presented with bacterial tracheobronchitis and conjunctivitis due to beta-lactamase-producing nontypeable Haemophilus influenzae. He was febrile (38.9 °C; 102.0 F), and had repeated episodes of hypertension. He was treated with levofloxacin 500 mg/day, ciprofloxacin eye drops, acetaminophen, and guaifenesin. Humidification of his trachea and the airway was sustained by insertions of saline into the stoma as well as breathing humidified air. The main challenge was to maintain the patency of his airway as the mucus was very dry and viscous and tended to stick to the walls of his trachea and the stoma. His condition improved within 7 days and he had a complete recovery.

Conclusions

Maintaining the patency of the airway in laryngectomees who suffer from lower respiratory tract infection is of utmost importance as the mucus can be very dry and viscous and can stick to the walls of the trachea and the stoma.

Ex vivo humidifying capacity and patient acceptability of stoma cloths in laryngectomized individuals

BACKGROUND

Heat and moisture exchangers (HMEs) improve respiratory function after laryngectomy, but there is virtually no information on the benefit of traditional stoma cloths or other covers.

METHODS

Two sequential studies were performed: (1) an ex vivo test was used to compare the humidifying capacity of stoma cloths to other coverings; and (2) a 4-week randomized trial was then performed to assess patient acceptability of cloths both alone and with an HME (N = 18).

RESULTS

The humidifying capacity of the coverings tested varied widely. For stoma cloths, a humidifying capacity of 13.7 mg/L was found to decrease to 8.5 mg/L if air-leaks around the cloth occurred. Patients who used HMEs disliked stoma cloths because they interfered with voicing, they became soiled more easily, and were less effective at reducing coughing and mucus production.

CONCLUSION

Although less acceptable to patients who use an HME, stoma cloths do provide significant humidifying capacity and should be encouraged when HMEs are unavailable or inappropriate. © 2017 Wiley Periodicals, Inc. Head Neck 39: 921-931, 2017.

Cost-effectiveness of heat and moisture exchangers compared to usual care for pulmonary rehabilitation after total laryngectomy in Poland

The beneficial physical and psychosocial effects of heat and moisture exchangers (HMEs) for pulmonary rehabilitation of laryngectomy patients are well evidenced. However, cost-effectiveness in terms of costs per additional quality-adjusted life years (QALYs) has not yet been investigated. Therefore, a model-based cost-effectiveness analysis of using HMEs versus usual care (UC) (including stoma covers, suction system and/or external humidifier) for patients after laryngectomy was performed. Primary outcomes were costs, QALYs and incremental cost-effectiveness ratio (ICER). Secondary outcomes were pulmonary infections, and sleeping problems. The analysis was performed from a health care perspective of Poland, using a time horizon of 10 years and cycle length of 1 year. Transition probabilities were derived from various sources, amongst others a Polish randomized clinical trial. Quality of life data was derived from an Italian study on similar patients. Data on frequencies and mortality-related tracheobronchitis and/or pneumonia were derived from a Europe-wide survey amongst head and neck cancer experts. Substantial differences in quality-adjusted survival between the use of HMEs (3.63 QALYs) versus UC (2.95 QALYs) were observed. Total health care costs/patient were 39,553 PLN (9465 Euro) for the HME strategy and 4889 PLN (1168 Euro) for the UC strategy. HME use resulted in fewer pulmonary infections, and less sleeping problems. We could conclude that given the Polish threshold of 99,000 PLN/QALY, using HMEs is cost-effective compared to UC, resulting in 51,326 PLN/QALY (12,264 Euro/QALY) gained for patients after total laryngectomy. For the hospital period alone (2 weeks), HMEs were cost-saving: less costly and more effective.

Pathohistological changes of tracheal epithelium in laryngectomized patients

Total laryngectomy results in a permanent disconnection of the upper and lower airways. Thus, the upper airways are bypassed and can no longer condition, humidify, and filter the inhaled air, leading to damage of the tracheobronchial epithelium. There is little scientific information available about the effects of tracheostoma breathing and the degree of mucosal damage in laryngectomized patients. The aims of this study were to determine the histopathologic findings and investigate the potential impact of using a heat and moisture exchanger (HME) on the tracheal epithelium in long-term tracheostomy patients. Tracheal mucosal biopsies were taken from a total of 70 patients. Specimens were stained with hematoxylin and eosin and examined by a light microscope. Normal pseudostratified ciliated columnar epithelium was found in only 9 (12.9%) cases; while, 17 (24.3%) cases had some degree of basal cell hyperplasia. Squamous metaplasia was the most common finding (50%). Pre-invasive lesions (mild and moderate squamous dysplasia) were found in only one patient who used an HME, and in eight (11.4%) non-users. Although the HME cannot completely restore the physiological functions of the upper respiratory track, it delivers a better quality of air to the lower airways and has a positive effect on tracheal mucosa.