Tracheo-innominate artery fistula: a rare complication in a laryngectomized patient

A tracheo-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Rarely, it can also occur in laryngectomized patients. We report a post-laryngectomy, post-radiotherapy patient using a metal tracheostomy tube, who developed a tracheo-innominate artery fistula about two months after radiotherapy. To our knowledge this is only the second reported case in a laryngectomized patient. The computed tomography (CT) angiography findings helped confirm the diagnosis and the patient was successfully managed by surgical exploration and ligation of the innominate artery. Coagulase negative Staphylococcus aureus was cultured from a tracheal swab. The clinical features, CT angiography findings, management protocols and possible aetiological factors are discussed.     

Inhalation of a safety pin by a laryngectomized patient: a case report

Otolaryngologists are well aware of the potentially devastating consequences of inhaling a sharp foreign body. We report here a case of a laryngectomized patient who accidentally inhaled a safety pin through his tracheal stoma under highly unusual circumstances. This proved to be a life-threatening situation which resolved only after a complicated hospital admission culminating in a thoracotomy. We use this case to suggest guidelines that otolaryngologists may wish to discuss with their laryngectomized patients with regard to stomal care.     

Aspirated foreign body in a laryngectomized patient: case report and literature review

The presence of a permanent tracheal stoma in a laryngectomized adult is a predisposing factor for foreign-body aspiration, as are conditions that impair normal protective airway mechanisms. Such an aspiration can cause significant morbidity if it is not properly managed. The use of rigid bronchoscopy to remove an aspirated object can be difficult in these patients, and a high percentage of them require thoracotomy, especially for the removal of sharp objects. An emphasis on patient education regarding the handling of objects around the stoma in laryngectomized adults is key to preventing aspiration and its complications.     

Ipratropium bromide nasal spray for treatment of rhinorrhea in the laryngectomized patient: a pilot study.

Many who have had a total laryngectomy complain of unrelenting rhinorrhea that is often very difficult to control. This study was undertaken to evaluate the effect of ipratropium bromide (IB), an anticholinergic nasal spray, on rhinorrhea in these patients. This was designed as a prospective, randomized, double-blind, placebo-controlled, crossover pilot study. Participants were selected if they had a total laryngectomy and complained of rhinorrhea. They were asked to rate the severity and duration of their rhinorrhea each day throughout the study on a scale from zero to six. Each participant was initially given a saline nasal spray for one week. They were then randomized to use either IB or saline for the double-blinded portion of the study. Two sprays of IB at a dose of 42 micrograms/spray (0.06%), or saline, were administered intranasally twice daily for two weeks, after which time the participants were given another nasal spray (either IB or saline) for the crossover portion of the study. Six patients entered and completed the study. Those patients using the IB recorded a mean 55% decline in severity and a mean 51% decline in duration of the rhinorrhea as compared to placebo. The relief in both severity and duration of rhinorrhea obtained by patients was analyzed using the Wilcoxon signed-rank test and found to be highly significant (p < 0.001). Despite the limitations of a small sample size in this study, ipratropium bromide nasal spray significantly reduced both the severity and duration of rhinorrhea in laryngectomized patients. We suggest ipratropium nasal spray as a safe, effective way to treat chronic rhinorrhea in laryngectomized patients, improving their quality of life.     

The Blom-Singer tracheostoma valve as a valuable addition in the rehabilitation of the laryngectomized patient

Prosthesis-assisted tracheo-esophageal speech has proven its value in post-laryngectomy voice rehabilitation, although manual occlusion of the tracheostoma during speech is necessary. In contrast a tracheostoma valve enables hands-free speech. We have now had experience with 30 patients using the Blom-Singer tracheostoma valve for more than 6 months and have found that most patients prefer prosthesis-assisted speech with the tracheostoma valve. Measurement of several speech parameters with digital and valve occlusion of the tracheostoma did not show any significant differences between the two speaking conditions. Problems included maintenance of an airtight seal, outward forcing of the valve diaphragm during forced expiration and subjective increased airflow resistance.Adapted from a presentation at the 5th International Congress on Surgical and Prosthetic Voice Restoration after Total Laryngectomy. Grado, Italy, 11 September 1993     

Auditory neuropathy in a patient with mitochondrial myopathy and multiple mtDNA deletions

Auditory neuropathy (AN) is a hearing disorder characterized by the absence or severe distortion of the auditory brainstem responses, in the presence of preserved otoacoustic emissions. This peculiar combination suggests the presence of a defect impinging upon the functional complex formed by inner hair cells, the primary afferents (spiral ganglion neurones) and the first order synapses between hair cells and the cochlear nerve. Typically, AN patients show a severe speech perception impairment, which appears reduced out of proportion to pure tone threshold, but the clinical presentation of AN is quite complex. Hearing loss is a common symptom associated with mitochondrial diseases; however, AN has only rarely been reported in these disorders. Here we report a rare association, the first case observed in Italy, in a patient with autosomal recessive mitochondrial myopathy and mitochondrial DNA multiple deletions, and a hearing deficit with the audiological and electrophysiological features of AN.     

How we did it: neopharyngeal stricture management with the nitinol stent in the laryngectomized patient: our disappointing results

? Serial dilatation, the mainstay of benign ‘neopharyngeal’ stricture management, can have inconsistent results. ? Nitinol stents, as a metallic self‐expanding coil, may have a role in such patients. ? Such stents were inserted in four patients but two had to be removed because of intractable pain. ? It is concluded that nitinol stents are unlikely to have a significant role in the management of neopharyngeal stricture management.     

