ACTA oTorhinolAryngologiCA iTAliCA 2010;30:235-258Round Table96th National CongressItalian Society of Otorhinolaryngology ...
round Table S.i.o. national Congressconoscenza dell’anatomo-fisiologia della laringe operata. Nel lavoro che segue partire...
introductiontion of the vertical partial laryngectomy and supraglottic             the cricoid and at least one of the ary...
Round Table S.I.O. National CongressAnatomy and Physiology of the operated larynxAnatomo-fisiologia della laringe operataE...
Anatomy and Physiology of the operated larynxtilage in animals receiving hydrochloric acid and pepsin        cortical acti...
E.m. Cunsolocommanded, and is slower during controlled swallowing             The other particularly current issue, in the...
Anatomy and Physiology of the operated larynxtion of a “neoglottis”. We will, therefore, describe the ba-sic anatomy and p...
E.m. Cunsoloductory, will bring the arytenoid body and vocal processfrom an inferomedial starting position to a superolate...
Anatomy and Physiology of the operated larynxgery 18, due partly to the enormous progress achieved in             rently d...
Round Table S.I.O. National CongressSpeech therapy rehabilitationLa riabilitazione logopedicaM.P. LUPPI, f. NIzzoLI, G. BE...
Speech therapy rehabilitationoidoepiglottopexy or ThEP) or the base of the tongue (cri-         Breathing exercisescohyoid...
m.P. luppi et al.•	 rasping: the patient is seated, the tracheostomy tube           it is best to avoid pasta in broth, sh...
Speech therapy rehabilitation5    demard d, demard F. Reèducation vocale après larynngec-         9                       ...
Round Table S.I.O. National CongressSurgical rehabilitationRiabilitazione chirurgicaG. BErGAMINI, L. PrEsUTTI, M. ALIcANDr...
Surgical rehabilitationsurgical rehabilitation using hyaluronic acid 13 with bothaugmentation aims and in order to improve...
g. Bergamini et al.(Fig. 2) in an attempt to avoid relapses or reconstruc-         the mouth of the oesophagus, which by s...
Surgical rehabilitation                                                                            Fig. 7. Materials that ...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche...
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Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche chirurgiche

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Il recupero della funzione deglutitoria e fonatoria dopo chirurgia parziale della laringe metodiche logopediche e tecniche chirurgiche

  1. 1. ACTA oTorhinolAryngologiCA iTAliCA 2010;30:235-258Round Table96th National CongressItalian Society of Otorhinolaryngology and Cervico-Facial Surgery (S.I.O. e Ch.C.F.)Rimini, May 13-16, 2009Deglutition and phonatory function recoveryfollowing partial laryngeal surgery: speech therapymethods and surgical techniquesIl recupero della funzione deglutitoria e fonatoria dopo chirurgia parzialedella laringe: metodiche logopediche e tecniche chirurgicheModerator: L. Presutti (Modena)Proceedings edited by: L. Presutti, g. bergaMiniENT Department, University Hospital of Modena, ItalySummArySince the introduction of laryngeal surgery, practitioners have recognised the need for the rehabilitation of the two essential functions ofthe laryngeal system: swallowing and speech. in the early 1950s and then in 1970, European including italian Authors established furthermilestones in conservative laryngeal surgery.Physiological anatomy of the operated larynx: A correct knowledge of the anatomy and physiology of the operated larynx is fundamentalto the success of functional laryngeal cancer surgery. herewith, an analysis is made of the anatomical and physiological foundation of thelarynx in a multifactorial approach: the anatomical and physiological foundation of this kind of surgery is the cricoarytenoid unit (CAu).This structure has both a “classic” and an “updated” definition.These notes illustrate how the functional outcome, following laryngeal cancer surgery, relies on respecting all the elements in that constel-lation of factors that permit minimal anatomic and functional dignity of the neolarynx.Speech therapy rehabilitation: An analysis is made of the speech therapy rehabilitation programme; the purposes of re-education are: acti-vation of the deglutition mechanisms, arytenoid mobilisation and activation of arytenoid mucosal vibration. We analyze the different stepsof the rehabilitation programme that starts with diagnosis and continues during hospitalisation and after the patient’s discharge.Surgical rehabilitation: Another important chapter is the surgical rehabilitation. in fact, for many years, the alternative to functional pro-cedures in which the glottic or supraglottic level are preserved (cordectomy of varying extents, supraglottic horizontal laryngectomy) wastotal laryngectomy, as replacement sphincteric function was not believed to be possible. in some cases, due to the persistence of swallow-ing difficulties, with progressive weight loss and the occurrence of repeated episodes of aspiration with bronchopneumonic complications,use of PEg can represent a provisional measure to allow an extension of the rehabilitation programme. if the functional situation does notimprove sufficiently to allow adequate, risk-free eating, patients are often offered total laryngectomy. Since the late 1980s, some Authorshave suggested surgical methods that aim to improve neoglottic competence and, consequently, the functions (swallowing and voice) re-lated to the sphincteric ability of the larynx. This functional rehabilitation surgery is gradually being adopted, after the early experiencesbased exclusively on injective laryngoplasty techniques, in the light of more detailed evaluations of the various causes of deglutition failure.moreover, only with injective methods is it possible to find solutions to minimal pre- and post-deglutition disorders. in parallel with theattempts to solve the problems of neoglottic insufficiency, a voice surgery technique has been developed with the aim of improving glotticcompetence following cordectomy to improve voice quality and eliminate the phonoasthenia that often represents the greatest handicap forthese patients.Functional evaluation protocol and our caseload: For all these reasons, it is very important to evaluate the impact that surgery can have interms of dysphagia and, when possible, the need to quantify it, in relation also to the patient’s quality of life. Correct deglutition, in fact,is the result of a precise coordination of the many structures present in the head and neck. Therefore, we analyse in detail the functionalprotocol, correlated with the data in our series, that is broken down into the analysis of the fundamental functions of the pharyngolaryngealorgan, i.e., an evaluation of swallowing, speech and respiratory functions, which together contribute to influencing the patient’s quality oflife.KEy WordS: Larynx • Partial laryngectomy • Swallowing • Phonation • RehabilitationriASSunToAlla base della chirurgia laringea vi è la necessità della riabilitazione di due delle funzioni fondamentali legate al viscere laringeo: ladeglutizione e la fonazione. È a partire dagli anni ’50 e successivamente negli anni ’70 che si posero ulteriori capisaldi nella chirurgiaconservativa laringea.Anatomofisiologia della laringe operata: Alla base del successo della chirurgia oncologica funzionale della laringe vi è una corretta 235
  2. 2. round Table S.i.o. national Congressconoscenza dell’anatomo-fisiologia della laringe operata. Nel lavoro che segue partiremo analizzando quelle che sono le basi anatomo-fisiologiche in maniera multifattoriale, ponendo attenzione al fondamento anatomo-fisiologico di tale chirurgia rappresentato dall’UnitàCrico-Aritenoidea; di questa struttura si può fornire una definizione “classica” ed una definizione “attualizzata”. Si evince come il favore-vole esito funzionale dopo chirurgia funzionale oncologica della laringe derivi dal rispetto di tutti i fattori che consentono dignità anatomofunzionale ad un neo-laringe “a minima”.riabilitazione logopedia: A seguire analizzaremo il percorso riabilitativo logopedico, i cui scopi sono l’attivazione del meccanismo deglutitorio,la mobilizzazione aritenoidea e l’attivazione della vibrazione della mucosa aritenoidea. Analizzeremo quindi i vari steps dell’iter riabilitativologopedico che inizia al momento della diagnosi, prosegue durante il ricovero e si protrae dopo la dimissione dal reparto ospedaliero.riabilitazione chirurgica: Altro capitolo fondamentale riguarda la riabilitazione chirurgica. Per molto tempo infatti l’alternativa agliinterventi funzionali con conservazione del piano glottico o sopraglottico (cordectomia più o meno allargata, laringectomia orizzontalesopraglottica) è stata la laringectomia totale perché non si riteneva possibile una funzione sfinterica sostitutiva. In alcuni casi, per ilprotrarsi della difficoltà deglutitoria con calo ponderale progressivo e per il verificarsi di ripetuti episodi di aspirazione con complicanzebroncopneumoniche, il ricorso alla PEG può costituire una misura provvisoria per consentire un prolungamento dell’iter riabilitativo; sela situazione funzionale non migliora consentendo una alimentazione adeguata e senza rischi la laringectomia totale è spesso la soluzioneche viene prospettata al paziente. Alcuni Autori fin dalla fine degli anni ’80 hanno proposto metodiche chirurgiche finalizzate a migliorarela competenza neoglottica e di conseguenza le funzioni (deglutizione e voce) correlate con la capacità sfinterica della laringe. Questachirurgia di riabilitazione funzionale sta trovando una sistematizzazione dopo iniziali esperienze basate esclusivamente su tecniche dilaringoplastica iniettiva alla luce di valutazioni più approfondite delle varie cause del fallimento deglutitorio. Parallelamente ai tentatividi soluzione delle insufficienze neoglottiche si è sviluppata una fonochirurgia finalizzata al miglioramento della competenza glottica dopocordectomia per migliorare la qualità vocale ed eliminare la fonastenia che costituisce talvolta l’handicap maggiore per questi pazienti.Protocollo di valutazione funzionale e casistica: Appare pertanto evidente la necessità di