Socioeconomic Influence on Speech Rehabilitation After Total Laryngectomy.

OBJECTIVE: Speech rehabilitation following a total laryngectomy significantly impacts the quality of life. Indwelling prosthetic voice restoration provides optimal outcomes; however, the long-term maintenance of these devices carries considerable financial costs, which are not universally covered by insurance. This investigation aimed to analyze associations between socioeconomic factors and outcomes in postlaryngectomy speech rehabilitation. STUDY DESIGN: Retrospective cohort analysis. SETTING: Academic tertiary-care center from May 2014 to September 2021. METHODS: In patients undergoing total laryngectomy, the incidence of tracheoesophageal puncture with indwelling vocal prostheses (TEP-VP) placement within the first postoperative year was compared among household income, demographic factors, and disease characteristics. Functional and maintenance outcomes served as secondary endpoints. RESULTS: Seventy-seven patients were included. Forty-five (58%) underwent indwelling TEP-VP (41 primaries). Eighty-nine percent of patients with annual incomes greater than $50k underwent TEP-VP compared to only 35% with incomes less than $50k/year. TEP-VP was performed in 85% of patients with commercial insurance, 70% with Medicare, 42% with Medicaid, and 0% with no insurance. On multivariate analysis, annual household incomes greater than $50k were predicted for TEP-VP placement (odds ratio: 12.7 [2.45-65.8], p = .002). The utilization of postoperative speech therapy and functional communication outcomes were similar among socioeconomic groups. Twelve patients were unable to afford supplies within the first year, with differences noted among insurance (p = .015) and income status (p = .003). CONCLUSION: Disparities in vocal and speech rehabilitation following laryngectomy may disproportionally affect underserved patients.

Long-term outcomes and cost-effectiveness of a magnet-based valve voice prosthesis for endoprosthesis leakage treatment.

PURPOSE: Tracheoesophageal speech is considered the gold standard for rehabilitation following total laryngectomy. The main reason of voice prosthesis failure is the endoprosthesis leakage. Provox ActiValve® incorporates a magnet-based valve system to achieve active closure of the valve to treat these leakages, with the drawback of being significantly more expensive. The aim of the study was to compare the Provox Vega® and Provox ActiValve® duration and costs in patients with replacements increase due to endoprosthetic leakage. METHODS: Prospective case-crossover study in laryngectomized patients with Provox Vega® and endoprosthesis leakage to whom a Provox ActiValve® was placed. Survival and possible factors that affect voice prosthesis were studied using Kaplan-Meier curves and Cox Proportional Hazards Regression. Cost-effectiveness analysis from the perspective of the Spanish Public National Health System with incremental cost-effectiveness calculation was performed. RESULTS: A total of 159 prostheses were evaluated. The most frequent reason for replacement was the endoprosthesis leakage (N = 129; 83.77%) in both models. The mean duration-time of Provox Vega® was 44.77 ± 2.82 days (CI 95%, 39.18-50.35; median 36 days), and 317.34 ± 116.8 days (CI 95% 86.66-548; median 286 days) for the Provox ActiValve® (p < 0.000). For every replacement not made thanks to the Provox ActiValve® there was saving of 133.97€ CONCLUSIONS: The Provox ActiValve® is a cost-effective solution in patients with increased prosthesis replacements due to endoprosthetic leakage, reducing the number of changes and cost compared to Provox Vega®.

Laringe eletrônica para reabilitação vocal de pacientes submetidos à laringectomia total / Electronic larynx for vocal rehabilitation of patients submitted to total laryngectomy

