Laryngectomy Stoma Research Articles

Republication de : Description of a novel technique for creation of a custom-made prosthesis to aid vocalisation following laryngectomy

There are various options to restore phonation after laryngectomy; one option involves using tracheo-oesophageal voice by placing a speaking valve through the tracheo-oesophageal wall. Some patients struggle to obtain good fixation of an adhesive base plate to the skin; this can result in air leakage and poor voice. We describe a technique using a custom-made prosthesis to provide a better base plate for fixation of the heat and moisture exchange cassette. This technique involves making an impression of the anterior neck around the laryngectomy stoma to create an anatomically fitted prosthesis, which accurately fills the void around the stoma. The custom-made prosthesis provides a more individualised fit compared to a standard base plate, helping improve vocalisation and communication.

N’opérez pas vos patients le jour de votre anniversaire !

There are various options to restore phonation after laryngectomy; one option involves using tracheo-oesophageal voice by placing a speaking valve through the tracheo-oesophageal wall. Some patients struggle to obtain good fixation of an adhesive base plate to the skin; this can result in air leakage and poor voice. We describe a technique using a custom-made prosthesis to provide a better base plate for fixation of the heat and moisture exchange cassette. This technique involves making an impression of the anterior neck around the laryngectomy stoma to create an anatomically fitted prosthesis, which accurately fills the void around the stoma. The custom-made prosthesis provides a more individualised fit compared to a standard base plate, helping improve vocalisation and communication.

Emergency management of neck stoma patients during the coronavirus pandemic: a national nurse survey.

Neck stoma patient care involves significant clinical complexity. Inadequate staff training, equipment provision and infrastructure have all been highlighted as causes for avoidable patient harm. To establish the perception of knowledge and confidence levels relating to the emergency management of neck stomas among UK nurses during the COVID-19 pandemic. A nationwide prospective electronic survey of both primary and secondary care nurses via the Royal College of Nursing and social media. 402 responses were collated: 81 primary care and 321 secondary care; the majority (n=130) were band 5. Forty-nine per cent could differentiate between a laryngectomy and a tracheostomy; ENT nurses scored highest (1.56; range 0-2) on knowledge. Fifty-seven per cent could oxygenate a tracheostomy stoma correctly and 54% could oxygenate a laryngectomy stoma correctly. Sixty-five per cent cited inadequate neck stoma training and 91% felt inclusion of neck stoma training was essential within the nursing curriculum. Clinical deficiencies of management identified by nurses can be attributed to a lack of confidence secondary to reduced clinical exposure and education.

Description of a novel technique for creation of a custom-made prosthesis to aid vocalisation following laryngectomy

There are various options to restore phonation after laryngectomy; one option involves using tracheo-oesophageal voice by placing a speaking valve through the tracheo-oesophageal wall. Some patients struggle to obtain good fixation of an adhesive base plate to the skin; this can result in air leakage and poor voice. We describe a technique using a custom-made prosthesis to provide a better base plate for fixation of the heat and moisture exchange cassette. This technique involves making an impression of the anterior neck around the laryngectomy stoma to create an anatomically fitted prosthesis, which accurately fills the void around the stoma. The custom-made prosthesis provides a more individualised fit compared to a standard base plate, helping improve vocalisation and communication.

Endobronchial ultrasound through laryngectomy stoma using adhesive base plate

Endobronchial ultrasound through laryngectomy stoma using adhesive base plate

Multidisciplinary airway response teams: Concept, structure, & implementation

Airway management challenges encompass the anticipated (eg, airway pathology, history of difficult intubation, bleeding) and the unanticipated. Challenging airway situations also occur in patients with existing in situ tracheostomy tubes and laryngectomy stomas or in intubated patients around the time of planned or unplanned extubation. Preparedness to handle difficult airway scenarios requires a structured approach to patient assessment, identification, and planning. Preparedness also necessitates an organized, disseminated, and predefined process to deliver appropriate resources efficiently to the bedside in an emergency at any time of day. Specialized equipment, multidisciplinary expertise, clinical algorithms, effective communication, and teamwork are critical components of an effective response system. A structured multidisciplinary airway rapid response team that includes both an anesthesiologist and a surgeon is one model to effect such as system.

Tracheostomy Management during the COVID-19 Pandemic.

The ongoing coronavirus disease 2019 pandemic has led to unprecedented demands on the modern health care system, and the highly contagious nature of the virus has led to particular concerns of infection among health care workers and transmission within health care facilities. While strong data regarding the transmissibility of the infection are not yet widely available, preliminary information suggests risk of transmission among asymptomatic individuals, including those within health care facilities. We believe that the presence of a tracheostomy or laryngectomy stoma poses a unique risk of droplet and aerosol spread particularly among patients with unsuspected infection. At our institution, guidelines for the care of open airways were developed by a multidisciplinary open airway working group, and here we review those recommendations to provide practical guidance to other institutions.

