Long-term results of olfaction rehabilitation using the nasal airflow-inducing ("polite yawning") maneuver after total laryngectomy

OBJECTIVES: To study the long-term results of the nasal airflow-inducing maneuver (NAIM) as an olfaction rehabilitation tool after laryngectomy and to investigate the effectiveness of a new, simpler odor detection test (ODT) called the smell disk test (SDT), or Zürcher Geruchstest. DESIGN: Intervention study. SETTINGS: National cancer center. PATIENTS: Forty-one laryngectomees who received olfaction rehabilitation training with the NAIM 4 months to 2 years earlier. This so-called polite yawning maneuver creates an "underpressure" in the oral cavity, which, in turn, generates a nasal airflow that enables odor molecules to again reach the olfactory epithelium. MAIN OUTCOME MEASURES: Olfaction acuity testing with a standard ODT, along with a questionnaire, providing a subjective olfaction score (present odor perception scale [POPS]), and the SDT, as well as assessment of the patients' correct execution of the NAIM by speech-language pathologists on video recordings made during odor testing and long-term assessment of olfaction acuity. RESULTS: The correlation between the previously used ODT-POPS combination and the SDT was kappa = 0.56 (P<.001). Based on these results, we preferred to use the much simpler SDT instead of the laborious combination of the ODT-POPS. Based on the SDT results, 19 (46%) of the 41 laryngectomees were "smellers" and could be considered normosmic. There was a significant relationship (P =.03) between the patient's correct execution of the NAIM and whether or not the laryngectomee was a smeller according to the SDT. CONCLUSIONS: The effectiveness of the NAIM, or so-called polite yawning technique, for the rehabilitation of olfaction in individuals who have undergone total laryngectomy was reconfirmed. Long-term olfaction rehabilitation was achieved in about 50% of the patients, but more intensified training may be needed to increase the percentage of successfully rehabilitated individuals. The SDT is an effective and simple test for the assessment of olfaction acuity after laryngectomy.     

Effectiveness of olfactory rehabilitation with the nasal airflow-inducing maneuver after total laryngectomy: one-year follow-up study

OBJECTIVE: To assess the long-term results of the nasal airflow-inducing maneuver in olfaction rehabilitation in patients who had undergone laryngectomy. DESIGN: Prospective interventional study. SETTING: University hospital. PATIENTS: Twenty-four patients who had undergone laryngectomy (21 men and 3 women; mean age, 68 years) who received olfactory rehabilitation with the nasal airflow-inducing maneuver were reevaluated 6 and 12 months after primary treatment. MAIN OUTCOME MEASURE: Olfactory function was tested by means of a semistructured interview; the Questionnaire on Olfaction, Taste and Appetite; and the Scandinavian Odor-Identification Test. Quality of life was measured with the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-H&N35 questionnaires. Patients were categorized as smellers or nonsmellers based on results of the Scandinavian Odor-Identification Test. RESULTS: Before treatment, 10 of 24 patients (42%) were smellers and 14 (58%) were nonsmellers. At 6-month follow-up, 20 of 23 patients (87%) were smellers, whereas after 12 months, 21 of 24 patients (88%) were smellers. Long-term olfaction rehabilitation was achieved in 11 of 14 patients (79%) with anosmia, and 15 of all 24 patients (63%) could be classified as having normal olfactory capacity at the end of the study. CONCLUSION: The nasal airflow-inducing maneuver is a patient-friendly, inexpensive, and effective method for restoring the sense of smell in patients after laryngectomy, and the results persist in the long term.     

Alterations in nasal physiology after laryngectomy: the nasal cycle

Several changes in nasal physiology have been reported following laryngectomy. This paper reviews these changes and investigates the cycle of alternating distribution of nasal airflow in 20 adults. Information about the cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15-minute intervals during a 6-8 hour period. Five control subjects demonstrated a nasal cyclic activity which was absent in five patients 1-3 years post-laryngectomy. Two patients with preoperative cycles showed none three weeks after laryngectomy. Three patients with a temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. Five patients showed no alteration after operation involving no diversion of supraglottic airflow (tonsillectomy). These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary, cessation during acute absence, and independence of the cycle from superior laryngeal innervation.     