CONTEXTO: Este PTC tem por objetivo avaliar as evidências científicas atualmente disponíveis acerca da eficácia e segurança da laringe eletrônica na reabilitação da fala em pacientes laringectomizados. O câncer de laringe faz parte do conjunto de neoplasias malignas de diferentes localizações que compõem o carcinoma epidermóide de cabeça e pescoço (CECP), representando 25% destes tumores. Ocorre predominantemente em homens, sendo esperados 6.360 novos casos neste grupo, e 990 casos em mulheres, segundo estimativas do INCA para 2016. Nos tumores avançados de laringe, a cirurgia de retirada total do órgão é necessária, a denominada laringectomia total. Como consequência, o indivíduo perde a capacidade de fala, causando prejuízo para a qualidade de vida do paciente. A reabilitação fonatória integral é fundamental para que estes indivíduos possam retornar ao convívio social e profissional de forma satisfatória. A laringe eletrônica (eletrolaringe) é um equipamento eletrônico movido a bateria recarregável tipo bastão vibrador, portátil, leve e de fácil utilização e aprendizagem. O paciente pressiona o equipamento na região submandibular ou na porção mediana do pescoço (papada) e aciona o botão para emissão do som. Ele emite uma vibração sonora contínua, que é transmitida ao ressonador buconasofaríngeo, e pelos órgãos articuladores, como lábios, língua e dentes, é transformada em palavra falada. Uma das desvantagens do seu uso, em relação às demais opções terapêuticas seria o fato do equipamento produzir um som contínuo, monótono, com tonalidade robótica e sem inflexões de sentimento. Seu uso também requer o uso de uma das mãos, de forma alternada para não cansar muito os braços. Por outro lado, suas vantagens incluiriam maior facilidade de aprendizado pelos pacientes e não requerer cirurgia para sua colocação inicial ou substituição frequente (como a prótese traqueoesofágica). TECNOLOGIA E INDICAÇÃO: Laringe eletrônica - Neoplasia maligna da laringe (CID-10 C32). PERGUNTA: O uso da laringe eletrônica é eficaz, seguro e custo-efetivo em pacientes com câncer de laringe submetidos à laringectomia total, quando comparado às demais técnicas de reabilitação da voz (prótese traqueoesofágica ou voz esofágica)? EVIDÊNCIAS CIENTÍFICAS: Foi realizada pelos pareceristas uma busca nas bases de dados Medline e Embase por estudos que avaliassem desfechos como qualidade de vida e auditivos-perceptivos. As evidências e recomendações foram classificadas seguindo a recomendação GRADE. Foram selecionados para análise 15 estudos para extração dos resultados, os quais aplicaram metodologias e desfechos muito diversos. Desta forma, destes foram selecionados apenas os desfechos principais relacionados à qualidade de vida (V-RQOL, VHI, QLQ-C30) e perceptivos (inteligibilidade e aceitabilidade da fala). Os resultados, de uma maneira geral, não apontaram para melhor qualidade de vida percebida pelo grupo de pacientes com laringe eletrônica, em relação aos demais grupos. Também não foi observado melhor desempenho da tecnologia em termos perceptivos. A quase totalidade dos estudos são do tipo transversal, e possuem tamanho de amostra muito pequeno para que se possa inferir conclusões decisiva em relação à melhor performance de alguma das tecnologias em detrimento das demais. QUALIDADE DAS EVIDÊNCIAS: a qualidade das evidências foi classificada como de muito baixa qualidade. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO INCREMENTAL: o impacto orçamentário incremental estimado para cinco anos (2018 a 2022) aponta para um incremento nos custos com a incorporação da laringe eletrônica da ordem de R$ 10,3 milhões a R$ 31,7 milhões em 5 anos, dependendo da oferta da tecnologia (oferta limitada aos pacientes em casos de falha nas outras duas técnicas ou oferta a todos os pacientes, respectivamente), ou de economia de recursos da ordem de R$ 3,5 milhões no caso da oferta como opção à prótese traqueoesofágica após falha na reabilitação por voz esofágica. CONSIDERAÇÕES FINAIS: O balanço entre a qualidade das evidências disponíveis e os benefícios demonstrados é fraca a favor da incorporação do equipamento laringe eletrônica, frente à qualidade das evidências disponíveis, sem evidências suficientes em relação ao melhor desempenho da tecnologia quando comparada à prótese traqueoesofágica ou voz esofágica, seja em termos de qualidade de vida e desempenho ou de inteligibilidade e aceitabilidade da voz. Considerando um cenário de alto índice de falhas da voz esofágica, onde menos da metade dos pacientes têm sucesso com a técnica, que prepondera no cenário nacional, e considerável proporção de falha da prótese traqueoesofágica, prover aos pacientes uma alternativa de fácil uso à completa afonia, parece ser factível e importante para esses pacientes, frente ao impacto estimado para esta alternativa. RECOMENDAÇÃO: FRACA a favor da incorporação, para a reabilitação dos pacientes laringectomizados RECOMENDAÇÃO INICIAL DA CONITEC: Os membros do plenário presentes na 65ª Reunião da CONITEC em 05 de abril de 2018 recomendaram por unanimidade que a matéria fosse submetida à consulta pública com recomendação favorável à incorporação, mediante elaboração de fluxo de utilização em relação às demais opções de tratamento. CONSULTA PÚBLICA: A consulta pública nº 22, de 23 de maio de 2018, foi realizada no período de 25 de maio a 13 de junho de 2018. Foram recebidas 562 contribuições, sendo 444 do formulário "experiência ou opinião" e 118 do formulário "técnico-científico". Após a apreciação das contribuições encaminhadas pela consulta pública, o plenário da CONITEC entendeu que não houve argumentação suficiente para alterar sua recomendação inicial, mantendo-se a recomendação favorável à incorporação da laringe eletrônica para a reabilitação vocal após laringectomia total, mediante elaboração de fluxo de utilização em relação às demais opções de tratamento. RECOMENDAÇÃO FINAL DA CONITEC: Os membros da CONITEC presentes na 68a reunião ordinária, no dia 04 de julho de 2018, deliberaram, por unanimidade, recomendar a incorporação ao SUS da laringe eletrônica para neoplasia maligna da laringe. Foi assinado em 04/07 o registro de deliberação n° 354/2018 pela incorporação da tecnologia ao SUS. DECISÃO: Incorporar a laringe eletrônica para neoplasia maligna da laringe no âmbito do Sistema Único de Saúde ­ SUS, dada pela Portaria nº 39 de 11 de setembro de 2018, publicada no DOU 12/09/2018.