Jejunal grafts for reconstructing a phonatory neoglottis in laryngectomized patients

Summary After laryngopharyngectomy and reconstruction of the upper digestive tract, a free jejunal graft can be anastomosed in an isoperistaltic direction end-to-end to the trachea and the hypopharynx in order to form a shunt for vocal rehabilitation. Following placement of the shunt, no special care is required nor does any patient show any aspiration. Because of a low-flow resistance of the shunt, patients so treated possess long-lasting phonation with loud and modulated voices.     

Jejunal grafts for reconstructing a phonatory neoglottis in laryngectomized patients

After laryngopharyngectomy and reconstruction of the upper digestive tract, a free jejunal graft can be anastomosed in an isoperistaltic direction end-to-end to the trachea and the hypopharynx in order to form a shunt for vocal rehabilitation. Following placement of the shunt, no special care is required nor does any patient show any aspiration. Because of a low-flow resistance of the shunt, patients so treated possess long-lasting phonation with loud and modulated voices.     

Microbial colonization of Blom-Singer indwelling voice prostheses in laryngectomized patients: a perspective from India

We analyzed a series of adults with an implanted voice prosthesis that had malfunctioned and required removal as a result of the attachment and growth of microorganisms. Our goal was to determine the characteristics of these colonizing microbes. We swabbed the esophageal side of each prosthesis to obtain microbial flora for analysis with standard culture media. In all, we studied 22 prostheses in 18 patients (3 patients had received multiple prostheses). We found mixed contamination (both yeast and bacteria) in 19 of the 22 cultures (86.4%); the other 3 cultures yielded bacteria only, and there was no instance of yeast only. The most common yeast isolated was Candida albicans (68.2% of cultures), and the most common bacterium was Pseudomonas aeruginosa (63.6%). The average lifetime of the prostheses was 201 days (～6 mo, 3 wk). This study, which was the first of its kind in India, revealed that the microbial picture here was different from that found in previously reported studies of European populations. We presume the differences are attributable to different lifestyles and dietary habits.     

Heat and moisture exchangers as a treatment option in the post-operative rehabilitation of laryngectomized patients

A multi-institutional, prospective clinical study was undertaken to investigate whether the use of a heat and moisture exchanger (HME) in the period following total laryngectomy could prevent the development or reduce the severity of respiratory symptoms. Fifty-nine patients from three hospitals were provided with HMEs, either immediately post-surgery or, in the case of post-surgical radiotherapy, upon completion of the radiotherapy. For the total sample (n= 59) statistically significant improvements over time (between 3 and 6 months) could be found in forced expectoration (P < 0.05), in the perceived voice quality (P < 0.001), social anxiety (P < 0.001), social interactions (P < 0.001) and in feelings of anxiety and depression (P < 0.05). Repeated measures analysis of variance indicated statistically significant group differences over time in forced expectoration and stoma cleaning (P < 0.05). No statistically significant differences over time were noted between the regular and non(regular) HME user groups in voice quality or in various aspects of daily living.     

Clinical significance of elevated osteopontin levels in head and neck cancer patients

OBJECTIVES: Osteopontin (OPN) is associated with several human malignancies, but the role of OPN in head and neck cancer (HNC) remains unclear. We investigated the clinicopathologic relevance of serum OPN levels in HNC patients. METHODS: Serum OPN levels in HNC patients were determined by quantitative sandwich enzyme immunoassay (EIA). OPN levels and their correlation with clinical features were examined. In addition, serum squamous cell carcinoma (SCC) antigen was examined simultaneously. RESULTS: The mean OPN level was significantly higher in HNC patients (99.5 ng/ml) than in control subjects (55.3 ng/ml). OPN levels were significantly higher in patients with advanced stage HNC than in patients with early stage HNC. OPN levels did not correlate with SCC antigen levels. CONCLUSIONS: OPN may play a role in the pathogenesis of head and neck cancer (HNC), and serum OPN may be a potential biomarker of HNC.     

Incidence of severe tracheobronchitis and pneumonia in laryngectomized patients: a retrospective clinical study and a European-wide survey among head and neck surgeons

Laryngectomized patients, lacking conditioning of the breathing air in the upper respiratory tract, have reported considerable pulmonary complaints. It is assumed that these patients also run a higher risk of developing severe respiratory infections. Unfortunately, there is little scientific information available about the occurrence of respiratory infections and related health costs in these patients with and without the use of an HME. Therefore, the occurrence of respiratory infections in laryngectomized patients was investigated in the Netherlands Cancer Institute and by means of a survey among head and neck oncology surgeons throughout Europe. The number of tracheobronchitis and/or pneumonia events was retrospectively scored between 1973 and 2013 in medical records of 89 laryngectomized patients treated in our institute. To assess expert experiences and opinions regarding these pulmonary problems, a study-specific survey was developed. The survey was sent by email to head and neck surgeons from ten different countries. In the medical record study, an average of 0.129 respiratory infections per patient/year was found in non-HME users and 0.092 in HME users. In the survey (response rate HN surgeons 20 %; countries 90 %) 0.285 episodes per patient/year in non-HME users was statistically higher than the 0.066 episodes per patient/year in HME users. The average mortality in the HME user group per entire career of each physician was estimated at 0.0045, and for the non-HME user group this was 0.0152. There is a tendency that the number of tracheobronchitis and pneumonia episodes in non-HME users is higher than in HME users.     

The use of a prosthetic speech aid for a laryngectomized esophageal speaker with right hemiparesis of the tongue: a case report.

A dental-palatal prosthetic device, which had been demonstrated to aid laryngectomees who use the glossal press method of esophageal speech, was used on a patient whose primary method of air charging was bilabial plosive injection and who had a right hemiparesis of the tongue. Cointervention of a prosthodontist and a speech pathologist is described.