Factors correlated to voice prosthesis functionality and duration in laryngectomised patients

Objective: Total laryngectomy usually affects in a catalytic way the production of voice, the respiratory function as well as the personal and social life of the laryngectomises patient. Since the introduction of the tracheoesophageal voice restoration by Singer and Blom in 1979, the prospective of a successful method of voice rehabilitation following laryngectomy was raised. In addition to esophageal speech and artificial larynx, a great number of patients achieved an intelligible, functional speech, which is much closer to “normal speech”, requires minimum effort and provides a worldwide accepted method of voice restoration after laryngectomy. Aim: Purpose of the current study is to identify and analyze factors which contribute in adequate function and duration of the voice prosthesis. Factors introduced and analyzed were: the influence of radiotherapy, neck dissection, size of the voice prosthesis, saliva’s electrolyte composition and pH, bacterial and fungal colonization of voice prosthesis, pulmonary function, efficacy of voice production among with phonation characteristics and probable correlation in voice prosthesis’ function and duration. Materials and methods: A retrospective review was performed in 70 laryngectomised patients between 1st of January 1998 until 1st of January 2005. All patients included in the study had a total laryngectomy performed and voice prosthesis was used to restore speech after surgery. Voice prosthesis used was the PROVOX (ATOS Medical AB, Hosby, Sweden), type Ι and ΙΙ. The PROVOX voice prosthesis was inserted through the tracheosophageal fistula and cannot be removed or replaced from the patient. Replacement of the Provox voice prosthesis is carried out with a disposable insertion tool (a loading tube and an inserter) for the insertion of the voice prosthesis directly through the stoma into the fistula. The technique is well tolerated from the patient but requires some technical skill and ability from the physician, so it can be adequate placed through the tracheosophageal fistula. Results: Fifty-one male patients met the introduction criteria. The number of voice prosthesis studied was 160. Patient’s age was between 51 and 76 years (mean age 66 years). All patients retained adequate voice prosthesis function for a significant period of time. The duration of voice prosthesis studied was between 10 to 46 weeks. Most of voice prosthesis studied (51 prosthesis), remained functional between 24 and 28 weeks. The size of voice prosthesis did not influence the total time in which voice prosthesis did remain functional. In our work increased sized of voice prosthesis correlated with minimized bacterial and fungal colonization. Radiotherapy, through the decreased salivary flow, did influence the duration of voice prosthesis. On the other hand, neck dissection was not a factor of diminished functionality. Radiotherapy was not correlated with the number of bacteria isolated from the silicone material. Liturgical voice prosthesis correlated with an increased number of bacteria, but there was no evidence that this fact related, in any way, with patient’s morbidity. In cases with a diminished salivary flow, an increased number of bacteria and fungal colonization was noted, and a decreased functionality and duration of voice prosthesis was also present. Increased saliva’s pH levels had an impact in prosthesis duration. Average increased level of saliva’s pH was correlated with adequate voice prosthesis functionality and duration. The most frequent bacteria isolated from voice prosthesis were Staphylococcus aureus in 48.5% of all cases. Even when there was only one type of bacteria present, Staphylococcus aureus was the dominant type with 15.8%. In cases of fungal colonization, the most frequent type isolated was Candida albicans, with 66.9%. Pulmonary function was efficient in all cases for voice production, even after radiotherapy or neck dissection. The size of voice prosthesis had no effect in pulmonary function and voice production. There was not a statistical significance between pulmonary parameters measured and