The voice and swallowing profile of adults with laryngotracheal stenosis before and after reconstructive surgery: A prospective, descriptive observational study.

OBJECTIVES: Airway reconstruction for laryngo tracheal stenosis (LTS) improves dyspnoea. There is little evidence relating to impact upon voice and swallowing. We explored voice and swallowing outcomes in adults with LTS before and after reconstructive surgery. DESIGN: Outcome measures were collected pre-reconstructive surgery, two-weeks post-surgery and up to 4-6 months post-surgery. SETTING: Tertiary referral centre. PARTICIPANTS: With ethical approval, twenty consecutive adult (≥18 years) LTS patients undergoing airway reconstruction were prospectively recruited. MAIN OUTCOME MEASURES: These included physiological values (maximum phonation time (MPT) and fundamental frequency; penetration aspiration score, residue score), clinician-reported (GRBAS, functional oral intake score, 100ml Water Swallow Test) and patient-reported outcomes (Voice Handicap Index-10, Reflux Symptoms Index, Eating Assessment Tool, Dysphagia Handicap Index). RESULTS: The observational study identified patient-reported and clinician-reported voice and swallow difficulties pre- and post-surgery; median and interquartile range are reported at each time point: Voice Handicap Index-10 23 (8-31); 20.5 (9-33.5), 24.5 (12.5-29); Dysphagia Handicap Index 9 (0-37); 13 (7-44); 15 (4-34); GRBAS grade 1(1-2); 2 (1-2.5); 2(1-2); 100ml Water Swallow Test volume score 16.7 (11.1-20); 14.3 (12.5-16.7); 16.7 (14.3-20.0); 100ml Water Swallow Test capacity score 16.3 ± 9.0; 11.0 ± 4.1; 12.5 ± 2.6. CONCLUSIONS: We present the first prospective data on voice and swallowing outcomes in adults with LTS before and after reconstructive surgery. The variability of the outcomes was higher than expected but importantly, for many the voice and swallow outcomes were not within normal limits before surgery. The clinical value of the study demonstrates the need for individual assessment and management of LTS patients' voice and swallowing.

'Is there something wrong with your voice?' A qualitative study of the voice concerns of people with laryngotracheal stenosis.

BACKGROUND: Acquired laryngotracheal stenosis (LTS) is a rare condition that causes breathlessness and dyspnoea. Patients have reconstructive airway surgery to improve their breathing difficulties, but both LTS and the surgery can cause voice difficulties. The existing evidence base for management of voice difficulties for adults with LTS focuses on symptoms. There is limited information to provide clinical guidance for speech and language therapists (SLTs) and a limited understanding of the impact of voice changes on adults with LTS. AIM: To investigate the lived experience of adults with laryngotracheal stenosis (LTS), who have had reconstructive surgery; here focussing on voice concerns with the aim of guiding clinical care for SLTs. METHODS AND PROCEDURES: A phenomenological, qualitative study design was used. Focus groups and semi-structured interviews were completed with adults living with LTS who had had reconstructive surgery. Audio recordings were transcribed and inductive thematic analysis was used by the research team to identify themes and sub-themes. OUTCOMES AND RESULTS: A total of 24 participants (five focus groups and two interviews) took part in the study before thematic saturation was identified in analysis. Three main themes were identified specific to the experience of living with LTS: the Medical, Physical and Emotional journey. All participants referenced voice difficulties as they related to each of these overall themes. Sub-themes directly related to voice included experience of surgery, information provision, staff expertise/complacency, symptoms, symptom management, identity, support networks, impact on life and living with a chronic condition. CONCLUSIONS AND IMPLICATIONS: In this qualitative study participants have described the integral part voice difficulties play in their lived experience of LTS and reconstructive surgery. This is considered in the context of their clinical care and the need for individualised management and information provision throughout the course of their condition. The broader research literature relating to voice difficulties is explored with links made to people with LTS and recommendations made for future research into people living with LTS and dysphonia. WHAT THIS PAPER ADDS: What is already known on this subject Adults with laryngotracheal stenosis (LTS) experience voice changes as a result of their condition, and the surgeries necessary as a treatment. These changes can lead to altered pitch, vocal fatigue, loss of pitch range and loss of volume control. Although there are known psychosocial implications both to living with a chronic condition and voice difficulties there has been no research exploring this in adults with LTS, and there is minimal clinical guidance for speech and language therapists (SLTs) working with these patients. What this paper adds to existing knowledge This research is the first study to explore the lived experience of adults with LTS who undergo reconstructive surgery, focusing on their voice concerns. This study demonstrates the multifactorial impacts of voice changes on all aspects of the lives of adults with LTS and the need for individualised information provision and clinical care to help support them. What are the potential or actual clinical implications of this work? Adults with LTS want expert SLTs to facilitate their care and support them throughout their LTS journey alongside other support networks. They want to be carefully prepared for reconstructive surgery and given clear information about symptoms and management of their voice difficulties. This has led to the reorganisation of the care pathway at our centre, and the introduction of a patient-led pretreatment session.

