Does tracheostomy cause peristomal recurrence?

Pre-operative tracheostomy is required in 51 per cent of our laryngectomees, predominantly in those with subglottic cancers and advanced tumours. In the 1990s, post-operative RT or emergency laryngectomy was advocated for emergency tracheostomy patients, even though the evidence for tumour seeding causing peristomal recurrence was questionable and the tracheostomy tract is completely resected at the time of laryngectomy.

The question we tried to address was whether seeding of cancer cells into the tracheostomy tract causes peristomal recurrence. We conducted a retrospective review of 43 clinically staged T₃ glottic cancers treated with primary total laryngectomy and post-operative RT, and found no difference in peristomal recurrence between tracheostomy and non-tracheostomy patients.^{Reference Fagan and Loock3} Though not conclusive (as all patients received RT), the results did question whether tracheostomy caused peristomal recurrence. Given supportive evidence from studies by Rubin et al.,^{Reference Rubin, Johnson and Myers4} Pezier et al.^{Reference Pezier, Nixon, Joshi, Pang, Guerrero-Urbano and Oakley5} and Mei et al.,^{Reference Mei, Huang, Wu, Zhao, Yang and Liu6} we do not consider pre-operative tracheostomy to be an independent indication for post-operative radiation therapy, unless the tracheostomy tract passed through a tumour, or the tracheostomy was necessitated by subglottic extension or advanced cancer.

Management of thyroid gland with laryngectomy

Joseph Ogura (1955) and Sir Donald Harrison (1973) advocated routine thyroid lobectomy with total laryngectomy, as do the current National Comprehensive Cancer Network guidelines (2020).^{Reference Viljoen, McGuire, Alhadad, Dalvie and Fagan9} The reasoning is to clear occult neck level VI nodal metastases as might occur with subglottic and hypopharyngeal cancers, or to resect possible direct cancer extension to the thyroid gland. However, the thyroid gland is located some distance from the glottis, making direct extension unlikely unless there is subglottic tumour extension.

Compared to an incidence of clinical or subclinical hypothyroidism of 5–10 per cent in the general population, the pooled risk of hypothyroidism following total laryngectomy with thyroid lobectomy is approximately 32 per cent, and, following laryngectomy, thyroid lobectomy and RT, the risk is approximately 89 per cent.^{Reference Viljoen, McGuire, Alhadad, Dalvie and Fagan9} There is also an attendant risk of hypoparathyroidism. In developing countries, this can be problematic, as patients may not have access to or be able to afford thyroid hormone and calcium replacement or monitoring.

In order to determine whether routine thyroidectomy is oncologically indicated, we conducted a retrospective clinicopathological study of 102 total laryngectomies performed for clinically staged T₃ glottic squamous cell carcinoma.^{Reference Fagan and Kaye7} We found that the thyroid gland was involved in only two cases, both with subglottic extension. Hence, we changed our practice to preserve the thyroid, unless there was subglottic or hypopharyngeal cancer, or intra-operative evidence of direct tumour extension to the thyroid.

We subsequently assessed the oncological safety of the above practice in a retrospective review of 142 total laryngectomy patients, of which 69 had thyroid-preserving laryngectomy and 73 had thyroid lobectomies.^{Reference McGuire, Viljoen, Rocke, Fitzpatrick, Dalvie and Fagan8} We found that there were no significant differences in local tumour recurrence or survival.

In a recent retrospective review of 84 total laryngectomy patients, we investigated whether thyroid-sparing total laryngectomy does indeed decrease the risk of hypothyroidism.^{Reference Viljoen, McGuire, Alhadad, Dalvie and Fagan9} As is summarised in Table 1, preserving both thyroid lobes was significantly associated with preservation of thyroid function, although this advantage was lost in patients receiving post-operative radiation therapy.

Table 1. Impact of thyroid preservation on thyroid function

RT = radiotherapy

Based on these three studies, it is our practice to reflect the thyroid and inspect the larynx, and to preserve the thyroid, unless there is direct tumour extension to the thyroid, or there are concerns about paratracheal nodes in patients with subglottic extension or cancer of the hypopharynx (Figure 1).

Fig. 1. It is our practice to reflect the thyroid and inspect the larynx for extralaryngeal cancer extension.

Is tracheoesophageal speech appropriate in a developing world community?

We fit over 90 per cent of patients with voice prostheses. However, voice prostheses are expensive and are unaffordable for many public hospitals and patients. Our speech therapists are responsible for patient selection, pre-operative counselling and long-term management of fistula speech.

We surgically optimise fistulae for speech by performing pharyngo-oesophageal myotomy, creating a capacious pharynx by closing the pharynx transversely, having liberal indications for augmenting the pharyngeal repair with a pectoralis major flap, and dividing the sternal heads of the sternocleidomastoid muscles to create a flat peristomal profile.

We first conducted a study to determine whether fistula speech was appropriate in a developing world setting given its expense, and whether to include socioeconomic status, literacy levels and proximity to the hospital as selection criteria for fistula speech.^{Reference Fagan, Lentin, Oyarzabal, Iaacs and Sellars10} Fistula speech was the primary mode of communication in 81 per cent of patients, and was unaffected by employment status or proximity to specialist services. Even though it was affected by literacy level and type of housing, several illiterate shack dwellers acquired good speech.

