Laryngectomy

Last updated
Laryngectomy
Diagram showing the position of the stoma after a laryngectomy CRUK 361.svg
Anatomical changes following a laryngectomy
ICD-9-CM 30.2 30.3 30.4
MeSH D007825
MedlinePlus 007398

Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). [1] In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. [2] This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods (surgeries through the mouth, radiation and/or chemotherapy). A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. [3] Less invasive partial laryngectomies, including tracheal shaves and feminization laryngoplasty may also be performed on transgender women and other female or non-binary identified individuals to feminize the larynx and/or voice. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery. [1]

Contents

History

The first total laryngectomy was performed in 1873 by Theodor Billroth. [4] [5] The patient was a 36 year old man with a subglottic squamous cell carcinoma. On November 27, 1873 Billroth performed a partial laryngectomy. Subsequent laryngoscopic examination in mid-December 1873 found tumor recurrence. On December 31, 1873 Billroth performed the first total laryngectomy. The patient was discharged four months later after he learned to use the artificial larynx, which enabled him to speak despite the removal of his vocal cords. Unfortunately, the patient developed a recurrence of the lesion, accompanied by metastatic nodes, and passed away a year following the surgery. [6]

Older references credit a Patrick Watson of Edinburgh with the first laryngectomy in 1866, [7] [8] but this patient's larynx was only excised after death.

The first artificial larynx was constructed by Johann Nepomuk Czermak in 1869. Vincenz Czerny developed an artificial larynx which he tested in dogs in 1870. [9]

Following the pioneering efforts of Billroth, the practice of total laryngectomy gained momentum among surgeons. The early attempts at this procedure, including the second ever performed by Bernhard Heine in 1874 and subsequent operations by Hermann Maas and others, often resulted in the patient's death due to complications or recurrence of disease within months. It wasn't until Enrico Bottini in Italy achieved the first long-term survival of a laryngectomy patient that the potential for lasting success was realized. The period also saw notable failures and challenges, including the tragic case of Crown Prince Frederick of Germany (the future Frederick III). Misdiagnosed initially in 1887 by Morell Mackenzie as benign, Frederick's condition was later identified as cancerous, leading to his death after a tracheostomy. This case highlighted the controversies and difficulties in diagnosing and treating laryngeal cancer, which persisted into the early 20th century. [6]

Advancements in direct laryngoscopy and suspension laryngoscopy, credited to Killian and Lynch respectively, improved the evaluation and surgical management of the larynx. Despite significant challenges such as wound infection, anesthesia, and shock, pioneers like George Washington Crile—which performed the first laryngectomy in U.S. in 1892—made significant contributions to reducing operative mortality and advancing techniques in neck surgery and the management of metastatic disease. [6]

Incidence and prevalence

According to the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer, there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer. [10]

In 2019 it is estimated that there will be 12,410 new laryngeal cancer cases in the United States, (3.0 per 100,000). [11] The number of new cases decreases every year at a rate of 2.4%, [11] and this is believed to be related to decreased cigarette smoking in the general population. [12] The number of laryngectomies performed each year in the U.S. has been declining at an even faster rate [13] due to the development of less invasive techniques. [14] A study using the National Inpatient Sample found that there were 8,288 total laryngectomy cases performed in the US between 1998 and 2008, and that hospitals performing total laryngectomy decreased by 12.3 per year. [15] As of 2013, one reference estimates that there are 50,000 to 60,000 laryngectomees in the US. [14]

Identification

To determine the severity/spread of the laryngeal cancer and the level of vocal fold function, indirect laryngoscopies using mirrors, endoscopies (rigid or flexible) and/or stroboscopies may be performed. [1] Other methods of visualization using CT scans, MRIs and PET scans and investigations of the cancer through biopsy can also be completed. Acoustic observations can also be utilized, where certain laryngeal cancer locations (e.g. at the level of the glottis) can cause an individual's voice to sound hoarse. [1]

Examinations are used to determine the tumor classification (TNM classification) and the stage (1-4) of the tumor. The increasing classifications from T1 to T4 indicates the spread/size of the tumor and provides information on which surgical intervention is recommended, where T1-T3 (smaller tumors) may require partial laryngectomies and T4 (larger tumors) may require complete laryngectomies. [1] Radiation and/or chemotherapy may also be used.[ citation needed ]