Acoustic assessment of erygmophonic speech of Moroccan laryngectomized patients.

INTRODUCTION: Acoustic evaluation of alaryngeal voices is among the most prominent issues in speech analysis field. In fact, many methods have been developed to date to substitute the classic perceptual evaluation. The Aim of this study is to present our experience in erygmophonic speech objective assessment and to discuss the most widely used methods of acoustic speech appraisal. through a prospective case-control study we have measured acoustic parameters of speech quality during one year of erygmophonic rehabilitation therapy of Moroccan laryngectomized patients. METHODS: We have assessed acoustic parameters of erygmophonic speech samples of eleven laryngectomized patients through the speech rehabilitation therapy. Acoustic parameters were obtained by perturbation analysis method and linear predictive coding algorithms also through the broadband spectrogram. RESULTS: Using perturbation analysis methods, we have found erygmophonic voice to be significantly poorer than normal speech and it exhibits higher formant frequency values. However, erygmophonic voice shows also higher and extremely variable Error values that were greater than the acceptable level. And thus, live a doubt on the reliability of those analytic methods results. CONCLUSION: Acoustic parameters for objective evaluation of alaryngeal voices should allow a reliable representation of the perceptual evaluation of the quality of speech. This requirement has not been fulfilled by the common methods used so far. Therefore, acoustical assessment of erygmophonic speech needs more investigations.

Cost-effectiveness of heat and moisture exchangers compared to usual care for pulmonary rehabilitation after total laryngectomy in Poland.

The beneficial physical and psychosocial effects of heat and moisture exchangers (HMEs) for pulmonary rehabilitation of laryngectomy patients are well evidenced. However, cost-effectiveness in terms of costs per additional quality-adjusted life years (QALYs) has not yet been investigated. Therefore, a model-based cost-effectiveness analysis of using HMEs versus usual care (UC) (including stoma covers, suction system and/or external humidifier) for patients after laryngectomy was performed. Primary outcomes were costs, QALYs and incremental cost-effectiveness ratio (ICER). Secondary outcomes were pulmonary infections, and sleeping problems. The analysis was performed from a health care perspective of Poland, using a time horizon of 10 years and cycle length of 1 year. Transition probabilities were derived from various sources, amongst others a Polish randomized clinical trial. Quality of life data was derived from an Italian study on similar patients. Data on frequencies and mortality-related tracheobronchitis and/or pneumonia were derived from a Europe-wide survey amongst head and neck cancer experts. Substantial differences in quality-adjusted survival between the use of HMEs (3.63 QALYs) versus UC (2.95 QALYs) were observed. Total health care costs/patient were 39,553 PLN (9465 Euro) for the HME strategy and 4889 PLN (1168 Euro) for the UC strategy. HME use resulted in fewer pulmonary infections, and less sleeping problems. We could conclude that given the Polish threshold of 99,000 PLN/QALY, using HMEs is cost-effective compared to UC, resulting in 51,326 PLN/QALY (12,264 Euro/QALY) gained for patients after total laryngectomy. For the hospital period alone (2 weeks), HMEs were cost-saving: less costly and more effective.

Annual national direct and indirect cost estimates of the prevention and treatment of cervical cancer in Brazil

OBJECTIVE: To estimate the annual direct and indirect costs of the prevention and treatment of cervical cancer in Brazil. METHODS: This cost description study used a "gross-costing" methodology and adopted the health system and societal perspectives. The estimates were grouped into sets of procedures performed in phases of cervical cancer care: the screening, diagnosis and treatment of precancerous lesions and the treatment of cervical cancer. The costs were estimated for the public and private health systems, using data from national health information systems, population surveys, and literature reviews. The cost estimates are presented in 2006 USD. RESULTS: From the societal perspective, the estimated total costs of the prevention and treatment of cervical cancer amounted to USD $1,321,683,034, which was categorized as follows: procedures (USD $213,199,490), visits (USD $325,509,842), transportation (USD $106,521,537) and productivity losses (USD $676,452,166). Indirect costs represented 51% of the total costs, followed by direct medical costs (visits and procedures) at 41% and direct non-medical costs (transportation) at 8%. The public system represented 46% of the total costs, and the private system represented 54%. CONCLUSION: Our national cost estimates of cervical cancer prevention and treatment, indicating the economic importance of cervical cancer screening and care, will be useful in monitoring the effect of the HPV vaccine introduction and are of interest in research and health care management. .

