LARYNGEAL CARCINOMA- MANAGEMENT

Dr Vikas

MANAGEMENT OF LARYNGEAL CANCERS

Multidisciplinary teams

Minimum team defined by British Association of Otolaryngologist,-

head and neck surgeon is an otolaryngologist, a

radiotherapist/oncologist, nurse, speech and swallowing therapist

CARCINOMA IN SITU

Is replacement of the full depth of epithelium by malignant cells,

without those transgressing the basement epithelium

Tis should be regarded as part of the continuum of early laryngeal

cancer and managed as T1 carcinoma

High possibilities of recurrent disease suggests holding back use of

radiotherapy for those leisions where resection would lead to

significant functional defecits and use of surgical technique wherever

possible

GLOTTIC CANCER

Carcinoma in situ

Trans oral endoscopic CO2 laser

Microlaryngoscopic cord stripping

Regular follow up is essential

Glottic T1NO

Narrow field Radiotherapy

Voice conservation surgery

Type of surgery depends upon location of lesion within glottis

Mid cord lesion

Trans oral Endoscopic cordectomy/ CO2 laser cordectomy

>90% cure rates

Good voice quality

Very short treatment period

Tracheostomy is avoided

Laryngofissure with cordectomy-

>90% cure rates

slightly inferior voice quality

Temporary tracheostomy is required

Cord lesion extending to the anterior commissure-

Radiation therapy

Vertical frontolateral laryngectomy

Endoscopic CO2 laser excison (experience required)

Pure anterior commissure lesion

May cause early cartilage invasion ( absence of inner perichondrium)

May involve base of epiglottis or cricothyroid membrane without

causing cord fixity.

T3/T4 lesion may clinically be Under staged as T1/T2 lesion

Cure rates will be drastically compromised with radiotherapy

Surgery is preferred modality.

GLOTTIC T2 N0

Includes –

Superficial tumors where vocal cords are freely mobile but the suface

extension is beyond glottis( T2a)

Infiltrative tumors causing impaired cord mobility(T2b)

For T2a lesions Radiotherapy should be Treatment of choice

Voice is near normal

Regular follow up is required

Salvage surgery on failure of radiotherapy

T2b lesions being more infiltrative

Best Treated with VPL or supracricoid laryngectomy with CHEP.

Voice remains hoarse

Results of randomized controlled trial of surgery versus radiotherapy

for early glottic laryngeal cancer.

Surgery Radiotherapy

Five-year survival T1 100 91.7

T2 97.4 88.8

Five-year disease-free Tl 100 71.1

Survival T2a 78.7 60.1

GLOTTIC T3, T4

Fixation of vocal cord is grave prognostic sign

Results with surgery are far superior to those with surgery alone.

Alternative is radical radiotherapy with surgery reserved for salvage of

radiotherapy failures.

Strict follow up is required

Detection of recurrences

Harwood et al, registered a surgical salvage rate of 60%

In india due to extremely poor follow up total laryngectomy is

preferred.

SUPRA GLOTTIC CANCER

Mobile cords and No cartilage invasion-

Chief determinants of choice of therapy are-

Status of cervical lymph nodes

Age

Pulmonary status

Subsite within supraglottis

.

Minimal or no neck disease N0/ N1

Lesion of infrahyoid epiglottis

Surgery claims superior cure rates in comparison to radiotherapy

If pulmonary status is poor radiotherapy is preferred (no involvement of pre-

epiglottic space on CT/MRI )

Involvement of pre-epiglottic space- near total laryngectomy is preferred.

Lesions of suprahyoid epiglottis

Generally exophytic

Unlikely to involve pre-epiglottic space

Respond well to radiotherapy

Neck is included in radiation field

Small localized lesions best resected endoscopically with CO2 laser

Neck dissection may be carried out after 2 weeks if required.

Bulky nodal disease N2/N3

Responds poorly to radiation

therapy

TOC- primary surgery with

post operative radiotherapy.

