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.     

Transient quadriplegia following re-puncture of tracheo-oesophageal fistula

We present a case of a laryngectomized patient who underwent re-puncture of tracheo-oesophageal fistula for speaking valve voice restoration, resulting in a previously unreported inherent complication of this procedure: extradural abscess of the cervical spine with transient quadriplegia.     

Speech therapy after total laryngectomy and esophageal replacement in a preschool patient: A case study

This case study reports the development of a speech and language therapy program for a preschool boy laryngectomized at age two and three-quarters. Etiology was attributed to the accidental ingestion of lye, which caused severe burns and subsequent damage to both the larynx and esophagus. During the 20-month hospital stay, colon transplantation to the pharynx and laryngectomy were performed and a speech therapy program was initiated. The speech pathologist worked closely with the patient by stimulating his speech and language, developing his articulation skills, and finally providing him with a means of using expressive speech via an electrolarynx designed for him. In addition to the case study, this report reviews the different methods of alaryngeal speech, and suggests the need for further research in developing these methods as viable alternatives for the young laryngectomized child.     

Laryngectomy - a treatment on the way out? Voice restoration, quo vadis?]

BACKGROUND: The number of laryngectomized patients in stationary rehabilitation decreases, while the number of laryngectomized - carrying a voice-prosthesis - increases. PATIENTS: From 1980 to 1999 more than 7000 laryngectomized participated in stationary rehabilitation. RESULTS: The number of laryngectomized dropped from an average of more than 400 per year between 1980 and 1989 to less than 300 between 1990 and 1999 to merely 130 in 1999. Until 1992 oesophageal speech dominated over voice-prosthesis with less than 1 %. Since 1994 the number of voice-prosthesis is increasing at about 10 % a year to 60 % in 1998 and 1999. Patients with voice-prosthesis were insufficiently cared for medically and left on their own in matters concerning their voice function. CONCLUSIONS: The decreasing number of laryngectomized is in part caused by economic reasons, and in part by increasingly organ-saving therapeutical procedures. Logopedic therapy for patients with voice-prosthesis results in an earlier and wider range of voice function.     

Cervical necrotizing fasciitis with thoracic extension after total laryngectomy

Cervical necrotizing fasciitis (CNF) with thoracic extension is rare. It has never been reported in laryngectomized patients. A case of fatal CNF in a laryngectomized patient equipped with a voice prosthesis is presented. Diagnosis and treatment are discussed. CNF with thoracic extension was diagnosed on clinical picture, computed tomography (CT) and biopsies were taken just above the tracheostoma. Antibiotic treatment was started and extensive debridement of the affected tissues performed. A minor extension to the left pleura was considered irresectable. Irradical debridement and the impossibility of administering hyperbaric oxygen therapy caused death within two day after presentation. CNF is a rare disease and to our knowledge, has never been reported after total laryngectomy. This case emphasizes the need for early antibiotic treatment and radical surgical resection of the affected tissues.     

Method for the study of pulmonary function in laryngectomized patients

ObjetiveThe aim of the study is to develop a instrumental method capable to achieve pulmonary air function test (spirometry) by assembling the spirometer mouthpiece to the laryngectomized patient´s stoma.Material and methodOur study was carried out in 33 laryngectomized patients (all male). The spirometer tests were done with a Datospir 92 by Sibelmed® equipment, which consists of a dry Fleish pneumotacographer with flow and volume chart register. We have made a stoma-spirometer adapter with a cardboard tube, an adhesive and silicone disc.ResultsThe whole sample achieved excellent outcome with the stomaspirometer adapter. Nor air leak neither high resistence were measured while spirometry was performed.ConclusionsWe consider that the facts studied may enable us to add, pragmatically, new resources to the more effective understanding of the respiratory handicap in the laryngectomized population.     