Ex vivo water exchange performance and short-term clinical feasibility assessment of newly developed heat and moisture exchangers for pulmonary rehabilitation after total laryngectomy.

Laryngectomized patients suffer from respiratory complaints due to insufficient warming and humidification of inspired air in the upper respiratory tract. Improvement of pulmonary humidification with significant reduction of pulmonary complaints is achieved by the application of a heat and moisture exchanger (HME) over the tracheostoma. The aim of this study was to determine whether the new Provox HMEs (XM-HME and XF-HME) have a better water exchange performance than their predecessors (R-HME and L-HME, respectively; Atos Medical, Hörby, Sweden). The other aim was to assess the short-term clinical feasibility of these HMEs. The XM-HME and XF-HME were weighed at the end of inspiration and at the end of expiration at different breathing volumes produced by a healthy volunteer. The associations between weight changes, breathing volume and absolute humidity were determined using both linear and non-linear mixed effects models. Study-specific questionnaires and tally sheets were used in the clinical feasibility study. The weight change of the XM-HME is 3.6 mg, this is significantly higher than that of the R-HME (2.0 mg). The weight change of the XF-HME (2.0 mg) was not significantly higher than that of the L-HME (1.8 mg). The absolute humidity values of both XM- and XF-HME were significantly higher than that of their predecessors. The clinical feasibility study did not reveal any practical problems over the course of 3 weeks. The XM-HME has a significantly better water exchange performance than its predecessor (R-HME). Both newly designed HMEs did succeed in the clinical feasibility study.

The Amatsu's tracheoesophageal shunt: analysis of 84 cases.

INTRODUCTION: Amatsu's tracheoesophageal shunt can be indicated for vocal rehabilitation in candidates to total laryngectomy. It is performed in the period of the procedure of total laryngectomy and has been indicated due to its technical facility, exemption from the use of voice prosthesis, and lack of additional costs for its maintenance. OBJECTIVE: To evaluate the results obtained with the Amatsu's tracheoesophageal shunt, along 14 years of experience, in two Brazilian hospitals. STUDY DESIGN: Clinical retrospective. MATERIAL AND METHOD: From 1991 to 2005, eighty-four patients were submitted to the Amatsu's tracheoesophageal shunt. Seventy-seven (91.7%) were male and seven (8.3%) female, aged between 30 and 82 years, mean age of 57.5 years, and an average age of 52 years. All patients had squamous cell carcinoma of larynx and/or hypopharynx. Sixty-eight (81.0%) were stage III or IV. They were submitted to total laryngectomy and the Amatsu's tracheoesophageal shunt was performed during the tumor removal surgery. The following variables were analyzed: acquisition of intelligible speech, vocal recovery time after surgery, and the occurrence of specific surgical complications of the shunt (pulmonary aspiration). RESULTS: Seventy-six patients were evaluated with respect to the effectiveness of the technique. Fifty-three patients (70.0%) presented vocalization by the shunt; in 46 patients (60.5%), the speech was fully intelligible. The time required for restoration of speech was 12-87 postoperative days. Of the 83 patients evaluated in relation to the development of complications, 25 (30.1%) presented aspiration by the shunt during oral ingestion. In 23 patients (27.7%), the aspiration was managed conservatively without complications. Two patients (2.4%) required surgical closure of the shunt due to intractable aspiration. CONCLUSION: Vocal rehabilitation with the Amatsu's tracheoesophageal shunt is effective in most patients who underwent total laryngectomy. It can be evidenced by the acquisition of intelligible speech in most patients. The aspiration, although often, is not shown to be a limiting complication.

[Social integration and its relevance for quality of life after laryngectomy]. / Soziale Integration und deren Bedeutung für die Lebensqualität nach Laryngektomie.

BACKGROUND: Social networks and social participation generally have positive effects on health. Yet, little is known about how patients after total laryngectomy (TLE) are integrated into the society. Aim of this study was to investigate how patients are socially integrated after a TLE and if social integration is associated with certain areas of quality of life. PATIENTS AND METHODS: In a longitudinal multi-centred study 161 laryngectomees were interviewed 1 year after the total laryngectomy. Social integration was measured on the basis of an index formed by the questionnaire "Psychosocial Adjustment after Laryngectomy" and questions about social support. To assess quality of life, we used the questionnaire from the European Organisation for Research and Treatment of Cancer EORTC QLQ-C30. RESULTS: 58% of all patients are well integrated 1 year after surgery. Well integrated persons have less problems in different components of quality of life. They report higher levels of social (OR 4.07; CI: 1.96-8.47) and role functioning (OR 3.59; CI: 1.61-8.02). Successful social integration is also associated with higher emotional well-being (OR 8.57; CI: 3.59-20.46). CONCLUSIONS: There is evidence that 1 year after TLE only about half of the patients feel socially integrated. Because of the negative association of poor social integration with social, emotional and role functioning, patients should be supported in their attempts to take actively part in social life.