valutare l’impatto che la chirurgia comportain termini di disfagia, e qualora sia possibile la necessità di quantificarla, anche in relazione alla qualità della vita del paziente. Unacorretta deglutizione è infatti il risultato di una precisa coordinazione di molteplici strutture del distretto testa-collo. Pertanto analizzeremoin dettaglio, correlandolo ai dati della nostra casistica, il protocollo di valutazione funzionale che si articola nell’analisi delle funzionifondamentali dell’organo faringo-laringeo, ossia la valutazione della funzionalità deglutitoria, fonatoria e respiratoria, che insiemeconcorreranno a influenzare la qualità della vita del paziente in esame.PArolE ChiAvE: Laringe • Laringectomia parziale • Deglutizione • Fonazione • Riabilitazioneacta otorhinolaryngol ital 2010;30:235-258 received: July 20, 2010 - Accepted: August 20, 2010Round Table S.I.O. National CongressIntroductionIntroduzioneL. PrEsUTTI, M. ALIcANDrI-cIUfELLIENT Department, University Hospital of Modena, ItalySince the advent of laryngeal surgery, practitioners have who had undergone total laryngectomy were able to pro-recognised the need for the rehabilitation of the two essen- duce an articulated, yet audible voice 1. in the early decadestial functions of the laryngeal system: swallowing, which of the 20th Century, in addition to rehabilitation techniquesfor obvious reasons is necessary for survival; and speech, involving implanted aids, speech therapy rehabilitationour main means of communication and, consequently, es- techniques aimed at producing a belched voice were de-sential for interpersonal relationships. Although the first vised and later developed. The first attempts at combinedtrue laryngectomy, performed by Billroth, is convention- surgical-implant rehabilitation were made by delavan (inally thought to have been conducted in 1873 1 phonatory 1924) 1 and Briani (in 1952) 1. like their predecessors, theserehabilitation techniques were described for the first time Authors used implants, this time integrating them with thein the early 1900s 1 and involved the use of aids such as the patient’s tissues in surgical procedures 1.artificial larynx devised by gussenbauer and Caselli 1 and At the same time, to overcome the significant functionalthose involving nasal or oral tubes (used by gluck, Caselli consequences of laryngectomy, important progress wasand Tapia 1): by suitably arranging the upper resonators and made in laryngeal surgery techniques by primarily Eu-appropriately deviating the flow of exhaled air, patients ropean Authors starting in the 1950s, with the introduc-236
  3. 3. introductiontion of the vertical partial laryngectomy and supraglottic the cricoid and at least one of the arytenoids, these proce-laryngectomy 1-4. Whereas most modern laryngologists dures were a success from both an oncological and a func-have abandoned the vertical technique on account of its tional standpoint. These Authors observed that the swallow-high post-operative stenosis rates and subsequent frequent ing competence of the neoglottis was guaranteed even withimpossibility of decannulation, horizontal supraglottic la- just one arytenoid that by “bowing” towards the epiglottis orryngectomy, on the other hand, has become part of daily base of the tongue was able to adequately protect the respi-practice in the head and neck surgery field and as it spares ratory tract. The same mobility of the residual arytenoid orthe glottis, it poses far less important issues with regards arytenoids made it possible to obtain “compensation” voicesto rehabilitation, the true focus of this round Table. perfectly adequate for normal interpersonal relationships, byin the early 1970s, italian Authors, particularly Staffieri and allowing the arytenoid mucosa to vibrate against the residualSerafini, established further milestones in conservative laryn- epiglottis or base of the tongue.geal surgery 1. The technique introduced by Staffieri involved Subtotal laryngectomy procedures remained substantiallythe creation of a phonatory neoglottis during total laryngecto- unchanged from the 1970s, until rizzotto et al. (2006) 5my procedures: this brought significant benefits for patients, reviewed the tracheohyoidopexy and tracheohyoido-ep-making it possible to obtain a perfectly audible voice simply iglottopexy techniques. By observing the importance ofby closing the tracheostomy stoma during expiration to allow the functional cricoarytenoid unit (unlike Authors such asthe air to vibrate the surgically-furnished valve between the Serafini and mayer who previously used similar techniquestrachea and the neo-hypopharynx. in 1970, Serafini 1, on the but overlooked this aspect), these Authors performed subto-other hand, presented the results of a laryngectomy with tra- tal laryngectomies even in unilateral hypoglottic tumours:cheohyoidopexy reconstruction: which, together with may- the tracheohyoidopexies described in the paper by rizzottoer’s experience (1959) 2, was the first attempt at avoiding a et al. involved the removal of significant portions of cricoidpermanent tracheostomy in subtotal laryngectomy subjects. on the tumour side, but preserved at least one arytenoid unit,Although Staffieri’s laryngectomy technique frequently gave the portion of cricoid below, the superior laryngeal nerve,unsatisfactory results with belched voice production and Ser- lateral internal branch (plus, the recurrent laryngeal nerve),afini’s technique was characterised by a high post-operative and by performing the reconstruction directly between thepulmonary aspiration rate, these procedures, nevertheless, trachea and hyoid bone (with or without the residual epi-represented attempts that stimulated later surgeons to im- glottis): in their paper, they reported functional results com-prove their methods and led us to the results we have today. parable with conventional subtotal procedures.undoubtedly, Serafini can be credited with having believed Those who work in the laryngeal surgery field constantlyin the potential of subtotal surgery, encouraging many laryn- have to manage the deglutition and phonatory rehabili-gologists in italy and worldwide to adopt the technique. A tation of laryngectomised patients, fully aware of all thenumber of changes were later introduced to Serafini’s origi- medical, nutritional, psychological, organisational andnal procedure: the tracheohyoidopexy technique thus evolved even economical issues that face both patients and medi-and, as experience developed, increasingly precise oncologi- cal practitioners. it goes without saying that the greatercal indications were classified and, once the main aim of de- the efforts to spare the larynx, the more diffuse conser-cannulation was achieved, increasingly safe and encourag- vational laryngeal surgery techniques and the more im-ing results were obtained in cancer patients. indeed, in 1971, portant the vocal and deglutition rehabilitation techniquesAlaimo, labayle and Bismuth 3 published their reports on the become. The purpose of this round Table is, therefore, tocricohyoidopexy technique, and, in 1974, Piquet, desaulty focus attention on the issues of post-laryngectomy speechand decroix published the results of their experience with a and swallowing rehabilitation, in the light of contempo-cricohyoidoepiglottopexy procedure 4. despite involving the rary surgical techniques, which primarily aim to spare theremoval of most of the laryngeal structures, preserving just organ and respect function and quality of life.References 3 Piquet JJ, desaulty A, delacroix g. La crico-hyoido-pexie technique operatoire et resultats fonctionels. Ann otolaryn-1 Staffieri m, Serafini i. La riabilitazione chirurgica della voce gol Chir Cervicofac 1974;91:681-6. e della deglutizione dopo laringectomia totale. relazione 4 labayle J, Bismuth r. La laryngectomie totale avec recon- ufficiale Atti del XXiX Congresso nazionale Aooi, 1976. struction. Ann otolaryngol Chir Cervicofac 1971;88:219-28.2 mayer Eh, reider W. Technique de laringectomie permet- 5 rizzotto g, Succo g, lucioni m, et al. Subtotal laryngec- tant de conserver la permeabilité respiratoire (la crico-hy- tomy with tracheohyoidopexy: a possible alternative to total oido-pexie). Ann otolaryngol 1959;76:677-81. laryngectomy. laryngoscope 2006;116:1907-17.Address for correspondence: dr. l. Presutti, u.o.C. otorinolarin-goiatria, Azienda ospedaliero-universitaria di modena, via delPozzo 71, 41100 modena, italy. 237
  4. 4. Round Table S.I.O. National CongressAnatomy and Physiology of the operated larynxAnatomo-fisiologia della laringe operataE.M. cUNsoLoENT Department, University Hospital of Modena, Modena, ItalyCorrect knowledge of the anatomy and physiology of the eration when planning surgery and be sometimes treatedoperated larynx is crucial to the success of functional la- surgically during the laryngeal cancer procedure (Fig. 1).ryngeal cancer surgery. A fundamental distinction must Bruno et al. 2 identified a number of quantitative parame-be made between procedures involving the removal, to a ters, visible on pre-operative computed tomography (CT)greater or lesser extent 1, of the vocal fold and those that scans, that can be useful in pinpointing the position ofnot only alter the endolaryngeal soft tissues, but also en- the neolarynx in the neck following crico-hyoido-epiglot-tail the reductive remodelling of the laryngeal framework topexy (ChEP), of prognostic importance as far as con-and repositioning of the neolarynx within the neck. cerns post-operative functional recovery.it addition to the morphology of the neolarynx, other The role of lPr in glottic tissue repair processes and,pre-existing and/or post-surgical anatomic and function- more generally, in all procedures involving laryngealal elements that can prove decisive to the success of the and/or laryngotracheal reconstructions, deserves specialprocedure must also be considered. of these, the most mention. The negative influence of lPr in glottic repairimportant are the presence of spinal cord disease, laryn- processes has been analysed in studies on animals and,gopharyngeal reflux (lPr), any upper respiratory and more recently, in clinical studies on humans. in animaldigestive tract disorders following radiotherapy, salivary studies 3, irrigation using hydrochloric acid with a phflow alterations and, last but not least, the patient’s psy- of 3 and pepsin was administered for 4 or 8 weeks afterchological conditions. vocal cord stripping. This group of animals experiencedCervical spinal disease can take the form of cumbersome delayed healing, intense inflammation, epithelial erosionbone spurs on the vertebral bodies in severe spinal arthri- and formation of granular tissue, with distant sequelaetis or concomitant diffuse idiopathic Skeletal hyperosto- that evolved into rigid scar tissue, with significant densesis (diSh). These conditions must be taken into consid- collagen deposition. This immediate and delayed tissue damage was evaluated quantitatively and showed a clear statistical significance compared to the control group re- ceiving sterile saline solution irrigations. in a recent clinical study 4, healing after vocal cord sur- gery for benign tumours was compared between a control group (50 patients) and a group of 120 patients with lPr, documented with 24-hour dual probe ph monitoring and whose clinical severity was evaluated using subjective parameters, (rSi: reflux Symptom index) and objective laryngeal parameters (rFS: reflux Finding Score). 