Managing penetrating injuries adequately and effectively depends a great deal on proper assessment of the injury. This study carried out was done at The Aga Khan University Hospital to assess the role of clinical examination and CT scan imaging in evaluation of penetrating neck injuries. A total of 68 students were included, with ages ranging from 3 to 74 years. The involved zones and the injured structures were noted. Results showed a high sensitivity of clinical examination in assessing vascular (81%) and airway trauma (77%), with a low sensitivity for esophageal trauma (34%). For CT scan the sensitivity was 90% for vascular trauma, 83% for airway trauma and 53% for esophageal injuries. Clinical findings and CT scan imaging are important assessment tools for evaluation of penetrating neck traumas, with a high sensitivity for vascular and airway injuries

Ali, Naeem Sultan

Junaid, Montasir

Kazi, Maliha

Khan, Mumtaz Jamshed

Masoom, Aria

English

eCommons@AKU

eCommons@AKUSection of Otolaryngology, Head & Neck Surgery Department of SurgeryApril 2013Utility of clinical examination and CT scan inassessment of penetrating neck traumaMaliha KaziMontasir JunaidAga Khan University, montasir.junaid@aku.eduMumtaz Jamshed KhanNaeem Sultan AliAria MasoomFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_otolaryngol_head_neckPart of the Otolaryngology Commons, and the Surgery CommonsRecommended CitationKazi, M., Junaid, M., Khan, M. J., Ali, N. S., Masoom, A. (2013). Utility of clinical examination and CT scan in assessment ofpenetrating neck trauma. Journal of the College of Physicians and Surgeons Pakistan, 23(4), 308-309.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_otolaryngol_head_neck/86Vol. 55, No. 12, December 2005 540Original ArticleSpeech Results with Tracheoesophageal Voice Prosthesis after Total LaryngectomyMohammad Sohail Awan, Imtinan Ahmed, Yassar Iftikhar Ahmad, Daniyal AhmadDepartment of Otolaryngology-Head and Neck Surgery, The Aga Khan University Hospital, Karachi, Pakistan.AbstractObjective: To assess the success rate of tracheoesophageal voice prosthesis as the primary mode of voicerehabilitation in patients after total laryngectomy.Methods: Medical record files of 35 patients subjected to total laryngectomy were reviewed for determining suc-cess or failure of the voice prosthesis. The indicators used were quality of speech and utility of the device.Subsequent complications that developed were also assessed. In addition other factors taken into considerationwere pharyngeal myotomy, use of radiation, and timing of replacement. All thirty five patients (n=35) had pros-thesis placed at the time of laryngectomy.Results: The success rate at one month and four months follow up was 85.18%. Of note, 3 patients were lostto follow-up, 3 patients died of disease and 2 had recurrence of disease.Conclusion: Our results confirm the effectiveness, longevity and safety of the tracheoesophageal voice pros-thesis for speech rehabilitation following total laryngectomy (JPMA 55;540:2005).IntroductionVoice rehabilitation after total laryngectomy has tra-ditionally centered on the development of esophagealspeech and the use of the artificial larynx.Tracheoesophageal puncture and prosthetic rehabilitation ofvoice have become commonplace since the first successfulplacement of voice prosthesis by Singer and Bloom in1980.1 The possibility of achieving effective speech usingthe prosthetically-rehabilitated voice is greater. The result-ing quality of voice is also considered superior to theesophageal speech.2,3 Complications involving the voiceprosthesis have been few and minor. Problems documentedin the English literature include colonization of the pharynxwith Candida, a high air flow resistance of the prosthesisand hypertonic pharyngeal segment. The two major types ofprosthesis: indwelling and non-indwelling, need differentia-tion because of the latter's demands on and the ability of thepatient to change and replace the prosthesis without a physi-cian's assistance.The recently designed Bloom-Singer valve is low-resistance indwelling silicone voice prosthesis. Encouragedby the success reports we began using the tracheoe-sophageal speaking valve as the primary prosthesis to reha-bilitate patients after total laryngectomy at our institution.The objectives of this study were to assess initial speakingsuccess and complication rates, and to compare the findingswith other reports.Patients and MethodsBetween September 2000 and October 2004, atotal of 35 male patients underwent primary  tracheoe-sophageal puncture with insertion of Bloom-Singer valveprosthesis in the section of Otolaryngology, Aga KhanUniversity Hospital. Ages ranged from 38 to 83 yearswith a mean of 35 years. After excluding 3 patients, whodid not return, the follow-ups since the placements ofBloom-Singer prosthesis, ranged from 2 to 18 monthswith a mean of 11 months. Total laryngectomy was indi-cated in all patients with laryngeal squamous cell carcino-ma. Due to fear of radiation induced necrosis and subse-quent dislodgment of prosthesis, none of the patients whohad undergone external beam radiotherapy were selectedfor placement of