radiotherapy or the size of voice prosthesis. In our work fluency, maximum phonation time, articulation and speech rate were not correlated with alterations caused by radiotherapy or the size of voice prosthesis. Additionally, all patients were able to communicate through the telephone with the environment. Quality voice was able to be produced by all study patients and this has an affirmative impact in patient’s social and professional aspects of their life. Based on patient’s respond to the questionnaire filed in every voice prosthesis replacement, there was a clear consequent that voice prosthesis functionality was related with the number of times in which patient cleaned the prosthesis through the day. Consistent use of the cleaning brush device was an observation noted in all patients with sufficient voice prosthesis functionality. Local and general personal hygiene was the most important factor to maintain quality of speech and use of voice prosthesis with no major concerns for a significant period of time. Cleaning hands regularly minimizes the number of bacteria which transfer through fingers to voice prosthesis in cases when a stoma button is not used. Conclusions: Adequate hydration and salivary flow especially in a previously radiated field, among with thorough personal hygiene and consistent cleaning of the prosthesis were the most important factors contributed in voice prosthesis functionality and duration noted in our work.Εισαγωγή: Η ολική λαρυγγεκτομή επηρεάζει με καταλυτικό τρόπο την παραγωγή της φωνής, την αναπνευστική λειτουργία, αλλά και την προσωπική και κοινωνική ζωή του ασθενή. Σημαντική πρόοδος σημειώθηκε τα τελευταία χρόνια μετά την πρώτη περιγραφή της φωνητικής πρόθεσης από τους Singer και Blom το 1979, η οποία αύξησε θεαματικά τις προοπτικές αποκατάστασης της φωνής σε ασθενείς που υποβάλλονται σε ολική λαρυγγεκτομή. Σε σύγκριση με την οισοφάγειο ομιλία και την χρήση του τεχνητού λάρυγγα, ένας μεγάλος αριθμός ασθενών κατόρθωσε να αποκτήσει μια ικανοποιητική φωνή, που ακούγεται φυσιολογική, παράγεται με μικρή προσπάθεια, χρειάζεται σύντομη εξοικείωση και αποτελεί σήμερα σύγχρονο και ευρύτατα αποδεκτό τρόπο επανορθωτικής αποκατάστασης της φωνής. Σκοπός: Στόχος της παρούσας μελέτης είναι ο καθορισμός, η ανάλυση και η αξιολόγηση των παραμέτρων που συμβάλλουν στη διάρκεια και καλή λειτουργικότητα της φωνητικής πρόθεσης. Οι παράμετροι που μελετήθηκαν και αξιολογήθηκαν ήταν η επίδραση της ακτινοθεραπείας, της τραχηλικής εκσκαφής, του μεγέθους της φωνητικής πρόθεσης, η ηλεκτρολυτική σύσταση και το pH του σιέλου του ασθενή, ο βακτηριακός και ο εποικισμός του υλικού της φωνητικής πρόθεσης από μύκητες, οι παράμετροι της πνευμονικής λειτουργίας και η εκτίμηση της παραγόμενης φωνής και των φωνητικών χαρακτηριστικών, σε σχέση με την λειτουργικότητα και την διάρκεια της φωνητικής πρόθεσης. Υλικό και μέθοδος: Έγινε μια αναδρομική μελέτη σε ένα δείγμα 70 ασθενών που υπεβλήθηκαν σε ολική λαρυγγεκτομή από την 1η Ιανουάριου του 1998 έως την 1η Ιανουάριου του 2005. Στην μελέτη συμπεριελήφθησαν ασθενείς που είχαν υποβληθεί σε ολική λαρυγγεκτομή και στους οποίους τοποθετήθηκε φωνητική πρόθεση για την αποκατάσταση της φωνής. Ο τύπος της φωνητικής πρόθεσης που μελετήθηκε ήταν η PROVOX φωνητική πρόθεση (ATOS Medical AB, Hosby, Sweden), τύπος Ι και ΙΙ. Η Provox φωνητική πρόθεση εισάγεται μέσω μιας οπής στο τραχειοοισοφαγικό κανάλι και παραμένει στην θέση της, χωρίς αλλαγή από τον ασθενή. Η αρχική εισαγωγή κατά την διάρκεια της ολικής λαρυγγεκτομής είναι η μέθοδος που προτείνουν οι εμπνευστές της πρόθεσης, αλλά η τοποθέτηση μπορεί να γίνει και αρκετούς μήνες αργότερα. Η Provox φωνητική πρόθεση αντικαθίσταται μέσω ενός σωλήνα εισαγωγής της πρόθεσης και ενός προωθητήρα καθιστώντας εύκολη την τοποθέτηση και αρκετά ανεκτή από τον ασθενή, αλλά απαιτεί κάποια επιδεξιότητα από τον κλινικό γιατρό και προσοχή για σωστή τοποθέτηση μέσω της τραχειοοισοφαγικού συριγγίου. Αποτελέσματα: Από τους ασθενείς της μελέτης πληρούσαν τα κριτήρια εισόδου 51 άρρενες ασθενείς, από τους οποίους αφαιρέθηκαν και μελετήθηκαν συνολικά 160 φωνητικές προθέσεις. H ηλικία των ασθενών ήταν από 51 έως 76 έτη (μέση ηλικία: 66 έτη). Με βάση τα αποτελέσματα της έρευνας οι ασθενείς