50% of patients with lPr were randomised to receive pre- and post-operative proton pump inhibitor (PPi) treatment and the anatomical and functional results were evaluated over a one-year follow-up period. The results obtained demon- strated a significant delay in vocal cord re-epithelisation processes and the persistence of high rSi and rFS scores in the untreated patients. This clinical finding confirms the importance of lPr and its pre- and post-operative treat- ment, with adequate doses of PPi. The negative impact of lPr on repair processes, follow- ing laryngeal surgery, is related to the extent of laryngealFig. 1. Pre-operative CT: patient with laryngeal cancer (indication to SCL- demolition. in one study on rabbits, subject to laryngotra-CHEP) and DISH syndrome. Treatment of this latter condition takes place at cheal reconstruction 5, the Authors observed intense mu-the same time as the laryngeal cancer operation. cosal inflammation, with necrosis of the underlying car-238
  5. 5. Anatomy and Physiology of the operated larynxtilage in animals receiving hydrochloric acid and pepsin cortical activation, even automatic deglutition, which rep-irrigations. These alterations were more marked in the resents the quantitatively predominant event; 2. Both typesgroup receiving irrigations with ph of 4 hydrochloric acid of deglutition involve several anatomically and function-compared to those in the group receiving that with a ph ally separate areas of cortex, with a different pattern duringof 1.5. moreover, this latter group of animals was less automatic, compared to voluntary, swallowing; 3. volition-prone to coughing, when evaluated quantitatively (using al swallowing of both saliva and water boli are associatedthe Cough response Scoring System), compared to those with a pre-eminent activation of the caudal portion of theirrigated with hCl with a ph of 4. The pathophysiological cingulate gyrus; 4. There are pre-eminent and more con-basis underlying these events can probably be attributed stant foci of cortical activation, which are activated in bothto the immediate swallowing reflex that is activated when types of swallowing, represented by the precentral lateralthe pharyngo-laryngeal mucosa comes into contact with a gyrus (Brodmann areas 4 and 6), the post-central lateralstrongly acidic solution. This swallowing reflex is so fast gyrus and the right insula.and efficacious that it prevents acid micro-aspirations in Perhaps the most surprising aspect of this study is thethe lower respiratory tract and restricts the mucosal dam- documentation of the cortical events that occur at theage caused when it comes into contact with the areas of the same time as the most elementary act of deglutition, thelarynx subject to reconstruction. despite the limits related automatic swallowing of saliva, termed, on account ofto the artificiality and complexity of the trial model, this its basic nature, “naïve saliva swallowing”. not only is itfinding has important clinical repercussions. it underlines invariably associated with cortical activation, but, in thisthe detrimental effect of slightly acidic and/or non-acidic context, it also activates the “nobler” motor areas, such aslPr and the decisive importance of the sensitive inner- the premotor cortex (Brodmann area 6) and, above all, thevation of the hypopharynx and larynx, which is able to precentral lateral gyrus, area 4, which includes the pri-activate an effective coughing reflex, the afferent branch mary motor cortex, which is, therefore, indicated as m1.of which is the internal branch of the superior laryngeal When applied to the clinical setting, these notions allow anerve. Another “extralaryngeal” aspect that can prejudice broadening of the concept of post-operative dysphagia fol-functional recovery after major laryngeal surgery and that lowing major tumour surgery on the upper respiratory tract,merits closer investigation is the patient’s psychological intended not merely as an alteration of deglutition for eat-conditions and related anatomic and functional conditions, ing and drinking (voluntary bolus swallowing), but also inrepresented by the cortical control of laryngeal functions, the broader basic concept of controlling the physiologicalin general, and deglutition, in particular. salivary flow, managed by “naïve saliva swallowing”. Con-The latest studies using functional magnetic resonance im- sequently, in laryngeal tumour surgery, a key role is playedaging techniques (fmri), have confirmed the complexity by all the surgical measures adopted to preserve an ade-of neuronal control of deglutition, defining a highly co- quate “pharyngolaryngeal wall” and the integrity of sen-ordinated “swallowing neural sensory-motor network” in sory innervation, as well as the recognition and adequatewhich different cortical areas and encephalic and brainstem treatment of post-operative salivary flow disorders 7.structures interact to provide a safe and effective transport in recent years, a number of studies have been publishedof the liquids and solid foods from the lips to the stomach. on the “swallowing cortical network” 8, with the aim ofin 2001, martin et al. published a report on a fundamental applying this knowledge to clinical practice, both in pa-study, conducted on healthy volunteers 6, for the definition tients whose swallowing disorders are secondary to neu-of the cortical areas activated to promote and coordinate rological damage and whose anatomical “damage” is inthe act of deglutition. The underlying assumption was to the peripheral laryngopharynx, as occurs following ma-make a distinction between “spontaneous” salivary deglu- jor functional laryngeal tumour surgery. in these patients,tition (automatic swallowing) and deglutition controlled by there is a post-surgical alteration of the laryngopharyn-a voluntary action (volitional swallowing), which, in turn, geal structures, with preserved integrity of the centralcan be broken down into voluntary salivary deglutition and neurological network. Precisely on account of the impor-voluntary swallowing of a bolus (liquid or solid). in the tance of cortical control of all types of swallowing, thisstudy of martin et al., healthy volunteers were also evalu- network can be functionally altered due to the patient’sated by fmri-4T in three different swallowing “modes”: post-operative psychological conditions. A recent study1. naïve saliva swallowing; 2. voluntary saliva swallow- on healthy volunteers, conducted by Palmer et al. 9, com-ing: performed with a frequency of one swallow a minute; pares the dynamics of the oral preparation phase, the oral3. Water bolus swallowing: swallowing of a fixed quantity and pharyngeal stage of solid bolus swallowing, when it(3 ml) of water administered once a minute, through a tube takes place automatically or following a voluntary act ofin the mouth. The synchronism of the cortical events and deglutition, performed after completion of the oral prepa-acts of deglutition was guaranteed by recording laryngeal ration phase and triggered by a command given by theexcursions. The still-valid results of this landmark study investigator. The overall dynamics of the initial phases ofcan be summarised as follows: 1. All swallowing involves deglutition are more efficacious when automatic and not 239
  6. 6. E.m. Cunsolocommanded, and is slower during controlled swallowing The other particularly current issue, in the functional anatomy(larger number of masticatory acts, slower propulsion, of the larynx, is what we refer to as the “cellular physiologystoppage of the bolus at the valleculae). The pathophysi- of the larynx” 13. This area focuses on connective cells andological implications of this observation are easily iden- the intercellular substance they produce, as concerns both itstifiable and explain the organisational complexity of the fibrous (elastin and collagen) and amorphous components.neuronal network that governs spontaneous deglutition. Familiarity with these aspects of cell physiology has allowedon a practical level, the points raised previously highlight a better understanding at molecular level of the repair proc-the importance of early rehabilitation of the swallowing esses that take place after anatomical cord damage and theirfunction in patients after major laryngeal surgery, with the “undesired” evolution towards cordal scarring.triple aim of optimising the dynamics of the neolarynx, recently, hirano et al. 14 conducted a study on cord tis-obtaining a true reprogramming of the neuronal network sue repair processes in patients undergoing vocal cordthrough phenomena of neuroplasticity 10 and a minimi- surgery of various types. The purpose of the study wassation of the effects of volitional control, which can be the molecular quantification of the various componentscounterproductive to correcting deglutition dynamics. of the extracellular matrix: collagen, elastin, hyaluronicif, as