LitAlert #52
Automatic speaking valve in tracheo-esophageal speech: treatment proposal for a widespread usage
In total laryngectomy (TL) patients voice prostheses (VP) can be implanted to restore speech by creating a tracheoesophageal voice. Automatic Speaking Valves (ASV) allow hands-free speech for the patients by automatically occluding airflow during exhalation. However, some challenges persist, like adhesive detachment and increased respiratory effort. The aim of the study was to investigate the percentage of ASV use in a large cohort of laryngectomized patients with VPs. Furthermore, they examined reasons for non-use and proposed tailored rehabilitation strategies. 110 patients were included and 57 underwent intervention involving breathing and phonation exercises. Before and after training patients answered questionnaires assessing ASV use, average adhesive lifetime during ASV use, hands-free speech duration and skin irritation. Results showed that during the initial assessment 17.27% of the patients used ASV. Primary reasons for non-use included fatigue and adhesive durability issues. Post-training analysis showed statistically significant improvements in all measured parameters. After intervention ASV usage increased by 43%, reaching a 60% usage level. This highlights the effectiveness of targeted rehabilitation in improving ASV adherence.
Decisional Conflict in Patients with Advanced Laryngeal Carcinoma: A Multicenter Study
Historically patients with a locally advanced laryngeal carcinoma (T3 and T4) usually underwent total laryngectomy (TL). However, in more recent years preserving the larynx has become more common to avoid a permanent tracheostoma and loss of natural voice. Studies have shown that general quality of life (QoL) is similar between the two modalities, however there are differences in functionality. The complexity of these treatment options may lead to decisional conflict (DC) for patients. This multicenter prospective cohort study aimed to research the level of DC in locally advanced laryngeal carcinoma patients facing decision-making for treatment, and to identify possible associated factors. Forty-five included patients were asked to complete questionnaires on DC and a knowledge test at baseline, directly after counseling, and 6 months post-treatment. It was shown that following counseling as well as post-treatment patients experienced clinically significant DC score. The knowledge levels regarding treatment and consequences were relatively low, and lower for TL patients compared to CRT patients. The perceived level of shared decision-making score was high, for both patients and physicians. The authors conclude patients with advanced larynx cancer commonly experience significant DC. Their limited understanding of treatment modalities highlights the necessity for improved patient counseling.
Evidence-Based Recommendations in Primary Tracheoesophageal Puncture for Voice Prosthesis Rehabilitation
Tracheoesophageal voice rehabilitation after a total laryngectomy (TL) is considered the gold standard treatment. Tracheoesophageal puncture (TEP) is a surgical procedure that is required for insertion of a voice prostheses. The surgical procedure can be done either during laryngectomy called primary TEP, or delayed until after the patient's surgical recovery, called secondary TEP. This systematic review aimed to establish evidence-based recommendations regarding indications, contraindications and complications in primary TEP with voice prosthesis placement. Based on clinical evidence from 91 included studies, 19 statements were formulated. The statements include recommendations for primary TEP around technique, indication and contraindications. The review also emphasizes the importance of a multidisciplinary assessment for candidate selection. Furthermore, it also provides detailed recommendations for managing complications, such as periprosthetic leakage and postoperative infection. The majority of them (78.95%) had Level 4 evidence and a Grade C recommendation. As the level of evidence is low, there's insufficient evidence when comparing primary TEP and secondary TEP outcomes. This highlights the need for further research to elucidate the role of primary versus secondary TEPs for laryngectomy patients.
Late laryngeal dysfunction in head and neck cancer survivors
There is an increasing incidence of head and neck cancer (HNC) worldwide and the treatment options include surgery, chemotherapy, radiation, and immunotherapy. Despite advances in radiation therapy, long-term post-radiation changes to the larynx pose significant challenges, leading to functional impairment and increased risk of aspiration, impacting patients' quality of life. The research aimed to characterize the extent of laryngeal dysfunction in long-term HNC survivors. The study included 30 participants, predominantly male, treated mainly for oropharyngeal squamous cell carcinoma. Common symptoms included swallowing dysfunction (83%), voice change (67%), and chronic cough (17%). Vocal fold motion abnormalities were observed in 61% of participants. No significant correlation was found between time since treatment and laryngeal dysfunction (correlation coefficient r = .182, p = .34). Altogether the article emphasizes the importance of early screening for laryngeal dysfunction in HNC survivors to prevent complications and improve their quality of life.
Surgical closure of enlarged tracheoesophageal fistula after laryngectomy: A systematic review of techniques
As previously reported, between 18-35% of laryngectomy patients may experience leakage around their prosthetics, and tracheoesophageal fistula enlargement was identified as the cause for peripheral leakage in 7% of patients with a voice prosthesis. Enlarged tracheoesophageal fistulas can primarily treated with e.g. injection of materials around the fistula site or removal of the voice prosthesis to encourage closure. However, in 20%-32% of enlarged tracheoesophageal fistula cases surgical closure is needed to avoid complications. This systematic review aims to evaluate surgical closure techniques for enlarged tracheoesophageal fistula after laryngectomy reported in literature and compare the success rates of primary closure versus vascularized flap reconstruction. Fourteen studies reporting outcomes for the reconstruction of tracheoesophageal fistula were included. In these studies, primary closure was used in 98 patients, vascularized flap in 74 and occlusive device in 8. Out of 180 patients, primary closure was successful in 62% (61 of 98 patients), while vascularized flap reconstruction had an 89% success rate (66 of 74 patients). This systematic review supports the use of vascularized flap interposition between the esophageal and tracheal lumens over primary closure, due to higher success rates in surgical closure of enlarged tracheoesophageal fistula.
Dysphagia After Total Laryngectomy: An Exploratory Study and Clinical Phase II Rehabilitation Trial with the Novel Swallowing Exercise Aid (SEA 2.0)
Patients undergoing a total laryngectomy (TL) face lifelong challenges including adaptation to altered anatomy, loss of natural voice, and swallowing difficulties (dysphagia). Up to 72% of patients have self-reported long-term swallowing problems after TL. Dysphagia rehabilitation typically involves non-surgical techniques such as exercises targeting swallowing muscles. The aims of this exploratory study were to explore the nature of dysphagia in laryngectomized patients with dysphagia, and its rehabilitation using a novel Swallowing Exercise Aid (SEA 2.0). Twenty patients participated in a six-week exercise program with the SEA 2.0, performing exercises, Chin Tuck Against Resistance (CTAR), Jaw Opening Against Resistance (JOAR) and Effortful Swallow Against Resistance (ESAR), three times per day, seven days a week for six weeks. The training program using the SEA 2.0 was completed by all participants. Compliance was 95%, with only one participant completing less than 70% of the training program due to the intensity of exercise. After 6 weeks of exercise, subjective swallowing measures (MD Anderson Dysphagia Inventory, MDADI and Eating Assessment Tool, EAT-10) showed clinically relevant improvements; and the objective measures for CTAR and JOAR strengths had increased with 27.4 and 20.1 Newton, respectively. After 8 weeks rest, T2, subjective and objective swallowing assessments were slightly reduced, but still significantly better than at baseline. This study demonstrates promising outcomes with a six-week rehabilitation program using the novel SEA 2.0. Remarkably high adherence was observed, and both subjective and objective measures of swallowing function showed improvements.
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