VOCAL CORD FIXITY / CARTILAGE INVASION

Total or Near total laryngectomy is indicated.

SURGERY

Advantages:

1.Treatment in single sitting

2.Minimal absence from employment

3.Certainty of removal of specimen & ability to assess margin surgically

4.Allows further laryngeal surgery or radiotherapy in case of recurrence

Disadvantages

Affect voice quality

Access sometimes difficult

Requires general anaesthesia & may need repeated operations for

which patient may not be fit

RADIATION –ADVANTAGES

Functional preservation.

Patient's preference

No Post Operative complication

Deals effectively with the microscopic invasion into the adjacent

lymphatic and venous channels

DISADVANTAGES

Ineffective at the necrotic centre of tumor so ineffective against large

bulky tumors

Relatively ineffective against Radio resistant tumors

Post radiation reactions

Morbidity

TRANSORAL LASER SURGERY

INCLUSIONAL CRITERIA

Complete endoscopic visualization of the carcinoma

Tumor extension to the contralateral VC < 3mm

Absence of arytenoid involvement (except vocal process)

Subglottic extension < 5mm

Supraglottic extension no further than lateral extension of ventricle

Mobile vocal folds

No cartilage involvement

ADVANTAGES

Good voice quality

Good swallowing

Lower complications rates

Lower costs

Shorter hospitalization

Tracheostomy and NG tubes not routinely required

OPERATIVE CONSIDERATIONS

Increased difficulty in identification of recurrent carcinoma in irradiated tissue leads to routine use of frozen section

All margins to be confirmed by permanent section post-op.

Strict follow-up with fibroscopic examination and serial imaging allowing early detection of recurrence

The use of CO2 laser excision after radiation failure does not preclude its use for persistent or multiple recurrent disease

OUTCOMES

In 40% of cases more than one laser-assisted surgery was

required

Local control rate was 51-87% (Mean 65%)

Subsequent total laryngectomy was necessary in 25%

Overall control rate including those requiring total

laryngectomy was 80-100% (Mean 83%)

Complications

Complication rates are <5% and from most to least common include:

Granuloma formation

Laryngeal edema

Laryngeal stenosis

Chondronecrosis

PARTIAL LARYNGECTOMY

Aim

Is to perform oncological clearance of tumour with as much

preservation of normal voicing and swallowing as possible

Emphasis should be given to

Survival is more important than voice

Partial laryngectomies require experience and training

Patient must have good pulmonary reserve

More radical PL should be avoided in patients who have been

previously irradiated

VERTICAL PARTIAL LARYNGECTOMY

Cordectomy- resection of the entire cord up to the vocal process of the

arytenoid, may be achieved by an open approach via a laryngofissure

Frontolateral laryngectomy- extends cordectomy to take in that part of the

thyroid cartilage into which the anterior commissure inserts

Anterior frontal laryngectomy- removes this region together with part of

both cords

Hemilaryngectomy-removes a vertical block of larynx to include one cord

(occasionally including arytenoid) and the anterior two-thirds of the ipsilateral thyroid

cartilage.

Removal of:

One vocal fold - from anterior commissure to vocal process

½ of opposite vocal fold may also be removed if involved

Ipsilateral false vocal cord

Ventricle

Paraglottic space (and overlying thyroid cartilage)

CONTRAINDICATIONS

Large T3 or any T4 lesion

Intrarytenoid or cricoarytenoid joint involvement

Bilateral arytenoid cartilage involvement or bilaterally diminished vocal cord mobility

Thyroid cartilage penetration

Supraglottic extension exceeding 10mm at the anterior commissure or 5mm at the vocal process of the arytenoid

Poor pulmonary function

OPERATIVE CONSIDERATIONS

The use of intraoperative frozen sections is imperative for maximal local control

All margins should be confirmed with permanent section postoperatively

In the event of failure of salvage VPL total laryngectomy remains an option and this will not ultimately affect local control. 8

