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Objectives/Hypothesis: Customization of the tracheoesophageal (TE) voice prosthesis (VP) is often preferred over surgical closure to prevent aspiration around the VP in laryngectomized patients with an enlarged tracheoesophageal puncture (TEP), but it has not been thoroughly evaluated. Study Design: Single-institution prospective trial. Methods: A prospective trial was conducted to evaluate the effectiveness of a customized VP with the addition of an enlarged tracheal and/or esophageal collar in patients with leakage around an enlarged TEP. Absence of leakage around the VP after placement defined immediate effectiveness. Long-term success was defined by the prevention of adverse events related to leakage during the study period. Events that defined failure included: permanent gastrostomy dependence, aspiration pneumonia, and/or surgical TEP closure. Results: Twenty-one patients with enlarged TEP were enrolled (2003–2006). Insertion of a customized VP was unsuccessful in one patient; 145 customizations were performed in the remaining 20 patients (median, 3.5 customizations) during the trial period. Of the customizations, 77% (112/145) prevented leakage immediately after VP insertion. The most common adverse event was dislodgement of the prosthesis (11%) or the collar alone (7%) in 18% (26/145) of customized VP placements. Six patients who died of disease were not evaluable for long-term outcomes. Long-term success was achieved in 80% (12/15) of evaluable patients who avoided permanent gastrostomy, aspiration pneumonia, and surgical TEP closure. Conclusions: Prosthetic customization offers an effective method to prevent leakage around the VP in many patients with an enlarged TEP, thereby preserving TE voice while avoiding surgical closure in this high-risk population.

Body image can be affected by bodily experiences extending beyond physical appearance. This study evaluated associations among speech, eating, and body image concerns for surgically treated patients with oral cavity, midface, and cutaneous cancers of the head and neck.Using a cross-sectional design, 280 participants completed the Body Image Scale, a survey evaluating disease-specific body image issues, and the Functional Assessment of Cancer Therapy Scale-General.Participants with speech and eating concerns reported the highest levels of body image/appearance dissatisfaction compared with those without such concerns. This group also reported greater cognitive and behavioral difficulties associated with body image concerns and significantly higher levels of interest in psychosocial interventions to address appearance-related difficulties compared with all other participants.Findings point to the need for more comprehensive psychosocial care for patients with head and neck malignancies reporting speech and eating difficulties, which extent beyond functional rehabilitation.

Objectives/Hypothesis: An enlarging tracheoesophageal puncture (TEP) site after total laryngectomy is associated with substantial functional, hygienic, and potentially life-threatening problems. The enlarged TEP is challenging to manage. TEP injection (TEP-I) for control of the enlarged puncture site may be beneficial in avoiding surgery. Our study reviewed the clinical outcomes of patients at a single institution with enlarged TEP treated by office-based TEP-I. Study Design: Retrospective study. Methods: Chart review of eight patients who had an enlarged TEP with leakage around the prosthesis treated with TEP-I after attempted customization of voice prostheses. Patient demographics and treatments were reviewed, and injection efficacy was evaluated by the duration of leakage resolution. Results: Eight patients underwent 20 TEP-I procedures. The average duration of leak resolution after each injection was 174.5 days. There were no complications. Six patients required custom modifications of the voice prosthesis to control TEP leakage after TEP-I, and all patients resumed their baseline speech and swallowing function. There was a trend toward an increase in number of injections among patients with N+ disease, disease recurrence, a history of irradiation and secondary TEP. No patients required surgical closure of the TEP. Conclusions: Office-based TEP-I is a safe and effective treatment option for patients with an enlarged TEP site who have failed more conservative measures. A history of irradiation, disease recurrence, secondary TEP, and high-volume neck disease were predictive of multiple injections. Further study is warranted to accurately identify patients who may benefit from TEP-I to control leakage around the TEP.

Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high-risk individuals, and surgical and prosthetic correlates of TEP enlargement.Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort.Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (odds ratio [OR](adjusted) , 4.3; 95% confidence interval [CI], 1.0-19.1), postoperative stricture (OR(adjusted) , 3.2; 95% CI, 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (OR(adjusted) , 6.2; 95% CI, 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement.Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors.