Care of laryngectomy stomas in general practice.

Laryngectomy stomas are formed following excision of the larynx, usually for the treatment of an underlying malignancy. This is a permanent stoma in which thetrachea is separated from the oesophagus and brought to an opening in the neck. The complication rate of laryngectomy stomas is reported to bemore than 60%. The purpose of this article is to provide an overview of total laryngectomy stomas and inform general practitioners (GPs) of the frequently encountered complications, to improve stoma-related care and ultimately patient outcomes. Numerous early and late complications can be encountered by a GP, some of which are potentially life-threatening and require prompt recognition. Care ofpatients who have had a laryngectomy is multi-disciplinary, and GPs are often the first point of contact. The importance of a well-informed GP who can treat the patient and identify when they require referral to a stomal therapy nurse, speech pathologist or surgeon cannotbe understated.

Hemodynamic response to tracheal intubation in postlaryngectomy patients.

Background and Aims:Endotracheal intubation in postlaryngectomy patients is usually accomplished by inserting endotracheal tube directly into the laryngectomy stoma. The primary objective of our study was to assess the systolic blood pressure (SBP) response to intubation in postlaryngectomy patients. Secondary objectives included assessment of changes in heart rate (HR), mean arterial pressure (MAP), and to estimate tracheal component of hemodynamic response to intubation in normal patients by finding out the relative reduction in hemodynamic response that might occur in postlaryngectomy patients.Material and Methods:This was a prospective, observational study. Forty postlaryngectomy patients formed group L and 40 normal patients constituted group N. After induction of anesthesia and neuromuscular blockade, direct laryngoscopy and tracheal intubation were performed in group N, whereas an endotracheal tube was passed through the laryngectomy stoma directly into the trachea in group L. Hemodynamic responses were documented. Chi-square test, independent samples t-test, and analysis of covariance (ANCOVA) test were applied.Result:Group L patients were significantly older with significantly lower baseline HR with higher SBP and MAP. As baseline values were not comparable, they were taken as covariates and ANCOVA was applied. Adjusted mean values were then compared. Immediately after induction HR, SBP and MAP were comparable in both groups. Subsequent comparison of adjusted mean values showed significantly higher HR, SBP, and MAP in group N immediately after intubation and 1,3,5, and 10 min later (P < 0.001). At 15 min, HR and SBP were significantly higher in group N with comparable MAP.Conclusion:Hemodynamic stress response to endotracheal intubation is minimal or absent in postlaryngectomy patients. They mostly present with elevated blood pressure and develop hypotension following induction that persists despite intubation.

Modified custom-made laryngectomy stoma prosthesis

Introduction: A tracheo-oesophageal valve for speech restoration is commonly used following total laryngectomy. Limitations include leakage around the prosthesis, granuloma formation and lack of retention due to poor tissue integrity and altered anatomy post-surgery. This poses a significant challenge when using conventional rehabilitation techniques and patient focused adaptations are necessary.We present the use of a custom-made laryngectomy stoma prosthesis to improve functional voice restoration.

Tracheostomy Complications as a Trigger for an Airway Rapid Response: Analysis and Quality Improvement Considerations.

To analyze the subset of airway rapid response (ARR) calls related to tracheostomy identified over a 46-month period from August 2011 to May 2015 to determine proximate cause, intervention, and outcome and to develop process improvement initiatives. Single-institution multidisciplinary retrospective cohort study. Tertiary care academic medical center in a large urban setting. Hospital inpatients with an in situ tracheostomy or laryngectomy who experienced an ARR. Detailed review of operator, hospital, and patient records related to ARR system activations over a 46-month period. ARR was activated for 28 patients with existing tracheostomy. The cohort included open tracheostomy (n = 14), percutaneous tracheostomy (n = 8), laryngectomy stoma (n = 3), and indeterminate technique (n = 3). The most frequent triggers for emergency airway intervention were decannulation (n = 16), followed by mucus plugging (n = 4). The mean body mass index of ARR patients was higher than that of a comparator tracheostomy cohort (32.9 vs 26.3, P < .001). BMI was >40 in 9 ARR patients. There was 1 mortality in the series. Tracheostomy is a major trigger for ARR with potential fatal outcome. Factors that may contribute to tracheostomy emergencies include high body mass index, surgical technique for open tracheostomy or percutaneous tracheostomy, tracheostomy tube size, and bedside tracheostomy management. Results have triggered a hospital-wide practice improvement plan focused on tracheostomy awareness and documentation, discrete process changes, and implementation of guidelines for emergency management.