Extended fronto-lateral laryngectomy with simultaneous reconstruction by means of a mucochondral nasal septum flap

As treatment for laryngeal cancers the extended fronto-lateral laryngectomy allows tumor to be removed that involves the glottis with the vestibule of the larynx. Since 1979 we have performed 417 extended fronto-lateral laryngectomies with simultaneous reconstruction of the anterior part of the larynx using a mucoperichondral flap from the anterior septum. This operation was indicated for stage T1b cancer (175 cases), stage T2 tumor (231 tumors) and T3 extended operations with epiglottectomy (11 cases). For the total number of 417 patients operated on, 19 cases during the 5-year period of following had local recurrences that required total laryngectomy. In 11 cases, metastases to the cervical lymph nodes required surgical neck dissection. In the remaining 387 cases, a normal air passage and a large laryngeal lumen were found. In 15 cases graft rotation into the larynx made respiration and phonation difficult but without dyspnea occurring. Follow-up to a maximum of 18 years showed that the oncological and functional results after this surgical procedures are encouraging. Received: 26 September 1998 / Accepted: 12 March 1999     

Effectiveness of olfactory rehabilitation according to a structured protocol with potential of regaining pre-operative levels in laryngectomy patients using nasal airflow-inducing manoeuvre

This pilot study aims to evaluate the effectiveness of the Nasal Airflow-Inducing Manoeuvre (NAIM) when employing a structured protocol as well as investigate if early rehabilitation has the potential to return olfaction to pre-operative levels in patients undergoing laryngectomy following laryngeal cancer. Prospective study of cases conducted during 1 year, 2009–2010, at the Department of Ear-, Nose and Throat at Sahlgrenska University Hospital, Gothenburg, Sweden. Ten patients with laryngeal cancer and about to undergo laryngectomy were identified, of which four were included in the study. The remaining six patients were unfit to participate (n = 4) or declined participation (n = 2). Testing was conducted pre- and post-operatively and at each NAIM training session. Patients received three initial NAIM sessions followed by reinforcement training at 3, 6 and 12 months. Measures included Scandinavian Odour-Identification Test (SOIT), a semi-structured interview and questionnaires including European Organisation for Research and Treatment of Cancer, QLQ-C30 and QLQ-H&N35. All patients were normosmic smellers according to SOIT at the study end-point. One patient reported higher SOIT scores at 12 months follow-up compared to pre-operatively. Remaining patients had scores close to that reported pre-operatively. Using subjective measures, olfaction improved in all patients with one patient’s final score surpassing pre-operative scores. By implementing a structured protocol consisting of three training sessions early following laryngectomy with additional reinforcement sessions at 3, 6 and 12 months, NAIM is effective in terms of improving smelling ability. There also appears to be potential for restoring olfaction to a patient’s pre-operative level as reflected by both olfactory testing and PRO instruments. However, larger studies are needed to further explore the findings highlighted by this study.     

全喉切除术后鼻腔长期形态观察

目的:研究全喉切除术后长期气流缺失对鼻腔形态的影响.方法:应用A1鼻声反射仪,测量32例全喉切除术后患者的鼻腔最小截面积(MCSA)、鼻腔容积,并与正常对照组进行比较.用鼻内镜观察鼻腔形态变化,问卷调查评估患者的主观症状,对不同症状程度之间鼻声反射结果进行比较.结果:术后1年以内组、术后1年以上组鼻腔MCSA、鼻腔容积较正常对照组均显著扩大(P<0.05),术后1年以上组与术后1年以内组相比鼻腔MCSA、鼻腔容积均差异无统计学意义(P>0.05).鼻内镜检查示鼻腔各结构呈萎缩性改变.问卷调查显示,患者术后均有不同程度的鼻阻塞感、鼻干、嗅觉减退等.中度鼻阻塞感时鼻腔MCSA、鼻腔容积最大,重度鼻干或重度嗅觉减退时鼻腔MCSA、鼻腔容积也最大.结论:全喉切除术后,鼻腔各结构出现萎缩性改变,鼻腔MCSA、鼻腔容积均变大,症状不同程度之间鼻声反射结果不同.     

Rehabilitation of the olfactory sense after laryngectomy -- the larynx bypass

BACKGROUND: Patients after laryngectomy lose their previous sense of smell, since air normally circulates via the tracheostoma and active air intake through the nose is no longer possible. The larynx bypass with a throat mask is an aid here. Nasal air circulation is made possible by this connecting piece between the mouth and tracheostoma. MATERIALS AND METHODS: Twenty patients (17 men and 3 women, mean age 60 years) who underwent laryngectomy between November 2003 and February 2004 were examined using Sniffin' Sticks with and without the larynx bypass. Moreover, patients were asked about the practicability of the larynx bypass using a visual analog scale (VAS). In addition to larynx bypass function, we were also interested in the handling for the laryngectomized patients. RESULTS: Overall, patients were able to correctly identify more items with the larynx bypass. The results were significantly better with than without the larynx bypass (p < 0.001). However, the first application of the larynx bypass was considered cumbersome. The median VAS was 5. CONCLUSION: Patients had a better sense of smell with the larynx bypass. However, due to its rather moderate practicability, the larynx bypass does not seem to be suited for daily use in its present form.     