previously mentioned, there has been a rapid ex- acid, fibronectin and decorin. The results showed a greatpansion in the definition of the central neuronal network variability in post-surgical outcomes, inside which differ-controlling laryngeal functions, no less significant is the ent behaviours can be identified for collagen and decorinquantitative and qualitative evolution in the knowledge of and for elastin, hyaluronic acid and fibronectin. The post-motor and sensory control of the laryngopharyngeal sys- operative collagen and decorin content is related to thetem, which has led to the definition of the concept of the depth of the surgical resection of the cords and subsequent“neurosensory compartimentalisation” of the larynx. All scarring process. The greater the depth of the resection,the areas of intrinsic laryngeal muscle have been defined the greater the deposition of thick, disorganised collagenin relation to their muscle fibre population at structural, fibres, especially in cases of post-operative radiotherapy.ultrastructural and biomolecular levels, intra-muscular The opposite occurs for decorin, which is preserved indistribution of nerve fibres, density of neuromuscular more superficial cordectomies, but tends to drop in deeperplaques and, consequently, in the amplitude of the mo- procedures. decorin is a small-chain proteoglycan thattor units. The most extensively studied muscular district governs the collagen fibrils, preventing them from form-is that of the thyroarytenoid muscle, and, specifically, its ing large bundles and thus avoiding the formation of denseinternal component, or vocal muscle 11. scar tissue. decorin is, physiologically, primarily presentmore recently, the same attention has been dedicated to the in the more superficial layers of the lamina propria, whichdefinition of the pharyngeal constrictor muscles 12. This ac- explains the histological findings reported. deposition oftivity has led to the identification of a sophisticated “neu- the other components of the extracellular matrix, such asromuscular compartimentalisation” that, as for the intrinsic elastin, fibronectin and, above all, hyaluronic acid, on themuscles of the larynx, varies significantly with age. The other hand, occurs regardless of the depth of vocal cord re-pharyngeal constrictors are divided into two distinct and section and their content in the post-operative cord tissue isfunctionally separate layers: the slow inner layer (Sil), in- governed by highly variable, individual factors. There arenervated by the glossopharyngeal nerve (iX) and the fast many practical repercussions of the elements that came toouter layer (Fol), innervated by the vagal nerve (X). This light in this study, all of them of great clinical importance,anatomical and functional layering of the constrictor mus- making the indications for phoniatric and/or voice surgerycles is only present in humans, it appears around two years after endoscopic cordectomy, even in the more superficialof age and disappears after the age of 70. The Sil is made procedures, an issue of great current interest.up of muscle fibres with myosin heavy chain (mhC) iso- however, there is no doubt that the post-operative redefi-forms of the slow-tonic and a-cardiac type. These mhC nition of the operated larynx occurs above all followingisoforms are highly specialised in tonic muscle contraction procedures that reduce the laryngeal framework. At aand are linked to the need of controlling deglutition when pathophysiological level, it is correct to define the type ofin an erect position, with a low aerodigestive crossroads, laryngectomy, indicating the most caudal anatomic ele-typical of adult. The Fol, with fast tonic mhC and vagal ment above which the neolarynx is reconstructed: henceinnervation, on the other hand, is specialised in the peri- the definition of supraglottic horizontal laryngectomystaltic food bolus propulsion. once again, these considera- (Shl), supracricoid laryngectomy (SCl) (crico-hyoido-tions lead us to consider the aerodigestive crossroads as an epiglottopexy [ChEP], crico-hyoidopexy [ChP]) and su-integrated functional structure with synergic, overlapping pratracheal laryngectomy (STl). it goes without sayingvagal and glossopharyngeal sensory-motor innervation. on that procedures requiring the anatomical and functionala practical level, this calls for surgical respect of all those redefinition of the operated larynx are those entailingstructures not involved in the neoplastic process, including the resection of the glottic level of the cords, the naturalall mucosal, muscular, nervous and vascular components. sphincter of the larynx, calling for the surgical reconstruc-240
  7. 7. Anatomy and Physiology of the operated larynxtion of a “neoglottis”. We will, therefore, describe the ba-sic anatomy and physiology of the neolarynx after SCland STl procedures.The anatomical and physiological foundation of this kindof surgery is the cricoarytenoid unit (CAu). This structurehas both a “classic” and an “updated” definition. Fig. 3. Diagram of the neoglottis. The front half comprises the base of theThe classic definition was developed in 1992, by J.J. Piquet tongue, the rear half by at least one ef-et al.,15 the original version of which is provided below: ficacious CAU.“L’unité crico-aryténoïdienne se compose d’un squelettefibro-cartilagineux constitué par le cartilage cricoïde ainsi glotte est particuliére car haute ou additale, située dans leque d’un ou deux cartilages aryténoïdes articulés entre eux. plan de la margelle laryngée”. This defines the concept ofCette articulation ne peut rester fonctionelle que dans la the “neoglottis”, a circular structure, the true upkeeper ofmesure où les muscles crico-aryténoïdiens posterieur, crico- neolaryngeal functions: respiratory function, speech func-aryténoïdiens latérals et inter-aryténoïdiens parfois, sont tion and deglutition function. The neoglottis is, therefore,respectés avec leur innervation, leur vascularisation ainsì a circular structure in which the rear 180° are, schemati-qu’un plan muqueux de coverture à preserver”. The funda- cally, represented by at least one efficient CAu, whereasmental aspect of this definition of CAu lies in the specifi- the anterior 180° are represented by the base of the tongue,cation not so much of its anatomical appearance, but rather overlapped, when applicable, by the residual suprahy-its functional appearance that represents the essence of the oid epiglottis (Fig. 3). The functional competence of thislarynx only if it is perfectly intact as regards to its complex “ring” stems not so much from the anatomical-functionalcricoarytenoid joint, its muscular apparatus, sensory-motor integrity of each of its components, but rather, to an equallyinnervation and mucosal coating. This “classical” concept important extent, from the juxtaposition of the front halfof the CAu has been replaced by a more “extreme” ver- with the back half. This is what makes “position” the sec-sion, with a graphic schematisation that graced the cover ond requisite of an optimised CAu. These elements formof the october 2006 issue of laryngoscope (Fig. 2). once the grounds for the success of major functional laryngealagain, we provide the original definition: “one cricoaryten- surgery, and are linked to the rehabilitation and/or surgicaloid unit (half posterior cricoid plate and one arytenoid)” 16. work performed to correct functional failures.reducing the framework makes it all the more urgent to The first anatomical element of the “position” of the ne-maintain intact the function of all components of the CAu oglottis is the lifting of the residual larynx, in a cranialand stresses the second fundamental element of the physi- direction, towards the base of the tongue. For this, theological anatomy of the neolarynx, the ‘position’ element. reconstruction must be stable, which is obtained by over-here, it becomes necessary to introduce the second “hinge” lapping and positioning the concave portion of the hyoiddefinition of the issue, the definition of “neoglottis”, which body on top of the cricoid or, in the case of STl, the upperwe will borrow, once again, from J.J. Piquet: “La néo-glot- rings of the trachea. This also guarantees a correct align-te est constituée d’une partie antérieure musculaire basi- ment of the reconstruction in relation to the respiratorylinguale (à laquelle s’ajoute l’épiglotte dans une CHPE) lumen, the essential condition for natural breathing. onceet d’une partie postérieure correspondant à une ou deux the structural correctness of the mutual relationships be-unités crico-aryténoïdiennes… La situation de la néo- tween the components of the neoglottis has been guaran- teed, the performance of respiration, speech and degluti- tion functions will require a specific dynamic pattern for each of the three functions, that is based, as mentioned previously, on a correct neoglottis neuromuscular appara- tus and a good degree of cricoarytenoid joint freedom. Respiratory function requires an adequate lumen along the whole reconstructed respiratory tract and an effica- cious opening of the residual larynx. This function is as- signed to the posterior cricoarytenoid muscle, innervated by the inferior or recurrent laryngeal nerve. The contrac- tion of this muscle, considering its insertion of the muscu- Fig. 2. CAU: Current concept. lar apophysis of the arytenoid and the degrees of freedom Articular, neuromuscular, vascular of the cricoarytenoid joint, will produce a multiplane arch and mucosal integrity of the cri- coarytenoid complex is essential. movement of the body and vocal process of the arytenoid, The continuity of the cricoid carti- in an upwards, outwards and backwards direction. This lage is not necessary. spatially complex movement, more simply defined as ab- 241
