RESUMEN
PURPOSE: To identify the anatomic structures whose damage or malfunction cause late dysphagia and aspiration after intensive chemotherapy and radiotherapy (RT) for head-and-neck cancer, and to explore whether they can be spared by intensity-modulated RT (IMRT) without compromising target RT. METHODS AND MATERIALS: A total of 26 patients receiving RT concurrent with gemcitabine, a regimen associated with a high rate of late dysphagia and aspiration, underwent prospective evaluation of swallowing with videofluoroscopy (VF), direct endoscopy, and CT. To assess whether the VF abnormalities were regimen specific, they were compared with the VF findings of 6 patients presenting with dysphagia after RT concurrent with high-dose intra-arterial cisplatin. The anatomic structures whose malfunction was likely to cause each of the VF abnormalities common to both regimens were determined by literature review. Pre- and posttherapy CT scans were reviewed for evidence of posttherapy damage to each of these structures, and those demonstrating posttherapy changes were deemed dysphagia/aspiration-related structures (DARS). Standard three-dimensional (3D) RT, standard IMRT (stIMRT), and dysphagia-optimized IMRT (doIMRT) plans in which sparing of the DARS was included in the optimization cost function, were produced for each of 20 consecutive patients with advanced head-and-neck cancer. RESULTS: The posttherapy VF abnormalities common to both regimens included weakness of the posterior motion of the base of tongue, prolonged pharyngeal transit time, lack of coordination between the swallowing phases, reduced elevation of the larynx, and reduced laryngeal closure and epiglottic inversion, contributing to a high rate of aspiration. The anatomic structures whose malfunction was the likely cause of each of these abnormalities, and that also demonstrated anatomic changes after RT concurrent with gemcitabine doses associated with dysphagia and aspiration, were the pharyngeal constrictor muscles (median thickness near midline 2.5 mm before therapy vs. 7 mm after therapy; p = 0.001), the supraglottic larynx (median thickness, 2 mm before therapy vs. 4 mm after therapy; p < 0.001), and, similarly, the glottic larynx. The constrictors and the glottic and supraglottic larynx were, therefore, deemed the DARS. The lowest maximal dose delivered to a stricture volume was 50 Gy. Reducing the volumes of the DARS receiving > or =50 Gy (V(50)) was, therefore, a planning and evaluation goal. Compared with the 3D plans, stIMRT reduced the V(50) of the pharyngeal constrictors by 10% on average (range, 0-36%, p < 0.001), and doIMRT reduced these volumes further, by an additional 10% on average (range, 0-38%; p <0.001). The V(50) of the larynx (glottic + supraglottic) was reduced marginally by stIMRT compared with 3D (by 7% on average, range, 0-56%; p = 0.054), and doIMRT reduced these volumes by an additional 11%, on average (range, 0-41%; p = 0.002). doIMRT reduced laryngeal V(50) compared with 3D, by 18% on average (range 0-61%; p = 0.001). Certain target delineation rules facilitated sparing of the DARS by IMRT. The maximal DARS doses were not reduced by IMRT because of their partial overlap with the targets. stIMRT and doIMRT did not differ in target doses, parotid gland mean dose, spinal cord, or nonspecified tissue maximal dose. CONCLUSIONS: The structures whose damage may cause dysphagia and aspiration after intensive chemotherapy and RT are the pharyngeal constrictors and the glottic and supraglottic larynx. Compared with 3D-RT, moderate sparing of these structures was achieved by stIMRT, and an additional benefit, whose extent varied among the patients, was gained by doIMRT, without compromising target doses. Clinical validation is required to determine whether the dosimetric gains are translated into clinical ones.
