Voice Restoration Research Articles

Has Esophageal Speech Returned as an Increasingly Viable Postlaryngectomy Voice and Speech Rehabilitation Option?

The literature on postlaryngectomy voice and speech rehabilitation is long-standing. Although multiple rehabilitation options have existed over the years, the acquisition and use of esophageal speech (ES) has decreased significantly over the past 40 years. This reduction coincides with the increased application of tracheoesophageal puncture (TEP) voice restoration. The literature suggests that voice acquisition failures observed secondary to TEP may represent a similar phenomenon that led to ES acquisition failures. A comprehensive review of the literature on ES and TEP voice/speech was conducted. Specific attention was directed toward information on ES and TEP speech failures. Information on pharyngoesophageal segment (PES) spasm in the context of ES and TEP voicing failures was of specific importance. Similarities between voicing failures with both ES and TEP were identified. In order to resolve spasm in TEP speech, proactive efforts to eliminate it were undertaken, and regardless of the method used, voicing improvements were observed. These data suggest that both ES and TEP speech acquisition failures may be related to the same control mechanisms influencing the PES. The elimination of PES spasm provides evidence that justifies the reconsideration of ES. Consequently, ES may return as an increasingly viable postlaryngectomy voice and speech rehabilitation option.

Communication competence and disability secondary to laryngectomy and tracheoesophageal puncture voice restoration.

There is a large body of research showing the negative impact of a total laryngectomy on the resultant voice signal across multiple outcomes (e.g., speech intelligibility/acceptability, listener comprehension, voice quality). However, there is limited information on the effects of laryngectomy on broader communication acts, particularly in the area of pragmatics, commonly referred to as the social use of language. Considering that individuals with a laryngectomy (IWL) frequently report reduced quality of life as well as reduced communicative competency, expanding the current research to include pragmatics is warranted. To explore the pragmatic changes in communication experienced by tracheoesophageal speakers. The current study adapted an existing 17-item measure to assess verbal, non-verbal, paralinguistic and receptive communication competence via self-report. This adapted measure was then distributed to 65 tracheoesophageal speakers (52 males, 13 females, mean age = 63.4±8.5 years). Both negative and positive pragmatic changes to communication were reported by participants secondary to laryngectomy. This included changes in verbal (negative -37.5%, positive -15.15%); non-verbal (negative -9.54%, positive -35.45%; and paralinguistic acts (negative -29.55%, positive -34.09%). Changes to receptive communication were also noted (negative -14.78%, positive -43.19%). The overall results suggest that communication changes post-laryngectomy exist well beyond the paralinguistic areas (e.g., intelligibility, voice quality) and that males and females may approach or respond to changes in communication differently. Results are discussed specific to clinical intervention and the importance of including assessment of pragmatic function post-laryngectomy. What is already known on this subject While there is a large body of research on the changes to the speaker and listener following laryngectomy, there is minimal information on how the use of alaryngeal speech affects overall communication, specifically in the area of pragmatics or the social use of language. What this paper adds to existing knowledge This study used an adapted version of the widely used Pragmatic Protocol to delineate changes in pragmatic components of communication for tracheoesophageal speakers. What are the potential or actual clinical implications of this work? Clinically, this information can be used by healthcare professionals to educate and prepare IWL on potential changes in the underrecognized area of pragmatics.

Management of blunt and penetrating laryngeal trauma

Patients presenting with laryngotracheal trauma can be in alife-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving agood functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using acombination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy.

Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient's immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient's own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.

Phonosurgical Injection Approaches for Voice Restoration After Open Partial Horizontal Laryngectomies: A Pilot Study

The aim of the present study is to evaluate the efficacy of phonosurgical corrective approaches based on injection laryngoplasties and pharyngoplasties followed by speech therapy for voice restoration after unsatisfactory phonatory results of open partial horizontal laryngectomies. Ten patients with not satisfying phonatory results despite speech therapy after type II or type III open partial horizontal laryngectomies (OPHLs) were included. Each patient underwent a voice restoration program based on phonosurgery (injection laryngoplasty and/or injection pharyngoplasty) with hyaluronic acid and/or calcium hydroxyapatite, followed by post-surgical voice rehabilitation. Voices were recorded and analysed through spectrographic, aerodynamic, perceptual, laryngoscopic and self-assessment evaluations before the treatment (T0), after 1 month (T1) and after three months (T2). Significant improvements in the patients voices were found between T0, T1 and T2 concerning acoustic, perceptual, aerodynamic, laryngoscopic and self assessment evaluations. The results of the present study support phonosurgical injection procedures followed by speech therapy as an effective strategy for voice restoration after type II or type III OPHLs in selected patients.