Laryngeal Sarcoidosis and Swallowing: What Do We Know About Dysphagia Assessment and Management in this Population?

INTRODUCTION: Sarcoidosis is a chronic granulomatous disease of unknown aetiology and laryngeal involvement is seen in a small percentage of cases. Dysphagia is a common but under-reported symptom. Little is known about how dysphagia typically presents or is managed in the context of this fluctuating disease. We present our case series using an SLT-led model of assessment and management. METHODS: A literature search was conducted for any articles that reported both laryngeal sarcoidosis and dysphagia. We then analysed a case series of laryngeal sarcoidosis patients treated at Charing Cross Hospital. We report on multidimensional swallowing evaluation and rehabilitative interventions. RESULTS: Seventeen papers report both laryngeal sarcoidosis and dysphagia, with only one paper giving details on the nature of the dysphagia and the treatment provided. In our case series (n = 7), patients presented with FOIS Scores ranging from 5 to 7 pre-operatively (median = 6). Aspiration (median PAS Score = 6 and Range = 3-8) and pharyngeal residue were common. Sensory issues were also prevalent with most unaware of the extent of their difficulties. Management interventions included safe swallowing advice, compensatory strategies, exercises and close surveillance given their potential for repeated surgical interventions. CONCLUSION: Laryngeal sarcoidosis is a rare condition. Dysphagia is under-reported and our experience highlights the need for specialist dysphagia intervention. Further research is required to understand dysphagia management requirements in the context of this fluctuating disease process.

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction.

Acquired laryngotracheal stenosis (LTS) is a rare condition causing dyspnea and stridor. Patients often require multiple surgical procedures with no guarantee of a definitive outcome. Difficulty swallowing is a recognised problem associated with LTS and the reconstructive surgeries required to manage the condition. The breathlessness patient's experience impacts on swallowing, and the vulnerable structures of the larynx are implicated during complex surgeries. This leads to dysphagia post-surgery, with some patients experiencing more chronic symptoms depending on the biomechanical impact of the surgery, or a pre-existing dysphagia. Despite this there is limited observational research about the dysphagia associated with LTS, with no exploration of the patient experience. Our aim was to investigate patient experience of living with LTS focussing on dysphagia in order to guide clinical practice. A qualitative study was completed using focus groups and semi-structured interviews with 24 patients who have had reconstructive surgery for LTS. Thematic analysis was used to identify three over-arching themes: The Physical Journey, The Emotional Journey and The Medical Journey. Key sub-themes included the importance of self-management and control, presence of symptoms, benefits of therapy, living with a life-long condition, fear and anxiety, autonomy, medicalisation of normal processes and the dichotomy between staff expertise and complacency. Swallowing was connected to all themes. The results are reviewed with consideration of the wider literature of lived experience particularly in relation to other chronic conditions and those that carry a high symptom burden such as head and neck cancer. Future clinical and research recommendations have been made. Akin to other clinical groups, adults with LTS are keen that management of their swallowing is person-centred and holistic.

"A Major Quality of Life Issue": A Survey-Based Analysis of the Experiences of Adults With Laryngotracheal Stenosis with Mucus and Cough.