  8. 8. E.m. Cunsoloductory, will bring the arytenoid body and vocal processfrom an inferomedial starting position to a superolateralend position, thus widening the respiratory lumen.The phonatory and deglutition functions both requirethe competence of a neoglottic spincter. This neoglotticsphincter will invariably be constituted by the juxtaposi-tion of the CAu to the rear and the base of the tongueto the front. The action of the front half of the neoglot-tic sphincter will be guaranteed by the retropulsion of thebase of the tongue, downwards and backwards. in SClwith ChEP procedures, this sphincter will be assisted bythe presence of the residual epiglottis, to give it a correctposition, making it possible to follow the movements ofthe base of the tongue, without, simultaneously represent-ing an obstacle for the respiratory lumen.As mentioned previously, the competence of the rear halfof the neoglottic sphincter depends on the CAu and isbased on a complex cricoarytenoid movement, which oc-curs with a synergical action, of recorrential competence,of the lateral cricoarytenoid, posterior cricoarytenoid and,when both arytenoids are presence, interarytenoid mus-cles. The contraction of the lateral cricoarytenoid mus-cle tends to pull the muscular apophysis downwards andforwards, causing the arytenoid to move over the cricoidso that the vocal apophysis and the arytenoid body draw Fig. 4. Dynamics of the neoglottis in the 3 fundamental functions. Thean arc downwards, inwards and forwards. As the lateral arytenoid excursions (“le rideau de scène”) are shown on the right hand side. The dynamics of the neoglottis on the vertical plane: retropulsion of the base ofcricoarytenoid muscle contracts, the posterior cricoaryte- the tongue and “le salut aryténoïdienne” is shown on the left.noid muscle relaxes, tilting the arytenoid body forwards.When present, the simultaneous contraction of the inter-arytenoid muscle produces a tighter action of the posterior has the essential purpose of allowing glottic competence,sphincter, thus favouring the meeting of the anterior as- whilst the active participation of the CAu is predomi-pects of the arytenoids. These complex articular and neu- nant. Piquet defines this dynamic action of the neoglotticromuscular dynamics produce a multiplane movement of sphincter as: “mécanisme léger”.the arytenoid that draws a quarter- or semi-circular arc in deglutition, on the contrary, the retropulsion of the basewith an internal concavity moving forwards, downwards of the tongue is active, to allow a real tightening of theand inwards. on laryngoscopic observation, this com- neoglottis. Consequently, it is a “mécanisme lourd”.plex dynamic can be schematically split into two essen- Neoglottic vibration: So far, we have described the as-tial components, for which the original French names pects of the neoglottic “framework” that do not take intoare used: “le salut aryténoïdienne” and “le rideau de consideration the behaviour of the mucosa, the vibrationscène”(J.J. Piquet) (Fig. 4). of which is essential in allowing the neoglottic sphincter“Le salut aryténoïdienne”: describes the vertical com- to produce a “neovoice”. The phonatory vibrations of theponent of the arytenoid body, which tilts forwards and mucosa involve the arytenoid hoods and the other elementsdownwards, towards the base of the tongue. This causes of the neoglottis, particularly in the case of SCl-ChEP,the posterior cricoarytenoid muscle to relax. when the vibratory pattern will also involve the mucosa of“Le rideau de scène”: describes the horizontal compo- the epiglottis and the piriform fossa, as an element of thenent, favoured by the lateral cricoarytenoid muscle, which neo-aryepiglottic folds. recently, Saito et al. 17 proposed abrings the arytenoid into medial contact with the contra- classification of the mucosal vibratory patterns of the neo-lateral, if present, or up to the contralateral laryngeal wall, glottis after SCl-ChEP. The Authors defined 3 areas ofin the case of a single residual arytenoid. it should be a mucosal vibration, defined: Area A (arytenoid/s); Area Etrue “curtain falling”, with one or two curtains. (epiglottis); Area S (piriform sinus mucosa). The vibra-Whereas the above description refers to the fundamental tory patterns encountered are: Type A; Type S; Type AS;mechanism that guarantees neoglottic competence, the Type AE and Type AES.dynamics will be different in the occlusion mechanisms This proposal responds to the currently particularly ur-for phonation and deglutition. gent need to identify classification systems to evaluatein phonation, the retropulsion of the base of the tongue the functional results of functional laryngeal cancer sur-242
  9. 9. Anatomy and Physiology of the operated larynxgery 18, due partly to the enormous progress achieved in rently dealt with in the literature of various disciplinesvideo-laryngoscopy techniques. and, therefore, “dispersed” but worthy of further specula- tive and clinical exploration. These notes illustrate how the functional outcome fol-Conclusions lowing laryngeal cancer surgery relies on respecting allThe topic of the anatomy and physiology of the operated the elements in that constellation of factors that permit alarynx is undoubtedly complex and multifactorial, cur- minimal neolarynx anatomic and functional dignity.References 11 Cunsolo Em, marchioni d, di lorenzo g, et al. Attualità in tema di anatomo–fisiologia e biomeccanica della laringe. in:1 remacle m, van haverbeke C, Eckel h, et al. Proposal for magnani m, ricci maccarini A, Füstös r, editors. La Vide- revision of the European Laryngological Society classifica- olaringoscopia. relazione ufficiale XXXii Convegno nazi- tion of endoscopic cordectomies. Eur Arch otorhinolaryngol onale di Aggiornamento Aooi, Pollenzo (To); 16-17 ottobre 2007;264:499-504. 2008.2 Bruno E, napolitano B, Sciuto F, et al. Variations of 12 mu l, Sanders i. Neuromuscular specializations within neck structures after supracricoid partial laryngectomy: human pharyngeal constrictor muscles. Ann otol rhinol A multislice computed tomography evaluation. orl laryngol 2007;116:604-17. 2007;69:265-70. 13 Cunsolo Em, Casolino d, Cenacchi g. La fisiologia cellu-3 Jong-lyel roh Jl, yoon yh. Effect of acid and pepsin on lare delle corde vocali. in: Casolino d, editor. Le disfonie: glottic wound healing - A simulated reflux model. Arch fisiopatologia, clinica ed aspetti medico-legali. relazione otolaryngol head neck Surg 2006;132:995-1000. ufficiale del lXXXiX Congresso nazionale Sio, San Bene-4 Kantas i, Balatsouras dg, Kamargianis n, et al. The influ- detto del Tronto, 22-25 maggio 2002. Pisa: Pacini Editore; ence of laryngopharyngeal reflux in the healing of laryngeal 2002, p. 64. trauma. Eur Arch otorhinolaryngol 2009;266:253-9. 14 hirano S, minamiguchi S, yamashita m, et al. Histologic5 Carron Jd, greinwald Jh, oberman JP, et al. Simulated re- characterization of human scarred vocal folds. J voice flux and laryngotracheal reconstruction - a rabbit model. 2009;23:399-407. Arch otolaryngol head neck Surg 2001;127:576-80. 15 Piquet JJ, Chevalier d, lacau-Stguily J, et al. Aprés exérèse6 martin ru, goodyear Bg, gati J, et al. Cerebral cortical horizontale glottique, sus-glottique, glosso-sus-glottique et representation of automatic and volitional swallowing in hu- hémipharyngolaryngée. in: Traissac l, editor. Réhabilitation mans. J neurophysiol 2001;85:938-50. de la voix et de la déglutition après chirurgie partielle ou totale du larynx. Socièté Française d’Oto-Rhino-Laryngol-7 Bomeli Sr, desai SC, Johnson JT, et al. Management of ogie et de Pathologie Cervico-Faciale. Paris: Arnette; 1992, salivary flow in head and neck cancer patients - A systematic p. 173-92. review. oral oncol 2008;44:1000-8. 16 rizzotto g, Succo g, lucioni m, et al. Subtotal laryngec-8 michou E, hamdy S. Cortical input in control of swallowing. tomy with tracheohyoidopexy: a possible alternative to total Curr opin otolaryngol head neck Surg 2009;17:166-71. laryngectomy. laryngoscope 2006;116:1907-17.9 Palmer JB, hiiemae Km, matsuo K, et al. Volitional con- 17 Saito K, Araki K, ogawa K, et al. Laryngeal function after trol of food transport and bolus formation during feeding. supracricoid laryngectomy. otolaryngol head neck Surg Physiol Behav 2007;91:66-70. 2009;140:487-92.10 ludlow Cl, hoit J, Kent r, et al. Translating principles 18 marioni g, marchese-ragona r, ottaviano g, et al. Su- of neural plasticity into research on speech motor con- pracricoid laryngectomy: is it time to define guidelines to trol recovery and rehabilitation. J Speech lang hear res evaluate functional results? A review. Am J otolaryngol 2008;51:S240-58. 2004;25:98-104.Address for correspondence: dr. E.m. Cunsolo, u.o.C. otori-nolaringoiatria, Azienda ospedaliero-universitaria di modena, viadel Pozzo 71, 41100 modena, italy. 243
  10. 10. Round Table S.I.O. National CongressSpeech therapy rehabilitationLa riabilitazione logopedicaM.P. LUPPI, f. NIzzoLI, G. BErGAMINI, A. GHIDINI, s. PALMAENT Department, University Hospital of Modena, ItalyThe speech therapy rehabilitation programme starts with To obtain a voice produced in the glottis (cord-neocord),diagnosis and continues during hospitalisation and after vocal sounds (vowels and syllables with surd and sonantthe patient’s discharge. occlusive phonemic components) are used at acute pitchThe distance from the rehabilitation centre can be an unfa- but moderate intensity constantly using laryngeal manipu-vourable element for the correct application of the whole lation which will favour compensation by the healthy vocalprotocol and the achievement of optimal functional re- cord. This will be followed by vocal exercises to prolongsults, particularly from a vocal point of view. and strengthen the sound through the repetition of sylla-Psychological support is important for controlling and re- bles (surd and sonant occlusives), monotonous variablespecting the anxiety and depression that arises following combined vowels, pitch changes with vowels and syllables,the diagnosis of a tumour. it is, therefore, essential that the disyllabic words, reading of words, sentences and stories.speech therapist is able to meet the patient before the pro- in those cases in which one of the other vocal compen-cedure in order to establish that relationship of trust which sations is required, we use exercises with lowered headis fundamental for rehabilitation programme compliance. facilitating postures, vocal sounds with a low pitch andduring the pre-operative meeting, the speech therapist moderate intensity