A Multidisciplinary Approach to Secondary Tracheoesophageal Puncture for Voice Prosthesis Insertion Using Flexible Esophagoscopy

BackgroundTracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. MethodsOur study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. ResultsWe identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. ConclusionOur multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

Comprehensive Evaluation of Vocal Outcomes and Quality of Life after Total Laryngectomy and Voice Restoration with J-Flap and Tracheoesophageal Puncture.

Simple SummaryLaryngopharyngectomy is still the treatment of choice in locally advanced pharyngolaryngeal tumors not eligible for organ preservation protocols. Loss of speech capacity has been reported as one of the factors that most affect the patient-reported quality of life. Thus, the reconstructive goals are restoring the pharynx and possibly the voice in such a scenario. For decades, tracheoesophageal puncture (TEP) has allowed proper voice rehabilitation; however, TEP has a non-neglectable financial expenditure and complication rate. Therefore, we recently reported a novel flap design and surgical technique that shares the same principles of TEP, without the need to change any device over time, named J-flap. This study aimed to analyze both techniques’ subjective and objective vocal outcomes and their impact on overall and voice-related quality of life.Background: Tracheoesophageal puncture with a voice prosthesis is the gold standard for speech rehabilitation in patients that receive a laryngopharyngectomy. However, a novel surgical technique, using a tubularized anterolateral tight flap, named “J-flap,” has been demonstrated to produce adequate voice restoration. We aimed to compare the outcomes and the quality of life of patients who underwent voice rehabilitation with both techniques. Methods: We enrolled patients that underwent laryngopharyngectomy and voice restoration surgery. The control group received a tracheoesophageal puncture with a voice prosthesis, while the study group received J-flap reconstruction. A total of 20 patients received voice prosthesis rehabilitation, while 18 received J-flap reconstruction. Speech and vocal outcomes and quality of life metrics were collected. Results: The objective phonatory performances and the acoustic voice analysis did not outline a significant difference. Speech pathologists judged the consonant pronunciation in the J-flap group as less accurate (p < 0.001). The voice handicap index revealed a moderate impairment for the J-flap group (p < 0.001). Quality of life scores were higher for the voice prosthesis group. Conclusion: Voice prostheses and J-flaps share similar objective phonatory outcomes. Quality of life was more impaired in the J-flap group. In our view, these two techniques possess complementary characteristics in clinical practice, taking into account health care system regulations and patients’ social background.

How I do it: modified lichtenberger-brown tracheoesophageal puncture procedure

BackgroundTracheoesophageal puncture (TEP) with use of a prosthesis is nowadays a standard for voice restoration after laryngectomy. Different TEP approaches exist.MethodsWe retrospectively reviewed our series of patients who underwent TEP by a novel technique, based partially on the Lichtenberger endo-extralaryngeal needle carrier. The instrument is covered with a protective Nelaton catheter and introduced via the mouth to the neopharynx/esophagus. No rigid endoscope is used for visualization of the TEP site. The tip is palpated through the stoma at the posterior tracheal wall and incision is done to the catheter tip. The prosthesis is introduced through the mouth and the neopharynx in a retrograde fashion.ResultsIn 14 laryngectomees with postoperative radiation voice prosthesis was successfully placed with this technique. A total of 18 procedures were performed. One misplacement occurred. No other early or late complications were observed or any other TEP or prosthesis related problems.ConclusionsThe rationale of our technique is to simplify the procedure, avoid risk-bearing approaches and instruments such as rigid endoscopes, simplify the armamentarium and reduce tissue trauma. The initial clinical experience in 18 TEPs confirmed it usefulness in both standard and anatomically challenging situations.Trial registrationThe current study obtained the ethical approval from the Faculty of Medicine at Medical University "Prof. Dr. Paraskev Stoyanov"—Varna, Bulgaria (Protocol 087/24.10.2019 (retrospectively registered).Graphical abstract