voice prosthesis. Prosthesis was placedprimarily at the time of their laryngectomy. None had adelayed tracheoesophageal puncture. Patients who neededreplacement for another type of prosthesis were notincluded in this study. Of the 35 patients, 17 had pharyn-geal myotomy at the time of tracheoesophageal  puncture.Patients ability to produce speech (yes or no), thequality of the speech (good, fair or poor), whether they usedthe device as a primary or a secondary means of communi-cation or not at all, were assessed. The assessment of voicerestoration based on Harrison-Robillard Shultz tracheoesophageal puncture (TEP) rating scale was done at onemonth after placement of prosthesis and later at fourmonths.Surgical TechniqueFour procedures were included in the operativetechnique to reduce complications. The first step involvedcreation of a durable tracheostoma that has reduced tenden-cy for stenosis and patency without a tracheal cannula.Tissues are defatted and tracheal ring is fixed to the inferi-or skin margin. A monofilament suture is placed around the541 J Pak Med Assoctracheal ring and is secured by a vertical mattress tech-nique. A triangular wedge of skin from the superior flap isinterposed into the resulting defect expand the area of thestoma as a bivalving technique. The membranous trachealwall is closed with the overlying skin of the superior flap toproduce a flat posterior stoma.  Placement of TEP involvesinsertion of a right-angled hemostatic clamp through theunrepaired pharyngostoma until it distends the membra-nous wall from posterior to anterior. The membranous tra-chea is incised in order to permit the tips of hemostat toprotrude into the tracheostoma. Cautious approach isadvised because separation of tracheoesophageal party wallmay occur at this stage. If this occurs the risk of salivarycontamination increases, with subsequent infection andnecrosis of the membranous trachea.ResultsOf the 32 patients for whom follow-up was avail-able, 3 patients died of disease. Two patients ware alive withrecurrence of disease, and the remainders were alive with noevidence of cancer. We evaluated the remaining 27 patientsfor voice production and quality with use of voice prosthe-sis at one month and four months follow up using the scaleshown in table 1. At the initial evaluation, 16 patients hadexcellent speech, 7 good speech and 4 poor speech (Table2). No change in voice quality was detected at the secondfollow up. Based on the ability to produce sound and thequality of speech, 23 of 27 patients were judged to have ini-tial success (85.18%). The main reason for failure of 4patients was lack of manual coordination.Table 1. Voice evaluation after using voice prosthesis.Table 2. Results of voice evaluation (n = 27).Till the last follow-up all 27 patients had their prosthesisin place. The commonly documented reasons for the failure ofvoice prosthesis such as infection, radiation fibrosis, cere-brovascular accident were not seen in our population.The most common complication encountered with theprosthesis was partial retraction of the prosthesis into theesophagus (3 cases). These were successfully retrieved withoutuntoward consequences. Three patients developed granulationtissue around the prosthesis which was removed with electro-cautery. Localized cellulitis leading to the closure of tracheoe-sophageal puncture, did not develop in any patient.DiscussionTracheoesophageal voice prosthesis is documentedas a superior method of speech rehabilitation after totallaryngectomy compared with other methods such as electro-larynx and esophageal speech.4,5 Moreover, the possibilityof producing an effective voice is reached much earlier andrequires less voice training as reported by other workers.6Several studies have also shown that the quality of life ofpatients with voice prosthesis is higher than patients com-municating by other means.7 Our success rate (85%) wascomparable to previous reports.2,8 This could be due toexclusion of patients with secondary punctures and thosewith radiation therapy.The use of muscle-relaxing procedures for thepharyngoesophagus to avoid spasm and resultant dysfluen-cy is well described in literature.9 This may be in the formof pharyngeal constrictor myotomy or a pharyngeal plexusneurectomy.  The myotomy technique consists of a posteri-or midline incision through the fibers of the middle pharyn-geal constrictor muscle, the inferior pharyngeal constrictormuscle, and the cricopharyngeus muscle.  A midline poste-rior approach is minimally traumatic and preserves the vas-cularity of the underlying mucosal segment while avoidingthe possibility of reformation of the upper esophagealsphincter.The more recently proposed pharyngeal plexusneurectomy offers a number of advantages over the myoto-my. It reduces the trauma to the pharyngeal wall and the risein sphincter tone of the upper esophageal segment duringoesophageal insufflation.10 The elasticity of the constrictormuscles of the pharynx, as well as the vasculature, is pre-served. These differences from myotomy are expected todecrease post operative complications while preserving thequality of voice.The pharyngeal plexus is identified on the ipsilaterallaryngospharynx while the larynx is still intact. The fibersare stretched and divided and the edges are electrocoagulat-ed. This effectively denervates the inferior pharyngeal con-strictor muscle and partially denervates the cricopharyngeusmuscle.A.  