Gustatory and olfactory dysfunction in laryngectomized patients

After total laryngectomy surgery, nasal airflow is moved permanently to the tracheostomy opening, compromising the contact of odorant molecules with the nasal cavity, which may reflect changes in the olfactory and gustatory perception in these individuals.ObjectiveTo evaluate the functions of smell and taste in total laryngectomized patients. Study design: a study of series.MethodThe sample included a group of 25 patients submitted to total laryngectomy and another group of 25 patients who did not underwent the procedure. The taste function was evaluated by gustatory strips of filter paper. To assess the olfactory function we employed the Brief Smell Identification Test.ResultsAmong the laryngectomized patients there was more hypogeusia (80%, p < 0.05), as well as hyposmia (88%, p < 0.001), alone and concomitant (72%, p < 0.001). Concerning flavor discrimination, the bitter taste did not differ between the groups - which was different from the other flavors. In the olfactory aspect, laryngectomized patients performed worse in detecting warning and food-related odors. We found that a history of smoking and alcohol consumption were significantly more frequent among laryngectomized patients.ConclusionWe found a decrease of gustatory and olfactory functions in total laryngectomized patients in this study.     

Comparison of two face masks used to deliver early ventilation to laryngectomized patients

Emergency airway management of laryngectomized patients is inherently complicated by the altered contours of their necks, by the presence of awkwardly placed tracheostomas, and by stomal strictures. Effective ventilation can also be compromised by the presence of hypertrophic peristomal scar tissue and by tumor recurrence. One common method of airway management involves the use of a pediatric face mask attached to a standard ventilation bag. We conducted a study of 20 laryngectomized patients to determine if they could be adequately ventilated through two commonly used pediatric face masks--the Laerdal mask and the Ambu mask. Ten of these patients had had an end tracheostoma in place for at least 1 year, and the remaining 10 had undergone stoma placement only recently. We found that all 20 patients achieved an adequate peristomal seal when using the Laerdal mask, whereas only 11 adequate seals were achieved with the Ambu mask. Therefore, we recommend that the Laerdal pediatric mask be used for early ventilation in laryngectomized patients.     

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.     

Rhinorrhoe nach Laryngektomie

After laryngectomy, the transport of intranasal secretions is often inadequate due to the lack of the nasal ventilation. Consequently, persistent and disruptive anterior rhinorrhea may occur. We report the case of a 61-year-old man who had recently undergone a laryngectomy and who was successfully treated with bilateral injections of botulinum toxin into the anterior portion of the inferior turbinates. After treatment, rhinorrhea was clearly reduced. Therefore, symptomatic treatment of anterior rhinorrhea with local injections of botulinum toxin type A should be considered as an option to improve the quality of life in laryngectomized patients.     

Tongue strength: Part I: Following total laryngectomy

Surgical repositioning of the genioglossus muscle, as in total laryngectomy, may have an adverse effect on the protrusive strength of the tongue. To test this premise, anterior and lateral tongue strength measures were obtaind from 10 laryngectomized and 15 normal subjects by means of a pressure transducer and recording device. The results indicated no significant difference between laryngectomized and normal subjects on tongue strength measures. Further, all laryngectomized subjects were judged to have good to excellent esophageal speech. It was concluded that laryngectomy does not adversely affect the major musculature concerned with protrusive tongue strength for proficient esophageal speakers.     

Exceptionally elevated creatine kinase levels in a laryngectomized patient: hypothyroid myopathy

We present a laryngectomized patient with unspecific complaints of fatigue whose laboratory findings were out of proportion with the clinical presentation. The enormously high blood levels of creatine kinase (CPK) (8000 IU/l, normal range 30-190 IU/l) and thyroid-stimulating hormone (100 mU/l, normal range 0.5-4.5 mU/l) led to diagnosis and treatment of and recovery from hypothyroid myopathy. Hypothyroidism reduces the ability of the muscle to maintain its adequate energetic economy, via several suggested mechanisms. This may lead to injury (myopathy) that allows enzymes such as CPK to leak out of cells and causes elevation of their serum levels. To our knowledge, this is the first reported case of a patient previously treated for head and neck cancer who developed hypothyroid myopathy, presenting with exceptionally elevated CPK levels. This is noteworthy, since hypothyroidism may be easily avoided by a comprehensive follow-up of patients treated for head and neck cancer.     

Tongue strength: Part II: In artificial alaryngeal speech

Tongue strength does not appear to be reduced in proficient esophageal speakers. However, no data exist on tongue strength for laryngectomized subjects who have not developed esophageal speech. Anterior and lateral tongue strength measures were obtained from 13 laryngectomized subjects who used an artificial larynx and 15 normal subjects by means of a pressure transducer and recording device. The results indicated that laryngectomized subjects had significantly weaker tongues in two of three directions measured. It was concluded that laryngectomy may affect tongue strength, but that the method of alaryngeal speech utilized postoperatively influences the return to normal.     

