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Swallowing Outcomes Following Laryngectomy and Pharyngolaryngectomy
E. C. Ward, PhD;
B. Bishop, BSpPath (Hons);
J. Frisby, BSpThy;
M. Stevens, MBBS
Arch Otolaryngol Head Neck Surg. 2002;128:181-186.
ABSTRACT
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Objectives To determine the incidence of dysphagia (defined as the inability to
manage a diet of normal consistencies) at hospital discharge and beyond 1
year postsurgery and examine the impact of persistent dysphagia on levels
of disability, handicap, and well-being in patients.
Design Retrospective review and patient contact.
Setting Adult acute care tertiary hospital.
Patients The study group, consecutively sampled from January 1993 to December
1997, comprised 55 patients who underwent total laryngectomy and 37 patients
who underwent pharyngolaryngectomy with free jejunal reconstruction. Follow-up
with 36 of 55 laryngectomy and 14 of 37 pharyngolaryngectomy patients was
conducted 1 to 6 years postsurgery.
Main Outcome Measures Number of days until the resumption of oral intake; swallowing complications
prior to and following discharge; types of diets managed at discharge and
follow-up; and ratings of disability, handicap, and distress levels related
to swallowing.
Results Fifty four (98%) of the laryngectomy and 37 (100%) of the pharyngolaryngectomy
patients experienced dysphagia at discharge. By approximately 3 years postsurgery,
21 (58%) of the laryngectomy and 7 (50%) of the pharyngolaryngectomy patients
managed a normal diet. Pharyngolaryngectomy patients experienced increased
duration of nasogastric feeding, time to resume oral intake, and incidence
of early complications affecting swallowing. Patients experiencing long-term
dysphagia identified significantly increased levels of disability, handicap,
and distress. Patients without dysphagia also experienced slight levels of
handicap and distress resulting from taste changes and increased durations
required to complete meals of normal consistency.
Conclusions The true incidence of patients experiencing a compromise in swallowing
following surgery has been underestimated. The significant impact of impaired
swallowing on a patient's level of perceived disability, handicap, and distress
highlights the importance of providing optimal management of this negative
consequence of surgery to maximize the patient's quality of life.
INTRODUCTION
DYSPHAGIA, or impaired swallowing function, has been established as
a predominant negative sequelae following laryngectomy and pharyngolaryngectomy
surgery.1-5
Despite this, few investigations have specifically examined the nature of
the presenting dysphagia, including postoperative and long-term complications,
patterns of recovery, or long-term dietary outcomes. In addition, the documented
incidence figures for dysphagia following total laryngectomy and pharyngolaryngectomy
are noted to vary widely from study to study. Presently, the incidence of
dysphagia following total laryngectomy has been reported to range from 10%6 to 60%.7 Similarly,
the overall reported incidence of dysphagia following pharyngolaryngectomy
with free jejunal graft reconstruction currently ranges from 2%8
to 58%.9 The inconsistency in these figures
in both patient populations seems to stem from the use of various definitions
of "successful" swallowing. Many authors have categorized successful swallowing
as the ability to achieve oral intake regardless of consistency, eg, "successful
swallowing is the ability to maintain nutrition without tube feeding."10(p396) Others have included the ability to swallow
modified consistencies as their optimal outcome, eg, "adequate swallowing
is the ability to tolerate a soft diet."11(p954)
Although such broad definitions of swallowing success may be adequate when
evaluating the outcomes of different surgical techniques, they fail to accurately
reflect the true number of patients postsurgery who are unable to resume their
normal, premorbid swallowing function. Consequently, it is possible that the
figures reported in the literature may have underestimated the number of patients
who may experience difficulties and associated distress related to altered
swallowing function postsurgery.
