Surgical Outcome and Quality of Life After Total Laryngectomy in Advanced Laryngeal Cancer- A Study in Combined Military Hospital, Dhaka

Abstract

Introduction: Total laryngectomy is the gold standard treatment for advanced laryngeal cancer. Sacrifice of voice is one of the most important shortcomings of the procedure. Possibility of achieving good quality voice is greater with prosthesis compared to other method. Post laryngectomy voice rehabilitation with prosthesis yield excellent outcome in most of the cases. Swallowing, pulmonary and olfactory rehabilitation should be managed by multidisciplinary team for better quality of life (QoL). Objectives: The purpose of this study was to observe the outcomes of voice, swallowing pulmonary and olfactory rehabilitation and QoL following total laryngectomy. Methods: This cross sectional retrospective clinical study was conducted at the Head & Neck Oncology Unit, Combined Military Hospital (CMH), Dhaka. Total 57 candidates were selected. Diagnosis was done by thorough clinical examination, Fibre Optic Laryngoscopy. Contrast Enhanced Computed Tomography (CECT) scan of neck was done except few cases where MRI of neck was done for subtle cartilage erosion was suspected. Examination under anaesthesia, direct larangoscopy and biopsy was done for every cases. Candidates were post chemo-radiated/ radiated biopsy proven recurrent cases, clinically nonfunctional larynx with aspiration and radiologically evident of cartilage erosion. In all cases artificial voice prosthesis was used. All the laryngectomees underwent voice, swallowing, pulmonary and olfactory rehabilitation in laryngectomy club of head & neck oncology unit, CMH Dhaka for a period of 3 months as per standard protocol. 1. Classified ENT Specialist & Head-Neck Surgeon, Dept of ENT and Head-Neck, Surgery, Combined Military Hospital, Chattogram. 2. Professor & Chief, Head & Neck surgery Division, BSMMU, Dhaka. 3. Classified ENT Specialist & Head Neck Surgeon, Dept. of ENT and Head-Neck Surgery, Combined Military Hospital, Cumilla. 4. Classified ENT Specialist & Head – Neck Surgeon, Dept. of ENT and Head-Neck Surgery, Combined Military Hospital, Barishal. 5. Graded ENT Specialist & Head – Neck Surgeon, Dept. of ENT and Head-Neck Surgery, Combined Military Hospital, Bir Uttam Shaeed Mahbub Senanibash, Kholahati, Parbatipur. Address of correspondence: Lieutenant Colonel (Dr.) Muhammad Ali Azad, Classified ENT Spl & Head Neck Surgeon, Dept. of ENT and Head-Neck Surgery, Combined Military Hospital, Chattogram, Bangladesh. Mobile: +8801714056245, E-mail: aliazad101052@gmail.com Introduction: Total laryngectomy is still indispensable procedure in treating advanced or recurrent cancer of larynx and hypopharynx. The larynx has important functions in olfaction and respiration and is more than just an organ of voice production. Its removal requires rehabilitation of all three systems. Perhaps loss of voice is the most distressing to the patients as they loss power of communications and establishment of an acceptable voice is critical for successful psychological adjustment. Multidisciplinary team effort is mandatory to achieve optimal results and good QoL. Prosthetic rehabilitation of voice in laryngectomized patient has become popular after the original article published by Singer and Blom (1980)1. subsequently several high quality voice prosthesis were introduced and have been used successfully such as Panje2, Groningen3 etc. The possibility of achieving good voice is greater with prosthesis comparing with the esophageal voice. Now a days the provox voice prosthesis is the commonest prosthesis used. The first provox voice prosthesis manufactured by Atos Medical, Sweden in 1990. Several version of provox introduced till date. In 2009 the third generation provox vega with smart Inserter was introduced. In our study provox voice prosthesis and vega voice prosthesis were used4-6. Materials and Methods: This cross sectional retrospective study was conducted among the patients suffering from advanced laryngeal cancer had undergone total laryngectomy from Jan 2013 to Jan 2020 in the department of ENT & head-Neck surgery, Combined Military Hospital, Dhaka. Candidates were post chemo-radiated/ radiated biopsy proven recurrent cases, clinically non functional larynx with aspiration and radiologically evident of cartilage erosion. Results: Among the 57 patients 42 of them are using voice prosthesis without any complications till to date. Voice rehabilitation started after wound healing & developed meaningful voice in around 6 weeks. Satisfactory speech & voice outcomes were observed near about 3 months. Voice quality was assessed by multivariate statistical analysis. Excellent voice was observed for 38 patients, good voice for 12 patients, fair voice for 05 patients and poor voice for 02 patients. Troubleshooting like mycotic infection developed in 6 patients which was managed by anti-fungal medication with regular appropriate cleaning, Pharyngocutaneous fistula developed in 5 patients, 3 healed later by pressure dressing and anticholinergic & 1 required exploration and flap reconstruction, 01 developed recurrent stomal stenosis which managed surgically by Y-V advancement. Prosthesis expelled out in 3 cases. 02 cases developed dysphagia due to tonicity of pharyngoesophageal (PE) segment & managed by botox injection. Significantly better voice & swallowing were reported by patients undergone laryngectomy alone in comparison with patients receiving adjuvant radiotherapy & patient undergoing salvage laryngectomy. Conclusion: Awareness should be developed as sacrifice of voice box is no more a permanent comorbidity of total laryngectomy. Excellent voice can be developed by insertion of voice prosthesis as well as swallowing pulmonary and olfactory rehabilitation following laryngectomy for better of QoL.