Laryngeal dysfunction in the oncology population is common and may detract from quality of life (QoL) due to vocal restriction and aspiration. Therapies to address this complex issue have not been explored to date. We examined the outcomes among oncology patients treated with a minimally invasive office-based surgical approach for the rehabilitation of laryngeal dysfunction.A retrospective analysis was carried out of oncology patients referred for laryngeal dysfunction. Patients who underwent minimally invasive injection laryngoplasty (IL) were selected. Subjective outcome measures, objective voice analysis parameters, and swallowing studies were annotated.Sixty-one patients underwent IL for the management of laryngeal dysfunction. Lung cancer was the most common cancer diagnosis (39.3%), and 52% of patients had thoracic malignancies. All patients had a self-reported improvement in vocal function with a single injection, and 55 patients (90%) reported lasting effects at 3 months. In patients with pre- and postoperative voice analysis, phonatory function increased from 5.0 to 10.5 s, more than twofold improvement compared with baseline functioning. Seventy-one percent of patients who aspirated before injection no longer required a modified diet. There were no major complications.Interventions to improve the QoL in oncology patients continue to evolve. We report significant improvements in both subjective and objective measures of laryngeal function after IL for vocal fold dysfunction that are both immediate and sustained. We conclude that IL is a safe and efficacious procedure for the treatment of laryngeal dysfunction in oncology patients, resulting in palliation and improved QoL.

To review the clinical results of office-based injection laryngoplasty with two different therapeutic materials in patients with vocal fold paralysis and history of radiation therapy to the larynx.Retrospective study.Chart review of 11 patients who underwent office-based injection laryngoplasty with calcium hydroxylapatite or micronized Alloderm. All patients had a history of radiation therapy to the neck, with the larynx included in the radiation field. Voice analyses, clinical outcomes, and complications were reviewed. Efficacy of the procedure was evaluated by comparing pre- and postinjection mean phonation time (MPT) results from voice analysis data.A total of 15 injections were performed in 11 patients with vocal fold paralysis (one females, 10 males, mean age 62 years). Data from voice analyses before and after the procedure were available for nine injections. The MPT was significantly increased among patients undergoing the procedure (P.05). All procedures were successful, and only one self-limited complication was reported.Office-based injection laryngoplasty is a safe procedure with acceptable clinical results in patients with vocal fold paralysis who have a history of radiation therapy to the larynx.

Background. Swallowing physiology, diet, and patient-reported outcomes were evaluated after induction chemotherapy for oral tongue cancer. Methods. Fifteen of 23 patients enrolled in a phase II clinical trial of induction chemotherapy followed by surgical resection for oral tongue cancer underwent instrumental and perceptual analysis of speech and swallowing. Oropharyngeal swallow efficiency (OPSE) was calculated. Patient-reported outcomes were collected. We compared pre- and postchemotherapy results. Results. OPSE scores were not significantly different (p > .05) after induction chemotherapy; however, patient-reported swallowing and diet levels were significantly higher (p < .001 and p = .015, respectively). Diet levels improved from soft-chewable to full diet in most patients. Speech intelligibility did not change (p = .328). Conclusion. It appears that induction chemotherapy has a negligible effect on speech and swallowing physiology but may provide symptomatic improvement of pain and swallowing after treatment. Further investigations are needed to corroborate these findings. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

To describe swallowing physiology and functional outcomes at select intervals after definitive radiotherapy for laryngeal carcinoma. We also examined associations among patient, tumor, and treatment characteristics and swallowing outcomes.Retrospective review.The University of Texas M. D. Anderson Cancer Center, Houston.This study cohort included 40 patients who underwent definitive radiotherapy for laryngeal carcinoma (from February 2001 to June 2004).Modified barium swallow (MBS) studies were performed for 32 patients at 3 test intervals following irradiation: less than 6 months, 6 to 11 months, and 12 or more months. We recorded the presence or absence of aspiration (sensate or silent), 5 pharyngeal phase disorders, and 2 structural abnormalities. We also recorded pretreatment dysphagia complaints, feeding tube dependency, T classification, disease site, mucositis grade, and radiotherapy schedule with or without chemotherapy.Eighty-four percent of patients (27 of 32) referred for MBS studies after undergoing radiotherapy aspirated; 44% (12 of 27) did so silently. Silent aspiration was more prevalent during MBS studies conducted 1 or more years after radiotherapy. Pharyngeal phase disorders were observed more frequently than structural abnormalities (P.01). Most patients required a feeding tube (78% [31 of 40]); however, 52% of the tubes (16) were eventually removed. We found no significant association between the occurrence of aspiration and disease site, T classification, treatment regimen, or pretreatment variables (P.05). Pretreatment and posttreatment levels of feeding tube dependency were significantly associated (P = .03). Patient-reported dysphagia before treatment did not predict posttreatment swallowing outcomes (P.05).Dysphagia is a common outcome after laryngeal preservation with radiotherapy. Contrary to expectations, few parameters that we measured were significantly associated with swallowing outcomes in our study.