της παρούσας μελέτης διατηρούσαν λειτουργική την φωνητική πρόθεση για σχετικά μεγάλο χρονικό διάστημα. Η χρονική διάρκεια παραμονής λειτουργικής φωνητικής πρόθεσης ήταν από 10 έως 46 εβδομάδες. Το μεγαλύτερο ποσοστό των υπό εξέταση φωνητικών προθέσεων (51 προθέσεις) παρέμεναν λειτουργικές μεταξύ 24 και 28 εβδομάδων. Το μέγεθος της φωνητικής πρόθεσης δεν επηρέασε τον χρόνο που αυτή παρέμενε λειτουργική. Αύξηση του μεγέθους της φωνητικής πρόθεσης συνοδευόταν, στις μετρήσεις μας, από σχετική ανθεκτικότητα στον εποικισμό από βακτήρια και μύκητες. Η ακτινοθεραπεία επηρέασε την διάρκεια και την λειτουργικότητα της φωνητικής πρόθεσης, μέσω της μειωμένης σιαλικής ροής, ενώ η διενεργηθείσα τραχηλική εκσκαφή δεν επηρέασε οριακά την χρονική διάρκεια που παρέμεινε λειτουργική η φωνητική πρόθεση. Από την άλλη η ακτινοθεραπεία δεν επηρέασε τον αριθμό των απομονωθέντων βακτηρίων και μυκήτων που απομονώθηκαν στις καλλιέργειες των φωνητικών προθέσεων. Σε φωνητικές προθέσεις που παρέμεναν λειτουργικές για μεγάλο χρονικό διάστημα παρατηρήθηκε η παρουσία αυξημένου αριθμού βακτηρίων. Δεν υπήρξε ένδειξη πως αυτό συνέβαλε κατά οποιονδήποτε τρόπο στην επιβάρυνση της υγείας του ασθενή και δεν αποτελούσε αποδεδειγμένα εστία επιμόλυνσης ή ενοφθαλμισμού βακτηρίων ή μυκήτων σε άλλα όργανα. Η μελέτη των μεταβολών του σιέλου απέδειξε πως ασθενείς που εμφανίζουν μειωμένη ροή σιέλου, εμφανίζουν αυξημένο ποσοστό απομόνωσης στις καλλιέργειες τους βακτηρίων και μυκήτων, δυσλειτουργία της φωνητικής πρόθεσης και μειωμένη διάρκεια. Η μακρά παραμονή λειτουργικής φωνητικής πρόθεσης συνοδευόταν από τιμές pH σιέλου περισσότερο βασικές και λιγότερο όξινες. Η παραμονή της πρόθεσης σε περισσότερο βασικό περιβάλλον την καθιστούσε και περισσότερο λειτουργική. Η μελέτη των καλλιεργειών των φωνητικών προθέσεων απέδειξε πως στελέχη Staphylococcus aureus απομονώθηκαν ως τα πλέον συχνά, σε ποσοστό 48,5%, σαν αίτιο δυσλειτουργίας της πρόθεσης. Ακόμα και στις περιπτώσεις απομόνωσης ενός μόνο βακτηρίου ο Staphylococcus aureus ήταν ο πλέον συχνός με ποσοστό 15,8%. Από τα στελέχη μυκήτων που εποικίζουν τις φωνητικές προθέσεις της μελέτης η Candida albicans απομονώθηκε σε ποσοστό 66,9%. Η πνευμονική λειτουργία παρέμενε ικανοποιητική για την παραγωγή της φωνής μέσω της πρόθεσης ακόμα και μετά από ακτινοθεραπεία ή τραχηλική εκσκαφή. Επίσης το μέγεθος της φωνητικής πρόθεσης δεν επηρέασε την παραγόμενη φωνή. Δεν υπήρξε στατιστικώς σημαντική σχέση ανάμεσα στις παραμέτρους της σπειρομέτρησης των ασθενών της μελέτης σε συνάρτηση με την ακτινοθεραπεία ή το μέγεθος της φωνητικής πρόθεσης. Στην παρούσα μελέτη η ροή, η διάρκεια και ο ρυθμός της παραγόμενης φωνής ήταν ανεξάρτητα από μεταβολές που επέφερε η ακτινοθεραπεία, η τραχηλική εκσκαφή ή η μεταβολή του μεγέθους της φωνητικής πρόθεσης. Όλοι οι ασθενείς της μελέτης έκαναν ευρεία χρήση του τηλεφώνου ως μέσου επικοινωνίας με το περιβάλλον. Επιπρόσθετα, όλοι οι ασθενείς ήταν ικανοποιημένοι από την ποιότητα της παραγόμενης φωνής και από τον θετικό αντίκτυπο που επέφερε η χρήση της μεθόδου στην κοινωνική και επαγγελματική τους ζωή. Τέλος, από την ανάλυση του αντίστοιχου ερωτηματολογίου που συμπληρωνόταν σε κάθε αντικατάσταση φωνητικής πρόθεσης, προέκυψε πως η διάρκεια και η καλή λειτουργικότητα της φωνητικής πρόθεσης είχε σχέση με την συχνότητα καθαρισμού της φωνητικής πρόθεσης. Ασθενείς που χρησιμοποιούσαν επιμελώς και με την σωστή μέθοδο την ειδική ψήκτρα καθαρισμού, διατηρούσαν λειτουργική την φωνητική τους πρόθεση για μεγαλύτερο χρονικό διάστημα. Η διατήρηση τόσο τοπικής αλλά και γενικής προσωπικής υγιεινής είναι πολύ σημαντική παράμετρος καλής λειτουργικότητας της φωνητικής πρόθεσης. Ο καλός και συχνός καθαρισμός των χεριών μειώνει σημαντικά το ποσοστό των παθογόνων μικροοργανισμών που μεταφέρονται στην φωνητική πρόθεση από πλημμελή καθαρισμό των χεριών, κατά την διαδικασία σύγκλεισης του τραχειοστόματος με τα δάκτυλα. Συμπεράσματα: Επαρκής ενυδάτωση και διαβροχή από ικανή ποσότητα σιέλου της φωνητικής πρόθεσης, ιδιαίτερα σε ακτινοβολημένο πεδίο, μαζί με συχνή φροντίδα και καθαρισμό της, αλλά και επιμέλεια της προσωπικής υγιεινής, είναι οι σημαντικότεροι παράγοντες διατήρησης της λειτουργικότητας της φωνητικής πρόθεσης για μεγαλύτερο χρονικό διάστημ