The use of bipedicled flaps of strap muscles to replace excised intralarygeal soft tissue may facilitate post-op rehabilitation 13

Outcomes

Meta-analysis showed:

Local control rate 50-100% (mean 78%)

Approximately 15% of patients require completion laryngectomy for

second recurrence

Complications

Early - generally tracheostomy relatedInfection Aspiration and dysphonia

Late

AspirationChondritisLaryngeal stenosis (Must rule out local recurrence) Severe hoarseness Granulation tissueTumor recurrence

SUPRACRICOID LARYNGECTOMY

Removal of:Entire thyroid cartilageBilateral true and false vocal cordsVentriclesParaglottic and Preepiglottic spacesEpiglottisHyoid boneOne arytenoid (may spare both if not involved)

- At least one arytenoid must be spared to preserve phonation and sphincter functions

SUPRACRICOID LARYNGECTOMY

CONTRAINDICATIONS

Infiltration of both aryntenoid cartilages

Infiltration of cricoarytenoid joint or inter-arytenoid region

Subglottic extension >1cm below the vocal fold

Extension to the glossoepiglottic valecula

Major preepiglottic space invasion

Hyoid bone invasion

Invasion of outer perchondrium of thyroid cartilage

Extra-laryngeal spread

COMPLICATIONS

Swallowing disorders are the most common in the short term

Voice quality is hoarse, rough, breathy but with acceptable

intelligibility.

Aspiration Pneumonia is the most frequent complication (17.5%)

Neo-laryngeal edema

OUTCOMES

Disease-free survival 84.5%

Of the 15.5% failure of SCL, 66.7% successfully treated with Total

laryngectomy

3 year survival rate of 80 -100%

5 year survival rate of 69.4 -100%

SUPRAGLOTTIC LARYNGECTOMY

Following tracheostomy and raising of flaps, the supraglottis is

excised en block with cuts through both valleculae, aryepiglottic folds

and ventricles

Removal of upper half of thyroid cartilage and all the epiglottis

SUBTOTAL LARYNGECTOMY

Operation popularised by Biller & Lawson

Three- quarter laryngectomy combining supraglottic laryngectomy with

vertical hemilaryngectomy on the side of the tumour

Indication

Supraglottic cancer which involve an arytenoid &/or vocal cord on one

side only

Tumour should be no longer than 2cm in maximum diameter

Should not extend in subglottis

NEAR- TOTAL LARYNGECTOMY

Described by Pearson

Technically complex procedure to create a physiological voice shunt

based on mobile arytenoid

No significant gains over total larygectomy

TOTAL LARYNGECTOMY

Mainstay of treatment for advanced laryngeal cancer

Fistly performed by Billroth in 1870

Curative as well as palliative.

The current 5 yr. survival rate of patients following total Laryngectomy

is about 80%

CHEMOTHERAPY

Palliative

Adjunctive

Chemoradiation

Surgery followed or preceded by

Chemoradiation

MANAGEMENT OF THE NECK

Main predictor of survival in squamous cell carcinoma is the presence,

number and extracapsular spread of lymph node metastases

N0

Elective neck dissection is commonly performed for management of

node negative T2-4 supraglottic cancer

Risk (Shah et a1.)--

Supraglottic -16-43%

Transglottic – 11-52%

Subglottic – 19-65%

Elective neck irradiation

N+ NECK IN LARYNGEAL CANCER

N1

modified neck dissection is procedure of choice

N2a or N2b

Choice of either MRND or RND followed by postoperative

radiotherapy or chemotherapy

N3

Whether or not to operate depends upon

staging of disease

presence or absence of fixation & what node is fixed to

experience of surgeon

need of patient

VOICE REHABILITATION FOLLOWING

LARYNGECTOMY

INTRODUCTION

TEP (Tracheo-oesophageal puncture) is considered gold standard

among various voice rehabilitation procedures

A good percentage of patients undergoing total Laryngectomy regain

esophageal voice

FUNCTIONAL ALTERATIONS FOLLOWING TOTAL

LARYNGECTOMY

Loss of speech.