The psychosocial aspects of dysphagia, which arise as a consequence
of long-term swallowing dysfunction, and their ultimate impact on a patient's
quality of life have received minimal attention in the literature. The restoration
of the ability to swallow and eat normally by mouth is critical for full social
rehabilitation of patients,12 and the inability
for some patients to return to a normal diet following surgery can have a
negative impact on quality of life.2 Ackerstaff
et al1 evaluated the functional disorders and
lifestyle changes following total laryngectomy and found that as many as 25%
of patients report alterations to their diet, including avoidance of certain
consistencies as well as modifications to their style of eating. Investigations
have also shown that these monotonous dietary changes can often lead to reduced
appetite and weight loss, which ultimately result in poor quality of life.2
It is, therefore, the aim of the present study to document the incidence
and severity of dysphagia both in the immediate postsurgical and long-term
postsurgical phases of patients following either a total laryngectomy or pharyngolaryngectomy
procedure. In this study, dysphagia or a swallowing impairment has been defined
as any inability to manage a full diet of normal consistencies. In light of
the limitations of the definitions of dysphagia used in existing research,
we hypothesize that the true incidence of dysphagia in the total laryngectomy
and pharyngolaryngectomy population has been underestimated. Our study also
aims to specifically evaluate the impact of long-term swallowing dysfunction
on levels of perceived handicap and distress in the total laryngectomy and
pharyngolaryngectomy patient populations. It is hypothesized that any patient
who has not resumed the ability to manage a normal diet postsurgery will identify
themselves as having increased levels of disability, handicap, and distress
compared with those managing a normal diet.
PATIENTS AND METHODS
PATIENTS
Subjects included all patients admitted to the Royal Brisbane Hospital,
Brisbane, Australia, between January 1993 and December 1997 for either a total
laryngectomy or pharyngolaryngectomy with free jejunal interposition reconstruction.
Patients were excluded from the present study if they had undergone oral surgery
or had a coexisting neurological impairment or injury that may affect swallowing.
We identified 55 laryngectomy and 37 pharyngolaryngectomy patients who were
eligible. Of the laryngectomy patients, 50 were men and 5, women (mean ±
SD age at surgery, 63 years ± 8 years 10 months; range, 39-82 years).
Of the pharyngolaryngectomy patients, 34 were men and 3, women (mean ±
SD age at surgery, 59 years 9 months ± 8 years 9 months; range, 39-77
years). In the laryngectomy group, 17 (31%) had received prior radiotherapy;
27 (49%), postoperative radiotherapy; 2 (4%), both; and 9 (16%), no radiotherapy.
Of the pharyngolaryngectomy patients, 5 (14%) had received prior radiotherapy;
29 (78%), postoperative radiotherapy; 1 (3%), both; and 2 (5%), no radiotherapy.
PROCEDURE
Ethical clearance for data collection was obtained from the Royal Brisbane
Hospital and The University of Queensland. The medical records and speech
pathology files of all patients were reviewed, and details pertaining to medical
and surgical characteristics, postoperative swallowing complications, swallowing
assessments and management, and postsurgical dietary outcomes were collated.
Swallowing complications were defined as any symptom observed on either clinical
swallowing assessments or radiological investigations that resulted in a negative
effect on the patient's swallowing ability. Complications were divided into
those that occurred within the first month postsurgery (referred to as early
postsurgical complications) and those that occurred beyond the first month
postsurgery (referred to as late postsurgical complications). The immediate
but transient effects of radiotherapy were not included as a complication
in this study because those data were inconsistently reported in the medical
files. Six categories of dietary consistencies were used to classify the dietary
status of each patient: normal, soft selective (soft options of a normal diet),
soft mechanical (soft chewable consistencies), soft puree (vitamized foods
[foods blended with additional gravy or sauce]), liquid puree (liquefied foods),
and nonoral feeding. For the purposes of this study, clinically significant
dysphagia was defined as the inability to tolerate a normal diet, ie, able
to swallow all liquid and solid foods without any texture alteration required
and no requirement for any supplementary nonoral nutrition.
On completion of the retrospective medical record review phase of the
investigation, all patients were contacted to discuss their long-term swallowing
outcomes. At that time, all patients were at a minimum of 1 year and a maximum
of 6 years postsurgery. Only 36 of the 55 laryngectomy (30 men and 6 women;
mean ± SD years postsurgery, 3 years 3 months ± 1 year 6 months)
and 14 of the 37 pharyngolaryngectomy patients (13 men and 1 woman; mean ±
SD years postsurgery, 3 years 2 months ± 1 year 2 months) could be
contacted. Of the remainder, 32 of the 92 patients had deceased, and 10 of
92 had invalid contact details. During the interview, patients identified
(1) current dietary status and (2) levels of perceived swallowing disability,
handicap, and well-being/distress using the Therapy Outcome Measure Dysphagia
Scale (TOM),13 a series of 6-point scales for
which 0 indicates a highly negative result (extreme difficulties) and 5 indicates
a highly positive result (absence of difficulties).