Asunto(s)
Trastornos de Deglución/prevención & control , Desoxicitidina/análogos & derivados , Neoplasias de Cabeza y Cuello/tratamiento farmacológico , Neoplasias de Cabeza y Cuello/radioterapia , Neumonía por Aspiración/prevención & control , Radioterapia Conformacional/métodos , Antimetabolitos Antineoplásicos/efectos adversos , Terapia Combinada/métodos , Deglución , Trastornos de Deglución/etiología , Desoxicitidina/efectos adversos , Humanos , Hipofaringe/efectos de los fármacos , Hipofaringe/efectos de la radiación , Procesamiento de Imagen Asistido por Computador , Tonsila Palatina/efectos de los fármacos , Tonsila Palatina/efectos de la radiación , Músculos Faríngeos/efectos de los fármacos , Músculos Faríngeos/efectos de la radiación , Neumonía por Aspiración/etiología , Estudios Prospectivos , Lengua/efectos de los fármacos , Lengua/efectos de la radiación , GemcitabinaRESUMEN
OBJECTIVE: To gain insight into the clinical value of using the relatively new evaluation tool digital high-speed endoscopy in addition to the widely used method of videofluoroscopy for imaging of the neoglottis in tracheoesophageal speech after total laryngectomy. MATERIAL AND METHODS: Anatomical and morphologic characteristics of the neoglottis in 37 laryngectomized patients using tracheoesophageal speech were studied by means of visual assessment of digital high-speed endoscopy recordings and visual assessment and quantitative measures of videofluoroscopy recordings, using previously published protocols. RESULTS: Digital high-speed endoscopy provides information complementary to that of videofluoroscopy with respect to the location of the vibration, presence of a mucosal wave, regularity of the vibration and closure of the neoglottis The information provided by digital high-speed endoscopy overlaps with that provided by videofluoroscopy with respect to the amount of saliva (regurgitation of barium in videofluoroscopy) and the visibility of the origin of the neoglottis (presence of a neoglottic bar in videofluoroscopy). Additionally, relationships were found between the visual assessments of the high-speed recordings and some patient characteristics. CONCLUSIONS: Digital high-speed endoscopy provides additional insight into neoglottic characteristics that cannot be studied with videofluoroscopy. The application of both imaging methods enhances the insight into tracheoesophageal voicing.
Asunto(s)
Fluoroscopía/instrumentación , Procesamiento de Imagen Asistido por Computador/instrumentación , Laringectomía/rehabilitación , Laringoscopios , Procesamiento de Señales Asistido por Computador/instrumentación , Voz Esofágica , Grabación en Video/instrumentación , Anciano , Anciano de 80 o más Años , Deglución/fisiología , Femenino , Glotis/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Tono Muscular/fisiología , Fonación/fisiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/fisiopatologíaRESUMEN
OBJECTIVE: To evaluate the influence of primary myotomy on characteristics of the neoglottis in patients after laryngectomy. DESIGN: Patient survey. SETTING: University Medical Center St Radboud, Nijmegen, the Netherlands. PATIENTS: Nineteen consecutive patients who underwent laryngectomy (12 with primary lateral myotomy of the upper esophageal sphincter [marked by metal clips]; 7 not requiring myotomy [according to intraoperative palpation]). INTERVENTIONS: Videofluoroscopy. MAIN OUTCOME MEASURES: Visual assessments and quantitative measures of the neoglottis were used to study the relationships between myotomy, and anatomic and morphologic characteristics of the neoglottis. RESULTS: Quantitative measurements showed no difference between the neoglottic characteristics of the patients with (n = 12) and without (n = 7) myotomy, who were all judged to have moderate (n = 4) or good (n = 15) voice quality. Results for the entire patient group during phonation showed only 1 single neoglottic bar, no hypertonicity of the neoglottis, and a significant shortening of the neoglottic bar (P =.007). Results for the myotomy group during phonation showed elevation of the caudal clip (P =.046), shortening of the myotomy (P =.01), and decreased overlap of the cranial clip and the neoglottic bar (P =.007). Furthermore, significant relationships were found between the various quantitative measures of the neoglottis and those of the myotomy. CONCLUSIONS: Quantitative videofluoroscopy enables study of the influence of myotomy on the anatomic and morphologic characteristics of the neoglottis. Our results suggest that a planned myotomy of the upper esophageal sphincter is beneficial when prosthetic voice rehabilitation is applied after total laryngectomy.
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Carcinoma de Células Escamosas/cirugía , Fluoroscopía/métodos , Glotis/cirugía , Neoplasias Laríngeas/cirugía , Laringectomía/métodos , Músculo Liso/cirugía , Grabación de Cinta de Video , Adulto , Anciano , Unión Esofagogástrica/cirugía , Femenino , Humanos , Laringe Artificial , Masculino , Persona de Mediana Edad , Voz Esofágica , Tráquea/cirugíaRESUMEN
The present study was conducted to investigate voice quality in tracheoesophageal speech by means of perceptual evaluations and to develop a clinically useful subset of perceptual scales sufficient for these perceptual evaluations. The perceptual ratings were obtained from both naive and trained raters (speech-language pathologists [SLPs]) after listening to a read-aloud text. The perceptual evaluations were performed by means of 19 semantic bipolar 7-point scales for the naive raters and 20 semantic bipolar 7-point scales for the trained raters. The trained raters were also asked to judge the overall voice quality as good, reasonable, or poor. Both naive listeners and trained SLPs were able to perform reliable perceptual judgments. Naive raters judged the tracheoesophageal voice as more deviant than the trained raters did. Naive raters made judgments based on 2 underlying perceptual dimensions (voice quality and pitch), whereas the trained raters made judgments based on 4 underlying perceptual dimensions (voice quality, tonicity, pitch, and tempo). These perceptual dimensions were further subdivided into a subset of 4 perceptual scales for the naive raters and a subset of 8 perceptual scales for the trained raters. This appeared to provide a sufficient coverage of the underlying perceptual dimensions used by the listeners.
