New surgical method for closing downward migrated tracheoesophageal puncture

Cilj: Traheoezofagealni govor pomoću govorne proteze čini zlatni standard u rehabilitaciji glasa laringektomiranih bolesnika. Jedna od mogućih komplikacija vezana uz korištenje govorne proteze je spuštanje traheoezofagealne fistule. Cilj ovog rada je prikazati novu metodu kirurškog pristupa zatvaranja spuštene traheoezofagealne fistule. Ispitanici i metode: U istraživanju je sudjelovalo 6 bolesnika s spuštenom traheoezofagealnom fistulom. U liječenju smo koristili novu kiruršku metodu zatvaranja spuštene traheoezofagealne fistule koja se bazira na prikazivanju fistule u punom opsegu od 360° i postavljanju dvostruke ligature kanala traheoezofagealne fistule. Rezultati: U naših bolesnika nije došlo do komplikacija povezanih s kirurškim liječenjem (infekcije, krvarenje), kao niti do ponovnog spuštanja govorne proteze. Svi pacijenti su nakon ponovno postavljanja govorne proteze imali dobro rehabilitiran glas i govor. Zaključci: Metoda koju smo koristili u zatvaranju spuštene traheoezofagealne fistule je jednostavna i učinkovita. Također, obzirom da ne zahtjeva posebne kirurške instrumente lako je primjenjiva i dostupna za korištenje u svakodnevnoj kirurškoj praksi.Aim: Tracheoesophageal speech with voice prosthesis is a gold standard in voice rehabilitation of laryngectomized patients. One of the possible complications associated with the use of voice prosthesis is downward migration of tracheoesophageal puncture. The aim of this paper is to present new surgical method for closing downward migrated tracheoesophageal puncture. Patients and methods: The study included 6 patients with downward migrated tracheoesophageal puncture. In treatment we have used new surgical method for closing downward migrated tracheoesophageal puncture which is based on displaying the tracheoesophageal puncture in full range of 360° and placing a double ligature on tracheoesophageal puncture. Results: There were no complications associated with surgical treatment (infection, bleeding) or with recurrence of downward migration of speech prosthesis. All patients had a well rehabilitated voice and speech after reinserting the speech prosthesis. Conslusions: The method that we have used for closing downward migrated tracheoesophageal puncture is simple and effective, and also doesn’t require special instruments and thus we believe it can be used in everyday ENT practice

Basics of Voice Dysfunction – Etiology and Prevention of Voice Damage

Voice is one of the most important means of communication and as such should be taken care of. The etiology of voice disorders is diverse. Due to the development of the society we live in, way of life, environmental factors, and exposure to pharmacological agents as well as demands we make towards our voice, there is a substantial growth in the number of people with voice disorders. We tasked ourselves to find out if it is possible to enlighten people on the importance of voice, to motivate them to take care of it, to notice the changes in its quality and eventually ask for help. We assessed in which measure do we understand the importance of a healthy voice, and do we know which is the most important factor that adds to its decline. For a long number of years voice therapists and other experts in the voice disorder field have been discussing the optimal voice impostation as well as vocal exercises and methods behind voice recovery. They have all come to the same conclusion that phonation is dependant on the sort of the voice disorder and the patient motivation. We wanted to go one step further and investigate, dependence of voice quality and the damage etiology (organic – functional), which are the predominant causes, what are the factors that account for the damage and how the disorder motivates the patient and therefore influences the rehabilitation success rate

Analysis of Saliva Pepsin Level in Patients with Tracheoesophageal Fistula and Voice Prosthesis Complications

The aim of this crossectional study was to investigate the relationship between pepsin concentration in saliva and the occurrence of tracheoesophageal fistula (TEF) complications and voice prosthesis (VP) complications, after total laryngectomy and VP implantation. We assessed the concentrations of pepsin in the saliva of 41 laryngectomized patients and correlated it with the incidence of TEF complications (periprostethic leakage, atrophy, esophageal mucosa hypertrophy, granulations, fistula enlargement, and VP dislocation), VP complications (transprosthetic leakage, Candida infection) and voice quality. Pepsin levels were measured by enzyme-linked immunoadsorbent assay (ELISA). Voice quality was assessed by Harrison-Robilard – Schultz (HRS) scale. In all, 17 (42%) patients had complications. All of them had TEF complications, whereas VP complication, together with TEF was found in 9 (22%) patients. We found no significant correlation between adjuvant radiotherapy and TEF complications. Most of patients, 30 (73%), had positive pepsin level in saliva. Median value of pepsin concentration in all patients was 4.8 (range 81.7). Median pepsin concentration was higher in patients free of TEF or VP complications (6.6, range 81.7 vs. 3.2, range 19.3) but that difference was not statistically significant (Mann-Whitney test, Z –1.562, p=0.118). In addition, statistically insignificant negative correlation between pepsin levels and voice quality measured by HRS scale (Spearman’s rho, p>0.05). Although reflux was proposed as cause of TEF complications and pepsin has been proven as a most sensitive and specific marker of ekstraesophageal reflux, we did not find any statistically significant correlation between pepsin levels and occurrence of TEF or VP complications