Radiofrequency ablation of intubation granulomas

ObjectiveWe explored the outcomes and voice parameters of patients undergoing plasma radiofrequency (RF) ablation to treat intubation granulomas. Study designProspective case series. Methods and materialsPatients with intubation granulomas who met the inclusion criteria underwent RF ablation. The complete remission rate and voice function were evaluated preoperatively and at 6 months postoperatively. ResultsWe enrolled 13 patients with 25 intubation granulomas. The mean time between intubation and initial diagnosis was 38.6 days and that between intubation and surgical diagnosis was 2.7 months. All 25 granulomas were successfully removed and histologically confirmed. No surgical remnant was evident on the vocal folds and complete glottal closure was observed at 2 weeks postoperatively. No recurrence or RF ablation-related complications were observed during the 6-month follow-up. The complete remission rate was 100% (13/13). In addition, the mean hoarseness, roughness, breathiness, asthenia, and strain (GRBAS) scores, and the maximum phonation time (MPT), improved significantly after treatment (all P < 0.05). ConclusionsRF ablation is effective and safe for patients with intubation granulomas who failed medical management or request the procedure. In this study, the complete resolution rate was high and voice restoration outcomes were good.

Informing patient choice and service planning in surgical voice restoration: valve usage over three years in a UK head and neck cancer unit.

This study aimed to determine the number, reasons and costs of surgical voice restoration related tracheoesophageal valve attendances over 36 months at a head and neck oncology unit. Demographic, medical and valve related details from all patient contacts were recorded, including self-change information, urgent appointment information, modifications required and costs of prostheses. Over 3 years, 99 patients underwent 970 valve changes. The main reasons for changes were central leakage, prophylactic change and self-change at home. Changes were significantly more frequent in the first 12 months (mean, 42 days) compared with longstanding patients (mean, 109.96). Intervals between changes were unpredictable; no predictive factors reached statistical significance. Mean expenditure on valves was £966.63 per week (including value added tax and in-house customisation). Valve lifespan is comparable with outcomes in similar units despite more pre-emptive and patient-led changes and more comprehensive data inclusion. Investigation into how patient satisfaction and costs relate to valve selection and units' service delivery models is needed.

919 Surgical Voice Restoration – Improving Out of Hours Management: A Multidisciplinary Quality Improvement Project

Abstract Aim Swansea Bay University Health Board have a caseload of 37 surgical voice restoration (SVR) laryngectomies. These patients are excellently managed during working hours, by a SALT-led service. Concerns were raised regarding the quality of out of hours management: the aim of this project was to identify and address the factors contributing to the difference in care received. Method A questionnaire was sent to current junior doctors to assess knowledge and confidence when managing SVR patients. Phone interviews were conducted with SVR patients to discuss the issues from a patient’s perspective. The junior doctor team and SALT team liaised to identify contributing logistical issues. Results The junior doctor survey indicated both experience and confidence were low, including amongst senior trainees. 58.3% were unfamiliar with equipment used to change a speech valve. Patient interviews revealed several issues, such as delays to treatment and unnecessary admissions. Logistical concerns included inability to access equipment out of hours and an absence of departmental guidelines. Conclusions This project demonstrates a collaborative approach between junior doctors and SALT, to improve the quality of care for a sub-set of patients with highly specialised needs. We identified the contributing factors for the disparity in services and tailored interventions to provide the junior doctors responsible for out of hours care, with the knowledge and skills to provide a better standard of care.

Tracheoesophageal Voice Rehabilitation after Total laryngectomy: Primary Versus Secondary Tracheoesophageal Puncture

Background: Voice prosthesis is the current standard for post laryngectomy rehabilitation. Several clinical factors can affect the functional outcomes of voice prosthesis. Various complications are recorded with voice prosthesis. Objective: This study aimed to compare the results of primary and secondary provox insertion in patients with advanced laryngeal carcinoma undergoing total laryngectomy. Patients and Methods: Randomized-controlled clinical study included 24 patients with provox voice prosthesis rehabilitation 12 had primary tracheoesophageal puncture and 12 had secondary tracheoesophageal puncture. All patients were evaluated for successful voice restoration and complications rates. Results: Short-term success rate was 92% in the primary group and 83% in the secondary group. Long-term success rate was 83% in the primary group and 75% in the secondary group. Success rates were higher in the primary group but without statistically significant difference. Complications rate in the primary group was 58.3% and in the secondary group 66.6%. Complications rate was higher in the secondary group but without statistically significant difference. Conclusion: Provox voice prosthesis provides consistent and good voice results, which improve with time. Primary provox insertion had better success rates and fewer complications. Periprosthetic leak is the most common complication.