that are prolonged on nasal phonemeswill explain to the patient the functional issues connected and on the vibrating phonemes, which can be proposedwith the procedure and the re-education strategies used to either individually or combined with sonant or surd velarrestore compromised function. occlusives. After which, the patient will practice, by read-Adequate post-surgical rehabilitation is essential for all ing sentences and short stories, to improve prosody, whichfunctional cancer surgery that, with the exclusion of cor- is always lacking in these compensations and especiallydectomies, in which it is conducted on a purely outpatient in the sphincteric voice.basis, involves a phase during hospitalisation and a subse-quent post-discharge, outpatient or day hospital, phase. Horizontal functional laryngectomies in supraglottic horizontal laryngectomy (Shl), the re-Cordectomies sidual sphincteric structure is represented by the glotticPost-cordectomy speech therapy is aimed at recovering level (vocal cords and arytenoids). Consequently, at thethe voice and to be fully efficacious, it must favour the end of re-education, in the absence of functional deficitsmeeting of the cord and neocord, to prevent disadvanta- of these structures, the three laryngeal functions are opti-geous non-spontaneous compensations. it is precisely for mally restored.this reason that re-education starts early and, in any case, glottic horizontal laryngectomy (ghl) involves the re-after full surgical healing. section of the glottic level, leaving the false cords, aryten-in cases in which non-optimal vocal compensations and/ oids and aryepiglottic folds.or markedly dysfunctional attitudes are present, work will generally, there are no swallowing problems after thera-focus on eliminating these problems before adopting the py, due to the conservation of the two sphincteric struc-best phonatory mode. tures (epiglottis and false cords), however the voice willin those cases in which the new anatomical laryngeal be rough and have a low pitch, as it is generated by thesituation does not make it possible to achieve physiologi- vibrations of the false cords.cal cord-neocord compensation 1-4, phonatory exerciseswill aim to strengthen the false cord or arytenoepiglottic(sphincteric) voice, which will, in any case, allow the cor- Subtotal laryngectomiesdectomy patient to obtain enough voice for normal inter- in subtotal laryngectomies, the sphincteric function, thepersonal relationships. basis for the protection of the airways and for phonation,The first step is always to achieve a correct respiratory is represented by the cricoarytenoid unit, in which theredynamic (costo-diaphragmatic breathing) and good pneu- is a dynamic opposition between the arytenoids and themophonoarticulatory coordination 5. epiglottis (cricohyoidoepiglottopexy or ChEP, tracheohy-244
  11. 11. Speech therapy rehabilitationoidoepiglottopexy or ThEP) or the base of the tongue (cri- Breathing exercisescohyoidopexy or ChP and tracheohyoidopexy or ThP) 6.The deglutition and phonatory abilities of these patients These are performed in order to achieve correct costo-rely on the perfect function of the neoglottis and the con- diaphragmatic breathing, allowing the airflow to passservation of mucosal sensitivity as well as the patient’s through the natural respiratory tract, favouring a moreability to learn new swallowing and speech strategies. rapid reabsorption of the post-operative oedema.The same rehabilitation techniques are used for all func- They are initially performed with the tracheostomy open,tional laryngectomies, albeit with a number of variations then later by closing it with a finger.and customisations.Before discussing post-operative rehabilitation training, Costo-diaphragmatic breathing exercises:we must stress the importance of giving these patients ad- • slow inspiration through the nose, slow expirationequate psychological support, to avoid excessive anxiety through the mouth;and depression, which may negatively affect their compli- • slow inspiration through the nose, expiration in 3, 4, 5ance and confidence in a good rehabilitation outcome. blows, through the mouth;during the first meeting, the patient should be given de- • slow inspiration through the nose, fast expirationtailed information about the procedure and about their through the mouth;post-operative anatomic and functional situation: they will • slow inspiration through the nose, fast expiration withtemporarily have to breath through a tracheotomy tube and the articulation of an aphonous voice (preparatory ex-feed through a nasogastric (ng) tube, or, in certain cases, ercise for arytenoid mobilisation) 1 9 5.through a percutaneous endoscopic gastrostomy (PEg).The speech therapist will also discuss the re-educationalmethods to be used for deglutition and phonatory recov- Muscle training exercises:ery, attempting to instil a calm and trusting state of mind • exercises to control the head and neck, making rotatingtowards the procedure and post-operative recovery 7 8. movements, bending forwards, to the right, left and in extension;Rehabilitation objectives and schedule 7 9 • shoulder movements: raising and lowering, rotating one way and then the other, lifting the arm to the sideThe purposes of re-education are: the activation of the and to the front;deglutition mechanisms, arytenoid mobilisation and acti- • lip exercises: protrusion and stretching, kissing;vation of arytenoid mucosal vibration. • tongue exercises: sideways movements, sticking out theThese objectives are achieved by following the rehabilita- tongue, downwards, upwards, right and left, outwards ro-tion steps: tation in one direction, then the other, pressing against the• on the 5th post-operative day, if the cuffed tracheosto- inside of the cheeks, rotations in the oral vestibule, brush- my tube has been replaced with a fenestrated one, the ing the palate with an antero-posterior movement 7 11. breathing exercises can commence;• on the 6th post-operative day, arytenoid mobilisation exercises and mouth exercises in preparation for swal- Pharyngeal stimulation exercises lowing start; The aim of these exercises is to stimulate contraction of• on day 7, the patient is taught the facilitating degluti- the pharynx and they consist in causing the vomiting re- tion mechanism and tests will be performed swallow- flex using a cold mirror or tongue depressor. if no evident ing both saliva and jelled water; reaction is observed when the palatine veil is stimulated,• on day 8, the patient will be expected to swallow a the palatine pillar area can be stimulated 7 9. creamed meal administered directly with the speech therapist’s help;• in the days that follow, different foods, with different Laryngeal lift stimulation exercises textures will be introduced, up to the introduction of Following the procedure, the relationship between la- water, the most difficult manoeuvre. ryngeal lifting and opening the mouth of the oesophagusThe presence of the ng tube can hamper rehabilitation as it is altered and the exercises aim to restore this situation.gives the feeling of a foreign body and cricoarytenoid anky- however, these lifting manoeuvres are only partly pos-losis, due to the position of the tube on the joint. once the ng sible, due to the presence of the tube 9 10.tube and tracheostomy tube have been removed (discharge),outpatient vibration and resonance exercises will start 10 11.We will now analyse, in detail, the various phases of re- Arytenoid mobilisation exerciseshabilitation, schematically discussing the various speech These are used to obtain the best neolaryngeal closure andtherapy techniques. to favour vibration of the arytenoid mucosa. 245
  12. 12. m.P. luppi et al.• rasping: the patient is seated, the tracheostomy tube it is best to avoid pasta in broth, short pasta shapes, spa- closed with a finger, and he/she must breath in slowly then ghetti and rice, raw vegetables with filaments, pulses, give the loudest rasp possible, with the mouth only; acidic and spicy foods, all foods with both solid and liquid• rasp with vowel: the patient is asked to produce a rasp components, juicy fruit and that with seeds (strawberries, followed by a vowel, starting with /a/, then /e/ and /o/, kiwi fruit, orange, watermelon, melon, etc.). and then trying with /i/ and /u/ 1 9 11. liquids are introduced last of all, starting with milk and fruit juices which are more flavoursome and denser thanSwallowing exercises water. Fizzy drinks and alcoholic beverages should be avoided.The patient practices facilitating swallowing, in the fol- Whilst eating, it is important that the patient is in a peace-lowing sequence: ful environment, has time as long as necessary and is not1. closing the tracheostomy tube with a finger; surrounded by distracting factors (television, visitors) 4 8 9.2. short nasal inspiration;3. pause in apnoea during which the patient swallows, thrusting the tongue hard against the palate, as far back Voice recovery as possible and holding this muscular contraction for a once the patient has been discharged, rehabilitation train- few seconds after swallowing; ing continues on an outpatient basis for setting the neo-4. abrupt release of air from the mouth, with the possibil- voice. Patients who have undergone supraglottic larynge- ity of expelling any food fragments remaining in the ctomy do not usually require voice therapy. neolarynx or hypopharynx. The first step is to teach the patient how to perform correctThis mechanism is initially performed using: costo-diaphragmatic breathing 3 5.