Ex vivo assessment and validation of water exchange performance of 23 heat and moisture exchangers for laryngectomized patients.

BACKGROUND: Breathing through a tracheostoma results in insufficient warming and humidification of the inspired air. This loss of air conditioning, especially humidification, can be partially restored with the application of a heat and moisture exchanger (HME) over the tracheostoma. For medical professionals, it is not easy to judge differences in water exchange performance of various HMEs owing to the lack of universal outcome measures. This study has three aims: assessment of the water exchange performance of commercially available HMEs for laryngectomized patients, validation of these results with absolute humidity outcomes, and assessment of the role of hygroscopic salt present in some of the tested HMEs. METHODS: Measurements of weight and absolute humidity at end inspiration and end expiration at different breathing volumes of a healthy volunteer were performed using a microbalance and humidity sensor. Twenty-three HMEs from 6 different manufacturers were tested. Associations were determined between core weight, weight change, breathing volume, and absolute humidity, using both linear and nonlinear mixed effects models. RESULTS: Water exchange of the 23 HMEs at a breathing volume of 0.5 L varies between 0.5 and 3.6 mg. Both water exchange and wet core weight correlate strongly with the end-inspiratory absolute humidity values (r2 =0.89/0.87). Hygroscopic salt increases core weight. CONCLUSIONS: The 23 tested HMEs for laryngectomized patients show wide variation in water exchange performance. Water exchange correlates well with the end-inspiratory absolute humidity outcome, which validates the ex vivo weight change method. Wet core weight is a predictor of HME performance. Hygroscopic salt increases the weight of the core material. The results of this study can help medical professionals to obtain a more founded opinion about the performance of available HMEs for pulmonary rehabilitation in laryngectomized patients, and allow them to make an informed decision about which HME type to use.

Avaliação de voz e qualidade de vida após laringectomia supracricóide / Voice assessment and quality of life after supracricoid laryngectomy

OBJETIVO: Avaliar sujeitos submetidos a laringectomia supracricóide quanto à autoavaliação da voz, análises perceptivo-auditiva e acústica e impacto da alteração vocal na qualidade de vida. MÉTODOS: Estudo prospectivo, observacional, que envolveu 12 sujeitos do gênero masculino, com disfonia orgânica, média de idade de 59,3 anos, que realizaram laringectomia supracricóide para exérese de neoplasia maligna de laringe. Foi realizada análise perceptivo-auditiva, por meio da escala GRBASI em duplo-cego. A análise acústica realizada através do software VOXMETRIA® considerou parâmetros de frequência fundamental, jitter e shimmer, proporção harmônico-ruído e diagrama de desvio fonatório. A autoavaliação vocal e o estudo do impacto da disfonia na qualidade de vida dos sujeitos ocorreram por meio de aplicação dos protocolos: Qualidade de Vida em Voz (QVV) e o Índice de Desvantagem Vocal (IDV). RESULTADOS: A frequência das vozes variou entre 91,59 Hz e 260,05 Hz e as medidas de shimmer e jitter mostraram-se alteradas, comprovando as análises perceptivo-auditivas, que revelaram vozes com grau de desvio de moderado a intenso. A maioria dos sujeitos qualificou suas vozes como razoável ou boa. O QVV demonstrou escores brutos em níveis compatíveis com vozes disfônicas em 50,0%. O IDV mostrou predomínio do domínio orgânico. CONCLUSÃO: O grau de desvio vocal dos sujeitos mostrou-se entre moderado e intenso, confirmando parâmetros acústicos, enquanto que os sujeitos qualificaram suas vozes como razoáveis ou boas. Os escores do QVV e IDV revelaram predomínio de domínios físico e orgânico, respectivamente, com parte dos sujeitos com escores compatíveis a vozes disfônicas. Sugerem-se estudos que busquem aprofundar o conhecimento entre autopercepção da voz e impacto na qualidade de vida de sujeitos com disfonia decorrente de carcinoma de laringe.

