Compliance, quality of life and quantitative voice quality aspects of hands-free speech.

CONCLUSIONS: With the use of a new automatic stoma valve (ASV) it appears possible to rehabilitate patients who have previously been unsuccessful in acquiring hands-free speech. As well as making daily ASV use possible for an additional group of patients, this new device was also appreciated by many patients as an additional rehabilitation tool for specific occasions. Despite statistically significant improvements in aspects of voice and breathing using this novel ASV, improvement of peristomal adhesion is probably the main factor needed to further increase success rates. Nevertheless, our results show that it makes sense to keep trying to achieve hands-free speech, even if previous attempts have failed. OBJECTIVE: To make a long-term (6 months) assessment of compliance and aspects of voice, breathing and quality of life using a new ASV: the Provox FreeHands heat and moisture exchanger (HME). MATERIAL AND METHODS: This was a prospective clinical multicentre trial in 79 laryngectomized patients (8 regular ASV users, 58 previously unsuccessful users and 13 new users). Data were collected at baseline and after 1 and 6 months by means of European Organization for Research and Treatment of Cancer Quality of Life questionnaires and specific structured questionnaires concerning compliance, skin adhesion, voicing and pulmonary aspects. An objective assessment of voice parameters (maximum phonation time, maximum phonation time while counting, dynamic loudness range and number of pauses in a standard read-aloud text) was made for comparison of different stoma occlusion methods (digital occlusion via an HME and two different ASVs). A subjective assessment of overall voice quality was made. RESULTS: After 6 months, 19% of patients used the new ASV on a daily basis (mean 5 h/day), while 57% used it on an irregular basis as an additional rehabilitation tool for special occasions. Two-thirds of the study group indicated that they would continue to use the new ASV after the study period. With respect to the objective parameters, statistically significantly better maximum phonation times and dynamic loudness ranges were observed with the new ASV compared to the Blom-Singer ASV. However, the best results for all the objective parameters were obtained with digital occlusion via the Provox HME.

Quality of life assessment in laryngectomized individuals: do we need additions to standard questionnaires in specific clinical research projects?

OBJECTIVES: To assess, whether the EORTC questionnaires QLQ-C30 and QLQ-H&N35 give enough detailed information to study specific quality of life (QoL) related issues in laryngectomized individuals. DESIGN: Multicentre, prospective clinical trial; baseline measurement with EORTC questionnaires and an additional questionnaire, focusing on specific postlaryngectomy problems. SETTING: Head and Neck Department of one Comprehensive Cancer Center and three Academic Medical Hospitals in the Netherlands. PARTICIPANTS: Eighty laryngectomized individuals, selected to participate in a prospective clinical trial on hands-free tracheoesophageal speech. MAIN OUTCOMES MEASURES: Comparison of QoL dimensions, as assessed with the standard EORTC questionnaires, with the information obtained with additional questions, aimed at discovering in more detail, e.g. voice and respiratory problems in laryngectomized individuals. RESULTS: Based on the EORTC QoL questionnaires a good overall and voice specific QoL-level was found. However, the additional questionnaire showed that especially concerning voice and respiration more specific information was obtained. For example, despite an overall satisfaction with many aspects of the voice in more than three-quarters of the patients, speaking in a noisy environment was reported by 63% of the patients as being a serious problem, and a significant relation could be established between pulmonary and voicing problems (r = 0.28, P < 0.05), something also undetectable with the EORTC questionnaires. CONCLUSIONS: These findings underline the necessity to develop and use more specific additional questionnaires as an adjunct to the existing EORTC questionnaires, when studying specific symptoms in laryngectomized individuals, especially in order to detect intervention related changes over time.

Quantitative videofluoroscopy: a new evaluation tool for tracheoesophageal voice production.

OBJECTIVE: To develop a quantitative videofluoroscopy protocol using well-defined visual parameters and quantitative measures for the evaluation of anatomical and morphologic characteristics of the neoglottis in relation to perceptual evaluation of tracheoesophageal voice quality. DESIGN: A patient survey. SETTING: The Netherlands Cancer Institute, Amsterdam. PATIENTS: Thirty-nine individuals with laryngectomies, 30 with standard total laryngectomy and 9 with a partial or total pharynx reconstruction. INTERVENTIONS: Videofluoroscopy, speech recordings. MAIN OUTCOME MEASURES: Well-defined visual parameters and quantitative measures based on videofluoroscopy images should improve the evaluation of neoglottic characteristics in relation to voice quality. RESULTS: Quantitative measures were significantly related to visual assessment outcomes. Tonicity (P=.02) and presence of a neoglottic bar during phonation (P=.03) were significantly related to voice quality, as were several quantitative measures, especially the minimal distance between the neoglottic bar and anterior esophageal wall at rest (P<.001) and during phonation (P=.02), and the index for the relative increase of the maximal subneoglottic distance from rest to phonation (P=.01). CONCLUSIONS: This new quantitative videofluoroscopy protocol is a useful tool for the study of the anatomy and morphology of the neoglottis. With this protocol, characteristics relevant to tracheoesophageal voice quality can be defined. The quantitative measures are promising for a more standardized evaluation of the neoglottis in individuals who have undergone laryngectomy.

