No5(5) 2022
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DOI 10.37219/2528-8253-2022-5-55 |
Zabolotnyi DI, Tcimbalyuk EM, Kizim VV
Voice rehabilitation after laryngectomy: problems, complications and ways of
their elimination |
Zabolotnyi Dmitry I
State Institution “O.S. Kolomiychenko Institute of Otolaryngology of
National Academy of Medical Science of Ukraine”; Kyiv, Ukraine. Director
Doctor of Medical Sciences, Professor, Academician of the National Academy
of Medical Sciences of Ukraine
E-mail: amtc@kndio.kiev.ua
https://www.scopus.com/authid/detail.uri?authorId=6701512931
ORCID ID: https://orcid.org/0000-0001-9429-4414
Tcimbalyuk Evgeniya M.
State Institution “O.S. Kolomiychenko Institute of Otolaryngology of
National Academy of Medical Science of Ukraine”; Kyiv, Ukraine
ENT oncology department
Researcher
email:ecimbaliuk@gmail.com
Kizim Volodimir V.
State Institution “O.S. Kolomiychenko Institute of Otolaryngology of
National Academy of Medical Science of Ukraine”; Kyiv, Ukraine.
Department of ENT Oncopathology, Otolaryngologist-Oncologist
Candidate of Medical Sciences, docent
E-mail: vvkizim@gmail.com |
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Abstract
Topicality: According to the 2019-2020 cancer registry, the incidence
of laryngeal and laryngopharyngeal cancer remains high in Ukraine. Malignant
tumours of the larynx rank first among ENT organs accounting for 50-70%. The
incidence of laryngeal cancer has a tendency to constantly increase. At the
same time, 70% of patients with malignant tumours of the larynx are men of
working age which is 41-60 years.
The vast majority of cases of malignant tumours of the larynx (60-75%) are
diagnosed in stage 3-4 of the disease, when the main method of treatment is
laryngectomy. Total laryngectomy, which is necessary from an oncological
point of view, leads to a deep disability of the patient, namely loss of
voice. Difficulty or inability to communicate, social isolation cause severe
psychological trauma and is the main reason for refusal of radical surgery.
According to various authors, 35% of patients after extirpation of the
larynx use whispered speech, 30% use writing for communication.
Rehabilitation of the voice function in such patients would not only improve
the functional results of treatment and quality of life, but would also
facilitate social adaptation, thus reducing the number of refusals of
surgical treatment.
At the Department of Oncological Diseases of ENT Organs of the State
Institution “O. S. Kolomiychenko Institute of Otolaryngology of the National
Academy of Medical Sciences of Ukraine” to restore voice function after
laryngectomy, the TEP technique is used with Рrovox, Provox2, Vega, Voice
Master prostheses with low pressure for long-term use. The principle of
sound formation during rehabilitation with voice prostheses and shunting is
common and is based on the use of a strong flow of air from the lungs (about
3 litres), which is directed into the pharynx during exhalation with a
closed tracheostomy. The sound is formed at the level of the socalled
neoglottis. Thus, sufficient volume, speech intelligibility, fluidity,
emotional colouring is ensured, and individual characteristics of the voice
of each patient are preserved. The barrier function of the transmission
mechanism (prosthesis, shunt) is of great importance as it ensures the
absence of return current from the pharynx to the respiratory tract during
swallowing.
However, this technique of voice rehabilitation is noted to have a number of
problems that can be predicted and prevented, particularly in the
intraoperative period.
Aim: to analyse the difficulties and complications of TEP in patients
after laryngectomy and to develop measures for their prevention.
Materials and methods: The observation included 74 patients who
underwent treatment at the Department of Oncological Diseases of ENT Organs
of the State Institution “O.S. Kolomiychenko Institute of Otolaryngology of
the National Academy of Medical Sciences of Ukraine”. There were 65 men and
9 women aged 41-75 years.
The average age was 58 years. All patients underwent laryngectomy for
laryngeal or laryngopharyngeal cancer.
Eighteen patients underwent simultaneous laryngectomy with TEP, 44 patients
had delayed prosthesis fitting (within 2 months to 2 years), 6 patients
underwent TEP during pharyngostomy, and 6 patients had prosthesis fitting in
a previously formed shunt.
Patients with lesions of various parts of the larynx and laryngopharynx of
stage 2 (with subsequent recurrence of the tumour), stages 3 and 4 were
among the prosthetic patients. The course of treatment included pre- or
postoperative radiation therapy, polychemotherapy, total laryngectomy with
resection of the pharynx, tongue root, thyroid gland, selective and radical
neck dissection, and various combinations of these methods. In addition, 7
patients underwent tracheostomy.