Degree of use of tracheoesophageal speech (TES)ScoreTES Never used (0%) 0TES used less than 50% of time 1TES used 50-80% of time 2TES used all the time 3B.  Ease of production and intelligibility of speechVoice is too strain or too breathy 0Voice is mildly strained or mildly breathy 1Voice is easily produced; speech is intelligible 2Grade A Score between 5-6 Excellent 16Grade B Score between 3-4 Good 7Grade C Score between 1-2 Poor 4Vol. 55, No. 12, December 2005 542We used muscle-relaxing techniques in half of ourpatients with other half did not have this procedure. We didnot find any significant difference in the quality of thespeech in these two groups of patients.Voice improvement is gradual over time in the first 4months after the placement. Role of training and speechtherapy should be emphasized. Daily speech therapy wasstarted as soon as possible after laryngectomy during hospi-tal stay and continued thereafter at weekly intervals untilsatisfaction. Desulpehe K et al in his report mentioned thattraining and speech therapy have important effects on mostof the objective and subjective voice criteria.11Although four patients continued to have poorspeech on their long term followup, voice failure was notobserved in any case. Voice failure is defined as failure touse the voice prosthesis for regular day to day communica-tion.12 The morbidity associated with tracheoesophagealpuncture and prosthesis placement was relatively low andcomparable to other reports.13,14 We did not encounter anymajor or minor complications, except partial retraction ofprosthesis into oesophagus (3 cases).  These were success-fully retrieved without untoward consequences.  Threepatients developed granulation tissue around the prosthesiswhich was effectively treated by repeated chemical cauteri-zation in the clinic. The low incidence of complication inour series is attributed to mainly 2 reasons, the exclusion ofpatients with prior radiotherapy and tracheoesophagealpuncture as a primary procedure. The frequent problems offood and saliva leakage and occasionally oesophageal per-foration are usually experienced in patients undergoing sec-ondary tracheoesophageal puncture.15This study concluded that overall good voice quali-ty both objectively and by subjective assessment for tra-cheoesophageal voice prosthesis after total laryngectomy.Overall, the Bloom-Singer prosthesis was found to be aneffective and safe means for speech rehabilitation aftertotal laryngectomy.References1. Singer MI, Bloom ED. An endoscopic technique for restoration of voice afterlazryngectomy. ANN Otol 1980;89:529-33.2. Kesteloot K, Nolis I, Huygh J, Delaere P, Feenstra L. Costs and effects of tra-cheoesophageal speech compared with esophageal speech in laryngectomypatients. Acta Otorhinolaryngol Belg 1994;48:387-94.3. Quer M, Burgues-Vila J, Garcia-Crespillo P. Primary tracheoesophageal punc-ture Vs esophageal speech. Arch Otolaryngol Head Neck Surg 1992;118:188-90.4. Williams SE, Watson JB. Speaking proficiency variations according tomethod of alaryngeal voicing. Laryngoscope 1987;97:737-9.5. Casiano RR, Lundy DS. Voice and speech rehabilitation following laryngec-tomy. CUff Opin Otolaryngol Head Neck Surg 1996;4:94-7.6. Tardy-Mitzell MA, Andrews ML, Bowman SA. Acceptability and intelligibil-ity of tracheoesophageal speech. Arch Otolaryngol 1985;111:213-5.7. Aust MR, McAffery TV. Early speech results with Provox prothesis afterlaryngectomy. Arch Otolaryngol Head Neck Surg 1997;123:966-8.8. Callanan V, Gurr P, Baldwin O, White-Thompson M, Beckinsale J, Bennett J.Provox valve use for post-laryngectomy voice rehabilitation. J Laryngol Otol1995;109:1068-71.9. Singer MI, Bloom ED. A selective myotomy for voice restoration after totallaryngectomy.  Arch Otolaryngol 1981;107:670-3.10. Singer MI, Bloom ED. Hamaker RC. Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope 1986;96:50-3.11. Delsupehe K, Zink I, Lejaegere M, Delaere P. Prospective randomizedComparative Study of Tracheoesophageal Voice Prosthesis: Bloom-SingerVersus Provox. Laryngoscope 1998;108:1561-5.12. Singer MI, Blom ED, Hamaker RC, Yoshida GY. Applications of the voiceprosthesis during laryngectomy. Arch Otol Rhinol Laryngol 1989;98:921-5.13. Hilgers FJM, Schouwenburg PF.  A new low resistance, self retaining prosthe-sis for voice rehabilitation after total laryngectomy. Laryngoscope1990;100:1202-7.14. Van Weissenbrunch R, Albers FW. Vocal rehabilitation after total laryngecto-my using Provox voice prosthesis. Clin Otolaryngol 1993;18:395-64.15. McConnel F, Duck SW.  Indication for tracheoesophageal puncture speechrehabilitation.  Laryngoscope 1986;96:1065-8.

Utility of clinical examination and CT scan in assessment of penetrating neck trauma

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Utility of clinical examination and CT scan in assessment of penetrating neck trauma

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