Massive juvenile ossifying fibroma arising from the middle turbinate

A 19-year-old man presented with a long-standing history of nasal obstruction, which gradually became worse over the past 2years. Nasal endoscopy revealed a sizeable rounded mass covered by a normal-looking mucosa. Imaging studies showed a mass arising from the left middle turbinate that extended throughout the expanse of the anterior skull base. The tumour was resected via an endoscopic endonasal approach. Histopathological examination revealed a psammomatoid juvenile ossifying fibroma. The patient remains free of recurrence after almost 3years of follow-up. Only four cases of ossifying fibroma with middle turbinate localisation have been reported in the literature so far, with our case representing the fifth and most extensive case. Clinical, radiological and histological findings should all be considered for establishing the correct diagnosis. An endoscopic approach represents an excellent therapeutic option. Long-term clinical and radiological surveillance is required due to the risk of recurrence

Superiorly based subperiosteal orbital abscess: an uncommon presentation

A 32-year-old female patient presented with severe facial pain, right eye proptosis and diplopia. Endoscopy revealed ipsilateral crusting, purulent discharge and bilateral nasal polyps. Imaging demonstrated a subperiosteal abscess on the roof of the right orbit. Due to patient's significant ocular manifestations, surgical management was decided. The abscess was drained using combined endoscopic and external approach, via a Lynch-Howarth incision. Following rapid postoperative improvement, patient's regular follow-up remains uneventful. A subperiosteal orbital abscess is a severe complication of rhinosinusitis that can ultimately endanger a patient's vision. It is most commonly located on the medial orbital wall, resulting from direct spread of infection from the ethmoid cells. The rather uncommon superiorly based subperiosteal abscess occurs superiorly to the frontoethmoidal suture line, with frontal sinusitis being its main cause. Treating it solely endoscopically is more challenging than in medial wall abscesses, and a combined approach is often necessary

The challenge of drug resistance in cancer treatment: a current overview.