PURPOSE: To evaluate subjects submitted to supracricoid laryngectomy concerning vocal self-assessment, auditory-perceptual and acoustic analysis, and the impact of dysphonia on the quality of life. METHODS: Twelve male subjects, who underwent supracricoid laryngectomy for carcinoma resection, mean age of 59.3 years, took part in this prospective observational study. The auditory-perceptual analysis was performed through GRBASI scale in double blind. The acoustic analysis used the VOXMETRIA® software to obtain the fundamental frequency (f0), jitter, shimmer, glottal to noise excitation ratio and phonatory deviation diagram. The self-assessment and the impact of organic dysphonia on the quality of life of these subjects was observed through Voice-Related Quality of Life V-RQOL and Voice Handicap Index (VHI) protocols. RESULTS: f0 ranged between 91.59 Hz and 260.05 Hz, shimmer and/or jitter measures were fairly altered confirming the results of the auditory-perceptual analysis that revealed a vocal deviation degree from moderate to intense, despite the subjects having considered their voices as good or reasonable. However the V-RQOL results showed 50.0% of the subjects presenting gross scores consistent with dysphonic voices. The Voice Handicap Index showed highest scores for the organic domain. CONCLUSION: The vocal deviation degree of subjects varied from moderate to intense, corroborating the acoustic analysis; nevertheless, subjects classified their voices as reasonable and good. Scores of V-RQOL and VHI revealed predominance of the physic and organic domains respectively, compatible with dysphonic voices. Further studies are necessary for a better understanding of the relation between vocal self-assessment and impact on quality of life of subjects with dysphonia resulting from laryngeal carcinoma.

Provision of surgical voice restoration in England: questionnaire survey of speech and language therapists.

AIM: To conduct a questionnaire survey of speech and language therapists providing and managing surgical voice restoration in England. METHOD: National Health Service Trusts registering more than 10 new laryngeal cancer patients during any one year, from November 2009 to October 2010, were identified, and a list of speech and language therapists compiled. A questionnaire was developed, peer reviewed and revised. The final questionnaire was e-mailed with a covering letter to 82 units. RESULTS: Eighty-two questionnaires were distributed and 72 were returned and analysed, giving a response rate of 87.8 per cent. Forty-four per cent (38/59) of the units performed more than 10 laryngectomies per year. An in-hours surgical voice restoration service was provided by speech and language therapists in 45.8 per cent (33/72) and assisted by nurses in 34.7 per cent (25/72). An out of hours service was provided directly by ENT staff in 35.5 per cent (21/59). Eighty-eight per cent (63/72) of units reported less than 10 (emergency) out of hours calls per month. CONCLUSION: Surgical voice restoration service provision varies within and between cancer networks. There is a need for a national management and care protocol, an educational programme for out of hours service providers, and a review of current speech and language therapist staffing levels in England.

[Vocational rehabilitation after total laryngectomy]. / Berufliche Rehabilitation nach Laryngektomie.

BACKGROUND: Aim of this study was to find out how many patients after a total laryngectomy (TLE) return to work successfully and what factors support vocational rehabilitation. PATIENTS AND METHODS: Laryngectomees (n=231) aged up to 60 years completed questionnaires and structured interviews before TLE (t1), before rehabilitation (t2), at the end of rehabilitation (t3), 1 year after TLE (t4), 2 years after TLE (t5), and 3 years after TLE (t6). RESULTS: Prior to TLE, 38% of all respondents were employed, 34% were unemployed, 23% received disability-related and 3% age-related pension retirement. One year after TLE, 13% were employed, 15% 2 years and 14% 3 years after TLE. Unemployed were 10% (t4), 5% (t5), and 7% (t6) of the patients. For 59% of all respondents it was very important to have a job. Predictors of successful vocational rehabilitation were employment prior to TLE, age <50 years, being self-employed or clerical employee, good physical functioning, good speech intelligibility, high motivation to go back to work, and support from colleagues. CONCLUSION: Only few laryngectomees return to work. However, even before TLE only a third of the patients was employed, another third was unemployed. Most of the patients receive pension retirement after TLE. As return to work is important for many patients, patient consultations should consider possibilities to support vocational rehabilitation before offering to apply for retirement.

Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands.

PURPOSE OF REVIEW: Total laryngectomy rehabilitation (TLR) in Europe is not uniform, with quite some differences in approach and infrastructure between various countries. In, for example, the Netherlands, Switzerland, Scandinavia, and more recently also in the UK, head and neck cancer (HNC) treatment and rehabilitation shows a high level of centralization in dedicated HNC centres. In other European countries, the level of centralization is lower, with more patients treated in low-volume hospitals. This article focusses on the situation in the Netherlands and, where applicable, will discuss the regional variations in Europe. RECENT FINDINGS: Prosthetic surgical voice restoration (PSVR) presently is the method of choice in Europe, and use of oesophageal and electrolarynx voice has moved to the background. In most European countries (except the UK and Ireland), PSVR is physician driven, with an indispensable role for speech-language pathologists and increasingly for oncology nurses. Indwelling voice prostheses are mostly preferred, also because these devices can be implanted at the time of trachea-oesophageal puncture. Pulmonary rehabilitation is achieved with heat and moisture exchangers, which, based on extensive clinical and basic physiology research, are considered an obligatory therapy measure. In addition to PSVR, also issues such as smoking cessation, dysphagia/swallowing rehabilitation, and olfaction/taste rehabilitation are discussed. Especially, the latter has shown great progress over the last decade and is another example of increasing implementation of evidence-based practice in TLR. SUMMARY: TLR has shown considerable progress over the last decades, and through the intensified collaboration between all clinicians involved, significantly has improved vocal, pulmonary, and olfactory rehabilitation after total laryngectomy.

