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.

Rehabilitation of olfaction after laryngectomy by means of a nasal airflow-inducing maneuver: the "polite yawning" technique.

OBJECTIVE: To develop a nasal airflow-inducing maneuver and apply it in the olfactory rehabilitation of patients who have undergone laryngectomy. DESIGN: Intervention study; before-and-after trial. SETTING: National cancer center. PATIENTS: Forty-four patients who underwent laryngectomy; 34 men and 10 women; mean age, 64 years (range, 42-80 years); mean time since surgery, 6 years (range, 8 months to 18 years). INTERVENTION: In a prospective clinical intervention study, we assessed the effectiveness of a nasal airflow-inducing maneuver ("polite yawning," ie, yawning with closed lips). Speech therapists trained the patients in the maneuver, and its effectiveness in inducing nasal airflow was checked with digital and water manometers. MAIN OUTCOME MEASURES: Olfactory acuity was assessed before and after the intervention by means of an odor detection test and a structured questionnaire concerning olfaction, taste, and appetite. Patients were categorized as "smellers" and "nonsmellers" on the basis of the results of the odor detection test and the present odor perception scale derived from the questionnaire. RESULTS: The nasal airflow-inducing maneuver could be taught to all patients, mostly in only one 30-minute therapy session. Fifteen of the 33 patients in the pretreatment nonsmeller category converted to smellers, for a success rate of 46% (P<.001). CONCLUSION: The nasal airflow-inducing maneuver (the "polite yawning" technique) allowed almost half of the patients to recover their sense of smell.

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.

Deterioration of olfaction and gustation as a consequence of total laryngectomy.

INTRODUCTION: After total laryngectomy the absence of a nasal airflow results in a decrease in olfaction and perception of flavors. MATERIALS AND METHODS: Odor perception was assessed in 63 laryngectomized patients with two different olfactory tests. The methods used by patients to smell were observed during olfactory testing. Patients' judgment about their olfaction and gustation was assessed by means of a structured questionnaire, semistructured interview, and self-rating. RESULTS: Based on the results of the olfactory tests, patients were categorized as "smellers" and "nonsmellers." Approximately one third of the patients were able to smell the odorous substances used in the olfactory tests. The smellers more often used a variety of methods to smell than the nonsmellers (P < .002); in most patients the method consisted of active use of facial muscles. Patients appeared well able to judge their own odor perception. Compared with the smellers, the nonsmellers judged their odor perception as worse (P < .003) and reported a more severe decrease in gustation after the operation (P < .033). The results of this study in laryngectomized patients confirm the interrelation between olfaction and gustation: the nonsmellers reported a poorer gustation and a more severe decrease in gustation and appetite than both the smellers and a reference group of elderly persons (P < .05). Patients who reported a deterioration of olfaction and gustation tended to experience negative consequences such as the inability to smell smoke, leaking gas, or agreeable odors. CONCLUSION: Olfaction and odor-related flavor sensation are seriously deteriorated after total laryngectomy.

The influence of stoma occlusion on aspects of tracheoesophageal voice.

In this study, speech of 21 laryngectomized patients is investigated under 2 different stoma occlusion conditions, i.e. direct digital occlusion of the stoma (by thumb or finger), and digital occlusion (by finger) via a special heat and moisture exchanger with speech valve (Provox Stomafilter). For both conditions, acoustical analyses of voice quality (various pitch, amplitude, tremor and harmonicity measures) were performed on a sustained /a/, the mean maximum phonation time was calculated, and a phonetogram was made. Acoustical analysis was possible in 13 of the 21 voices (for the other voices, the pitch was too low or the voice was too aperiodic), but no statistical significant differences were found for any of the acoustical parameters studied. However, the maximum phonation time was significantly longer, and the dynamic range significantly larger, under the Stomafilter occlusion condition. The maximum phonation time showed a relevant improvement in 57% of the patients, while the dynamic range showed a relevant improvement in 35% of the patients. In total, 75% of the patients experience an improvement in one or both of these speech characteristics when using the Stomafilter occlusion. It can be concluded that optimal stoma occlusion by means of a specialized device has a positive influence on two relevant parameters of prosthetic voice production: maximum phonation time and dynamic loudness range.

Acoustical analysis and perceptual evaluation of tracheoesophageal prosthetic voice.

Voice analysis was performed on 21 "standard" laryngectomized, male patients with a Provox voice prosthesis, along with an age- and sex-matched control group of 20 normal speakers, using acoustical analyses (MDVP and CSL, Kay Elemetrics Corp.), maximum phonation time measurements, and perceptual evaluations. Comparison between MDVP and CSL revealed that the latter was not useful for the analysis of laryngectomized prosthetic voices. In contrast, MDVP seems suitable for this purpose, and contains a large number of parameters that significantly differentiate between patient and control speakers, as did the perceptual ratings and the maximum phonation time. Fundamental frequency appeared to be comparable for patients and control speakers. A significant influence of stoma occlusion and age was found for some voice parameters. Factor analyses showed correlations between the different MDVP parameters and correlations between the MDVP parameters and the perceptual ratings.