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Diferencial Semántico , Inteligibilidad del Habla , Percepción del Habla , Voz Alaríngea/psicología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Juicio , Masculino , Persona de Mediana Edad , Medición de la Producción del Habla , Patología del Habla y Lenguaje , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To develop and test the prototypes of a novel post-laryngectomy rehabilitation tool incorporating an obligatory, disposable heat and moisture exchanger (HME) and a reusable, multi-magnet automatic speaking valve (ASV). MATERIAL AND METHODS: The study subjects comprised 20 laryngectomized individuals (15 males, 5 females), 5 of whom were already using an ASV and 15 who were not. Three successive prototypes were tested. Data were collected by means of structured questionnaires, considering for example patient compliance, skin adhesion, voicing and coughing aspects, and voice and speech quality assessments, assessing for example maximum phonation time and dynamic loudness range. RESULTS: Of the 15 non-ASV users, 5 did not comply with the study due to peristomal skin adhesion problems. Of the remaining 15 patients, all 5 ASV users and 6/10 non-users were fully compliant with the new device. The cough-relief valve of the new device functions properly, as does the valve position adjustment for physical exertion. With this new device the maximum phonation time was longer than with a regular ASV (15.2 vs 11.6 s; p = 0.006) and the dynamic range was larger (33.0 vs 24.8 dB; p < 0.001). CONCLUSION: The test results obtained with this new device show that its advanced features (obligatory HME and multi-magnet valve systems) offer additional benefits for further improving vocal and pulmonary rehabilitation after total laryngectomy.
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Laringectomía/rehabilitación , Laringe Artificial , Fonación/fisiología , Traqueostomía/instrumentación , Calidad de la Voz/fisiología , Anciano , Temperatura Corporal , Diseño de Equipo , Femenino , Humanos , Magnetismo , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Estudios Prospectivos , Inteligibilidad del Habla , Pérdida Insensible de AguaRESUMEN
OBJECTIVES: To study the long-term results of the nasal airflow-inducing maneuver (NAIM) as an olfaction rehabilitation tool after laryngectomy and to investigate the effectiveness of a new, simpler odor detection test (ODT) called the smell disk test (SDT), or Zürcher Geruchstest. DESIGN: Intervention study. SETTINGS: National cancer center. PATIENTS: Forty-one laryngectomees who received olfaction rehabilitation training with the NAIM 4 months to 2 years earlier. This so-called polite yawning maneuver creates an "underpressure" in the oral cavity, which, in turn, generates a nasal airflow that enables odor molecules to again reach the olfactory epithelium. MAIN OUTCOME MEASURES: Olfaction acuity testing with a standard ODT, along with a questionnaire, providing a subjective olfaction score (present odor perception scale [POPS]), and the SDT, as well as assessment of the patients' correct execution of the NAIM by speech-language pathologists on video recordings made during odor testing and long-term assessment of olfaction acuity. RESULTS: The correlation between the previously used ODT-POPS combination and the SDT was kappa = 0.56 (P<.001). Based on these results, we preferred to use the much simpler SDT instead of the laborious combination of the ODT-POPS. Based on the SDT results, 19 (46%) of the 41 laryngectomees were "smellers" and could be considered normosmic. There was a significant relationship (P =.03) between the patient's correct execution of the NAIM and whether or not the laryngectomee was a smeller according to the SDT. CONCLUSIONS: The effectiveness of the NAIM, or so-called polite yawning technique, for the rehabilitation of olfaction in individuals who have undergone total laryngectomy was reconfirmed. Long-term olfaction rehabilitation was achieved in about 50% of the patients, but more intensified training may be needed to increase the percentage of successfully rehabilitated individuals. The SDT is an effective and simple test for the assessment of olfaction acuity after laryngectomy.