Novel Therapeutic Strategy for Pharyngoesophageal Stricture following Total Laryngectomy.

Current therapeutic strategies for pharyngoesophageal stricture, while effective in the short term, are protracted and costly in the longer term. Conceptually, if a stricture can be dilated with minimal tissue injuries, the rate of fibrosis and the resultant stricture recurrence could be reduced. We evaluated a prototype computer-controlled syringe pump device programmed to distend a commercially available balloon dilator at variable rate, asserting incremental lumen distension pressures tailored to the resistive force encountered within the stricture. We completed 17 graded dilatation procedures among 4 total laryngectomy patients. All patients had a short-term response (1 month), with a mean decrement (improvement) in Sydney Swallow Questionnaire score of 448 (total score range, 0-1700; normal <234). The overall procedural tolerability and safety were encouraging; the only complication was the displacement of the voice prosthesis during 1 dilatation. From a technical viewpoint, the main challenge was to maintain the balloon in position during dilatation.

Voice restoration with the advantage tracheoesophageal voice prosthesis.

OBJECTIVES: To determine whether the Blom-Singer indwelling Advantage tracheoesophageal voice prosthesis (TEP) extends prosthesis life span significantly in patients with documented premature device failure due to fungal colonization. STUDY DESIGN AND SETTING: Data were collected in a prospective manner on a total of 42 standard indwelling TEP users who exhibited early device failure, that is, between 2 weeks and 6 months, due to fungal colonization of the flap valve despite appropriate use of oral antifungal agents. There were 29 men and 13 women, whose ages ranged from 36 years 10 months to 86 years 8 months. METHODS: Baseline data were derived from the average number of days 3 previous standard indwelling prostheses functioned before leaking. An Advantage indwelling TEP was placed after the third change, oral antifungal agents stopped, and routine care implemented, that is, flush and brush the device in situ twice each day. Each participant was assigned to 1 of 3 groups. Group 1 had device failure equal to or less than 2 months (n = 12). Group 2 had device failure between 2 and 4 months (n = 19). Group 3 had device failure between 4 and 6 months (n = 11). RESULTS: Groups 1 and 2 exhibited significantly longer device life span, that is, 77 and 82 days, respectively (P < 0.01), and group 3 exhibited device life span that was longer but not significantly so, that is, 12 days (P > 0.05), after the change from standard to Advantage TEP. Individual data indicated that the majority of participants, that is, 32 of 42 (76.2%), experienced longer device life span after changing to the Advantage prosthesis. Specifically, 9 of 12 (75.0%) users in group 1, 17 of 19 (89.5%) users in group 2, and 6 of 11 (54.5%) users in group 3 exhibited longer device life span. The combination of using an Advantage TEP, discontinuing oral antifungal agents, and reducing the number of both TEP changes and clinic visits resulted in overall cost benefits for both the user and the health care system. The cost benefit for group 1 was dollar 520.00; group 2, dollar 393.00; and group 3, dollar 204.25. CONCLUSIONS: The Advantage TEP extended device life span significantly for standard indwelling device users with documented premature device failure due to fungal colonization, reduced costs associated with tracheoesophageal voice restoration rehabilitation, and enhanced user satisfaction by eliminating use of oral antifungal agents and reducing clinic visits. SIGNIFICANCE: Use of an Advantage indwelling voice prosthesis is warranted from both cost and user satisfaction perspectives when early and repeated device failure occurs as a result of fungal colonization. EBM RATING: B-3.

Botulinum neurotoxin for pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration.

OBJECTIVES/HYPOTHESIS: The purpose of the study was to evaluate the effectiveness of Botulinum neurotoxin (Botox) for elimination of pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration. STUDY DESIGN: A retrospective review was made of 62 patients between 1991 and 2002 who had Botox as the initial treatment for pharyngeal constrictor muscle spasm. METHODS: One hundred units of Botox properly diluted in 3 mL saline was instilled unilaterally under electromyographic guidance after fluoroscopic identification and marking of the contracted pharyngeal constrictor muscles. The patients were divided into three groups based on their response to the first Botox injection: group I, complete relaxation of the pharyngeal constrictors resulting in fluent voice, intratracheal phonation pressure of 20 to 40 cm H2O, and the ability to say 15 to 20 uninterrupted syllables; group II, hypertonic or incomplete relaxation of the pharyngeal constrictors resulting in intratracheal phonation pressure of 45 to 70 cm H2O and the ability to say 7 or 8 syllables; and group III, failure to produce relaxation of the pharyngeal constrictors. RESULTS: After the first injection of Botox, 49 (79%) patients were in group I or II (41 in group I and 8 in group II) and group III consisted of 13 patients. Thirty-four patients (55%) had group I (28) or II (6) responses for greater than 6 months. A second Botox injection enabled 6 of the 13 failures to move into group I. In all, 8 pharyngeal constrictor muscle myotomies (13%) were ultimately required in the 62 patients. The group I speaker for the longest period has enjoyed 11 years of fluency and successful daily use of a tracheostoma valve after two Botox injections. CONCLUSION: Botox relaxation of the pharyngeal constrictor muscles has proven to be effective, has replaced secondary pharyngeal myotomy for the initial treatment of pharyngeal muscle spasm, and is the only treatment in patients who are not candidates for elective surgery. Radiographic assessment, electromyographically monitored injection, and the number of Botox units appear to be important to successful outcomes.