LitAlert #44
Decreased Total Laryngectomy complications using a clinical care pathway
In the United States, more than 12,000 cases of laryngeal cancer are diagnosed annually. Total laryngectomy remains an important treatment for advanced and recurrent laryngeal cancer. The surgery results in significant anatomical alterations that affect the breathing, communication, and swallowing function of patients, which places a large demand on health care providers (HCPs) in the post-operative setting. In this retrospective analysis, the clinical outcomes of implementing a clinical care pathway post-laryngectomy were investigated. The goal of the pathway was to standardize interventions and improve delivery of care across a postoperative period of 7 days, providing a set protocol for medical examinations, physical therapy, tube feeding and use of HMEs. The primary outcome was defined as hospital length of stay (LOS). In total, 63 patients were included in the analysis. The pre-pathway cohort had a higher rate of total complications compared to the post-pathway cohort, however, the differences in individual complications were similar. The median LOS (10 days) was the same for both cohorts, although the median ICU LOS was one day greater in the post-pathway cohort. In conclusion, implementing a clinical care pathway may improve outcomes for total laryngectomy patients.
Application of transitional care after total laryngectomy
Adequate self-care education and patient support post laryngectomy is imperative to ensure continuity of care after discharge. In this study the aim was to investigate the effect of Transitional Care Measures (TCM), an extensive service consisting of home visits and telephone follow-ups, on self-care ability and quality of life (QoL) in the postoperative period. In total, 68 patients were enrolled and randomized into control group (conventional care) and observation group (transitional care). The control group were provided with instructions regarding basic nursing homecare at discharge, such as operating nasal feeding, tracheal humidification, and cannula changing. The observation group were in addition subjected to specific TCM guidelines and thereby received extended education, as well as a dedicated care team of HCPs, and a group chat intended for interaction between care team and patient/family members. At the 6-month follow-up after discharge, the observation group showed higher scores in self-care ability, greater satisfaction, higher QoL and better health knowledge compared to the control group – supporting the importance of adequate transitional care after total laryngectomy.
Swallowing exercise during Head and Neck Cancer treatment
Swallowing function impairment is a common side-effect of head-and neck cancer (HNC) treatment, and/or a consequence of the cancer itself. Dysphagia can have a considerable negative impact on the patient’s nutritional status and quality of life (QoL). This multi-center, randomized controlled trial aimed to examine the effects of individually designed swallowing therapy programs in HNC patients undergoing radiotherapy treatment during a 5-6 week period, in comparison to usual care. A total of 240 HNC patients were randomized to the intervention group (n=122), and control group (n=118). The overall result did not show a significant difference in swallowing safety, scored by penetration aspiration scale (PAS), between the two groups. Significant improvements were seen in mouth opening, QoL, depression and anxiety in the intervention group compared to control at 12 months after treatment. The authors hypothesize that the intervention duration may have been too short to see a significant improvement in swallowing safety, while highlighting the importance of dysphagia intervention, considering the long-term survival of HNC patients and the long-term effects on their swallowing function.
Quality of life after total laryngectomy
Total laryngectomy (TL), in conjunction with (chemo)radiotherapy, is associated with several side-effects with the potential to impact health-related quality of life (HRQoL) negatively. These side-effects range from voice problems and swallowing impairments to depression and anxiety. Data collection by means of patient reported outcomes is the foundation for evaluating QoL in TL patients. The most frequently used tools include validated questionnaires such as the EORTC QLQ-C30 and EORTC QLQH&N35. In this cross-sectional study the aim was to investigate HRQoL in TL patients using a study questionnaire on socio-demography and lifestyle, as well as five validated questionnaires on QoL: EORTC QLQ-C30, EORTC QLQ-H&N35, VRQOL, MDADI and HADS. Compared to normative reference populations, the 172 participants with TL scored worse on almost all scales/items of the EORTC questionnaires. The most clinically deviating scores were found in the senses problems, speech problems, dyspnea and teeth scales/items. The variable most strongly linked to decline in EORTC QLQ-C30 score was increasing number of comorbidities. Additionally, MDADI and V-RQOL scores showed a 46% prevalence of moderate/severe dysphagia and voice problems.
*EORTC (European Organization for Research and Treatment of Cancer) QLQ-C30 and QLQ-H&N35 = Quality of Life of Cancer Patients questionnaire, and Quality of Life of Cancer patients Head&Neck module, VROQL = Voice- Related Quality of Life questionnaire, MDADI= M.D. Anderson Dysphagia Inventory questionnaire, HADS= Hospital Anxiety and Depression Scale questionnaire.
How do listeners perceive alaryngeal speech?
In general, three main options for voice rehabilitation are available to the laryngectomized patient: tracheoesophageal speech (TES) by means of a voice prosthesis, esophageal speech (ES) and speech using an electrolarynx (EL). The success of the individual method varies from patient to patient depending on factors such as surgical outcome and anatomy, although TES is generally considered the gold standard due to superior voice quality. In recent years, the interest in research investigating listeners’ perception of alaryngeal speech has increased. In this study, 381 participants were asked to rate audio samples of TES, ES and EL speech and laryngeal speech in terms of intelligence, likeability, and employability. Results showed an overall preference for laryngeal speech. Remarkably, the highest rated alaryngeal modality of speech for female speech samples was ES, although for males, the highest rated modality was TES. The authors discuss whether the listeners’ preference for ES of the female speech samples could be explained by the breathy quality of ES. However, additional studies with more alaryngeal samples are needed to confirm this finding.
Communication after tracheostomy and laryngectomy using Augmentative and Alternative Communication
Adapting to new ways of voicing is vital for patients with a total laryngectomy or tracheostomy, one aspect being that patients with communication difficulties are more likely to experience worse quality of care. Before learning to speak after TL with the main voice restoration modalities there is a temporary period of acute aphonia. Augmentative and alternative communication (AAC) interventions include ways of communication that are directed towards aiding or replacing speech or writing. In this prospective cohort study, the impact of aphonia on quality of life (V-RQOL) and the effect of AAC intervention with iPads in laryngectomized or tracheostomized HNC patients was investigated. PROs were collected using relevant questions from V-RQOL and study-specific questionnaires on patient experience. The surveys were completed by 35 patients (n=18, pre-intervention and n=17, post-intervention with AAC). After surgery, a total of 89% of patients in the pre-intervention group reported communication difficulties which caused frustration (62%), anxiety (55%), and/or depression (44%). In the post-intervention group, patients reported less issues with communication, in particular communication of treatment and discharge plans with their HCPs. However, V-RQOL scores remained unchanged. Although the sample size in this study is small, authors suggest the implementation of AAC in the temporary aphonic period following TL or tracheostomy could provide a benefit to technologically skilled patients.
Total laryngectomy – still cutting edge?
Hoffmann TK. Total Laryngectomy-Still Cutting-Edge? Cancers (Basel). 2021;13(6).
An overview on indications, surgical procedures, possible complications, rehabilitation, and prognosis of total laryngectomy.
Salvage surgery for residual or recurrent laryngeal squamous cell carcinoma
An overview of different available surgical salvage strategies with their indications and contraindications and prerequisites.
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