Discussion

Our data collection highlights a comparable percentage of surgical voice restoration users within the cohort to that reported in the Australian literature.^{Reference Hancock, Ward, Burnett, Graciet, Lenne and MaClean3} In this large UK cohort of people with total laryngectomy, sex, employment status and time post-laryngectomy surgery were all found to be statistically significant factors in surgical voice restoration usage. None of the other variables (age, living circumstances and distance from the treatment centre) were predictive.

Previous smaller studies have failed to determine whether sex is of significance.^{Reference Risberg-Berlin, Rydén, Möller and Finizia17,Reference Lee, Gibson and Hilari18} Some studies have only included male participants.^{Reference Polat, Orhan, Kesimli, Gorgulu, Ulusan and Deger19} Given the greater prevalence of head and neck cancer in males, this large sample was able to identify that females were less likely to have surgical voice restoration: 63 per cent of females in contrast to 73 per cent of males. A recent qualitative study highlighted that females dislike their post-laryngectomy vocal quality, feel more vulnerable and are more reluctant to be perceived as different than male counterparts.^{Reference van Sluis, Kornman, Van Der Molen, Van Den Brekel and Yaron5}

Head and neck cancer survivors have a higher unemployment rate than survivors of other cancers.^{Reference Ross, Petersen, Johnsen, Lundstroem, Carlsen and Groenvoild20} Notably, a low percentage of people with total laryngectomy have been reported to return to work,^{Reference Singer, Keszte, Dietz, Kluge, Plontke and Heim21} particularly females.^{Reference Lee, Gibson and Hilari18} Occupation type has previously been reported to influence this, with those in manual jobs less likely to return to work.^{Reference Koch, Wittekindt, Altendorf-Hofmann, Singer and Guntinas-Lichius22} Most of our cohort (69 per cent) were of retirement age at the point of surgery. However, in the group who returned to work, 78 per cent used surgical voice restoration as their primary communication method.

Return to work following head and neck cancer is rarely addressed in depth by healthcare professionals,^{Reference Miller, Wilson and Diver23} but there is an argument that people with total laryngectomy should be supported to maintain employment post-surgery, as employment is associated with lower levels of anxiety and depression.^{Reference Broemer, Friedrich, Wichmann, Müller, Neumuth and Dietz24} One enabling factor appears to be successful communication,^{Reference Costa, López, García, León and Quer25} which is confirmed in our findings. It is also noteworthy that higher levels of general activity are reported by surgical voice restoration users than by those relying on other forms of communication.^{Reference Perry, Shaw and Cotton26}

Our results show that time post-laryngectomy was a significant factor for surgical voice restoration use: people with total laryngectomy who had their surgery most recently are less likely to use surgical voice restoration. Conversely, our previously published research^{Reference Dunton, Patterson, Glaister, Baker, Woodman and Rowe15} analysed the same sample and found that the longer the time elapsed post-surgery, the less likelihood of a heat moisture exchange device being used. At a time when organ preservation is the recommended primary treatment of choice,^{Reference Clarke, Radford, Coffey and Stewart2} laryngectomy surgeries are becoming increasingly complex in nature. When performed as a secondary, salvage procedure they often require the use of a ‘flap’ to close the pharyngeal defect. We hypothesise, therefore, that people with total laryngectomy whose surgery took place many years ago were more likely to have had a standard total laryngectomy. There is likely to be a greater number of ‘salvage’ laryngectomies over more recent years.

Debate is ongoing over whether performing a primary puncture in salvage laryngectomy surgery increases the risk of complications.^{Reference Johnson, Grammar and Medina27,Reference Scherl, Kauffels, Schützenberger, Döllinger, Bohr and Dürr28} Surgeons who believe this to be the case are more likely to avoid a primary puncture. This may also have been an influencing factor in our results. Furthermore, national guidelines do not currently state a recommended time for secondary puncture placement. With reference to our current study, we recognise that 25 per cent of our cohort had surgery fewer than 15 months prior to the data collection period (the interquartile range for non-surgical voice restoration users was 15–113 months). Hence, those people with total laryngectomy have been classed as non-surgical voice restoration users, but may have been awaiting a secondary puncture at the time of data collection.

Distance from centre was not a significant variable for predicting surgical voice restoration use. We hypothesise that this might be an important factor given the unpredictable frequency of voice prosthesis changes required and the requirement for potentially unplanned hospital visits, often at short notice.^{Reference Bradley, Counter, Hurren and Cocks29} It is unknown whether mode of transport and time taken to travel to the treatment centre may be more important than distance. Previously surgical voice restoration changes have generally required people with total laryngectomy to travel to a specialist NHS hospital for voice prostheses changes, the frequency of which is unpredictable.^{Reference McLachlan, Hurren, Owen and Miller12} However, there has been some evidence to suggest that community services can be cost-effective following the need to trial these during the Covid-19 pandemic.^{Reference Haag and Morgan30} Given the increased use of telemedicine within the NHS, it may be possible to implement models of care in the UK that provide remote support to individuals without the need for travel into tertiary centres. These pathways already work well in countries such as Australia.^{Reference Ward, Crombie, Trickey, Hill, Theodoros and Russell31}

Eleven (42 per cent) of the people with total laryngectomy living in a care facility used surgical voice restoration. This correlates with the figures relating to heat moisture exchange device use in this population and is a much lower proportion than for those living independently.^{Reference Dunton, Patterson, Glaister, Baker, Woodman and Rowe15} As far as we are aware, published work does not exist focusing on the care or lived experience of people with an altered airway (laryngectomy or tracheostomy) living in a residential or nursing home. Anecdotally, very few care homes in the UK are prepared to accept residents with an altered airway and may not be adequately equipped to look after this population.³² There is an identified lack of altered airway knowledge in the community,^{Reference Dooks, McQuestion, Goldstein and Molassiotis33,Reference Watson, Hamilton and Patterson34} with training directed more towards staff in hospital settings^{Reference McDonough, Crimlisk, Nicholas, Cabral, Quinn and Jalisi35} or self-care.^{Reference Spito and Cavaliere36} More training and support in community settings may enable safer altered airways care and thus maximise residents’ quality of life.