Practice of laryngectomy rehabilitation interventions: a perspective from India.

PURPOSE OF REVIEW: Total laryngectomy remains the treatment for a significant number of locally advanced cancers (T4) or as a salvage procedure following failure of chemoradiotherapy. Loss of natural voice is the most important disadvantage of this surgery, and impacts quality of life. In the past few decades, there has been emphasis on rehabilitative efforts after laryngectomy. Laryngectomy rehabilitation is practiced globally, and is subject to regional problems and constraints. This calls for better understanding of experiences of differing geographical regions, and the impact of the local socioeconomic conditions on post-laryngectomy rehabilitation. RECENT FINDINGS: Current world literature focuses on advances in voice prosthesis, which would lead to better rehabilitation as well as improve the life of prostheses. The current review focuses on voice rehabilitation post-laryngectomy: the existing world literature, and how it has impacted prosthetic voice rehabilitation in India, within the local constraints. SUMMARY: The practice of prosthetic voice rehabilitation is well established in the Indian scenario, with results favorably comparing to world literature. However, few centers have the expertise and support staff to implement an effective post-laryngectomy rehabilitative program. There is need for assessment in a structured manner of outcomes and economic benefits of post-laryngectomy rehabilitation.

[Causes and indwelling times of multiple voice prosthesis replacements in patients after total laryngectomy--analysis of 184 replacements in 42 patients]. / Przyczyny i czas pomiedzy kolejnymi wymianami protez glosowych u chorych po laryngektomii--analiza 184 wymian u 42 chorych.

INTRODUCTION: Implantation of the indwelling voice prosthesis has become the preferred method of voice rehabilitation after total laryngectomy. Frequent prosthesis dysfunction remains the major problem. AIM: Analysis of the indwelling time and indications for multiple voice prosthesis replacements. METHODS: Forty two patients after total laryngectomy due to laryngeal cancer (6 women and 36 men, mean age 62.1 ± 6.7 years) were included. 184 voice prosthesis replacements were analyzed (1271 patient-months). RESULTS: Mean time between replacements was 260 ± 150 days. The indwelling time decreased from 267 days to the first replacement to 100-160 days at eighth and subsequent exchanges (p < 0.01). Most frequent indications for replacement were leakage of fluids through the prosthesis, phonation problems caused by mucosal overgrowth around the prosthesis, inaccurate sizing, deformation, and spontaneous extrusion. The lifetime of voice prostheses was positively correlated with patients' age. Mycological culture of the smear taken from tracheoesophageal fistula at first replacement was positive in 34/41 cases, at the second in 29/31 cases, the third in 29/31, and at the fourth and subsequent replacements in all specimens. Most patients indicated the following factors as possible causes of a shortened lifetime of the prosthesis: use of alcohol and coffee (34% of responders), inappropriate dietary habits (sweets and tough foodstuff - 17%), cleaning of voice prosthesis discordant with the recommendations of the manufacturer (14%). CONCLUSIONS: Although our results confirm common indications for voice prosthesis replacement we also showed that the time between exchanges is gradually getting shorter. This observation could have implications for the current reimbursement practices.

Determining the efficacy and cost-effectiveness of the ActiValve: results of a long-term prospective trial.

OBJECTIVES/HYPOTHESIS: To investigate 1) whether the Provox ActiValve results in increased device-life in individuals with below average device-life, 2) whether it is cost-effective, and 3) whether it has any impact on voice-related quality of life. STUDY DESIGN: Prospective study. METHODS: Individuals who experienced below-average tracheoesophageal prosthesis (TEP) life were studied. RESULTS: Individuals with persistent below-average TEP life were enrolled in the study and underwent periodic re-evaluation. The majority (73%) experienced significant improvement as a result of use of the device. Those who continued to wear the device were followed for an average of 30.45 months (range, 14.70-43.49 months) and wore a total of 31 devices over this time. They demonstrated an average increase in device-life of more than 500%, going from an average of 1.93 months with a traditional indwelling device to 10.30 months with the ActiValve. The majority of individuals found that voicing with the ActiValve was either the same or better than with their previous indwelling TEP. Voice-related quality of life was not significantly different from that of a group of controls. Overall satisfaction with the device was high, and the majority would have chosen the ActiValve in the future. Overall, there were estimated to be cost savings to third-party payers through use of the ActiValve in this population. CONCLUSIONS: The ActiValve is effective in increasing device-life in selected patients who have failed conservative measures. Our protocol for use of the device requires individuals to meet several usage criteria before initial placement and to return for periodic monitoring.