Changes in normal swallowing mechanism

Changes in the pattern of respiration

Tracheostome problems;

Problems with loss of glottal occlusion, e.g. lifting;

Problems with airway diversion, e.g. loss of olfaction;

Body image/psychological/social problems.

REQUIREMENTS FOR NORMAL PHONATION

Active respiratory support

Adequate glottic closure

Normal mucosal covering of vocal cord

Adequate vocal cord length and tension control

Components of phonation

e

Lung (Bellows)

Larynx (Vibrator)

Articulators (Lips,

tongue, teeth)

METHODS OF SPEECH FOLLOWING LARYNGECTOMY

Esophageal speech

Electro larynx

TEP (Tracheo-oesophageal puncture)

ESOPHAGEAL SPEECH

All pts. Develop some degree of esophageal speech following

Laryngectomy

All alaryngeal speech modalities are compared with this modality

Till 1970’s this was the gold standard for all other post Laryngectomy

speech rehabilitation procedures

ESOPHAGEAL SPEECH - PHYSIOLOGY

Air is swallowed into cervical esophagus

This swallowed air is expelled out causing vibrations of pharyngeal

mucosa

These vibrations along with articulations of tongue cause speech to

occur

The exact vibrating portion of pharynx is the pharyngo-oesophageal

segment

The vibrating muscles and mucosa of cervical oesophagus and

hypopharynx cause speech

ESOPHAGEAL SPEECH – PE SEGMENT

This segment is made up of musculature and mucosa of lower

cervical area (C5-C7 segments).

Vibration of this segment causes speech in pts. Without larynx

Cricopharyngeal area is important

Cricopharyngeal spasm in these pts. Can lead to failure in developing

esophageal speech

Cricopharyngeal myotomy may help these pts. in developing

esophageal speech

PUMPING AIR INTO CERVICAL OESOPHAGUS

Injection method

Inhalational method

INJECTION METHOD

Enough positive pressure is built inside oral cavity to force air into

cervical oesophagus

Lip closure and tongue elevation against palate causes increase

intraoral pressure

Air is injected into the cervical oesophagus by voluntary swallowing

This method is also known as tongue pumping / glossopharyngeal

press / glossopharyngeal closure

INHALATIONAL METHOD

Uses the negative pressure used in normal breathing to allow air to

enter cervical oesophagus

Air pressure in the cervical oesophagus below Cricopharyngeal

sphincter is the same negative pressure as that of thoracic cavity

Pts. learn how to relax Cricopharyngeal sphincter during inspiration

allowing air to flow into cervical oesophagus as it enters the lungs

Pts. are encouraged to consume carbonated drinks which facilitates

air entry into cervical oesophagus helping in generation of esophageal

speech

ESOPHAGEAL SPEECH - ADVANTAGES

Patient’s hands are free

No additional surgery / prosthesis needed. Hence no extra cost for

the pt.

Pts. Get easily adapted to esophageal voice

ESOPHAGEAL SPEECH - DISADVANTAGES

Nearly 40% of pts fail to develop esophageal speech

Quality of voice generated is rather poor

Pt. may not be able to continuously speak using esophageal voice

without interruption. They will be able to speak only in short bursts

Significant training is necessary

Loudness / pitch control is difficult

Fundamental frequency of esophageal speech is 65 Hz which is lower

than that of male and female frequencies

CAUSES FOR FAILURE

Presence of cricopharyngeal spasm

Presence of reflux esophagitis

Abnormalities involving PE segment – like thinning of muscle wall in

that area

Denervation of muscle in the PE segment

Poorly motivated patient

ELECTROLARYNX

These are battery operated vibrating devices

It is held in the submandibular region

Muscle contraction and changes in facial muscle tension causes

rudiments of speech

Initial training to use this equipment should begin even before surgery

ELECTROLARYNX - TYPES

There are two types of electrolarynx

An external type that is placed against the neck

(the most common). Hypoesthesia of neck

during early phases of post op period can cause

difficulties

An oral type (intraoral placement device)External type (Neck type)

INTRAORAL ARTIFICIAL LARYNX

Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin.