The airways and ventilation after laryngectomy

Anatomy of the larynx Larynx external en.svg
Anatomy of the larynx

The anatomy and physiology of the airways change after laryngectomy. After a total laryngectomy, the individual breathes through a stoma where the tracheostomy has created an opening in the neck. There is no longer a connection between the trachea and the mouth and nose. After a partial laryngectomy, the individual breathes mainly through the stoma, but a connection still exists between the trachea and upper airways such that these individuals are able to breathe air through the mouth and nose. The extent of breathing through the upper airways in these individuals varies and a tracheostomy tube is present in many of them. Ventilation and resuscitation of total and partial neck breathers is performed through the stoma. However, for these individuals, the mouth should be kept closed and the nose should be sealed to prevent air escape during resuscitation. [16]

Complications

Different types of complications can follow total laryngectomy. The most frequent postoperative complication is pharyngocutaneous fistula (PCF), characterized by an abnormal opening between the pharynx and the trachea or the skin resulting in the leaking of saliva outside of the throat. [17] [18] This complication, which requires feeding to be completed via nasogastric tube, increases morbidity, length of hospitalization, and level of discomfort, and may delay rehabilitation. [19] Up to 29% of persons who undergo total laryngectomy will be affected by PCF. [17] Various factors have been associated with an increased risk of experiencing this type of complication. These factors include anaemia, hypoalbuminaemia, poor nutrition, hepatic and renal dysfunction, preoperative tracheostomy, smoking, alcohol use, older age, chronic obstructive pulmonary disease and localization and stage of cancer. [17] [18] However, the installation of a free-flap has been shown to significantly reduce the risks of PCF. [17] Other complications such as wound infection, dehiscence and necrosis, bleeding, pharyngeal and stomal stenosis, and dysphagia have also been reported in fewer cases. [17] [18]

Rehabilitation

Voice restoration

Total laryngectomy results in the removal of the larynx, an organ essential for natural sound production. [20] The loss of voice and of normal and efficient verbal communication is a negative consequence associated with this type of surgery and can have significant impacts on the quality of life of these individuals. [20] [21] Voice rehabilitation is an important component of the recovery process following the surgery. Technological and scientific advances over the years have led to the development of different techniques and devices specialized in voice restoration.[ citation needed ]

The desired method of voice restoration should be selected based on each individual’s abilities, needs, and lifestyle. [22] Factors that affect success and candidacy for any chosen voice restoration method could include: cognitive ability, individual physiology, motivation, physical ability, and pre-existing medical conditions. [23] [24]

Pre and post-operative sessions with a speech-language pathologist (SLP) are often part of the treatment plan for people undergoing a total laryngectomy. [25] Pre-operative sessions would likely involve counselling on the function of the larynx , the options for post-op voice restoration, and managing expectations for outcomes and rehabilitation. [23] Post-operative therapy sessions with an SLP would aim to help individuals learn to vocalize and care for their new voice prosthesis as well as refine their use of speech depending on the chosen method of voice restoration. [25]

Voice prosthesis Voice prosthesis.jpg
Voice prosthesis

Available methods for voice restoration:

For individuals using tracheoesophageal or esophageal speech, botulinum toxin may be injected to improve voice quality when spasms or increased tone (hypertonicity) is present at the level of the pharyngoesophageal segment muscles. [29] The amount of botulinum toxin administered unilaterally into two or three sites along the pharyngoesophageal segment varies from 15 to 100 units per injection. Positive voice improvements are possible after a single injection, however outcomes are variable. Dosages may need to be re-administered (individual-dependent) after a number of months, where effective results are expected to last for about 6 to 9 months. [29]

Oral feeding

The laryngectomy surgery results in anatomical and physiological changes in the larynx and surrounding structures. Consequently, swallowing function can undergo changes as well, compromising the patient's oral feeding ability and nutrition. [30] Patients may experience distress, frustration, and reluctance to eat out due to swallowing difficulties. [31] Despite the high prevalence of post-operative swallowing difficulties in the first days following the laryngectomy, most patients recover swallowing function within 3 months. [32] Laryngectomy patients do not aspirate due to the structural changes in the larynx, but they may experience difficulty swallowing solid food. They may also experience changes in appetite due to a significant loss in their senses of taste and smell. [33]