Importance Data support proactive swallowing therapy during radiotherapy (RT) or chemoradiotherapy (CRT) for pharyngeal cancers. The benefits of adherence to a regimen of swallowing exercises and maintaining oral intake throughout treatment are reported, but independent effects are unclear. Objective To evaluate the independent effects of maintaining oral intake throughout radiotherapy and adherence to preventive swallowing exercise. Design Retrospective observational study. Setting The University of Texas MD Anderson Cancer Center, Houston. Patients The study included 497 patients treated with definitive RT or CRT for pharyngeal cancer (458 oropharynx, 39 hypopharynx) between 2002 and 2008. Main Outcomes and Measures Swallowing-related end points were final diet after RT or CRT and duration of gastrostomy dependence. Primary independent variables included oral intake status at the end of RT or CRT (no oral intake, partial oral intake, or full oral intake) and adherence to a swallowing exercise regimen. Multiple linear regression and ordered logistic regression models were analyzed. Results At the conclusion of RT or CRT, 131 patients (26%) had no oral intake and 74% maintained oral intake (167 partial [34%], 199 full [40%]). Fifty-eight percent (286 of 497) reported adherence to swallowing exercises. Maintenance of oral intake during RT or CRT and swallowing exercise adherence were independently associated with better long-term diet after RT or CRT (P = .045 andP Conclusions and Relevance The data indicate independent, positive associations of maintenance of oral intake throughout RT or CRT and swallowing exercise adherence with long-term swallowing outcomes. Patients who either eat or exercise fare better than those who do neither. Patients who both eat and exercise have the highest rate of return to a regular diet and shortest duration of gastrostomy dependence.

Purpose/Objective(s): Many patients will require parenteral nutrition due to dysphagia during definitive radiation therapy for locally advanced head and neck cancer. However, the optimal timing of feeding tube (FT) insertion (prophylactic versus reactive) remains controversial. This study describes prospectively collected functional outcomes comparing prophylactic versus reactive FTs. Materials/Methods: Patients undergoing definitive radiation therapy for stage III and IV head and neck cancer between 2004 and 2009 prospectively underwent functional outcome assessment at baseline and 3, 6, 12, 24, and 36 months post-treatment. The use of FT and timing of insertion was at the discretion of the attending oncologist. Instruments included the Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS), the Performance Status Scale for Head and Neck Cancer Patients (PSSHN), and the Edmonton Symptom Assessment Scale. Multivariable analysis was conducted to determine the significance of FT status while controlling for potential confounding variables including age, gender, tumor stage, chemotherapy use, and primary site of disease. Results: A total of 178 patients were assessed with a median follow-up of 36.4 months. FTs were inserted prophylactically in 92 (51.7%), reactively in 23 (12.9%), and no tube in 63 (35.4%) patients. Compared to patients who received a prophylactic FT, those who had a reactive FT did not have a statistically significant difference in worse swallowing functional outcomes for PSS-HN subscales of eating in public (adjusted odds ratio [AOR] 1.65, p Z 0.42), understandability of speech (AOR 0.73, p Z 0.58), and normalcy of diet (AOR 1.39, pZ 0.66). Similarly, there were no differences in the RBHOMS levels for modified diet (AOR 1.00, pZ 0.99) and FT dependence (AOR 1.78, p Z 0.37). Patients who completed treatment without a FT had statistically significantly improved functional outcomes in PSS-HN and RBHOMS scores compared to both FT groups. Conclusions: Patients who received a reactive FT did not have a statistically significant difference in long-term functional outcomes compared to those with a prophylactically inserted FT. These findings warrant confirmation in a larger cohort of patients and should be considered when comparing the risks and benefits of different strategies for FT placement. Author Disclosure: H.C. Quon: None. C. Myers: None. A. Martens: None. J. Butler: None. R. Stimpson: None. D. Duerksen: None. H. CampbellEnns: None.