Intraoral cup should form a tight seal over the stoma. There should not be any air leak

Oral tip should be placed in the oral cavity

Pts exhaled air rattles the cup placed over the stoma

Changes in exhaled pressure can vary the quality of sound generated

ELECTROLARYNX - ADVANTAGES

Can be easily learnt

Immediate communication is possible

Additional surgery is avoided

Can be used as a interim measure till the patient masters the

technique of esophageal speech or gets a TEP inserted

ELECTROLARYNX - DISADVANTAGES

The main disadvantages include the mechanical, monotonous and

robot-like sound quality.

Expensive to maintain

The necessity to use a hand to operate the controls and dependence

on batteries.

Difficult while speaking over telephone

TYPES OF VOICE RESTORATION SURGERIES

Neoglottic reconstruction

Shunt technique

NEOGLOTTIC PROCEDURE

Trachea hyoidopexy

This can restore voice function in alaryngeal patients

Abandoned due to increased incidence of complications like

aspiration

SHUNT TECHNIQUE

Developed by Guttmann in 1930

Involves creation of shunt between trachea and esophagus

Lots of modifications of this procedure is available, Basic aim is to

divert air from trachea into the esophagus

TYPES OF SHUNTS

High trachea-esophageal shunt (Barton)

Low trachea-esophageal shunt (Stafferi)

TEP shunts (Guttmann)

CAUSES OF FAILURE OF SHUNT PROCEDURE

Aspiration through the fistula

Closure of the fistula

To avoid these problems prosthesis was introduced

TYPES OF PROSTHESIS

Figure- The sequence of events in respect of creating a

tracheo-esophqgeal fistula and insertion of a speaking

valve as a primary procedure.

(a) A stab incision is made in the back wall of the trachea

and the guide wire and applicator are introduced.

(b) The short esophagoscope is removed, the valve

is attached to the guide wire and pulled into place.

TEP

Was first introduced by Blom and Singer in 1979

One way silicone valve is introduced via the fistula

This valve served as one way conduit for air into esophagus while

preventing aspiration

This prosthesis has two flanges, one enters the esophagus while the

other rests in the trachea. It fits snugly into the trachea-esophageal

wound

Indwelling prosthesis have more rigid flanges when compared to that

of non indwelling ones

A medallion ring is attached to the non indwelling prosthesis to

prevent aspiration

TYPES OF TEP

Primary TEP – Performed during total laryngectomy

Secondary TEP – Performed 6 months after surgery

ANATOMICAL STRUCTURES TEP

TEP is performed in midline (Less bleeding)

Structures that are penetrated during TEP- membranous posterior

wall of trachea, esophagus and its 3 muscle layers and esophageal

mucosa

Interconnecting tissue in the trachea-esophageal space

ADVANTAGES OF TEP

Can be performed after laryngectomy / irradiation / chemotherapy /

neck dissection

Fistula can be used for esophago-gastric feeding during immediate

PO period

Easily reversible

Speech develops faster than esophageal speech

High success rate

Closely resembles laryngeal speech

Speech is intelligible

COMPARISON BETWEEN LARYNGEAL, OESOPHAGEAL AND

TRACHEO-OESOPHAGEAL SPEECH.