It is generally accepted that recent advances in anticancer agents have contributed significantly to the improvement of both the disease-free survival and quality of life in cancer patients. However, in many instances, a favorable initial response to treatment changes afterwards, thereby leading to cancer relapse and recurrence. This phenomenon of acquired resistance to therapy, it is a major problem for totally efficient anticancer therapy. The failure to obtain an initial response reflects a form of intrinsic resistance. Specific cell membrane transporter proteins are implicated in intrinsic drug resistance by altering drug transport and pumping drugs out of the tumor cells. Moreover, the gradual acquisition of specific genetic and epigenetic abnormalities in cancer cells could contribute greatly to acquired drug resistance. A critical issue in the clinical setting, is that the problem of drug resistance appears to have a negative effect on also the new molecularly-targeted anticancer drugs. Several ongoing efforts are being made by the medical community aimed to the identification of such resistance mechanisms and the development of novel drugs that could overcome them. In this review, the major drug resistance mechanisms and strategies to overcome them are critically discussed, and also possible future directions are suggested

Retropharyngeal Space Lipomas. A Systematic Review of the Reported Cases in the Literature

Retropharyngeal space lipomas (RSLs) comprise a group of very uncommon head and neck benign, soft tissue tumors that originally grow in the retropharyngeal space. They can develop as individual tumors or in the context of syndromic lipomatosis. Symptoms usually arise as expanding RSLs exert pressure on adjacent structures, and clinical manifestations are often atypical and overlapping. Given the rarity of this diagnosis, current evidence is scarce, providing a rather fragmented picture. A literature search was conducted in all major medical databases, without time limitations. Tumors were considered RSLs if a benign lipomatous tumor appeared to develop originally in the retropharyngeal space. Cases with syndromic lipomatosis that demonstrated at least one such tumor involving the retropharyngeal space were included. A total of 52 publications concerning 79 eligible cases were found. Two of these cases concerned patients with Multiple Symmetrical Lipomatosis. A male predominance was found (61.5%, n = 48). Dysphagia (65.2%, n = 43) was by far the most common symptom, followed by snoring (37.9%, n = 25), dyspnoea (34.8%, n = 23) and dysphonia (30.3%, n = 20). The most used imaging modality was Computed Tomography (CT) (64.1%, n = 41). Surgery was the treatment in 73 cases (93.6%). The transcervical was the most selected approach (50.7%, n = 37), followed by the transoral approach (38.4%, n = 28). Complete recovery was reported, following treatment, in 60 cases (75.9%). Retropharyngeal space lipomas are benign tumors with a higher prevalence in male patients. Dysphagia is the most common symptom. Imaging is necessary for diagnosis, with CT scanning being usually sufficient as a single modality test. More than half of the patients in the literature are treated via an external approach. Diminishing of symptoms and full postoperative recovery is the most common outcome

Nodal tumor volume as a prognostic factor for head and neck squamous cell carcinoma: a systematic review

Introduction: Several studies suggest that there is an association between the metastatic nodal tumor volume and the clinical outcome in patients with solid cancers. However, despite the prognostic potential of nodal volume, a standardized method for estimating the nodal volumetric parameters is lacking. Herein, we conducted a systematic review of the published scientific literature towards investigating the prognostic value of nodal volume in the carcinomas of head and neck, taking into consideration the primary tumor site and the human papillomavirus (HPV) status. Methodological issues: For this purpose, the biomedical literature database PubMed/MEDLINE was searched for studies relevant to the relationship of nodal volume to the treatment outcome and survival in head and neck squamous cell carcinoma (HNSCC) patients. Collectively, based on stringent inclusion/exclusion criteria, 23 eligible studies were included in the present systematic review. Results: On the basis of our findings, nodal volume is suggested to be strongly associated with clinical outcomes in HNSCC patients. Of particular note, there is an indication that nodal volume is an independent factor for further risk stratification for recurrence-free survival in patients with squamous cell carcinoma of the pharynx (oropharynx and hypopharynx). Extranodal extension (ENE) and HPV status should be also taken into consideration in further studies

