Release: July 29, 2000
Contact: Kenneth Satterfield
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Voice Quality and Patient Satisfaction Are High for Those Undergoing a Near-total Laryngectomy
A team of head and neck surgeons from Madrid proved that this procedure, allowing preservation of part of the larynx and tumor control, results in patients' retaining part or most of their voice
San Francisco, CA -- Traditionally, malignancies of the extended upper aero-digestive tract were treated with more aggressive techniques such as a total laryngectomy (complete surgical removal of the larynx). A consequence of this extreme surgical procedure was the complete loss of voice for the patient.
The Near-Total Laryngectomy, a surgical procedure described by B.W. Pearson in 1981, involves the removal of the tumor, as in a total laryngectomy, and the patient requires the surgical creation of a stoma, an opening in the neck directly into the windpipe, for breathing. But in this case, the entire larynx is not removed. Instead, the patient's own tissue is used to construct a shunt between the windpipe and the throat, allowing air to pass through and vibrate the pharynx. The remaining vocal chord works as a valve to avoid food getting into the trachea. The vocal sound created is then articulated by the patient into intelligible speech.
Now a team of head and neck surgeons from Madrid, Spain, have conducted an assessment of the voice retained by those undergoing this procedure. The authors of the study, "Voice Quality in Near-Total Laryngectomized Patients," are A. J. Del Palacio MD, Sol Marcos MD, R. Bernaldez MD, and J. Gavilan MD, all from the Department of Otolaryngology--Head and Neck Surgery, La Paz University Hospital, Autonomous University, de la Castellana 261, 28046, Madrid, Spain. The findings were presented before the 5th International Conference on Head and Neck Cancer, being held July 29 through August 2, at the San Francisco Marriott, San Francisco, CA. More than 1,500 leading head and neck surgeons from the United States and 46 nations will gather to hear the latest medical research in the diagnosis, treatment and reconstruction associated with head and neck cancer. The medical conference is sponsored by the American Head and Neck Society, www.headandneckcancer.org.
The purpose of their study was to assess as objectively as possible the quality of voice obtained by the subject patients, trying to achieve a deeper analysis than mere satisfactory voice qualification.
Methodology: Twenty-four male patients (mean age: 63; range 36-80) operated between 1991 and 1996 volunteered for the investigation. All underwent an NTL for extensive (T3,T4) laryngeal and/or hypopharyngeal carcinoma and had at least a follow-up time of two years (range two to seven years, mean 4.5 years). None of the speakers had a significant tongue resection during surgery nor a hearing impairment or pulmonary severe disease which could modify voice production.
The NTL procedure included the preservation of the recurrent laryngeal nerve in the side of the shunt creation, the arytenoid and a variable portion of the vocal cord. The addition of a pyriform sinus mucosal flap to augment the size of the shunt was the common procedure. Furthermore, all patients were ambulatory and at any moment of their follow-up were able to phonate (make sounds) by using the shunt occluding the tracheostoma with the finger.
Results: Nineteen of 24 patients used their phonatory shunts and achieve any kind of diaphragmatic voice; three used erygmophony, and two did not speak at all. Of the 19, eight (42 percent) had a voice with enough quality to be measured by the Voice Assessment program. A Fundamental Frequency (Fo) of 184 Hz and a mean Normalized Noise Energy (NNE) of -2.84. Mean maximum intensity was 94.5 dB (A). All had Maximum Phonation Time (MPT) above 5" and a mean of 14.5" with a mean s/z ratio of 1.3. Ten patients had a Frequency Range (FR) of only their Fo; four patients had five to 12 semitones; four were between one and two octaves and one was over the 24 semitones. Thirteen patients felt no fatigue or effort while speaking. Two patients did feel fatigue but did not make any effort to speak. and four suffered from fatigue and effort. None is aspirating significantly.
Conclusions: The study was not designed for quality of life assessment, but the researchers found that 89.48 percent of the patients were satisfied with their voice results and 78.95 percent were speaking effortlessly. With that measure, and that NTL myo-mucosal shunt does not require replacement nor specific care, the researchers suggest that near-total laryngectomy, if feasible, is a better chance for patient satisfaction than total laryngectomy with puncture or esophageal voice. The only limitations for its indication are secondary to tumor extent or previous radiotherapy.
Near-Total Laryngectomy provides the patients suffering of extensive laryngeal-hypopharyngeal malignancies a safe solution to preserve a socially useful voice, controlling their local disease. This voice compared to a laryngeal type is pathological regarding its noisy and perturbed condition, but almost normal considering MPT and intensity. Furthermore, some patients can achieve some modulation of their voices which can make them more expressive and receptive to improvement of communication skills. In addition, a significant majority of patients feel satisfied with their voices and most of them can speak effortlessly without fatigue and in a hands-free fashion.
The researchers believe more research is needed to determine the variables in the final quality of the NTL myo-mucosal shunt voice and why some patients can develop pitch control while others are limited to single modal fundamental frequency.
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