A more recent study of ours revealed that 93 per cent of patients fitted with a voice prosthesis used fistula speech as their primary mode of communication.^{Reference Fagan, Lentin and Quail11} This improvement was attributed to: improved selection criteria that focused on manual dexterity and cognitive function; more rigorous education relating to valve maintenance and dealing with valve extrusion; and fitting indwelling as opposed to removable prostheses, to reduce extrusion rates in patients living far from the hospital.

Our current practice to optimise the use of expensive voice prostheses, therefore, is: careful patient selection in terms of manual dexterity and cognitive function; not excluding patients based on educational or socioeconomic status, or distance from the hospital; rigorous education relating to valve maintenance and dealing with valve extrusion; and fitting indwelling prostheses to prevent extrusion.

Early oral feeding following total laryngectomy

Despite oral feeding traditionally being withheld for 7–10 days, pharyngocutaneous fistulae occur in 3–65 per cent of primary laryngectomies. Medina (2001) (cited in Aswani et al.^{Reference Aswani, Thandar, Otiti and Fagan12}) reported no difference in pharyngocutaneous fistula rates between early and delayed feeding. The question we posed was whether the same applied in a developing world setting with our more advanced tumours, more frequent neck dissections and poorly nourished patients.

We compared the pharyngocutaneous fistula rates in 40 primary laryngectomy patients fed according to the early feeding protocol (outlined in Table 2) with 39 historical control cases in whom feeding had been delayed for 7–10 days, and found no significant difference in fistula rates.

Table 2. Early feeding protocol

In a subsequent systematic review that compared early versus delayed feeding, I also reported that none of 11 studies found an association between early feeding and pharyngocutaneous fistulae with primary laryngectomy.^{Reference Fagan, Gooi and Agrawal13} It is therefore our current practice to introduce early feeding for primary laryngectomy patients given its psychological benefits, reduced nursing care and cost savings. Delayed feeding is still employed for patients in whom a flap has been used to reconstruct the pharynx, or in those who have undergone salvage surgery following radiation therapy.

Do proton pump inhibitors reduce pharyngocutaneous fistulae?

In this study, we conducted a prospective, placebo-controlled, double-blind, randomised, controlled trial to determine whether peri-operative PPIs reduce the incidence of pharyngocutaneous fistulae following primary total laryngectomies.^{Reference Stephenson and Fagan14} Forty patients were randomised to either receive 14 days’ PPI treatment (20 mg enteral omeprazole) or a placebo. There was a statistically significant difference (p = 0.04) in pharyngocutaneous fistulae in the omeprazole group (1 out of 21 (5 per cent)) versus the placebo group (6 out of 19 (32 per cent)). Hence, our current practice is to administer prophylactic PPIs for all total laryngectomy patients.

Are cloth stoma covers effective?

This section addresses the question: are cloth stoma covers effective to control the tracheal climate of laryngectomy patients? Neither our patients nor our public hospital can afford heat and moisture exchanger devices. Hence, we have cloth stoma covers made by a local seamstress for 35p, to humidify and warm the inspired air of laryngectomy patients (Figure 2).

Fig. 2. Cloth stoma cover (bib).

We conducted a study to determine whether our inexpensive stoma cover was effective, and how it compared with the commercial Buchanan® Bib and heat and moisture exchanger devices. A thermocouple temperature sensor and a relative humidity sensor were incorporated into a housing that permitted us to record the temperature and humidity of the expired air at the tracheostoma. The inexpensive stoma cover and Buchanan Bib both significantly improved humidity and temperature (p < 0.05), and were more effective than heat and moisture exchanger devices (p < 0.05).^{Reference Quail, Fagan, Raynham, Krynauw, John and Carrara15}

These findings were corroborated by Lansaat et al. in an ex vivo experimental setting.^{Reference Lansaat, van der Boer, Muller, van der Noort, van den Brekel and Hilgers16} We therefore recommend that cloth stoma covers be encouraged when heat and moisture exchangers are unavailable, unaffordable or inappropriate.

Does socioeconomic status affect quality of life after total laryngectomy?

South Africa is the most unequal society in the world in terms of the Gini Index. We conducted a study to examine whether QoL after laryngectomy is affected by socioeconomic status, and whether potential laryngectomy patients should be counselled differently depending on their socioeconomic status.^{Reference Scott, McGuire, Manning, Leach and Fagan17}

Specifically, we carried out a cross-sectional, observational QoL assessment of public (Groote Schuur Hospital) versus private patients, more than two years after laryngectomy. Quality of life was measured using the Updated University of Washington Quality of Life questionnaire, the Voice-Related Quality of Life questionnaire and the Brief Illness Perception questionnaire. The private and public patient cohorts differed significantly in terms of: levels of education (p < 0.001), income (p < 0.001), permanent employment (p < 0.001), social welfare grant recipient (p < 0.001), distance to the hospital (p = 0.008) and poorer living conditions (p = 0.001). Thirty-five per cent of the public patients lived in informal settlements or low-cost government housing.^{Reference Scott, McGuire, Manning, Leach and Fagan17}

The results of the study revealed that socioeconomic status did not significantly affect QoL.^{Reference Scott, McGuire, Manning, Leach and Fagan17} However, lower socioeconomic status was associated with better voice-related QoL, which concurs with a study by Agarwal et al.^{Reference Agarwal, Gogia, Agarwal, Agarwal and Mathur18} We therefore concluded that socioeconomic status should not affect indications for total laryngectomy, but that it should be considered when reporting voice outcomes of total laryngectomy patients.