Voice restoration using tracheoesophageal voice prostheses following total laryngectomy

Cilj: Totalna laringektomija opsežan je operativni zahvat koji se može izvesti sa ili bez resekcije vrata. Tijekom ovog postupka u potpunosti se odstranjuje grkljan, a traheja se mobilizira te pričvrsti za kožu u obliku trajnog otvora za disanje – traheostome. Najsloženiji problem u vezi s rekonstrukcijom funkcije larinksa, kojemu je posvećen najveći broj istraživanja, ponovno je uspostavljanje govora. Osnovne mogućnosti govorne rehabilitacije nakon totalne laringektomije jesu razvijanje vještine ezofagealnog govora, korištenje elektrolarinksa i traheoezofagealna punkcija s uporabom govorne proteze. Traheoezofagealna punkcija s govornom protezom je kirurška metoda izbora za govornu rehabilitaciju bolesnika. Punkcija može biti izvedena primarno, istovremeno s laringektomijom, i sekundarno, tjednima ili godinama nakon izvršene laringektomije. Materijali i metode: U razdoblju od 1. 1. 2004. do 31.12. 2008. godine na Klinici za otorinolaringologiju KBC-a u Rijeci liječeno je 125 laringektomiranih bolesnika. Indikacija za izvođenje totalne laringektomije bio je T3 ili T4 karcinom larinksa u 58 (46%) bolesnika, a u 67 (54%) bolesnika izvršena je parcijalna laringektomija. Rezultati: Metode govorne rehabilitacije bile su uspostava traheoezofagealnog (91%) i ezofagealnog (6%) govora i uporaba elektrolarinksa (3%). Govorne proteze postavljene su u 49 bolesnika primarnom punkcijom, a u 36 bolesnika sekundarnom punkcijom. Srednje vrijeme trajanja proteza iznosilo je 7,9 mjeseci. 10% proteza zamijenjeno je nakon manje od 3 mjeseca korištenja, 46% nakon 3 do 6 mjeseci, a 44% proteza korišteno je dulje od 6 mjeseci. Zaključak: Učinkovita rehabilitacija glasa bitna je i omogućava bolesniku povratak normalnim životnim funkcijama. Traheoezofagealni govor postao je metoda izbora za govornu rehabilitaciju nakon izvršene laringektomije.Aim: Total laryngectomy is an expansive operation and can be performed with or without neck dissection. During this procedure the entire larynx is removed, the windpipe is brought out to the skin and secured there in the form of a permanent tracheostome. The most difficult aspect of laryngeal function to reconstruct, and the one to which most research is dedicated to is the reattainment of speech. The main options for voice restoration after total laryngectomy are esophageal speech, electrolarynx speech, and tracheoesophageal speech. Tracheoesophageal puncture with prosthesis is currently the surgical method of choice for vocal restoration after total laryngectomy. This puncture tract can be created primarily, at the time of total laryngectomy, or secondarily, weeks or years following the laryngectomy. Patients and Methods: Between the period of 01.01.2004. and 31.12.2008., 125 laryngectomized patients have been rehabilitated at the Otorhynolaryngology Department of the Clinical Hospital Center Rijeka. The indication for total laryngectomy was T3 or T4 laryngeal carcinoma in 58 (46%) patients, and 67 (54%) patients underwent a partial laryngectomy. Results: The methods of voice rehabilitation were tracheoesophageal speech (91%), esophageal speech (6%) and artificial larynx (3%). A voice prosthesis could be inserted in 49 patients by primary puncture, in 36 patients by secondary puncture. The median device lifetime was 7,9 months. 10 % of the prostheses were replaced with a lifetime of less than 3 months, 46% from 3 to 6 months, and 44% devices longer than 6 months. Conclusion: Effective restoration of voice is critical to enabling the patient to return to normal functioning in their life. Tracheoesophageal speech has become the method of choice for postlaryngectomy voice restoration

