Ronald C. Hamaker

Further Experience with Voice Restoration after Total Laryngectomy

The current report describes a 40-month experience with 129 patients undergoing voice restoration by endoscopic tracheoesophageal puncture and use of a removable silicone valve. Successful acquisition of voice was achieved in 88% of patients with minimal complications. Observations of this group of laryngectomy patients suggest that esophageal voice is profoundly affected by the residual function of the pharyngeal constrictor musculature. Selective division of these muscles will enhance voice acquisition in a large number of failed esophageal speakers.

Tracheostoma Valve for Postlaryngectomy Voice Rehabilitation

Newer surgical techniques for postlaryngectomy voice rehabilitation provide a simple, effective method of communication but require manual occlusion of the tracheostoma during speech. We report the development of a unique tracheostoma valve that avoids the necessity for covering the stoma. This airflow-sensitive valve closes during speech and remains open with normal respiration. Results of a clinical trial with 50 patients over a ten-month period are encouraging. Our experience suggests that excessive vocal tract resistance to airflow is the principal limitation to effective valve use. Approaches to decreasing airflow resistance through the vocal tract to improve both voice production and tracheostoma valve use are discussed.

Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation.

Pharyngeal constrictor and cricopharyngeal spasm have been implicated as deterrants to esophageal speech acquisition as well as tracheoesophageal phonation. Recent efforts to reduce the resultant hypertonicity include pharyngeal constrictor myotomies and modifications of pharyngeal reconstruction during laryngectomy. Investigation of the innervation of the muscular wall of the pharynx led to the development of a pharyngeal plexus neurectomy technique to alter the tonicity of the pharynx without myotomy. The resultant alaryngeal speech is fluent, and acoustic parameters compare favorably to esophageal speech.

Intraoperative radiation therapy for recurrent head and neck cancer

Forty‐seven patients with recurrent head and neck cancer in a previously irradiated field were treated with surgical resection and intraoperative radiation therapy (IORT). Recurrent disease occurred at a median of 18 months from primary treatment, and was at the primary tumor site in 31 and metastatic to regional lymph nodes in 16. Recurrences were squamous cell carcinomas in 42 and adenoid cystic in five. Surgical resection left microscopic residual disease in 41 and gross residual in six. All patients received IORT with a median of 20 Gy. Two‐year actuarial survival is 54.9%, and 15 patients are alive and disease free with a median survival of 29 months. Two‐year actuarial local control is 61.5%. A trend toward increased survival (P < 0.09) and local recurrence control (P = 0.05) was noticed when treating microscopic residual disease as opposed to gross residual disease. Perioperative mortality was seen in 8.5% and there was no increase in morbidity secondary to IORT. The authors believe that surgical resection and IORT is an effective treatment modality for head and neck cancers recurrent in previously irradiated fields and is adaptable to tertiary care hospitals.

What is the role of carotid arterial resection in the management of advanced cervical cancer

From 1977 through 1988, 16 patients underwent carotid artery resection and reconstruction or simple ligation in the treatment of advanced cervical carcinomas. Three patients underwent carotid artery ligation, with postoperative transient ischemic attacks, which resolved, in one patient. In the remaining 13 patients, interposition saphenous vein grafts were used to reconstruct the resected carotid arteries. In one of these 13 patients, the previously unresected carotid artery ruptured and was treated by carotid artery resection with interposition vein grafting and coverage by a myocutaneous flap. There were two immediate postoperative strokes, with excellent neurologic recovery in one, and one late postoperative stroke (6 months). There was one postoperative death. Adjunctive intraoperative irradiation (1500 to 2000 rad) was employed in 15 patients to decrease the risk of recurrent disease. Since 1982, pectoralis major muscle flaps have been constructed in all patients to cover the vein grafts, with no subsequent carotid artery blowouts. Seven patients are free of cancer more than 1 year after surgery. In conclusion, carotid artery resection for the treatment of advanced cervical carcinomas may be accomplished with acceptable morbidity and mortality rates in carefully selected cases. Coverage of the vein graft by a myocutaneous flap appears to protect against carotid artery blowout. Intraoperative irradiation appears to decrease significantly the local recurrence rate of these aggressive tumors.

Zenker's diverticulum: Analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy

Objective: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenkers diverticulum. Study Design: Retrospective. Materials and Methods: A chart review was conducted of all patients with a Zenkers diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. Results: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. Conclusions: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenkers diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment. Key Words: Zenkers diverticulum, cricopharyngeal myotomy, surgical complications, diverticulectomy.

Feasibility of low doses of I-131 for thyroid ablation in postsurgical patients with thyroid carcinoma

The feasibility of using low doses of l-131 (30 mCi) for ablation of thyroid remnants following surgery for papillary and follicular thyroid carcinoma was examined in 21 patients. Six weeks following near-total thyroidectomy and three days following intramuscular thyroidstimulating hormone (10 IU), patients were given 30 mCi of l-131 and scans were performed 24 to 72 hours later. Remaining thyroid tissue was identifiable in the thyroid bed in 19 patients, and two patients also had evidence of cervical metastases. Patients with metastases received an additional 100 mCi of l-131. Follow-up l-131 scans were performed at nine to 15-month intervals in ten patients who initially received 30 mCi of l-131, and only one patient showed complete ablation of the residual thyroid tissue, whereas the remaining nine patients had persistent uptake of l-131 in the same regions in which the uptake was seen in the initial postoperative scans. One of the nine patients had evidence of a cervical metastasis as well. It is therefore apparent that total or near-total thyroidectomy rarely removes all thyroid tissue and that an “out-patient” dose of l-131 is not adequate for ablation of postoperative thyroid remnants.

Surgical salvage for stomal recurrence: A multi-institutional experience†‡

Recurrence of squamous cell cancer following total laryngectomy constitutes an extremely difficult therapeutic problem. Satisfactory management is elusive and frustrating to the head and neck oncologist. Various recommended therapeutic regimens include symptomatic treatment, palliation with chemotherapy and radiation, and aggressive surgical salvage. While surgery offers the only realistic chance at cure, this procedure is fraught with significant morbidity and a poor success rate.

Applications of the Voice Prosthesis during Laryngectomy

With the recent introduction of the voice prosthesis for alaryngeal speech rehabilitation, its application in the early postlaryngectomy period is gaining acceptance. One hundred twenty-eight patients received a tracheoesophageal puncture and adjunctive pharyngeal constrictor relaxation during laryngectomy. The voice prosthesis was applied as early as 10 days after surgery, and the results of a 9-year experience are presented. Eighty percent of the population achieved a durable voice, and the complications were infrequent. The results support the primary use of tracheoesophageal phonation as a relatively safe and reliable alternative to total laryngectomy alone.

Primary voice restoration at laryngectomy: 1989 update

The initial report on the technique of primary voice restoration at laryngectomy as performed by Head and Neck Surgery Associates of Indianapolis was published in 1985. The accumulated experience now approaches 140 cases with changes in surgical technique resulting in an improved success rate. These changes and the current status of the technique are presented in this report