In order to prevent the development of pharyngocutaneous fistula, it is common practice to reintroduce oral feeding as of the seventh to tenth day post-surgery, although the ideal timeline remains controversial. [34] Pharyngocutaneous fistula typically develops before the reintroduction of oral feeding, as the pH level and presence of amylase in saliva is more harmful to tissues than other liquids or food. Whether the reintroduction of oral feeding at an earlier post-operative date decreases the risk of fistula remains unclear. However, early oral feeding (within 7 days of the operation) can be conducive to reduced length of hospital stay and earlier discharge from the hospital, entailing a decrease in costs and psychological distress. [35]

Smell and taste rehabilitation

A total laryngectomy causes the separation of the upper air respiratory tract (pharyn), nose, mouth) and lower air respiratory tract (lungs, lower trachea). [36] Breathing is no longer done through the nose (nasal airflow), which causes a loss/decrease of the sense of smell, leading to a decrease in the sense of taste. [36] The Nasal Airflow Inducing Manoeuvre (NAIM), also known as the "Polite Yawning" manoeuvre, was created in 2000 and is widely accepted and used by speech-language pathologists in the Netherlands, while also becoming more widely used in Europe. [37] This technique consists of increasing the space in the oral cavity while keeping the lips closed, simulating a yawn with a closed mouth by lowering the jaw, tongue and floor of the mouth. [37] This causes a negative pressure in the oral cavity, leading to nasal airflow. [38] The NAIM has been recognized as an effective rehabilitation technique to improve the sense of smell. [37]

Quality of life

People with a partial laryngectomy are more likely to have a higher quality of life than individuals with a total laryngectomy. [36] People having undergone total laryngectomy have been found to be more prone to depression and anxiety, and often experience a decrease in the quality of their social life and physical health. [39]

Voice quality, swallowing and reflux are affected in both types, with the sense of smell and taste (hyposmia/anosmia and dysgeusia) also being affected in total laryngectomies (a complaint which is given very little attention by medical professionals). [36] [40] Partial or total laryngectomy can lead to swallowing difficulties (known as dysphagia ). [1] Dysphagia can have a significant effect on some patients' quality of life following surgery. [1] Dysphagia poses challenges in eating and social involvement, often causing patients to experience increased levels of distress. [1] This effect holds true even after the acute phase of recovery. [1] More than half of patients who received total laryngectomy were found to experience restrictions in their food intake, specifically in what they can eat and how they can eat it. [1] The diet limitations imposed by dysphagia can negatively impact a patient's quality of life, as it can be perceived as a form of participation restriction. [1] Accordingly, these perceived restrictions are more commonly experienced by dysphasic laryngectomy patients compared to non-dysphasic laryngectomy patients. [1] Therefore, it is important to consider dysphagia in short and long-term outcomes post-laryngectomy in order for patients to uphold a higher quality of life. [41] Often, speech-language pathologists are involved in the process of prioritizing swallowing outcomes. [41]

People receiving voice rehabilitation report best voice quality and overall quality of life when using a voice prosthesis as compared to esophageal speech or electrolarynx. [39] Furthermore, individuals going through non-surgical therapy report a higher quality of life than those having undergone a total laryngectomy. [39] Lastly, it is much more difficult for those using alaryngeal speech to vary their pitch, [42] which particularly affects the social functioning of those speaking a tonal language. [42]

Related Research Articles

Vocal cord nodules are bilaterally symmetrical benign white masses that form at the midpoint of the vocal folds. Although diagnosis involves a physical examination of the head and neck, as well as perceptual voice measures, visualization of the vocal nodules via laryngeal endoscopy remains the primary diagnostic method. Vocal fold nodules interfere with the vibratory characteristics of the vocal folds by increasing the mass of the vocal folds and changing the configuration of the vocal fold closure pattern. Due to these changes, the quality of the voice may be affected. As such, the major perceptual signs of vocal fold nodules include vocal hoarseness and breathiness. Other common symptoms include vocal fatigue, soreness or pain lateral to the larynx, and reduced frequency and intensity range. Airflow levels during speech may also be increased. Vocal fold nodules are thought to be the result of vocal fold tissue trauma caused by excessive mechanical stress, including repeated or chronic vocal overuse, abuse, or misuse. Predisposing factors include profession, gender, dehydration, respiratory infection, and other inflammatory factors.

<span class="mw-page-title-main">Laryngitis</span> Medical condition

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.