A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single Institution's experience with consistent application of provox indwelling voice prostheses.

OBJECTIVE: To assess long-term results with consistent use of indwelling voice prostheses (Provox; Atos Medical AB, Hörby, Sweden) for vocal rehabilitation after total laryngectomy. DESIGN: Retrospective clinical analysis. SETTING: Comprehensive national cancer center. PATIENTS: Three hundred eighteen patients (261 men and 57 women; mean age, 62 years) from November 1988, through May 1999. INTERVENTION: Standard wide-field total laryngectomy (287 patients) or total laryngectomy with circumferential pharyngeal resection (31 patients), and 2700 prosthesis replacements. Prostheses remained in situ during 364,339 days (1000 patient-years). MAIN OUTCOME MEASURES: Device lifetime, indications for replacement (device or fistula related), adverse events, and voice quality. RESULTS: Median patient-device follow-up was 67 months. Mean actuarial device lifetime for all indications for replacement was 163 days (median, 89 days). Main indications for replacement were device-related, ie, leakage through the prosthesis (73%) and obstruction (4%), or fistula-related, ie, leakage around the prosthesis (13%), and hypertrophy and/or infection of the fistula (7%). Adverse events occurred in 11% of all replacements in one third of the patients, mostly solvable by a shrinkage period, or adequate sizing and/or antibiotic treatment. Definitive closure of the tracheoesophageal fistula tract occurred in 5% of the patients. Significant clinical factors for increased device lifetime were no radiotherapy (P =.03), and age older than 70 years (P<.02). Success rate with respect to voice quality (ie, fair to excellent rating) was 88%, which was significantly influenced by the extent of surgery (P<.001). CONCLUSION: The consistent use of indwelling voice prostheses shows a high success rate of prosthetic vocal rehabilitation, in terms of the percentage of long-term users (95%), and of a fair-to-excellent voice quality (88% of patients).

Does waiting time for radiotherapy affect local control of T1N0M0 glottic laryngeal carcinoma?

This is a retrospective study of 362 patients with a T1N0M0 glottic laryngeal carcinoma treated by radiotherapy. Waiting time was defined as time from the day of histopathological diagnosis to the first day of radiotherapy. The Cox regression model was used to analyse the influence of waiting time for radiotherapy on the incidence of recurrence. The median follow-up time was 4.4 years. The median waiting time for radiotherapy was 43 days. Local recurrences were found in 58 patients. There was no significant correlation (P= 0.88) between waiting time and the outcome of early glottic cancer as analysed by Cox regression. This retrospective study did not demonstrate an effect of waiting time for radiotherapy on the outcome of early glottic laryngeal cancer.

High-speed digital imaging of neoglottic vibration after total laryngectomy.

OBJECTIVES: To establish the applicability of digital high-speed imaging in studying neoglottic mucosal vibration after total laryngectomy and to perform a structured evaluation of the recordings using a standardized assessment form to gain insight about the anatomical and morphologic characteristics of the neoglottis. DESIGN: Evaluation of a new clinical tool and description of clinical disorders in a patient survey. SETTING: The Netherlands Cancer Institute, Amsterdam. PATIENTS: Forty-six patients who underwent laryngectomy, 36 who underwent standard total laryngectomy and 10 who underwent a partial or total pharynx reconstruction (ie, myocutaneous pectoralis major flap [n = 4], free radial forearm flap [n = 2], tubed gastric pull-up [n = 3], and full gastric pull-up [n = 1]). INTERVENTION: Digital high-speed imaging, using a 90 degrees rigid laryngoscope, of the neoglottic vibration in prosthetic tracheoesophageal speakers after total laryngectomy. MAIN OUTCOME MEASURES: Digital high-speed imaging might overcome some of the problems of stroboscopy in studying irregular voices and could, therefore, be expected to give more insight into the anatomical and morphologic characteristics of the neoglottis. RESULTS: Digital high-speed recordings could be obtained in 44 of 46 patients. Using a structured evaluation form, a wide variability in anatomical and morphologic features could be established. CONCLUSIONS: Digital high-speed imaging appeared to be a useful tool in studying the irregular vibrations of the neoglottis. Evaluation by the structured evaluation form gives a good idea about the wide variability in anatomical and morphologic features of the neoglottis.