Editorial introductions.

Current Opinion in Otolaryngology & Head and Neck Surgery was launched in 1993. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of otolaryngology and head and neck surgery are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jo PattersonJo PattersonDr Jo Patterson is a Professor of Speech and Language Therapist and Associate Head of Research at the University of Liverpool and The Liverpool Head and Neck Centre. Her research portfolio includes proof of concept work, cohort studies, feasibility studies, multi-centre randomized control trials and the development and evaluation of complex interventions. She is committed to involving patients and keeping them central to research and service development. In 2016, she received a Royal College of Speech and Language Therapy Fellowship in recognition of her contribution towards the advancement of the profession, both as an academic and a practicing Speech and Language Therapist. As their specialist advisor, she represents the organisation on a number of committees and councils, contributing towards policy and strategic direction. She has extensively developed research capacity for Speech and Language Therapists nationally through grant and fellowship applications and provision of MSc and PhD supervision, teaching and mentorship. She continues to balance her time between clinical and academic practice. H. Fiona RobinsonH. Fiona RobinsonMiss H. Fiona Robinson is an Advanced Practitioner Speech and Language Therapist. She qualified as a Speech Therapist from Birmingham Polytechnic, UK in 1980, and in 2004, she was awarded Master of Science (Merit) (Advanced practice – Voice) from the University of Newcastle, UK, with a study into the efficacy of voice therapy for vocal fold paralysis. In 2006, in recognition of her contribution to the speech and language therapy profession in the UK, Miss Robinson was elected to the Fellowship of the Royal College of Speech and Language Therapists (RCSLT), UK. She has completed a post-graduate certificate in Medical Education at the University of Nottingham, UK with a particular interest in the development of E-learning. Her clinical interests include the diagnosis and rehabilitation of speech and swallowing disorders related to head and neck cancer, including surgical voice restoration, and the management of dysphonia. Currently she is working within the National Health Service (NHS) as an Advanced SLT Practitioner at the Nottingham University Hospitals NHS Trust, and is co-Director of SVS Associates, a company which runs skills training for speech and language therapists. Fiona is a founder member and past-Chair of the National Clinical Expert Network (RCSLT) in head and neck oncology. As a RCSLT Clinical Adviser she contributes widely to the SLT profession in the UK in the development of national policies. Johannes J. FaganJohannes J. FaganDr Johannes J. Fagan is Professor and Chairman of Otorhinolaryngology at the University of Cape Town in South Africa. He has authored 200 peer reviewed articles and book chapters. A major interest has been to advance head and neck surgery in Africa and the Developing World. To this end he self-publishes two free open access textbooks, “The Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery” and the “Open Access Guide to Audiology and Hearing Aids”.

Dynamic Study of Oesophageal Function during Phonation: Simple but Effective

Secondary aphonia significantly affects the quality of life of the laryngectomy patient despite the excellent success of the operation. Vocal rehabilitation often does not achieve the desired results, given the innumerable prognostic variables. Tracheo-oesophageal speech is considered the standard gold method of voice restoration, but a possible spasm of pharyngo-oesophageal segment is the prominent cause of rehabilitation failure. However, the phenomenon is difficult to identify and underestimated, and diagnostic methods are inquisitive or expensive. To propose a phonatory and swallowing evaluation essay of pharynx-oesophageal segment disorders, we conducted a retrospective study from 2012 to 2017 by selecting 6 patients who underwent total laryngectomy and voice prosthesis implantation that suffered from aphonia after surgery. All patients underwent dynamic phonation videofluoroscopy and plexus bath control test with lidocaine hydrochloride. All patients were then referred for treatment with neurotoxin blocker. In all cases, the analysed patients presented an air-trapping phenomenon with the formation of a spasmodic block upstream of an interrupted aerial column. The control test with lidocaine hydrochloride resulted in a transient improvement in speech performance. The neurotoxin block therapy subsequently performed ultimately led to an improvement in the patient’s rehabilitation process with a recovery of the phonatory performance. We describe the new use of a barium bolus as a diagnostic tool for identifying neopharynx disorders. Appropriately selected patients with pharynx-oesophageal segment disorders could benefit from a neurotoxin-blocking treatment to improve oesophageal speech.