<span class="mw-page-title-main">Head and neck cancer</span> Cancer arises in the head or neck region

Head and neck cancer develops from tissues in the lip and oral cavity (mouth), larynx (throat), salivary glands, nose, sinuses, or skin of the face. The most common types of head and neck cancer occur in the lips, mouth, and larynx. Symptoms predominantly include a sore that does not heal or a change in the voice. In those with advanced disease, there may be unusual bleeding, facial pain, numbness or swelling, and visible lumps on the outside of the neck or oral cavity. Given the location of these cancers, it is possible for an afflicted individual to experience difficulty breathing.

Esophageal speech, also known as esophageal voice, is an airstream mechanism for speech that involves oscillation of the esophagus. This contrasts with traditional laryngeal speech, which involves oscillation of the vocal folds. In esophageal speech, pressurized air is injected into the upper esophagus and then released in a controlled manner to create the airstream necessary for speech. Esophageal speech is a learned skill that requires speech training and much practice. On average it takes 6 months to a year to learn this form of speech. Because of the high level of difficulty in learning esophageal speech, some patients are unable to master the skill.

<span class="mw-page-title-main">Tracheoesophageal fistula</span> Medical condition

A tracheoesophageal fistula is an abnormal connection (fistula) between the esophagus and the trachea. TEF is a common congenital abnormality, but when occurring late in life is usually the sequela of surgical procedures such as a laryngectomy.

<span class="mw-page-title-main">Laryngeal papillomatosis</span> Medical condition

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.

An electrolarynx, sometimes referred to as a "throat back", is a medical device about the size of a small electric razor used to produce clearer speech by those people who have lost their voice box, usually due to cancer of the larynx. The most common device is a handheld, battery-operated device pressed against the skin under the mandible which produces vibrations to allow speech; other variations include a device similar to the "talk box" electronic music device, which delivers the basis of the speech sound via a tube placed in the mouth. Earlier non-electric devices were called mechanical larynxes. Along with developing esophageal voice, using a speech synthesizer, or undergoing a surgical procedure, the electrolarynx serves as a mode of speech recovery for laryngectomy patients.

A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice can be associated with a feeling of unease or scratchiness in the throat. Hoarseness is often a symptom of problems in the vocal folds of the larynx. It may be caused by laryngitis, which in turn may be caused by an upper respiratory infection, a cold, or allergies. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting one's voice, singing loudly, or speaking with a voice that is too high or too low can also cause temporary hoarseness. A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems.

<span class="mw-page-title-main">Telerehabilitation</span> Delivery of rehabilitation services over the internet

Telerehabilitation (or e-rehabilitation is the delivery of rehabilitation services over telecommunication networks and the internet. Telerehabilitation allows patients to interact with providers remotely and can be used both to assess patients and to deliver therapy. Fields of medicine that utilize telerehabilitation include: physical therapy, occupational therapy, speech-language pathology, audiology, and psychology. Therapy sessions can be individual or community-based. Types of therapy available include motor training exercises, speech therapy, virtual reality, robotic therapy, goal setting, and group exercise.

<span class="mw-page-title-main">Laryngology</span> Medical specialty

Laryngology is a branch of medicine that deals with disorders, diseases and injuries of the larynx, colloquially known as the voice box. Laryngologists treat disorders of the larynx, including diseases that affects the voice, swallowing, or upper airway. Common conditions addressed by laryngologists include vocal fold nodules and cysts, laryngeal cancer, spasmodic dysphonia, laryngopharyngeal reflux, papillomas, and voice misuse/abuse/overuse syndromes. Dysphonia/hoarseness; laryngitis ; *Spasmodic dysphonia; dysphagia; Tracheostomy; Cancer of the larynx; and vocology are included in laryngology.

<span class="mw-page-title-main">Oropharyngeal dysphagia</span> Difficulty controlling the mouth or throat for swallowing

Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of the symptoms. Patients with dysphagia can experience feelings of food sticking to their throats, coughing and choking, weight loss, recurring chest infections, or regurgitation. Depending on the underlying cause, age, and environment, dysphagia prevalence varies. In research including the general population, the estimated frequency of oropharyngeal dysphagia has ranged from 2 to 16 percent.

<span class="mw-page-title-main">Globus pharyngis</span> "Lump in the throat" sensation

Globus pharyngis, globus hystericus or globus sensation is the persistent but painless sensation of having a pill, food bolus, or some other sort of obstruction in the throat when there is none. Swallowing is typically performed normally, so it is not a true case of dysphagia, but it can become quite irritating. It is common, with 22–45% of people experiencing it at least once in their lifetime.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Spasmodic dysphonia, also known as laryngeal dystonia, is a disorder in which the muscles that generate a person's voice go into periods of spasm. This results in breaks or interruptions in the voice, often every few sentences, which can make a person difficult to understand. The person's voice may also sound strained or they may be nearly unable to speak. Onset is often gradual and the condition is lifelong.