Results and discussion: Surgical rehabilitation by the TEP technique
in patients with laryngeal and laryngopharyngeal cancer after laryngectomy
was carried out. The obtained results showed the following complications
during the surgery:
- Impossibility of the posterior tracheal wall perforation due to its
cicatricial-sclerotic changes in the area of tracheostomy, narrowing and
deformation – 5 cases;
- Injury to the walls of the pharynx and esophagus with a tube or trocar (in
case of cicatricial changes, tracheostoma deformations, cervical
osteochondrosis) – 3 cases;
- Detachment of the band from the prosthesis (due to excessive tension,
rigidity of the tracheal tissues, narrowing of the stoma and difficulty of
manipulations in this area) – 3 cases;
- Swallowing or aspiration of prosthesis – 1 case;
- Bleeding from the edges of the fistula – 6 cases;
- Difficulties during esophagoscope introduction (difficulty in extending
the neck due to cervical osteochondrosis, narrowing of the
pharyngoesophageal junction, difficulty in opening the mouth) – 12 cases;
- Prosthesis descent in fistula (the length of the prosthesis does not match
the length of the shunt) – 2 cases.
It should be noted that some patients had a combination of the above
mentioned problems and complications.
To overcome problems arising during surgery and to prevent complications, a
number of diagnostic and treatment measures have been introduced.
The formation of a permanent tracheostomy during laryngectomy is an
important stage of the operation.
The course of the postoperative period and the subsequent condition of the
patient depend on the shape and size of the tracheostomy opening. It should
be noted that under the influence of force of tracheobronchial apparatus,
the trachea stump is lowered to varying degrees, which contributes to the
narrowing of the stoma. In addition, gross post-operative and post-radiation
scar changes negatively affect the effectiveness of plastic surgery in this
area.
The main method of forming a tracheostomy is based on a racquet-shaped
excision of the skin around the stoma (suggested by Professor O. S.
Kolomiychenko in 1943) to stretch the edges of the tracheostomy. At the
Department of Oncological Diseases of ENT Organs of the State Institution
“O. S. Kolomiychenko Institute of Otolaryngology of the National Academy of
Medical Sciences of Ukraine” there has been developed a method that consists
in cutting the trachea in the anterior half parallel to the ring, then
obliquely to the top, with the excision of subcutaneous fatty tissue and
fixation of the tracheal wall to the connective tissue of the
sternoclavicular joint for 4 and 8 hours. In some cases, the anterior
pedicles of the sternocleidomastoid muscle are crossed (patent No. 117057
from 12.06.17).
The proposed method of forming a tracheostomy makes it possible to avoid
using a tracheostomy tube from the first day of the postoperative period,
form a permanent tracheostomy of the correct shape for further voice and
respiratory rehabilitation, reduces the risk of complications, does not
limit the oncological plan of surgery, does not make it difficult to perform
laryngectomy.
The stage of inserting the tube into the esophagus is also of great
importance. The implementation of the technique with an introduction of the
straight tube of the esophagoscope with the extension of the patient’s neck
is complicated by a number of factors such as: cervical osteochondrosis,
postoperative and post-radiation fibrosis, keloidosis of the soft tissues of
the front surface of the neck and pharynx. This increases the risk of a
fracture in the neck and the risk of tooth injury, as well as injury to the
soft tissues of the pharynx and esophagus.
At the Department of Oncological Diseases of ENT Organs of the State
Institution “O. S. Kolomiychenko Inst itute of Otolaryngology of the
National Academy of Medical Sciences of Ukraine”, the TES technique has been
improved by changing the design of the tube, which ensures minimal trauma,
reduces the time of surgical intervention, improves treatment outcomes and
increases the number of patients that can be treated (patent No. 117058).
Conclusions: The proposed method of forming a tracheostomy makes it
possible to create a permanent stoma of the correct shape for further voice
and respiratory rehabilitation in patients who underwent laryngectomy. In
patients of the risk group (hypersthenics, patients with a small diameter of
the trachea, in cases of tracheal resection), it makes it possible to avoid
using a tracheostomy tube from the first day of the postoperative period,
reduces the risk of complications, does not limit the oncological plan of
the operation.
An improved TES technique due to changes in the design of the esophageal
tube reduces the time of surgical intervention, improves treatment outcomes
and expands the possibilities for rehabilitat ion of pat ients.
Thorough preoperative preparation taking into account each patient’s
individual situation, compliance with the indications and technique of
surgery using the specified improvements help prevent and overcome the most
common intraoperative complications during TEP. |
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Keywords
cancer of the larynx, cancer of the laryngeal part of the pharynx,
laryngectomy, tracheoesophageal bypass, complications. |
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