Assessment of Otolaryngic Knowledge in Primary Care Residents

(1) Determine the amount of exposure to otolaryngology in medical training of non-otolaryngology residents. (2) Evaluate the general otolaryngic knowledge in these residents. Cross-sectional survey. Academic medical center. A 10-question multiple-choice quiz was given to residents in family practice, pediatrics, emergency medicine, and internal medicine during scheduled educational conferences. Residents were also asked if they ever participated in an otolaryngology rotation during medical school or residency. Medical students and otolaryngology residents completed the quiz to act as controls. A total of 98 examinations were analyzed (49 non-otolaryngology residents, 10 otolaryngology residents, and 39 second-year medical students). Only 24% of the non- otolaryngology residents had an otolaryngology rotation during medical school. The same amount (24%) had a rotation during residency. The average percentage correct on the quiz was 48%, 56%, and 92% for medical students, non-otolaryngology, and otolaryngology residents, respectively (P < 0.05). Questions with surprising results included one with an endoscopic image of the middle turbinate and examinees asked to identify the structure (non-otolaryngology residents = 18% correct). A laryngectomy stoma was shown and participants asked what would happen if the stoma was occluded for 10 minutes (non-otolaryngology residents = 20% correct). In this sample of non-otolaryngology residents, a minority experienced a clinical rotation in otolaryngology during medical school or residency. This nonvalidated questionnaire also suggested significant deficiencies in basic otolaryngic knowledge in these residents. Identifying mechanisms to improve exposure to otolaryngology in the medical training curriculum is needed.

General Otolaryngology Knowledge in Primary Care Residents

Objective: 1) Determine the amount of exposure to otolaryngology in medical training of nonotolaryngology residents (NOR). 2) Evaluate the general otolaryngology-related knowledge in these residents. Method: A 10-question multiple-choice quiz was given to residents in family practice, pediatrics, emergency medicine, and internal medicine during scheduled educational conferences. Residents were also asked if they ever participated in an otolaryngology rotation during medical school or residency. Medical students and otolaryngology residents completed the quiz to act as controls. Results: A total of 49 NOR and 44 medical students answered the questionnaire. Only 24% of the NOR had an otolaryngology rotation during medical school. The same amount (24%) had a rotation during residency. The average percentage correct on the quiz was 49%, 57%, and 91% for medical students, NOR, and otolaryngology residents respectively ( P &lt; .05). Questions with surprising results included one with an endoscopic image of the middle turbinate, and examinees were asked to identify the structure (NOR = 18% correct). A laryngectomy stoma was also shown, and participants were asked what would happen if the stoma was occluded for 10 minutes (NOR = 20% correct). Conclusion: In this sample of nonotolaryngology residents, a minority experienced a clinical rotation in otolaryngology during medical school or residency. This nonvalidated questionnaire also suggested significant deficiencies in basic otolaryngology knowledge in these residents. Identifying mechanisms to improve exposure to otolaryngology in the medical training curriculum is needed.

A simple method for re-dilatation of an acute tracheostoma stenosis

Tracheostomy or laryngectomy stomas may sometimes re-stenose, resulting in respiratory distress for the patient unless the stoma is rapidly re-dilated and an adequate airway re-established. This article describes a simple and effective method for the acute re-dilatation of a tracheostoma stenosis, using an aural speculum, prior to the insertion of a patent airway tube. This technique has been successfully used in our department since 1995 and, in our experience, causes significantly less distress to our patients when compared with other means employed previously.

New use of a tracheal tube for rescue breathing in laryngectomees in the community

The currently recommended method for rescue breathing in people who have had a laryngectomy is mouth-to-stoma. Even if they know what to do, by-standers are likely to find this technique unhygienic and therefore unacceptable. There is no equivalent of the pocket face mask for laryngectomees. This paper describes the practical differences that affect rescue breathing in patients with laryngectomy stomas and proposes a new use of a tracheal tube for rescue breathing in laryngectomees. Ten patients with permanent tracheal stomas scheduled for ENT surgery were ventilated successfully through a tracheal tube with the cuff applied to the outside of their tracheal stomas, following induction of anaesthesia and before the start of surgery. Observations of oxygen saturation, end-tidal carbon dioxide, expired tidal volume and chest movements were within acceptable limits. This device was simple to use and is hygienic and inexpensive. Laryngectomees' relatives, friends or carers with minimal training could use the tube in a mouth-to-tube-to-stoma technique should the need for rescue breathing arise. It could also be used by paramedic and medical staff in a mouth or bag-to-tube-to-stoma technique until a definitive airway can be inserted.