Long-term functional and quality of life outcomes in laryngectomized patients after successful voice restoration using tracheoesophageal prostheses

ObjectiveTo assess long-term functional and quality of life (QoL) outcomes and their predictive factors in laryngectomized patients after successful voice restoration using tracheoesophageal prostheses (TEP). MethodsThis cross-sectional study was conducted in alive and disease-free patients at least 1 year after total laryngectomy ± partial pharyngectomy. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core (QLQ-C30) and Head and Neck Cancer (QLQ-H&N35) QoL questionnaires, the Voice Handicap Index (VHI-10) questionnaire and the Hospital Anxiety and Depression Scale (HADS). The level of dysphagia was evaluated using the Dysphagia Handicap Index (DHI) and the Dysphagia Outcomes and Severity Scale (DOSS). Predictive factors of these clinical outcomes were determined in univariate and multivariate analysis. ResultsA total of 48 patients were included in this study. Long-term QoL and functioning scales scores were all superior to 70%. Main persistent symptoms were fatigue, dyspnea, senses, speech and coughing problems. A DOSS score ≥6, indicating normal/subnormal swallowing function, and a VHI-10 score ≤20, representing light to medium voice disorders, were found in at least 75% of patients. An anxiodepressive disorder (HADS global score ≥ 15) was reported by 15 (31%) patients and represented the main predictor of QoL and voice outcomes. A strong correlation was found between VHI-10 and global QoL scores. ConclusionsAfter successful voice restoration, laryngectomized patients achieved satisfactory QoL and functional outcomes. Psychological distress was the main determinant of long-term QoL and is therefore of critical importance in the multidisciplinary management of laryngectomized patients.

The Outcome of Voice Restoration with Provox&lt;sup&gt;®&lt;/sup&gt; after Total Laryngectomy

The Outcome of Voice Restoration with Provox&lt;sup&gt;®&lt;/sup&gt; after Total Laryngectomy

Voice rehabilitation after total laryngectomy with the infrahyoid musculocutaneous flap

Background It is important for the patients to reconstruct the voice phonic function by surgery after total laryngectomy in the developing countries. Aims/Objectives To investigate the clinical outcomes of voice reconstruction using an infrahyoid musculocutaneous flap for patients after total laryngectomies. Materials and methods Eighteen male patients recruited were laryngectomized. The infrahyoid musculocutaneous flap was designed. After total laryngectomy, the lower edge of the flap was sewed with the upper edge of the tracheostomy opening. Next, the lateral and medial edges of the flap were anastomosed to create a pronunciation tube. Finally, the remaining opening of the tube was sutured with the anterolateral wall of the hypopharynx to establish a communication with the pharyngeal cavity. Results A total of 17 cases of flaps were survived and only 1 necrosed. There were 17 patients without serious complications, except that 6 cases had mild irritable cough when gulping water. However, it could be relieved through blocking tracheostoma. One year after operation, all patients could more remarkably articulate clear, powerful, and consistent words. The articulatory configuration was existed under rigid laryngoscope and CT. Conclusions and significance The use of an infrahyoid myocutaneous flap is feasible for the voice restoration in the patients undergoing total laryngectomy.