A tracheo-esophageal puncture is a surgically created hole between the trachea (windpipe) and the esophagus in a person who has had a total laryngectomy, a surgery where the larynx is removed. The purpose of the puncture is to restore a person’s ability to speak after the vocal cords have been removed. This involves creation of a fistula between trachea and oesophagus, puncturing the short segment of tissue or “common wall” that typically separates these two structures. A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for oesophageal speech.

<span class="mw-page-title-main">Laryngopharyngeal reflux</span> Medical condition

Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.

<span class="mw-page-title-main">Voice prosthesis</span>

A voice prosthesis is an artificial device, usually made of silicone that is used in conjunction with voice therapy to help laryngectomized patients to speak. During a total laryngectomy, the entire voice box (larynx) is removed and the windpipe (trachea) and food pipe (esophagus) are separated from each other. During this operation an opening between the food pipe and the windpipe can be created. This opening can also be created at a later time. This opening is called a tracheo-esophageal puncture. The voice prosthesis is placed in this opening. Then, it becomes possible to speak by occluding the stoma and blowing the air from the lungs through the inside of the voice prosthesis and through the throat, creating a voice sound, which is called tracheo-esophageal speech. The back end of the prosthesis sits at the food pipe. To avoid food, drinks, or saliva from coming through the prosthesis and into the lungs, the prosthesis has a small flap at the back. There are two ways of inserting the voice prosthesis: through the mouth and throat with the help of a guide wire, or directly through the tracheostoma (anterograde) manner. Nowadays, most voice prosthesis are placed anterograde, through the stoma.

<span class="mw-page-title-main">Heat and moisture exchanger after laryngectomy</span>

Heat and moisture exchangers (HME) are used after laryngectomy to help reduce breathing restrictions and compensate nasal functions.

TransOral Robotic Surgery (TORS) is a modern surgical technique used to treat tumors of the mouth and throat via direct access through the mouth. TransOral Robotic Sleep Apnea (TORSA) surgery utilizes the same approach to open the upper airway of patients with obstructive sleep apnea. In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth) and pharynx (back of the throat) without any incisions through the neck, chin or lip (these incisions are necessary in traditional, non-robotic approaches). Current TORS techniques include radical tonsillectomy, resection of palate and base of skull tumors, hemiglossectomy and resection of tumors above and involving the larynx. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion.