Rehabilitation of the olfactory sense after laryngectomy: long-term use of the larynx bypass

Patients who undergo laryngectomy typically lose their sense of smell. One device that has been used to rehabilitate olfactory function in these patients is the larynx bypass. We conducted a long-term study of the larynx bypass in 16 laryngectomized patients. After undergoing objective and subjective baseline evaluations, patients were asked to use the device at home for at least 30 minutes each day for 3 months. They were also asked to record in a diary subjective ratings of their sense of smell and the practicability of using the device every day. At study's end, patients experienced a statistically significant improvement (p < 0.001) in olfactory function on objective measurement (Sniffin' Sticks testing). Subjective improvement was seen after 1 week (p < 0.001) and maintained throughout the study. Practicability scores improved statistically (p = 0.003), but the device remained difficult to use. The long-term use of the larynx bypass has not been studied previously, and we hope that our findings will serve as a basis for further investigation.     

The human nasal mucosa after deprivation of airflow: a study of laryngectomy patients.

The effects on the human nasal mucosa of airflow cessation can be studied conveniently in the laryngectomy patient. We studied 39 laryngectomy patients and 50 healthy adults. Mucociliary clearance was measured using the saccharin test, ciliary beat frequency (CBF) analyzed in inferior meatal brushings and transmission electron microscopical observations made in similar nasal brushings. Mucociliary clearance was no faster in laryngectomees (mean 15.4 +/- 7.8 min); however, CBF was higher in the laryngectomees (means 15.0 and 14.1 Hz; p less than 0.05), especially in the first weeks after surgery (mean 16.8 Hz; p less than 0.01). Mucus-producing cells gradually decreased in proportion over the first postoperative year. The changes in the nasal mucosa after airflow cessation are dynamic and require months to equilibrate. This has implications for the timing of postoperative assessment of patients undergoing airway surgery.     

Long-term results with a simple technique of stoma creation after laryngectomy

Stomal stenosis after laryngectomy has a major impact on patient rehabilitation. The major contributory factor is the operative technique. The goal is to achieve a widely patent stoma. The objective of the study was to review the long-term results of the technique of stoma creation used by the senior author (CJW). The simple technique, using skin triangles for tracheostoma creation after laryngectomy, has been used by the senior author for past 6 years. Review of 59 cases of total laryngectomy with or without partial pharyngectomies in whom this technique was used for stomaplasty. The technique described for stoma creation after total laryngectomy has been used in 59 patients (48 male, 11 female) over 6 years. The follow-up of these patients varies from 6 months to 6 years. Of these patients 54/59 (91.5%) did not have any problems with the stoma. A total of 5/59 (8.5%) patients, the stoma was narrow. Amongst these patients with narrow stoma, only 1 patient (1.7%) has had dilatation done and the others are managing reasonably with a stoma button. None of the patients in this study has required revision procedures on the stoma. The simple technique of stoma creation described in this study has good long-term results.     

Prevention of pharyngoesophageal spasm after laryngectomy with a half-muscle closure technique

Because pharyngoesophageal spasm can limit successful voice restoration after total laryngectomy, 24 patients underwent a modified pharyngeal closure in an effort to avoid this problem. All patients underwent total laryngectomy with appropriate neck dissections and pharyngeal closure with a half-muscle closure technique in which only one side of the remnant constrictor muscles was used to reinforce the primary closure. Twenty-three patients underwent voice restoration. Twenty-two (96%) had a functional voice, and 1 patient (4%) had pharyngoesophageal spasm that required a secondary myotomy. One fistula (4%) occurred and resolved with conservative measures. Quantitative voice analysis demonstrated no significant differences between half-closure patients and control patients for fundamental frequency (96 Hz versus 101 Hz) or intensity (57 dB versus 64 dB). Extensive qualitative analysis by trained and naive listeners revealed no differences. This preliminary report indicates the half-muscle closure modification of the pharyngeal closure at primary laryngectomy may provide a simple and effective means of avoiding pharyngoesophageal spasm and maintaining an effective voice without increased complications.     