Vocal Fold Paralysis from Recurrent Laryngeal Nerve Compression

Clinical Image A 63-year-old man with a recentlydiagnosed squamous cell cancer of the left lung was brought to the hospital byhis wife due to a 2-week history of progressive altered mentalstatus and a few months of hoarseness. Laboratory studiesshowed a calciumlevel of 14.4 mg per deciliter (reference range, 8.5 to 10.5). After treatment with intravenous fluids, calcitonin, and zoledronate, his serum calcium normalized after about three days and mental status improved back to baseline. Positron emission tomography with 2-deoxy-2-[18F] fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a large FDG-avid massin the left upper lobe involving the left hilum and left prevascular region (Panel A), and also an asymmetrically increased FDG uptake within the right vocal fold (Panel B, arrow; Panel C) (Figure 1) likely secondary to left vocal fold paralysis from left recurrent laryngeal nerve compression. Bedside flexible laryngoscopy was consistent with left vocal fold paralysis fixed in medial position. He was discharged with outpatient plans for chemotherapy initiation, and injection laryngoplasty for a stronger cough, voice restoration, and airway protection. However, his hypercalcemia progressively became refractory to calcitonin, bisphosphonates and denosumab delaying chemotherapy as well as his laryngoplasty. He started radiation therapy in the interim, but ultimately succumbed to the disease threemonthslater. Declaration of Interests: The authors declare that they have no competing interests.

Voice rehabilitation with phonatory prosthesis after total laryngectomy and pharyngolaryngectomy: comparison of functional outcomes between primary and secondary puncture

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tracheoesophageal puncture (TEP) with voice prosthesis (VP) placement is considered the standard for vocal rehabilitation after total laryngectomy (TL). This study aimed to compare the success rate of primary and secondary TEP and to evaluate the impact of clinical factors on functional outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective medical chart review was conducted in patients who underwent TL or pharyngolaryngectomy (PLT) and TEP. Variables collected included age, gender, comorbidities, tumor location and stage, extension of surgical resection, reconstruction, neck dissection, radiation therapy, salvage surgery, device lifetime, postoperative complications and successful voice restoration.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 186 patients were enrolled in this study, 164 patients (88.2%) underwent primary TEP and 22 (11.8%) secondary TEP. Successful voice rehabilitation was achieved in 76.9% of patients and there was no difference between primary and secondary TEP groups (76.2% vs. 81.8%, p=0.76). A poorer voice restoration outcome was found in patients who underwent radiation therapy (p=0.01) or salvage surgery (p=0.03). Adjuvant radiation was the only independent prognostic factor for functional success (OR=4.7, IC 95%= 1.4-15.9, p=0.04). VP related complications occurred in 65.7% of patients, with higher incidence in secondary TEP group (90.9% vs. 67.7%, p=0.03). Overall device lifetime was similar between primary and secondary groups (9.2 vs. 8.7 months, p=0.89).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Voice rehabilitation outcome was similar with primary and secondary TEP. However, TEP related complications were more common in secondary procedures. Primary TEP allows earlier voice restoration, avoiding a second surgical intervention. Functional success rate was poorer for patients who underwent radiation therapy.&lt;/p&gt;

Integrated Rehabilitation after a Cranial Brain Injury in the Conditions of a Sanatorium with Application of Barotherapy (Description of a Clinical Case)

Restoration after injuries is one of the key issues of medical rehabilitation practice. In the cases of severe traumatic brain injury, treatment and rehabilitation does not fit ordinary guidelines, and implementation of wider range of medical and rehabilitation technologies is necessary. In the case of a successful result in the rehabilitation process a clinical analysis of individual clinical examples is important for the medical community. The article presents the clinical case of the patient suffering from severe consequences of a head injury,in the form of severe speech impairment, paresis, communication disorders, and social maladaptation of the patient. The patient received a long-term stage rehabilitation in an in-patient department, composed of 5 treatment courses, during 11–12 days, lasting fora year. The rehabilitations courses included: pharmacotherapy, physiotherapeutic procedures, massage, acupuncture, physical therapy exercises individually with an instructor, barotherapy, etc. Rehabilitation had been carried out in the rehabilitation department by a multidisciplinary team, including neurologist, reflexologist, physiotherapist, physical rehabilitation specialist, occupational therapist,speech therapist, massage therapist and nurses. These specialists were trained during the implementation of the Pilot Project for the Development of Medical Rehabilitation in the Russian Federation in 2016. The dynamic monitoring of functional restoration within the framework of rehabilitation was performed using the International Classification of Functioning, as it reflects the state of health and disorders individually for the patient and estimate these indicators universally, where none of the functional disorders is a priority, and allows rehabilitation measures to be carried out more complex. The result was: increase in strength and functional capabilities of certain muscle groups, improved swallowing and voice formation and restoration of the minimal communicative capabilities in the sphere of social functioning.