Objective To evaluate the outcomes of voice restoration using office-based transnasal esophagoscopy (TNE) to guide placement of the secondary tracheoesophageal puncture (TEP). Design Retrospective chart review. Setting Two tertiary care medical centers. Patients The study included 39 patients who underwent the TNE-TEP procedure from January 2004 to December 2008. Main Outcome Measures Clinical, demographic, and TE speech–related data were recorded to examine the ease, efficiency, complications, and speech-related outcomes. Results Among 39 patients identified, the average age was 65 years (age range, 47-83 years), with 32 male (82%) and 7 female (16%) patients. Twenty-five patients (64%) underwent total laryngectomy; 8 (21%) underwent total laryngectomy with partial pharyngectomy; and 14 (36%) underwent microvascular flap reconstruction. The overall success rate of secondary TNE-assisted TEP placement was 97% (n = 38), with 1 unsuccessful attempt. There was no statistically significant correlation found between patients having undergone radiation therapy (either before or after oncologic resection) or a cricopharyngeal myotomy and successful TEP placement, type of reconstruction used to close the pharyngeal defect when compared with the difficulty in the placement of the TEP, development of complications associated with TEP placement, use of the TEP prosthesis, or speech intelligibility at the last follow-up visit. Thirty-one patients (79%) were still using their TEP prosthesis for speech at the last follow-up visit. Of the patients reviewed, 28 (72%) had understandable TE speech. Conclusions In-office TNE-assisted TEP placement can safely be performed, with excellent speech outcomes. Reconstruction with musculocutaneous or microvascular free-tissue transfer did not limit our ability to place secondary TEPs with TNE.

Objective: To evaluate swallowing recovery following supracricoid partial laryngectomy. Design: Retrospective review. Setting: Major comprehensive cancer center. Patients: Twenty-seven patients treated with supracricoid partial laryngectomy for primary or recurrent larynx cancer. Intervention: Functional swallowing strategies, maneuvers, and therapies based on objective modified barium swallow (MBS) study results. Main Outcome Measures: Hospital recovery (length of stay, decannulation rates, complications), swallowing outcomes (physiology, symptoms), and nutritional results (time to oral intake, tube dependency, final diet). Results: Supracricoid partial laryngectomy included 1 arytenoid cartilage in 8 of 27 patients. The mean (SD) length of hospitalization was 8 days (9.23 days [median, 6 days; range, 3-53 days]) with a mean (SD) number of weeks to decannulation of 5 (8.23 weeks [median, 1 week; range, 1-30 weeks]). One patient required permanent tracheostomy. The most common complications were pneumonia and subcutaneous emphysema (7 [26%] of 27 complications). Pneumonia occurred more often in patients who had received radiation therapy (P=.02). Twenty-two patients had MBS studies. Initially, all patients aspirated thin liquids and 55% (12 of 22) aspirated pureed consistencies owing to neoglottic incompetency. Diet modifications alone did not alleviate aspiration; 64% (14 of 22) of patients needed to use swallowing strategies. The supraglottic swallow maneuver was most effective in reducing or eliminating aspiration. Eighty-one percent (22 of 27) of patients returned to complete oral intake with mean (SD) time to feeding tube removal of 10 weeks (8.33 weeks [median, 6 weeks; range, 1-29 weeks]); 7 of these patients used swallowing strategies. Nineteen percent of patients (5 of 27) remained partially (4 of 27) or fully (1 of 27) tube dependent. Arytenoid resection did not significantly affect hospital course or swallowing outcomes. Conclusion: Supracricoid partial laryngectomy initially produces severe swallowing dysfunction but most patients return to oral intake following targeted dysphagia intervention.