Voice restoration using tracheoesophageal voice prostheses following total laryngectomy

Cilj: Totalna laringektomija opsežan je operativni zahvat koji se može izvesti sa ili bez resekcije vrata. Tijekom ovog postupka u potpunosti se odstranjuje grkljan, a traheja se mobilizira te pričvrsti za kožu u obliku trajnog otvora za disanje – traheostome. Najsloženiji problem u vezi s rekonstrukcijom funkcije larinksa, kojemu je posvećen najveći broj istraživanja, ponovno je uspostavljanje govora. Osnovne mogućnosti govorne rehabilitacije nakon totalne laringektomije jesu razvijanje vještine ezofagealnog govora, korištenje elektrolarinksa i traheoezofagealna punkcija s uporabom govorne proteze. Traheoezofagealna punkcija s govornom protezom je kirurška metoda izbora za govornu rehabilitaciju bolesnika. Punkcija može biti izvedena primarno, istovremeno s laringektomijom, i sekundarno, tjednima ili godinama nakon izvršene laringektomije. Materijali i metode: U razdoblju od 1. 1. 2004. do 31.12. 2008. godine na Klinici za otorinolaringologiju KBC-a u Rijeci liječeno je 125 laringektomiranih bolesnika. Indikacija za izvođenje totalne laringektomije bio je T3 ili T4 karcinom larinksa u 58 (46%) bolesnika, a u 67 (54%) bolesnika izvršena je parcijalna laringektomija. Rezultati: Metode govorne rehabilitacije bile su uspostava traheoezofagealnog (91%) i ezofagealnog (6%) govora i uporaba elektrolarinksa (3%). Govorne proteze postavljene su u 49 bolesnika primarnom punkcijom, a u 36 bolesnika sekundarnom punkcijom. Srednje vrijeme trajanja proteza iznosilo je 7,9 mjeseci. 10% proteza zamijenjeno je nakon manje od 3 mjeseca korištenja, 46% nakon 3 do 6 mjeseci, a 44% proteza korišteno je dulje od 6 mjeseci. Zaključak: Učinkovita rehabilitacija glasa bitna je i omogućava bolesniku povratak normalnim životnim funkcijama. Traheoezofagealni govor postao je metoda izbora za govornu rehabilitaciju nakon izvršene laringektomije.Aim: Total laryngectomy is an expansive operation and can be performed with or without neck dissection. During this procedure the entire larynx is removed, the windpipe is brought out to the skin and secured there in the form of a permanent tracheostome. The most difficult aspect of laryngeal function to reconstruct, and the one to which most research is dedicated to is the reattainment of speech. The main options for voice restoration after total laryngectomy are esophageal speech, electrolarynx speech, and tracheoesophageal speech. Tracheoesophageal puncture with prosthesis is currently the surgical method of choice for vocal restoration after total laryngectomy. This puncture tract can be created primarily, at the time of total laryngectomy, or secondarily, weeks or years following the laryngectomy. Patients and Methods: Between the period of 01.01.2004. and 31.12.2008., 125 laryngectomized patients have been rehabilitated at the Otorhynolaryngology Department of the Clinical Hospital Center Rijeka. The indication for total laryngectomy was T3 or T4 laryngeal carcinoma in 58 (46%) patients, and 67 (54%) patients underwent a partial laryngectomy. Results: The methods of voice rehabilitation were tracheoesophageal speech (91%), esophageal speech (6%) and artificial larynx (3%). A voice prosthesis could be inserted in 49 patients by primary puncture, in 36 patients by secondary puncture. The median device lifetime was 7,9 months. 10 % of the prostheses were replaced with a lifetime of less than 3 months, 46% from 3 to 6 months, and 44% devices longer than 6 months. Conclusion: Effective restoration of voice is critical to enabling the patient to return to normal functioning in their life. Tracheoesophageal speech has become the method of choice for postlaryngectomy voice restoration

Voice Rehabilitation of Broca\u27s Aphasia Following Total Laryngectomy

Total laryngectomy, as a consequence of carcinoma of the larynx, results in loss of speech function. Cerebrovascular stroke is the leading cause of reduced speech production ability, and thereby communication difficulties. The case is presented of a 60-year-old male patient who suffered stroke five years after a total laryngectomy. Speech rehabilitation was hampered due to the depressive state of the patient. Although contraindicated, the secondary voice prosthesis was implanted. Only at that moment the patient showed willingness and motivation for speech rehabilitation. The aim of this presentation is to demonstrate that not all neurological disorders are contraindicated for implantation of voice prostheses