RESULTS
The mean ± SD period of hospitalization was 19.0 ± 18.78
days (range, 5-127 days) in the laryngectomy group and 23.5 ± 15.10
days (range, 11-78 days) in the pharyngolaryngectomy group. Statistical comparison
revealed no significant difference between the duration of hospitalization
of the 2 groups. A number of patients experienced multiple swallowing-related
complications within the first month postsurgery, with 19 complications identified
in 15 (27%) of the 55 laryngectomy patients vs 35 in 24 (65%) of the 37 pharyngolaryngectomy
patients (Table 1). Statistical
analysis revealed a significantly (z = 3.364; P<.001) higher incidence of early swallowing complications
in the pharyngolaryngectomy group. There was no significant difference between
the number of late complications reported for 20 (36%) of the 55 laryngectomy
patients and 15 (40%) of the 37 pharyngolaryngectomy patients (Table 1).
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Table 1. Early and Late Complications With Impact on Swallowing Function*
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Postoperatively, all patients received initial nutrition via nasogastric
feeding to allow for the recovery of surgical tissue. At a mean ± SD
of 11.7 ± 7.31 days (range, 6-75 days) following surgery, each patient
was clinically assessed using either a modified barium swallow (7 patients
[8%]), diatrizoate meglumine (Gastrografin; Bristol-Meyers Squibb Co, Princeton,
NJ) swallow (37 patients [40%]), or blue dye swallow (48 patients [52%]) to
assess the feasibility of initiating oral intake. For 49 (89%) of the 55 laryngectomy
patients and 29 (78%) of the 37 pharyngolaryngectomy patients who presented
with no complications that would inhibit the resumption of oral intake, the
mean ± SD duration to oral alimentation was 10.7 ± 1.98 days
in the laryngectomy group and 12.1 ± 2.12 days in the pharyngolaryngectomy
group. Statistical comparison revealed the duration to oral alimentation was
significantly (t test = -2.886; P<.01) shorter in the laryngectomy group. The remaining 6 (11%)
of the laryngectomy and 8 (22%) of the pharyngolaryngectomy patients were
identified with fistulae or wound breakdown on the immediate radiographic
evaluation. The 6 laryngectomy patients (11%) received extended nasogastric
feeding for a mean ± SD of 24.7 ± 14.47 days. Five of the 8
pharyngolaryngectomy patients received extended nasogastric feeding for a
mean ± SD of 27.2 ± 9.63 days, while the remaining 3 pharyngolaryngectomy
patients (8%) received percutaneous endoscopic gastronomy feeding for a mean
± SD of 65.3 ± 23.44 days.
Following discharge, a further 15 (27%) of the laryngectomy and 6 (16%)
of the pharyngolaryngectomy patients who were identified with late complications
required periods of nonoral nutrition. Twelve (22%) of the laryngectomy and
2 (5%) of the pharyngolaryngectomy patients received nasogastric feeding for
a mean ± SD period of 36.6 ± 40.09 days and 17.0 ± 12.73
days, respectively. One pharyngolaryngectomy patient (3%) with long-term complications
required additional protein and energy supplements indefinitely, and the remaining
3 (5%) laryngectomy and 3 (8%) pharyngolaryngectomy patients required feeding
via percutaneous endoscopic gastronomy for a mean ± SD period of 23.3
± 17.93 days and 16.3 ± 13.05 days, respectively.
At hospital discharge, only 1 laryngectomy patient (2%) was tolerating
a normal diet. According to our definition of dysphagia, the remaining 54
laryngectomy patients (98%) and 37 pharyngolaryngectomy patients (100%) were
classified as dysphagic owing to their inability to manage foods of normal
consistency (Table 2). Statistical
analysis revealed no significant difference between the incidence of dysphagia
identified in the 2 groups at discharge.