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  24. ↑ Gress, Carla DeLassus (June 2004). "Preoperative evaluation for tracheoesophageal voice restoration". Otolaryngologic Clinics of North America. 37 (3): 519–530. doi:10.1016/j.otc.2003.12.003. ISSN   0030-6665. PMID   15163598.
  25. 1 2 Tang, Christopher G.; Sinclair, Catherine F. (August 2015). "Voice Restoration After Total Laryngectomy". Otolaryngologic Clinics of North America. 48 (4): 687–702. doi:10.1016/j.otc.2015.04.013. ISSN   0030-6665. PMID   26093944.
  26. ↑ Brook I (July 2009). "A piece of my mind. Rediscovering my voice". JAMA. 302 (3): 236. doi:10.1001/jama.2009.981. PMID   19602676.
  27. ↑ Brown DH, Hilgers FJ, Irish JC, Balm AJ (July 2003). "Postlaryngectomy voice rehabilitation: state of the art at the millennium". World J Surg. 27 (7): 824–31. doi:10.1007/s00268-003-7107-4. PMID   14509514. S2CID   9515030.
  28. ↑ "Larynx transplant: Q&A" . Retrieved July 25, 2017.
  29. 1 2 Khemani, S.; Govender, R.; Arora, A.; O'Flynn, P. E.; Vaz, F. M. (December 2009). "Use of botulinum toxin in voice restoration after laryngectomy". The Journal of Laryngology and Otology. 123 (12): 1308–1313. doi:10.1017/S0022215109990430. ISSN   1748-5460. PMID   19607736. S2CID   33085769.
  30. ↑ Coffey, Margaret; Tolley, Neil (2015). "Swallowing after laryngectomy". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (3): 202–208. doi:10.1097/moo.0000000000000162. PMID   25943964. S2CID   23470240.
  31. ↑ Maclean, Julia; Cotton, Susan; Perry, Alison (2009-06-01). "Post-Laryngectomy: It's Hard to Swallow". Dysphagia. 24 (2): 172–179. doi:10.1007/s00455-008-9189-5. ISSN   0179-051X. PMID   18784911. S2CID   8741206.
  32. ↑ Lips, Marieke; Speyer, Renée; Zumach, Anne; Kross, Kenneth W.; Kremer, Bernd (2015-09-01). "Supracricoid laryngectomy and dysphagia: A systematic literature review". The Laryngoscope. 125 (9): 2143–2156. doi:10.1002/lary.25341. ISSN   1531-4995. PMID   26013745. S2CID   206202759.
  33. ↑ Clarke, P.; Radford, K.; Coffey, M.; Stewart, M. (May 2016). "Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines". The Journal of Laryngology & Otology. 130 (S2): S176–S180. doi:10.1017/S0022215116000608. ISSN   0022-2151. PMC   4873894 . PMID   27841134.
  34. ↑ Aires, Felipe Toyama; Dedivitis, Rogério Aparecido; Petrarolha, Sílvia Miguéis Picado; Bernardo, Wanderley Marques; Cernea, Claudio Roberto; Brandão, Lenine Garcia (October 2015). "Early oral feeding after total laryngectomy: A systematic review". Head & Neck. 37 (10): 1532–1535. doi:10.1002/hed.23755. ISSN   1097-0347. PMID   24816775. S2CID   30024834.
  35. ↑ Talwar, B.; Donnelly, R.; Skelly, R.; Donaldson, M. (May 2016). "Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines". The Journal of Laryngology & Otology. 130 (S2): S32–S40. doi:10.1017/s0022215116000402. ISSN   0022-2151. PMC   4873913 . PMID   27841109.
  36. 1 2 3 4 Sadoughi, Babak (August 2015). "Quality of Life After Conservation Surgery for Laryngeal Cancer". Otolaryngologic Clinics of North America. 48 (4): 655–665. doi:10.1016/j.otc.2015.04.010. ISSN   1557-8259. PMID   26092764.
  37. 1 2 3 van der Molen, Lisette; Kornman, Anne F.; Latenstein, Merel N.; van den Brekel, Michiel W. M.; Hilgers, Frans J. M. (June 2013). "Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands" (PDF). Current Opinion in Otolaryngology & Head and Neck Surgery. 21 (3): 230–238. doi:10.1097/MOO.0b013e3283610060. ISSN   1531-6998. PMID   23572017. S2CID   215715884.
  38. ↑ Hilgers, Frans J. M.; Dam, Frits S. A. M. van; Keyzers, Saskia; Koster, Marike N.; As, Corina J. van; Muller, Martin J. (2000-06-01). "Rehabilitation of Olfaction After Laryngectomy by Means of a Nasal Airflow-Inducing Maneuver". Archives of Otolaryngology–Head & Neck Surgery. 126 (6): 726–32. doi:10.1001/archotol.126.6.726. ISSN   0886-4470. PMID   10864109. S2CID   27808756.
  39. 1 2 3 Wiegand, Susanne (2016-12-15). "Evidence and evidence gaps of laryngeal cancer surgery". GMS Current Topics in Otorhinolaryngology, Head and Neck Surgery. 15: Doc03. doi:10.3205/cto000130. ISSN   1865-1011. PMC   5169076 . PMID   28025603.
  40. ↑ Hinni, Michael L.; Crujido, Lisa R. (2013). "Laryngectomy rehabilitation". Current Opinion in Otolaryngology & Head and Neck Surgery. 21 (3): 218–223. doi:10.1097/moo.0b013e3283604001. PMID   23511606. S2CID   38780352.
  41. 1 2 Maghami, Ellie; Ho, Allen S. (2018). Multidisciplinary care of the head and neck cancer patient. Maghami, Ellie; Ho, Allen S. Cham, Switzerland. ISBN   9783319654218. OCLC   1023426481.{{cite book}}: CS1 maint: location missing publisher (link)
  42. 1 2 Chan, Jimmy Y. W. (June 2013). "Practice of laryngectomy rehabilitation interventions: a perspective from Hong Kong". Current Opinion in Otolaryngology & Head and Neck Surgery. 21 (3): 205–211. doi:10.1097/MOO.0b013e328360d84e. ISSN   1531-6998. PMID   23572016. S2CID   37522328.
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