Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey

Objective: Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence. Method: A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses. Results: Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making. Conclusion: Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment

Longitudinal TEP Size Stability

Objective: Tracheoesophageal speech rehabilitation is considered the gold standard after laryngectomy. Changes in size of the prosthesis are common in the early period after initial fitting. Size may be affected by factors over time necessitating continued assessment. This study will determine size stability in laryngectomized patients over a 5-year period. Method: Individuals s/p total laryngectomy and TEP with a minimum 5-year follow-up will be accrued. Data will be derived from chart review including demographic, surgical, medical, and prosthesis factors by stability of size over time after the first three-month initial fitting phase. Results: Thirty-seven patients, 32 males and 5 females, met the criteria and were included in the study. Mean age was 63.7 years (range, 41-78 years). Medical factors leading to total laryngectomy changed over the follow-up period with more recent patients only undergoing laryngectomy for either extremely advanced disease or recurrence versus persistent disease after chemo-radiation therapy. A total of 80% of patients required a change in the length and/or diameter of their prosthesis over the 5-year follow-up period regardless of other medical and surgical factors. Conclusion: Clinicians need to continually reassess prosthesis fit for the life of the patient to prevent inadvertant closure of the posterior fistula tract from a prosthesis that is too short or pistoning resulting in aspiration from a prosthesis that is too long. This contrasts previous reports of stability after initial fitting

Dysphagia After Total Laryngectomy

Previous thought was that total laryngectomy and difficulty with swallowing were incongruous. Patients were counseled that the loss of their larynx would leave them without a vocal source, but that swallowing would not be affected. Successful rehabilitation was defined as being cancer-free and regaining functional communication. Patients were not queried and frequently did not complain of dysphagia as long as they were able to maintain an oral diet. Knowledge has changed, and this article will focus on dysphagia in the patient with laryngectomy and will discuss anatomical sites to physiologic problems

Effect of Aging on Tracheoesophageal Speech Rehabilitation

Objective: 1) To determine whether tracheoesophageal puncture usage changes as a function of age. 2) To determine whether age is associated with voice deteroriation, need for repuncture, or dependence in stomal care. Method: Retrospective chart review on individuals following total laryngectomy and tracheoesophageal puncture (TEP) and minimum 1-year follow-up data after prosthesis placement. Data reviewed included demographic variables and medical/surgical factors related to laryngectomy. Outcome measures of voice deterioration, TEP use, repuncture, and change in dependent prosthesis management were compared with age. Results: Sixty-nine individuals were identified that met criteria; 58 men and 11 women. Mean age was 65 years (range, 43-88 years). Nine individuals, mean age of 70.0 years, did not use their prosthesis for speech purposes; 2 chose never to use it and the remainder became unable to speak due to further medical issues. Deterioration in speech was further noted in five individuals, mean age of 79.4 years. Seven individuals, mean age of 58.6 years, required a re-puncture due to extrusion. Six individuals with a mean age of 76.3 years became dependent over time for daily stoma management. Conclusion: Age was significantly associated with deterioration in alaryngeal voice quality and need for dependence in stoma care for older individuals while repunctures were associated with a younger age. These results support careful selection criteria and counseling when considering a tracheoesophageal puncture in an older aged individual

S191 – Unilateral Vocal Fold Paralysis: Medialization Results

Objectives Management of glottal insufficiency due to unilateral vocal fold paralysis (UVFP) has evolved from trans-oral injection to external thyroplasty to revisited injections (transoral or transcutaneous). Currently, preference is given to the less invasive injection medialization. Multiple injectable materials have been utilized with newer ones being introduced to manage concerns over permanency and vocal fold vibratory patterns. The purpose of this study is to evaluate the long-term results of injection medialization for UVFP in terms of stability of glottal closure and voice outcome vs. need for reinjection. Methods All patients with UVFP that underwent injection medialization and had follow-up studies more than 6 months were eligible for inclusion. Parameters studied included demographic data (age, gender), side of paralysis, etiology, degree of pre-injection glottal insufficiency, length of follow-up, degree of post-injection glottal closure, mucosal wave resolution, and Voice Handicap Index. Results 146 patients were identified with a mean age of 61.7 years (17–94); males (55%) and females (45%). Etiology was idiopathic (56%); iatrogenic (48%); tumor-related (9%); trauma (3%); and neurologic (2%). Degree of glottal insufficiency was mild (21%); moderate (29%); and severe (50%). Material injected was Cymetra in 80 patients and Radiesse in 66 patients. 45 (33%) patients underwent more than 1 injection. Details of patients requiring repeat injections with regards to the material injected and the other parameters will be presented. Conclusions Injection medialization via a transcutaneous approach has long-lasting results making it an appropriate minimally-invasive option for long-term medialization for UVFP

Longitudinal tracheoesophageal puncture size stability

The purpose of this study is to investigate prosthesis size stability over time and determine which factors influence need for change in size. Retrospective chart review. Teaching hospital. Retrospective chart review was performed on all individuals who had previously undergone total laryngectomy and tracheoesophageal puncture and had a minimum of 3 years of consistent and consecutive follow-up data after their prosthesis was initially placed. Data reviewed included demographic variables of age at time of tracheoesophageal puncture, ethnicity, and sex. Fifty patients were identified who met criteria for study inclusion with a mean age of 64.7 years (range, 43-86 years) with 41 (82%) men and 9 (18%) women. Surgical management was equally divided between those who underwent total laryngectomy (n = 25) as primary treatment vs those who had salvage laryngectomy (n = 25) for persistent or recurrent disease. Prosthesis size was stable, with no change in diameter or length, in only 5 (10%) patients and unstable in 45 (90%), as they were changed at least once. The only factor that demonstrated statistical significance was sex (Fisher exact test = 0.035), with women being more likely to have a stable prosthesis size over time. The results of this study demonstrate that 90% of patients who underwent total laryngectomy and tracheoesophageal puncture required a change in their prosthesis size beyond the first 3 months of expected healing. These results support the need for continual reassessment of the fistula tract when changing the prosthesis to ensure appropriate fit

SWALLOWING OUTCOMES FOR ELDERLY INPATIENTS REFERRED WITH DYSPHAGIA

Academi

Changing trends of speech outcomes after total laryngectomy in the 21st century: a single-center study

To describe the speech rehabilitation outcomes of patients undergoing total laryngectomy (TL) in the 21st century. Retrospective chart review. Tertiary academic center Retrospective review of 167 patients who underwent TL from June 2000 to February 2012. Demographics, disease variables, and surgical factors were reviewed. Primary alaryngeal speech modality, speech outcome, and tracheoesophageal puncture (TEP) complication rates were assessed. Overall TEP speech success rate (primary or secondary) was 72%. Overall TEP speech success rate was 76% for those with primary TEP and was 68% for those with secondary TEP. TEP speech success rates at first, second, and beyond second year were 75%, 72%, and 70%, respectively. Success rates for primary TL, salvage TL, primary TL with pharyngeal reconstruction, or salvage TL with pharyngeal reconstruction groups were 71%, 72%, 73%, and 71%, respectively. TEP-related complications occurred in 43% of patients, with no difference in complication rates between primary versus salvage TL or primary versus secondary TEP. For those with complications, TEP success rate was 65%. This study showed TEP speech-outcome success rates lower than what has been historically reported. There was no significant difference in TEP speech outcome between primary versus salvage TL or primary versus secondary TEP. Patients with TEP-related complications had TEP speech-outcome success rates comparable to those without any complication. TEP may continue to be a superior option as a mode of speech in patients with TL, including those undergoing salvage TL. 4