The Use of Ultrasound in Determining the Length of the Provox II Voice Prosthesis

The use of speech prosthesis after total laryngectomy has become an international standard for voice restoration today. Provox II voice prosthesis is not permanently inserted, and as such, it must meet the criterion of achieving prolonged retention time within the walls of tracheo-esophageal fistula (TEF). Complications after the insertion of speech prosthesis are familiar and anticipated but efforts are being made in order to reduce them. Part of the complications is caused by inadequate choice of the length of the prosthesis. The Department of Otorhinolaryngology and Head and Neck Surgery in Rijeka conducted a study which included 91 patients in the period from 01.01.2004. to 31.12.2010. We used ultrasound and computerized neck tomography on 58 (63.7%) patients in preoperative procedure through which we determined the length of the subsequent TE fistula. At the same time we used this opportunity to specify the length of the speech prosthesis we have inserted primarily or secondary. The number of respondents who had complications, and with whom we used neck ultrasound during preoperative procedure in order to determine the length of the prosthesis, was significantly smaller than the number of respondents who had complications but with whom we did not use the above mentioned procedure (5.6% vs. 15.5%, p=0.042). Comparing our results to other studies, we believe that we managed to reduce the number of complications caused by inadequate length of the prosthesis, by routine preoperative use of neck ultrasound. This procedure has extended the median retention time of the prosthesis within the TE fistula, thus improving the results of speech restoration using voice prosthesis on laryngectomized patients

Analysis of Saliva Pepsin Level in Patients with Tracheoesophageal Fistula and Voice Prosthesis Complications

The aim of this crossectional study was to investigate the relationship between pepsin concentration in saliva and the occurrence of tracheoesophageal fistula (TEF) complications and voice prosthesis (VP) complications, after total laryngectomy and VP implantation. We assessed the concentrations of pepsin in the saliva of 41 laryngectomized patients and correlated it with the incidence of TEF complications (periprostethic leakage, atrophy, esophageal mucosa hypertrophy, granulations, fistula enlargement, and VP dislocation), VP complications (transprosthetic leakage, Candida infection) and voice quality. Pepsin levels were measured by enzyme-linked immunoadsorbent assay (ELISA). Voice quality was assessed by Harrison-Robilard – Schultz (HRS) scale. In all, 17 (42%) patients had complications. All of them had TEF complications, whereas VP complication, together with TEF was found in 9 (22%) patients. We found no significant correlation between adjuvant radiotherapy and TEF complications. Most of patients, 30 (73%), had positive pepsin level in saliva. Median value of pepsin concentration in all patients was 4.8 (range 81.7). Median pepsin concentration was higher in patients free of TEF or VP complications (6.6, range 81.7 vs. 3.2, range 19.3) but that difference was not statistically significant (Mann-Whitney test, Z –1.562, p=0.118). In addition, statistically insignificant negative correlation between pepsin levels and voice quality measured by HRS scale (Spearman’s rho, p>0.05). Although reflux was proposed as cause of TEF complications and pepsin has been proven as a most sensitive and specific marker of ekstraesophageal reflux, we did not find any statistically significant correlation between pepsin levels and occurrence of TEF or VP complications

Histopathological changes in tracheal mucosa following total laryngectomy [Histopatološke promjene trahealne sluznice nakon totalne laringektomije]

The aim of this study was to determine the long term histopathologic changes in tracheal mucosa after a total laryngectomy , and to find out the relationship between the progression of histopathologic changes in tracheal mucosa and the duration of breathing through the tracheostomy. Tracheal mucosal biopsies were taken from a total of 35 patients, of both sexes, who underwent a total laryngectomy for laryngeal carcinoma at least one year prior. Histologic specimens of tracheal mucosa were stained with hematoxylin and eosin and examined under light microscopy. Almost all of the patients demonstrated histopathologic changes or abnormalities. Based on the results, histological findings were grouped into seven categories: normal respiratory epithelium, mild, moderate and advanced basal cell hyperplasia, squamous metaplasia, and slight and moderate and dysplasia. The time elapsed since surgery was calculated for each histopathological change separately. In laryngeal carcinoma patients, after a total laryngectomy histopathologic changes occur in tracheal mucosa. The mildest histopathological changes are found in the patients who had a longer period between the operation and the examination