OBJECTIVES: To investigate how the symptoms of mucus and cough impact adults living with laryngotracheal stenosis, and to use this information to guide future research and treatment plans. METHODS: A survey was developed with the support of patient advisors and distributed to people suffering with laryngotracheal stenosis. The survey comprised 15 closed and open questions relating to mucus and cough and included the Leicester Cough Questionnaire (LCQ). Descriptive statistics, X2 and thematic analyses were completed. RESULTS: In total, 641 participants completed the survey, with 83.62% (n = 536) reporting problems with mucus; 79% having daily issues of varying severity that led to difficulties with cough (46.18%) and breathing (20.90%). Mucus affected voice and swallowing to a lesser degree. Respondents described a range of triggers; they identified smoky air as the worst environmental trigger. Strategies to manage mucus varied widely with drinking water (72.26%), increasing liquid intake in general (49.35%) and avoiding or reducing dairy (45.32%) the most common approaches to control symptoms. The LCQ showed a median total score of 14 (interquartile range 11-17) indicative of cough negatively affecting quality of life. Thematic analysis of free text responses identified 4 key themes-the Mucus Cycle, Social impact, Psychological impact, and Physical impact. CONCLUSION: This study shows the relevance of research focusing on mucus and cough and its negative impact on quality of life, among adults with laryngotracheal stenosis. It demonstrates the inconsistent advice and management strategies provided by clinicians for this issue. Further research is required to identify clearer treatment options and pathways.

Ultrasound: an emerging modality for the dysphagia assessment toolkit?

PURPOSE OF REVIEW: Videofluoroscopy (VFSS) and fibreoptic endoscopic evaluation of swallowing (FEES) are established instrumental techniques to support differential diagnosis and treatment of oropharyngeal dysphagia. Whilst their value is undisputed, each tool is not without limitations. The COVID-19 pandemic has restricted access to VFSS and FEES leading clinicians to explore alternative or augmentative tools to support swallowing assessment.Ultrasound (US) is an established tool for visualisation of head and neck anatomy, including structures implicated in swallowing. Although US has been utilised in swallowing research for many years, its application has not translated into common clinical practice. This review presents and debates the evidence for and against use of US for clinical swallowing assessment. RECENT FINDINGS: Evaluation of swallowing muscle morphometry and measurement of isolated swallowing kinematics are two primary uses of US in swallowing assessment that have been identified in the literature. Use of US to detect bolus flow, aspiration and residues is in its early stages and needs further research. SUMMARY: US shows promise as an adjunctive modality to support assessment of swallowing. With standardisation, these measurements may have potential for transition into clinical care. Reliability and validity testing and development of normative data are imperative to ensure its use as an evidence-based instrumentation.

Voice and Swallowing Outcomes Following Airway Reconstruction in Adults: A Systematic Review.

OBJECTIVES: Laryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery. STUDY DESIGN: Systematic review. METHODS: Six databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria. RESULTS: A total of 143 abstracts were reviewed, with 67 articles selected for full-text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence-Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non-Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability. CONCLUSIONS: The literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 131:146-157, 2021.

Voice and swallowing outcomes for adults undergoing reconstructive surgery for laryngotracheal stenosis.

PURPOSE OF REVIEW: Adult laryngotracheal stenosis is a rare, multifactorial condition which carries a significant physical and psychosocial burden. Surgical approaches have developed in recent years, however, voice and swallowing function can be affected prior to treatment, in the immediate postoperative phase, and as an ongoing consequence of the condition and surgical intervention. In this study we discuss: the nature of the problem; surgical interventions to address airway disorders; optimal patterns of care to maximize voice and swallowing outcomes. RECENT FINDINGS: Studies in this field are limited and focused on surgical outcomes and airway status with voice and swallowing a secondary consideration. Retrospective studies of swallowing have focused on factors such as the duration of dysphagia symptoms following airway surgery and made comparisons between type of surgery, use of stent, and length of swallowing problems. The literature suggests that patients are likely to return to their preoperative diet. There has been a focus on voice outcomes following cricotracheal resection which results in a postoperative decrease in the fundamental frequency. However, study comparisons are limited by the use of inconsistent outcome measures (for both voice and swallowing) which are often not validated, with heterogeneous groups and varying surgical techniques. SUMMARY: The limited literature suggests that swallowing function is more likely to recover to presurgical status than voice function. Further prospective studies incorporating consistent instrumental, clinician, and patient-reported outcome measurement are required to understand the nature and extent of dysphagia and dysphonia resulting from this condition and its treatment.