Physical requirements Laryngeal speech Oesophageal speech Jracheo-rqesophageai

speech

initiator Lungs 500 mL Oesophageal air 40-70

mL

Lungs 500 mL

Vibrator Vocal cords Pharyngo-oesophageal

segment

Pharyngo-oesophageal

segment

Articulators Tongue, teeth, lips, soft

palate

Tongue, teeth, lips, soft

palate

Tongue, teeth, lips, soft

palate

DISADVANTAGES OF TEP

Pt should manually cover the stoma during voicing

Good pulmonary reserve is a must

Additional surgical procedure is needed to introduce it

Posterior esophageal wall can be breached

Catheter can pass through the posterior wall

TEP – PATIENT SELECTION

Motivated patient

Patient with stable mind

Patient who has understood the anatomy & physiology of the process

Patient should not be an alcoholic

Good hand dexterity

Good visual acuity

Positive esophageal air insufflation test

Patient should not have pharyngeal stricture / stenosis

Stoma should be of adequate depth and diameter

Intact trachea-esophageal wall

CONTRAINDICATIONS OF TEP

Extensive surgery involving pharynx, larynx with separation of

trachea-esophageal wall

Inadequate psychological preparation

Patient with doubtful ability to cope up with prosthesis

Impaired hand dexterity

Suspected difficulty during PO irradiation

PRIMARY - TEP

Hamaker first performed in 1985

Primary TEP should be attempted where ever possible

In this procedure puncture is performed immediately after

laryngectomy and prosthesis is inserted

Primary tracheo-oesophageal puncture is now accepted as the

optimal method for voice rehabilitation.

Prosthesis of sufficient length should be used

ADVANTAGES OF PRIMARY TEP

Risk of separation of trachea – esophageal wall is minimized

Tracheo – esophageal wall is stabilized to some extent by the

prosthesis

Flanges of prosthesis protects trachea from aspiration

Stomal irritation is less

Patient becomes familiar with prosthesis immediately following

surgery

Post op irradiation is not a contraindication

PRIMARY TEP - PROCEDURE

Because of exposure following laryngectomy it is easy to perform

Ideally performed before pharyngeal closure

Puncture is performed through pharyngotomy defect

Ryles tube can be introduced via the fistula to provide gastric feeding

in the post op period

SECONDARY TEP

Usually performed 6 weeks following laryngectomy

This allows pt time to develop esophageal speech

Area of fistula is identified using rigid esophagoscope

Prosthesis can be inserted immediatly

MODIFIED SECONDARY TEP PROCEDURE

Performed under local anesthesia

Patient placed in recumbent position with mild extension of neck with

a shoulder roll

Tracheostomy tube is removed

12 0’ clock position of tracheostoma visualized and infiltrated using

2% xylocaine with 1 in 100,000 adrenaline

Yanker’s suction tube is inserted into the oral cavity till it hitches

against 12-0 clock position of tracheostome

This area is incised using 11 blade and widened using curved artery

forceps

Blom singer prosthesis is then introduced through this fistula

12 – 0 CLOCK POSITION OF TRACHEOSTOMA

YANKER’S SUCTION TUBE INSERTED

TEP - INCISION

TEP - WIDENED

PROSTHESIS INTRODUCED

PROSTHESIS USED IN TEP

Blom-Singer prosthesis

Panje button

Gronningen button

Provox prosthesis

various tracheooesophageal voice prostheses:

(a) Blom-Singer 'duck bill' prosthesis with

introducer ;

(b) indwelling Provox prosthesis with introducer;

(c) Groningen low resistance prosthesis;

(d) indwelling Blom-Singer prosthesis, introducer

and 'gel cap'.

PANJE VOICE BUTTON

Biflanged tube with one way

valve

Can be inserted through the

fistula created for this purpose

It is supplied with an introducer

which makes insertion simple

Should be removed and cleaned

every two days

Can be removed, cleaned and

reinserted by the patient

GRONNINGEN BUTTON

Introduced by Gronningen in

Netherlands in 1980

It causes high airflow resistance

delayed speech in some

patients

Now low air flow resistance

tubes have been introduced

BLOM-SINGER PROSTHESIS Introduced by Blom and Singer in 1978

Commonly used prosthesis

This prosthesis acts as one way valve allowing air to pass into the esophagus and prevents aspiration