"The neocricoid": A new surgical technique to prevent and treat tracheostomal stenosis after total infracricoid laryngectomy

The goal is to present a new surgical technique that may solve and prevent tracheostomal stenosis after total infracricoid laryngectomy. The concepts on which the technique is based are explained and the technique as performed is described. The complete success achieved in three clinical cases treated with this technique is also presented.     

Mental health after laryngectomy and partial laryngectomy: a comparative study

Patients treated for laryngeal cancer are confronted daily with the effects of the operation. The choice of treatment method can have a significant impact on psychosocial adjustment. Three hundred and six out-patients who underwent surgical treatment for laryngeal cancer within the last two decades were interviewed in their own homes using the structured clinical interview for DSM-IV (SCID). Psychiatric disorders were diagnosed among 17.3% of the partial laryngectomy patients (PL) and 22.2% of the patients with total laryngectomy (LE). In comparing four variables (age, time elapsed since diagnosis, gender and subjective speech intelligibility), subjective speech intelligibility and age were the variables with a unique, significant effect on the frequency of psychiatric disorders, albeit only in the case of PL patients. The need for psychosocial rehabilitation for patients with partial laryngectomy tends to be underestimated. It is concluded that screening for psychological variables and subjective speech intelligibility can be beneficial for the identification of out-patients lacking appropriate treatment.     

Psychosocial adjustment after laryngectomy: a review of the literature

This paper reviews the literature on the psychosocial outcomes of a laryngectomy. The largest group of studies focuses on factors which contribute to esophageal speech acquisition, one important measure of rehabilitation outcome. Recently, the technique of tracheoesophageal puncture (TEP) has implicated new directions for studying post-surgical speech recovery. Other studies have defined post-surgical adjustment in terms of quality of life or psychological state. Taken together, the research suggests that long-term adjustment for the laryngectomee is shaped by multiple variables, which include: (a) extent of surgery; (b) preoperative visits by a fellow laryngectomee; (c) illness variables; (d) changes in lifestyle following surgery; (e) patient satisfaction with social support; (f) chronic pain, and (g) ability to communicate. We conclude that psychosocial variables contribute substantially to successful post-surgical adjustment.     

Screening and rehabilitation of olfaction after total laryngectomy in Swedish patients: results from an intervention study using the Nasal Airflow-Inducing Maneuver

OBJECTIVES: To examine the olfactory function in patients with laryngectomy and to assess the results of the Nasal Airflow-Inducing Maneuver (NAIM) odor-rehabilitation technique. DESIGN: A prospective intervention study. SETTING: University hospital. PATIENTS: Twenty-four patients, 21 men and 3 women, mean age 68 years, who underwent laryngectomy at least 5 months prior to intervention. INTERVENTION: Speech therapists trained patients in the NAIM technique: simultaneous lowering of the jaw, floor of the mouth, tongue, base of the tongue, and soft palate while the lips are closed. Three interventions were given within 6 weeks. MAIN OUTCOME MEASURE: Olfactory testing with semistructured interview, the Questionnaire on Olfaction, Taste, and Appetite (QOTA), and the Scandinavian Odor-Identification Test (SOIT). Quality of life was measured with European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-H&N35 questionnaires. The patients were categorized as smellers or nonsmellers based on the SOIT results. RESULTS: Before the treatment, 10 patients (42%) were smellers (ie, 6 had normosmia and 4 hyposmia), while 14 patients (58%) were nonsmellers (ie, all had anosmia). Thus, 18 patients had impaired olfaction. Using the NAIM technique, 13 (72%) of 18 patients with impaired olfaction showed improvement. Of the 14 nonsmellers, 7 converted to smellers after only 1 intervention session, giving us a success rate of 50% in anosmic patients after 1 session. CONCLUSIONS: Olfactory impairment is common in patients who underwent laryngectomy. The NAIM method is easy to learn and rapidly improves smell and taste. A single intervention session is sometimes sufficient, but many patients benefit from repeated training. The SOIT test is an effective and simple test for the assessment of olfaction acuity after laryngectomy.     

Rehabilitation of a voice function by means of prosthetic repair of voice after removal of the larynx for cancer

The paper presents treatment results in 223 patients who have undergone tracheoesophageal anastomosis with prosthetic repair of voice (PRV) after laryngectomy for cancer. PRV was made both simultaneously with laryngectomy (n=126) and after it (n=97). The procedure, complications and their prevention are described. The authors support the idea of the "gold standard"--voice repair for each laryngectomized patient. Tracheoesophageal anastomosis opens great prospects: loud intelligible speech recovered in 91.9% patients.