• facilitating postures: the patient is seated with the head in the case of ghl, training will follow the schedule in- thrust forwards and the trunk bent downwards; head, dicated previously for false cord voice compensation fol- trunk and neck must all be on the same plane, parallel lowing cordectomy 3. to the floor. in the event of laterocervical stripping and in other types of horizontal functional laryngectomy removal of one arytenoid, the patient is asked to turn (ChEP, ChP, ThEP, ThP), the arytenoid neovoice is ob- his/her head to the side of the residual arytenoid; tained by making a rasp that is articulated in the form of• facilitating manoeuvre: the therapist puts one hand be- short, energetic vowels: /a/ /o/ /e/ /i/ /u/, using chest, arm hind the neck of the seated patient and places the other and head pushing. resting on his/her chin. As he/she swallows, the speech This is followed by nasal /m/, in syllables: mA, mo, mE, therapist pushes the patient’s head forwards, inviting mi, mu, prolonging the final vowel with strong intensity him/her to put up some resistance; at the same time, each time; with the rapid and energetic production of the with the hand on the chin, he/she pushes downwards sonant and surd velar occlusive + uvular vibration + vow- and backwards 7 9-11. el: grA, gro, grE, gri, gru, KrA, Kro, KrE, Kri, Kru; with the production of the syllables with single andEating stratagems double surd and sonant occlusives (KA, Ko, KE, Ki, Ku;The first foods must be introduced in line with certain KAKA, KoKo, KEKE, KiKi, KuKu) and with variouschoices dictated by the different textures of the foods. vowel combinations (KiKiKE, ghighigA, gogoghE,The first to be introduced are dense foods like puddings, ghiEghiE).mousses, mashed potatoes, soft cheese, cool yoghurt, to The number of syllables repeated depends on the patient’sstimulate sensitivity (which is initially poor) and should re- phonatory duration.spect the patient’s favourite flavours to stimulate motivation. Treatment will continue with the reading of the first wordsA whole, creamy meal is then introduced, of which at with a sonant and surd occlusive phonemic component,least 70% must be eaten before it can be replaced with a followed by a mixed component, then by reading nurserynormal solid meal. rhymes, sentences and, finally stories 1 4 7 9 12. 3 Bonnet P, Arnoux-Sindt B, guerrier B, et al. La chirurgieReferences reconstructive du larynx. A propos de la readaptation fonc-1 Arnoux-Sindt B. Readaptation fonctionelle après chirur- tionelle des malades opères de c.h.e.p. et c.h.p. Cah orl gie reconstructive laryngèe Cah orl 1991;9:26-35. 1988;2:465-79.2 Bergamini g, luppi mP, Anceschi T, et al. La riabilitazi- 4 danoy mC, heuillet g, inedjian Jm, et al. Laryngectomies one precoce nelle laringectomie funzionali orizzontali. Acta reconstructives: que faire en reèducation et pourquoi? rev Phon latina 1992;14:3-12. laryngol otol rhinol (Bord) 1988;109:379-82.246
  13. 13. Speech therapy rehabilitation5 demard d, demard F. Reèducation vocale après larynngec- 9 romani u, Bergamini g, ghidini A, et al. Le laringectomie tomie partielles? rev laryngol otol rhinol (Bord) sub-totali ricostruttive nel trattamento del cancro della lar- 1984;105:415-7. inge. Acta otorhinolaryngol ital 1996;16:526-31.6 le huche F, Allali A. La Voce. vol. 3. milano: masson italia; 10 Karasalihoglu Ar, yagiz r, Tas A, et al. Supracricoid partial 1996, p. 55-7. laryngectomy with cricohyoidopexy and cricohyoidoepiglot-7 luna-ortiz K, nunez-vlencia Er, Tamez-velarde m, et al. topexy: functional and oncological results. J laryngol otol Quality of life and functional evaluation after supracricoid 2004;118:671-5. partial laryngectomy with cricohyoidoepiglottopexy in Mexi- 11 Segre r. La comunicazione orale normale e patologica. can patients. J laryngol otol 2004;118:284-8. Torino: C.g. Edizioni medico-Scientifiche; 1976, p. 390-4.8 makeieff m, Barbotte E, giovanni A, et al. Acoustic and aer- 12 Sparano ruiz AC, Weinstein gS. Voice rehabilitation after odynamic measurements of speech production after supracri- external partial laryngeal surgery. otolaryngol Clin north coid partial laryngectomy. laryngoscope 2005;115:546-51. Am 2004;37:637-53.Address for correspondence: dr.ssa m.P. luppi, u.o.C. otori-nolaringoiatria, Azienda ospedaliero-universitaria di modena, viadel Pozzo 71, 41100 modena, italy. 247
  14. 14. Round Table S.I.O. National CongressSurgical rehabilitationRiabilitazione chirurgicaG. BErGAMINI, L. PrEsUTTI, M. ALIcANDrI cIUfELLI, f. MAsoNIENT Department, University Hospital of Modena, ItalyFor many years, the alternative to functional procedures consequently, the functions (swallowing and voice) relatedin which the glottic or supraglottic level are preserved to the sphincteric ability of the larynx. This functional re-(cordectomy of varying extents, supraglottic horizontal habilitational surgery is gradually being adopted, after thelaryngectomy) was total laryngectomy, as replacement early experiences based exclusively on injective laryngo-sphincteric function was not believed to be possible. plasty techniques in the light of more detailed evaluationsThe merit goes to Serafini 1, despite the initial failures of of the various causes of deglutition failure.tracheohyoidoepiglottopexy, for having stimulated the moreover, only with injective methods is it possible toresearch into techniques to replace total laryngectomy 2-4 find solutions to minimal pre- and post-deglutition dis-making it possible to reconstruct the aerodigestive cross- orders that, due to the presence of an efficacious expul-roads, whilst maintaining the three functions of the lar- sive cough, do not constitute a risk for the lower airways,ynx, despite the absence of the “conventional” structures rather a cause of inconvenience for the patient in social(epiglottis, false cords, vocal cords) assigned to sphinc- situations, which thus compromises quality of life.teric function. in parallel with the attempts to solve the problems of ne-All this was facilitated by the simultaneous develop- oglottic insufficiency, a voice surgery technique has beenment of speech therapy strategies, thanks primarily to the developed with the aim of improving glottic competenceFrench schools, aimed at readapting swallowing first and following cordectomy to improve voice quality and elimi-subsequently speech to the neoglottis characterised by a nate the phonoasthenia that often represents the greatestdynamic opposition between the anterior structures (epi- handicap for these patients 8-11.glottis or base of the tongue) and one or two arytenoids tothe rear, which must maintain good movement for aryte- Cordectomynoid health.in the absence of the bases for adequate functional recov- in cordectomies, the functional sequelae are exclusivelyery (correct surgical technique with preservation of the voice-related. difficulties swallowing liquids for the fewfunction of the laryngeal nerves, correctly performed re- days immediately after the procedure are temporary andconstruction, immediate post-operative rehabilitation) or resolve spontaneously in a few days. dysphonia can bein the presence of various types of complication that cause the direct consequence of glottic insufficiency, the effectnon-optimal anatomic and functional sequelae, recovery of an anterior adherence (often inevitable when resec-of the swallowing function can be problematic especially tion also affects the anterior commissure) or caused byin patients whose neurological situation does not require supraglottic compensations (from false cords or aryteno-efficacious neuronal plasticity. epiglottic) favoured by certain situations, such as: oede-in some cases, due to the persistence of swallowing dif- matous arytenoids, pre-existent hypertrophy of the falseficulties, with progressive weight loss and the occurrence cords, extensive glottic resections, retroverted epiglottis,of repeated episodes of aspiration with bronchopneumon- spontaneous, unfavourable compensation due to the ab-ic complications, use of PEg can constitute a provisional sence of postoperative speech therapy.measure for allowing an extension of the rehabilitation Speech therapy can resolve speech problems after limitedprogramme. if the functional situation does not improve resection (type i and ii cordectomies) or after type iii cor-to allow adequate, risk-free eating, patients are often of- dectomies with the formation of significant neocord scar-fered total laryngectomy. ring. it is also the first line of treatment since any latein order to avoid this kind of conclusion to the treatment voice surgery, indicated in the event of unsatisfactory re-programme, which undoubtedly represents a failure for sults after rehabilitation, is not recommended for at leastfunctional surgery and is deeply frustrating for a patient who 6 months.has gone through a difficult and exasperating postoperative Some Authors have suggested immediate surgical reha-phase in the hope of avoiding permanent tracheostomy, bilitation, during the same surgical session as the cordec-since the late 1980s, some Authors 5-7 have suggested surgi- tomy, using autologous fat 12. on the basis of these expe-cal methods that aim to improve neoglottic competence and riences, we introduced into our clinical practice primary248
  15. 15. Surgical rehabilitationsurgical rehabilitation using hyaluronic acid 13 with bothaugmentation aims and in order to improve the scarringprocesses with a stiffer neocord and that therefore can beapplicable also to mucosectomy (type i cordectomy). Thismakes it possible to obtain a volume increase without ad-ditional morbidity around the harvesting site as occurs forfat and with a consequent reduction in the time neededto perform the procedure. We use a medtronic Xomedlaryngeal injector with a 27-gauge needle (orotrachealinjection set). Since hyaluronic acid is usually highly vis- Fig. 2. Resection of the anterior scarring with application of mitomycin.cous and consequently offers a certain resistance when in-jected using a small gauge needle, we developed a metal techniques using implants because it is modulable andplunger that makes it possible to exert adequate pressure presents less risk of extrusion. in the case of proceduresthat can be varied during the injection (Fig. 1). involving the commissural region or the juxta commis-deferred rehabilitation surgical procedures secondary sural one, the neocord can be inexistent with the newlyto cordectomy can be performed using injective laryn- formed perichondrium particularly close to the cartilage.goplasty, using biological materials (autologous fat, bo- This results in marked anterior glottic insufficiency thatvine collagen, homologous collagen, hyaluronic acid) or cannot be solved either with endoscopic enlargementsynthetic materials (polydimethylsiloxane – PdmS) and or by external medialisation. in such situations, Zeitelswith structural surgery 14-18. Whereas fat, collagen and et al. suggested a laryngoplasty of the anterior commis-hyaluronic acid can change in volume over time, due to sure that can be integrated with an injective method onpartial reabsorption, PdmS is stable and non-reabsorba- the rear two-thirds of the neocord 14 16.ble. The main problem related to injective laryngoplasty in the event of supraglottic false cord compensation, ifis the impredictability of the size of volume increase in this is adequate and the voice intense enough, particu-the neocord and the homogeneity of the distribution of larly in male patients, voice surgery could take the formthe material, as these two factors depend on the distend- of helping the ventricular bands to meet (injective laryn-ibility of the scar tissue. goplasty). if glottic compensation is believed to be morein the case of a neocord that is small and/or very close favourable and feasible, it is achieved by laser resectionto the thyroid cartilage, and that cannot therefore be en- of the false cords and surgical rehabilitation of the glot-larged by injection, type i thyroplasty must be performed, tic level. When arytenoepiglottic compensation occurs,using the goretex technique that allows a gradual detach- replacement, if deemed to be advantageous, will involvement of the perichondrium and simultaneous medialisa- partial laser resection of the arytenoid hood or of thetion of the neocord. goretex thyroplasty is preferable to aryepiglottic fold and voice surgery treatment of the glottic level. in some cases, dysphonia occurs second- ary to the formation of scar tissue in the anterior com- Hyaluronic acid: missure. The surgical solution can either be a resection Siringe for injection of the anterior scarring with application of mitomycin Fig. 3. Reconstruction of the commissure using a flap of adequately de- epithelised scar tissue and thinned and fixed with interrupted stitches on toFig. 1. Syringe with a particular metal plunger that makes it possible to ex- the upper face of one of the two vocal cords, following removal by laser va-ert adequate pressure that can be varied during the injection. porisation of the mucosal coating. 249
  16. 16. g. Bergamini et al.(Fig. 2) in an attempt to avoid relapses or reconstruc- the mouth of the oesophagus, which by slowing downtion of the commissure using a flap of adequately de- the pharyngeal phase of swallowing prolong contact be-epithelised scar tissue and thinned and fixed with inter- tween the bolus and the neoglottic aditus, thus increas-rupted stitches on to the upper face of one of the two ing the risk of post-deglutition aspiration; presence ofvocal cords, following removal by laser vaporisation of atonic piriform fossae or scarring roughness that causethe mucosal coating (Fig. 3). bolus stagnation, leading to a prolonged feeling of pres- ence of a foreign body and constituting a cause of post-Supraglottic laryngectomies deglutition aspiration; separation of the reconstruction, a factor that is particularly important in the absence ofFunctional problems are almost exclusively related to cas- the epiglottis since moving the neoglottis away from thees of supraglottic laryngectomy extended to the arytenoid hyoid bone vanquishes the protective mechanism of theand the vocal cords, however “classic” procedures can base of the tongue and compromises the efficiency ofpresent sequelae if the motility of one or both arytenoids arytenolingual compensation, due to the formation of ais compromised, if mucosal flaps compromise respiratory recess between the hyoid bone and cricoid cartilage at thetract patency, due to a reduced sensitivity that does not al- point in which the arytenoid usually comes into contactlow an efficacious adductory reflex of the vocal cords. The with the base of the tongue. it must not be forgotten that,coexistence of these factors will worsen the dysphagia. in particularly in elderly patients, it is possible that a bonethe case of breathing difficulties, the microlaryngoscopic spur (diSh syndrome), may compress the oesophagus,approach using a laser technique will make it possible, ei- constituting an obstacle to the progression of the bolus,ther through the resection of the mucosal flap or perform- which thus becomes an important concomitant cause ofance of a rear cordotomy to restore respiratory tract pat- postoperative dysphagia, an eventuality that should beency and to remove of the tracheostomy tube. if one side explored with a preoperative l-l projection x-ray of theof the larynx is immobile or one vocal cord absent, glottic cervical spine.insufficiency will be corrected by injective laryngoplasty The main causes of respiratory impairment are: persist-using the same technique as for laryngeal monoplegia 19. ence of oedema or arytenoid mucosal flap, stenosis of theBotulinum A toxin or cricopharyngeal myotomy may be neoglottis due to membranous or structural causes due toconsidered in cases of sensitivity deficits and/or abnormal the collapse of the cricoid cartilage (fracture caused bycricopharyngeal tone. reconstruction traction or chondritis sequelae), forward displacement of the cricoid due to incorrect reconstruc-Subtotal laryngectomies tion alignment. video fibroendoscopy is the fundamental technique forin the case of subtotal laryngectomies, the most frequent the diagnostic approach to these problems, as it is able tocomplication from a functional point of view is the per- document the anatomic and functional situation, in addi-sistence of swallowing problems of varying importance, tion to a sensitivity test and, using boli of varying textures,characterised by a risk of bronchopulmonary infection or provides an assessment of deglutition (FEES) that, in thecause discomfort while eating (need for accentuated fa- presence of a tracheotomy can also be completed with acilitating postures during swallowing, sudden coughing, hypoglottoscopic examination 21.stagnation of foods causing numerous rasps or need to The fibroendoscopic examination of swallowing is irre-perform liberating manoeuvres of various types) with con- placeable also for preoperative planning of a surgical cor-sequent difficulties eating certain foods and a tendency to rection by injective laryngoplasty in direct microlaryngos-avoid social events 20. dysphagia is often directly related copy, as during the procedure it is not possible to predictto poor compensation voice sonority, as both swallow- the injection points that will make it possible to correcting and voice are conditioned by the sphincteric capacity the disorder. during fibroscopy, an expert eye is able toof the cricoarytenoid unit. however, functional failure is guess the presence of a reconstruction separation (Fig. 4)sometimes of the respiratory type, making it impossible to requiring confirmation using a X-ray study: a laterolateraldecannulise patients. projection X-ray of the cervical spine (Fig. 5) and CT ofThe main causes of neoglottic insufficiency are: ankylo- the larynx with 3d reconstructions (Fig. 6), which is alsosis or arytenoid paralysis, backward displacement of the useful for identifying any cervical bone spurs.cricoid in relation to the hyoid bone, morpho-functional video fluoroscopy can be used as a complement to FEESdeficiency of the base of the tongue, however degluti- to document the extent of inhalation with the various bar-tion can also be compromised by other situations, such ium textures, to identify crico-pharyngeal hypertone oras: sensitivity deficit of the pharyngeal mucosa and/or scarring stenosis.neoglottis, preventing the triggering of the pharyngeal rehabilitation surgery is performed via the cervicotomyphase and the adductory laryngeal reflex; increase in route (reconstruction review and cervical spinal surgerycrico-pharyngeal tone or narrowing due to scarring of for Forestier’s syndrome), direct suspended microlaryn-250
  17. 17. Surgical rehabilitation Fig. 7. Materials that can be used depending on the infiltration site.Fig. 4. Fibroendoscopy showing a reconstruction separation. The materials that can be used, depending on the in-goscopic procedures (laser resection of the arytenoid mu- filtration site, are shown in Figure 7. our experiencecosal flap or membranous stenosis, laser myotomy of the is based on the use of vox-implants (uroplasty, inc.),crico-pharyngeal muscle and injective laryngoplasty), fi- whose injection site stability and absence of reabsorp-broendoscopic arytenoid augmentation. tion allow a stable result. This product is constituted by areconstruction review can correct situations of separation suspension of PdmS grains with a diameter of betweenand anterior or posterior cricohyoid misalignment and 100 and 200 mm in a polyvinylpyrrolidone (PvP) thatmembranous and cartilaginous stenosis, cervical spine acts as a thinner and carrier. The PvP is subsequentlysurgery with prevascular access makes it possible to elim- reabsorbed by the lymphoreticular system, whilst theinate compression on the oesophagus by filing the bone particle of PdmS, thanks to their size and superficialspurs. in direct microlaryngoscopy, as well as recanalisa- texture, which leads to the formation of a connectivetion of the respiratory tract, augmentation techniques can lattice, do not migrate. The injection system is consti-be used to reduce or eliminate neoglottic insufficiency and tuted by a gun whose plunger progresses in steps, eachto exclude or minimise any scarring furrows responsible time the lever is pressed. it adapts perfectly to the sy-for food stagnation. ringe containing the material and the luer lock type connection constitutes a solid graft with the needle in the pack. it is malleable enough to be shaped so as to allow the surgeon optimum surgical field visibility and correct needle tip direction, which is essential for posi- tioning the implant correctly. The injection sites are indicated in Figure 8. in general, 2 or 3 cc of PdmS only are used. Fig. 5. Laterolateral pro- jection X-ray of the cervical spine. Fig. 6. CT of the larynx with 3D reconstructions. Fig. 8. Injection sites. 251

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