This prosthesis is shaped like a duck bill hence known as “Duck bill prosthesis”

The duck bill end should reach up to oesophagus

It is an indwelling prosthesis can be left in place for 3 months

This prosthesis is available in varying lengths

PROVOX PROSTHESIS

Indwelling low air flow pressure

prosthesis

It has extended life time. Can

last a couple of yeas if used

properly

Insertion is easy

INDWELLING VERSUS NON INDWELLING PROSTHESIS

Indwelling prosthesis Non indwelling prosthesis

Can be left in place for 3-6 months Should be removed and cleaned every couple of

days

Requires specialist to do the job Pt. Can do it themselves

Less maintenance Periodical maintenance

Stoma should be greater than 2 cms Stoma should be greater than 2 cms

Oesophageal insufflation test should be positive Oesophageal insufflation test should be positive

PROBLEMS WITH TEP INSERTION

Leak through the prosthesis

Leak around the prosthesis

Immediate aphonia / dysphonia

Hypertonicity problems

Delayed speech

OESOPHAGEAL INSUFFLATION TEST

Should be performed before TEP

Assesses cricopharyngeal muscle response to esophageal distention

A catheter is placed through the nostril up to 25 cm mark. This

indicates probable site of puncture

Pt is asked to count numbers or vocalize “Ah”

INSUFFLATION TEST INTERPRETATION

Fluent voice on minimal effort – normal

Breathy voice indicating -hypotonic cricopharyngeal muscle

Hypertonic voice – “Cricopharyngeal spasm”

Spasmodic voice – “Extreme cricopharyngeal spasm”

COMMON PROBLEMS WITH TEP

Improper location of puncture

Inappropriate size of puncture

Presence of cricopharyngeal spasm

Leakage through and around the prosthesis

LOCATION OF TEP

12-0,’clock position of stoma

About 1-1.5 cms from trachea-cutaneous junction

If located superiorly pt may find it difficult to occlude

If located deep into the trachea then it becomes difficult to introduce

the prosthesis

MANAGEMENT OF LEAK THROUGH THE PROSTHESIS

Cause Solution

Valve in contact with posterior wall of

esophagus

Replace prosthesis with different length and size

Prosthesis length too short for the puncture

“Pinched valve”

Remeasure the puncture and replace with appropriate

size prosthesis

Valve deterioration Replace valve

Fungal colonization of valve with yeast Treat with nystatin

Back pressure High resistant prosthesis

Mucous / food lodgment Prosthesis to be cleaned

MANAGEMENT OF LEAK AROUND THE PROSTHESIS

Cause Solution

TEP location Remove prosthesis allow puncture to close

and repuncture

Unnecessary dilatation during valve placement To be avoided

Thin trachea-esophageal wall 6 mm or less Choose custom prosthesis

Prosthesis of incorrect length and size Choose correct length

Poor tissue integrity due to irradiation Custom prosthesis

TRACHEOSTOMAL PROBLEMS

•Patients who have undergone total laryngectomy will have a permanent tracheostomy with the

usual potential problems of increased chest infections, crusting and stenosis.

•Surgical attention to detail when fashioning the stoma with access to nebulization and

humidification devices can reduce these. The current trend is to use hands free occlusion for

speech and moisture conservation devices applied directly to the stoma.

Figure - Heat moisture exchange devices. (a)

Stomvent (Gilbeck); (b) Trachenaze Plus with shower

protector (Kapitex); (c)Trachenaze (Kapitex); (d)

Provox (Atos Medical).

RECENT ADVANCES

In 1998 , Strome et al, performed the first true laryngeal transplant in

Cleveland, USA.

In 2010 UC Davis Medical Center, California performed another

successful laryngeal transplant.

Recently, Delaere et al. have developed a procedure using tracheal

autotransplantation, with vascularity provided by a radial forearm free-

flap. Thirty-six patients have been treated with reportedly excellent

results.