Comparative intensity-pressure study of patients with a voice prosthesis

We have studied the qualities of the voice of the laryngectomized patients and theirs possibilities to modify the intensity depending to the pressure. During the measurement, it was necessary to explain to the patient how to use the material and it was an opportunity to help him in the way to product a voice prosthesis. Most of the patients produced a higher intensity with a higher pressure. However, some of them obtained high pressures without producing a voice. These patients modified the use of the prosthesis or could have an oedema for example. In conclusion, these measurements show that there is a relation between intensity and pressure but not absolutely in relation with a better voice quality.     

The effect of a Heat and Moisture Exchanger (Provox® HME) on pulmonary protection after total laryngectomy: a randomized controlled study

The goal of this randomized controlled study was to investigate the effect of Heat and Moisture Exchanger use on pulmonary symptoms and quality of life aspects in laryngectomized patients. Eighty laryngectomized patients were included and randomized into an HME and Control group. The effect of the HME was evaluated by means of Tally Sheets and Structured Questionnaires. The results showed a significant decrease in the frequency of coughing, forced expectoration, and stoma cleaning in the HME group. There were trends for the prosthetic speakers to report more fluent speech with the HME and for the HME group to report fewer sleeping problems. In conclusion, this study, performed in Poland, confirms the results of previous studies performed in other countries, showing that pulmonary symptoms decrease significantly with HME use and that related aspects such as speech and sleeping tend to improve, regardless of country or climate.     

Comunicación de necesidades en el paciente laringectomizado: Pictorrino©

ObjectiveTo design, create and validate a pictogram, called Pictorrino^©, as a tool to obtain direct and simple communication with laryngectomized patients.Patients and methodsIn a prospective sample of 10 laryngectomized patients within the first postoperative week, their principal needs and demands were evaluated, and were confirmed in a retrospective second sample of 10 laryngectomized patients who attended reviews in the outpatient clinic. Thereafter, pictograms were created to state such needs in as clear a fashion as possible.ResultsA pictogram was designed and validated, named and registered as Pictorrino^©, consisting of a board, which showed these pictograms on one of its sides, and a visual analogue scale of pain, with the aim of enabling the patient to express the demand or need at every moment.ConclusionsWith Pictorrino^© we have achieved a multicultural tool that allows a more direct communication with laryngectomized patients.     

Microbial colonization of silicone voice prostheses used in laryngectomized patients.

The aim of this study was to identify the microbial colonization of dysfunctioning voice prostheses in laryngectomized patients and determine the influence of patient radiation therapy on prosthesis life span. In a 40-month period, 257 outpatient voice prosthesis replacements were carried out in a laryngectomized group of 31 patients. The voice prostheses were all removed from the tracheo-oesophageal fistula after dysfunctioning of the prosthesis. Of the replaced prostheses 183 were cultured. The microbial cultures showed a predominant colonization with Candida albicans and commensal oral microflora. Radiation therapy induced xerostomia shortened the lifetime of the first inserted prosthesis in particular.     

Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap

IntroductionThe pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results.MethodsWe retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients.ResultsThere were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed.ConclusionsThe pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence.     

Measurement of blood flow to human nasal mucosa in normal and pathological conditions by the use of the 133Xe clearance technique

Summary The blood flow to nasal mucosa in normal subjects and in allergic rhinitis, vasomotor rhinitis and laryngectomized patients was measured using the ¹³³Xe clearance technique. The results were statistically compared and correlated with capillary diameter. Compared to the normal group, the blood flow to nasal mucosa increased in allergic and vasomotor rhinitis patients and decreased in laryngectomized patients. There was a statistically significant difference between allergic and vasomotor groups (p < 0.01), so the present method could be used in the differential diagnosis of rhinitis.     

Histologic findings in a larynx reconstructed by a nasoseptal autograft after partial laryngectomy

In the course of a 5-year follow-up of 16 patients who underwent plastic reconstruction of the larynx by a nasoseptal graft after extended frontal and frontolateral laryngectomies, one of them developed local recurrence of squamous cell carcinoma and was totally laryngectomized. Histological studies were made of the grafted cartilage and its mucosal lining. The microscopic findings are reported.