The impact of total laryngectomy: the patient's perspective.

PURPOSE/OBJECTIVES: To describe the experiences of patients who had total laryngectomy from their perspective. RESEARCH APPROACH: Descriptive, qualitative study. SETTING: Participants' homes or investigator's hospital office. PARTICIPANTS: 10 patients after total laryngectomy. METHODOLOGIC APPROACH: Data were collected by semistructured, open-ended interviews during a period of six months, with an interview topic guide built on the framework of the literature review. Data were analyzed with descriptive content analysis. Trustworthiness of the study was enhanced through the use of verbatim quotations, audible data analysis trail, and a reflexive approach. MAIN RESEARCH VARIABLES: Patients' experiences of undergoing total laryngectomy. FINDINGS: Patients who have undergone a total laryngectomy report difficulties and concerns that are largely functional and psychological. The functional difficulties reported included descriptions of altered swallow, excess phlegm, speech difficulties, weak neck muscles, and altered energy levels. The psychological concerns reported included descriptions of depression, regrets, and personal resolve. CONCLUSIONS: As a group, patients experience a broad range of problems well after completion of treatment, reinforcing the need for rehabilitation management for prolonged periods after surgery. INTERPRETATION: Nurses are suitably positioned to support this group of patients across the disease management trajectory, from the initial preoperative period to the postoperative period and through to the rehabilitative period and beyond.

An external neck brace to support the peristomal fixation of an automatic stoma valve (ASV): 3D stereophotogrammetrical assessment.

CONCLUSION: The external neck brace (ENB) is a new concept in the improvement of peristomal fixation of an automatic stoma valve (ASV), which was evaluated with a new imaging method. The addition of the ENB to the Flexiderm (FLD) and Xtrabase (XB) adhesives significantly reduced absolute mean differences between the speech and the non-speech conditions. OBJECTIVES: After total laryngectomy, peristomal fixation problems of adhesives and stoma valves are still the main reasons for the relatively small number of patients that actually use an ASV on a daily basis. Several concepts could not prevent these fixation problems. To overcome or at least diminish these attachment problems, an ENB has been developed to support peristomal adhesives. The mechanism behind this brace is that it absorbs the high stomal pressures created during tracheoesophageal speech. In this pilot study the mechanism outlined above was objectified using 3D stereophotogrammetrical measurements. METHODS: This was a prospective clinical pilot study in a university hospital setting, involving nine laryngectomized patients. Ten 3D images were taken of all patients using stereophotogrammetry; five pictures during a moment of speech and five during a non-speech condition. Two different peristomal adhesives were used during these two conditions: the Provox Flexiderm (FLD) adhesive and the Provox Xtrabase (XB) adhesive, both with and without the addition of the ENB. Besides these four combinations, a final fifth set-up using all the components (FLD + XB-ring + ENB) was added. Absolute mean differences were compared between two photographs of the area of interest, which is covered by the adhesive for all five different set-ups mentioned above. This was done during speech and non-speech conditions. RESULTS: Absolute mean differences at the region of the base plate between speech and non-speech conditions were most obvious while using just the FLD adhesive (4.70 mm). The use of the ENB significantly reduced the absolute mean difference to 0.58 mm (p < 0.02). The suggested set-up with a basis of the FLD adhesive combined with the solid ring extracted from the XB adhesive and the ENB showed the smallest absolute mean difference of 0.38 mm between speech and non-speech conditions (p < 0.025).

Assessment of communication and swallowing post-laryngectomy: a telerehabilitation trial.

Ten laryngectomy patients were assessed using a purpose-designed, multimedia videoconferencing system incorporating a freestanding, self-focusing camera. Swallowing, stoma and communication status were assessed simultaneously by a remote clinician and face-to-face, by a second clinician at the patient's site. The remote trial took place over a distance of approximately 1700 km using a commercial 3G phone network. A satisfaction questionnaire was also completed. There was excellent agreement between the two assessing clinicians. Image quality obtained via the freestanding camera was rated as lower than direct observation, but it was sufficient to assess the stoma and status of the voice prosthesis. During the trial, occasional difficulties with audio delays and image distortion were experienced, although these were manageable. Both patient and clinician satisfaction with remote assessment was high. The results provide further evidence to support the use of telerehabilitation for evaluating the speech and swallowing status of laryngectomy patients following discharge from acute care.