Multimodal Lip-Reading for Tracheostomy Patients in the Greek Language

Voice loss constitutes a crucial disorder which is highly associated with social isolation. The use of multimodal information sources, such as, audiovisual information, is crucial since it can lead to the development of straightforward personalized word prediction models which can reproduce the patient’s original voice. In this work we designed a multimodal approach based on audiovisual information from patients before loss-of-voice to develop a system for automated lip-reading in the Greek language. Data pre-processing methods, such as, lip-segmentation and frame-level sampling techniques were used to enhance the quality of the imaging data. Audio information was incorporated in the model to automatically annotate sets of frames as words. Recurrent neural networks were trained on four different video recordings to develop a robust word prediction model. The model was able to correctly identify test words in different time frames with 95% accuracy. To our knowledge, this is the first word prediction model that is trained to recognize words from video recordings in the Greek language

Interplay of Developmental Hippo–Notch Signaling Pathways with the DNA Damage Response in Prostate Cancer

Prostate cancer belongs in the class of hormone-dependent cancers, representing a major cause of cancer incidence in men worldwide. Since upon disease onset almost all prostate cancers are androgen-dependent and require active androgen receptor (AR) signaling for their survival, the primary treatment approach has for decades relied on inhibition of the AR pathway via androgen deprivation therapy (ADT). However, following this line of treatment, cancer cell pools often become resistant to therapy, contributing to disease progression towards the significantly more aggressive castration-resistant prostate cancer (CRPC) form, characterized by poor prognosis. It is, therefore, of critical importance to elucidate the molecular mechanisms and signaling pathways underlying the progression of early-stage prostate cancer towards CRPC. In this review, we aim to shed light on the role of major signaling pathways including the DNA damage response (DDR) and the developmental Hippo and Notch pathways in prostate tumorigenesis. We recapitulate key evidence demonstrating the crosstalk of those pathways as well as with pivotal prostate cancer-related ‘hubs’ such as AR signaling, and evaluate the clinical impact of those interactions. Moreover, we attempt to identify molecules of the complex DDR–Hippo–Notch interplay comprising potentially novel therapeutic targets in the battle against prostate tumorigenesis

Pediatric Laryngopharyngeal Reflux in the Last Decade: What Is New and Where to Next?

Background: Laryngopharyngeal reflux may affect people of any age; still, most of the accumulated knowledge concerns adults, and evidence regarding pediatric populations remains relatively restricted. This study aims to review the most recent and emerging aspects of pediatric laryngopharyngeal reflux from the last ten years. It also attempts to identify gaps in knowledge and highlight discrepancies that future research should urgently address. Methods: An electronic search of the MEDLINE database was conducted, limited to January 2012 through December 2021. Non-English language articles, case reports, and studies that concerned a purely or predominantly adult population were excluded. The information from the articles with the most relevant contribution was initially categorized by theme and subsequently synthesized into a narrative form. Results: 86 articles were included, of which 27 were review articles, eight were surveys, and 51 were original articles. Our review systematically maps the research done in the last decade and provides an updated overview and the current state-of-the-art in this subject. Conclusions: Despite discrepancies and heterogeneity in accumulating research, evidence gathered so far endorses a need for refining an escalating multiparameter diagnostic approach. A step-wise therapeutic plan appears to be the most reasonable management approach, starting with behavioral changes for mild to moderate, uncomplicated cases and escalating to personalized pharmacotherapy options for severe or nonresponsive cases. Surgical options could be considered in the most severe cases when potentially life-threatening symptoms persist despite maximal medical therapy. Over the past decade, the amount of available evidence has been gradually increasing; however, its strength remains low. Several aspects remain markedly under-addressed, and further adequately powered, multicenter, controlled studies with uniformity in diagnostic procedures and criteria are urgently needed