Bacterial colonization of laryngectomy stomas

Infections with organisms resistant to conventional antibiotics are of increasing concern. This observational study investigates the bacterial colonization of the peristomal area of laryngectomy patients. Thirty-two consecutive patients who had previously undergone laryngectomy were recruited from the Head and Neck Clinic of a teaching hospital. Swabs were taken from the laryngectomy stoma site, the mouth and both nasal cavities. Microbiological culture and isolation were performed following standard procedures. Despite no clinical sign of infection, 27 patients were found to be carriers of one or more organism (84.4 per cent). Staphylococcus aureus was detected in the peristomal area of 15 patients (46.9 per cent). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in seven (21.9 per cent) cases. In this series the authors found a high incidence of colonization with potentially pathogenic bacteria in laryngectomy stomas with no clinical signs of infection. In a significant number of patients, Gram positive organisms were identified that could potentially cause cellulitis or wound infections.

Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study.

We evaluated the incidence, risk factors and consequences of wound infection (WI) following major head and neck cancer surgery in an open non-comparative study. The study group, comprising 95 patients who underwent clean-contaminated procedures with opening of the upper aerodigestive tract for biopsy-proven squamous cell cancer, were studied over a 1-year period. Antibiotic prophylaxis was amoxicillin and clavulanic acid. More than 20 variables were prospectively recorded for each patient. The mean follow-up was 30 months. The overall WI rate was 50.5% (48/95). Most pathogens isolated from samples were gram-negative rods. In univariate analysis, we found three risk factors for WI: alcohol consumption (P = 0.07), a hypopharyngeal location (P = 0.02) and laryngectomy stoma (P = 0.01). WI were associated with postoperative fever (P = l.5 x 10(-11)), postoperative antibiotic therapy (P = 1.5 x 10(-5)) and postoperative death (P = 0.043). Patients without WI had a median postoperative hospital stay of 15 days compared with 29 days for those with WI (P < 0.001). Healing of WI was achieved after a median time of 48 days. WI delayed postoperative radiation therapy in 21 out of 33 evaluable patients. But overall survival, and local and metastatic failures were similar with and without WI. WI are associated with a heavy postoperative morbidity, but have no prognostic impact on cancer control.

The dose distribution of medium energy electron boosts to the laryngectomy stoma

An en face, medium energy electron boost of approximately 10 Gy is often given to stomal and peristomal tissues. Because the boost is considered a simple treatment, CT-based treatment planning is rarely used. Further, the results of such a plan might be inaccurate, as the complex dose distribution surrounding the stoma air cavity is poorly modeled by many treatment planning systems. We constructed three phantoms—two with a central vertical cavity to mimic the size and shape of the stoma and proximal trachea and one with a cavity inclined at 45° to the horizontal to better simulate anatomy. These were used to investigate the dose distribution surrounding the stoma. In all cases, the entrance to the stoma opening was centered in a field defined by a 7-cm circular cutout and the phantom was irradiated at a source-surface distance (SSD) of 100 cm with either vertically incident 9- or 12-MeV electrons. Film measurements were made at a range of depths below and lateral to the cavity. For the vertical cavity phantoms, diode measurements were performed and isodose plans using CT scans of the phantoms were generated on a modern treatment planning system. For these two phantoms, the combined effects of lateral scatter from surrounding material and reduced equivalent thickness for electrons which pass directly through the cavity increases the dose within a centimeter of the bottom of cavity by as much as 50% for 9 MeV and 70% for 12 MeV. In material at the shallower (“superior”) end of the inclined cavity, a overdose was noted. The dose increase is geometry dependent and is not predicted by the available treatment planning system. The potential of such a dose increase to affect normal tissues such as the neopharynx should be considered. PACS number(s): 87.53.–j, 87.66.–a

Universal ventilation laser tracheoscope.

A universal ventilation laser fiberoptic tracheoscope has been developed for use in endoscopic treatment of patients with obstructing benign and malignant lesions of the subglottis-cervicotrachea and laryngectomy tracheal stoma. This instrument features a ventilation connector for either side port or Venturi jet ventilation and a proximal connector with a sheath for delivery of a 0 degrees telescope, laser fiber, and suction catheter. Difficulties encountered with exposure and ventilation during laser treatment of the subglottis-cervicotrachea and laryngectomy stoma are overcome with this new instrument.