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Table 2. Dietary Consistencies Managed at Postoperative Discharge
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The long-term follow-up was conducted at a mean ± SD of 3 years
3 months ± 1.50 years postsurgery for laryngectomy patients and 3 years
2 months ± 1.17 years for pharyngolaryngectomy patients. At that time,
21 (58%) of the 36 laryngectomy and 7 (50%) of the 14 pharyngolaryngectomy
patients with dysphagia continued to be classified as having dysphagia (Table 3). Statistical comparison of proportions
revealed no significant difference between the incidence of long-term dysphagia
between the 2 groups.
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Table 3. Comparison of Dietary Consistencies Managed at Discharge and
Long-term Follow-up
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At follow-up, there was no significant difference (P = .39) between the mean ± SD TOM scores for levels of swallowing
disability experienced by either the total laryngectomy (4.39 ± 0.84)
or pharyngolaryngectomy (4.21 ± 0.97) group. Similarly, the mean ±
SD TOM scores for perceived levels of handicap in the total laryngectomy (4.14
± 0.96) and pharyngolaryngectomy (3.93 ± 0.73) patients and
the levels of well-being/distress in the total laryngectomy (4.25 ±
1.00) and pharyngolaryngectomy (4.36 ± 0.63) groups were not significantly
different (P = .23 and .89, respectively).
Within each surgical group, statistical comparisons were conducted between
the patients with and without dysphagia (Table 4). In the laryngectomy group, results revealed significantly
(P<.001) higher levels of disability, handicap,
and distress in the 15 patients with dysphagia compared with the 21 patients
without dysphagia. In the pharyngolaryngectomy patient group, there were insufficient
group numbers (7 with dysphagia and 7 without dysphagic) to validate statistical
comparison.14 However, an examination of the
group mean TOM scores revealed a consistently higher level of perceived disability,
handicap, and distress levels in the pharyngolaryngectomy patients with dysphagia.
Interestingly, although the patients without dysphagia in both groups rated
themselves as having no swallowing disability, some patients perceived that
they experienced a slight level of swallowing handicap and associated distress.
These ratings were most frequently attributed by the patient to an increased
duration necessary to eat a meal of normal consistency and disruptions to
taste and smell postoperatively.
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Table 4. Comparison of Perceived Levels of Swallowing Disability, Handicap,
and Distress Between Dysphagic and Nondysphagic Patients*
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COMMENT
Despite the differential nature of the 2 surgical procedures, both the
laryngectomy and pharyngolaryngectomy patient groups presented with comparable
levels of dysphagia at the point of discharge postsurgery. Specifically, the
present study revealed that 54 (98%) of the laryngectomy and 37 (100%) of
the pharyngolaryngectomy patients presented with persistent swallowing impairments
that prevented the management of normal dietary consistencies at discharge.
As a consequence of using more stringent criteria to define swallowing impairment,
the present percentages are significantly higher than previous reports of
postoperative dysphagia for either the laryngectomy or pharyngolaryngectomy
population.7, 9 The definitions
used in the present study, however, more accurately reflect the true existence
or absence of swallowing compromise. In light of this, the current figures
would seem to represent a more accurate indication of the true incidence of
patients who experience swallowing impairments, regardless of severity, following
total laryngectomy and pharyngolaryngectomy.
Following a mean period of 3 years postdischarge, longitudinal evaluation
revealed that over half of the patients in both surgical groups had achieved
optimal swallowing outcomes and resolution of the ability to manage a normal
diet. This represented a dramatic increase from 2% to 58% in the laryngectomy
group and 0% to 50% in the pharyngolaryngectomy group. In addition, 49 (89%)
of the laryngectomy and 29 (78%) of the pharyngolaryngectomy patients were
managing a soft diet or better at follow-up, and no patient continued to require
nonoral feeding support. These findings demonstrate good long-term functional
results for both surgical procedures consistent with previous literature.8, 15-16 The present incidence
figures, however, remain on the conservative side of the few existing reports
of long-term swallowing outcomes.8, 16
Hillman et al16 reported that 76% of their
laryngectomy patients at 24 months postsurgery managed a normal diet, while
Julieron et al8 similarly found that 76% of
pharyngolaryngectomy patients could manage foods of normal consistency at
12 months postsurgery.
Although the incidence of dysphagia at discharge and in the long-term
did not differ between the 2 surgical groups, significant differences were
noted in the early rehabilitation of oral intake between the groups. Specifically,
the more extensive surgical procedure associated with pharyngolaryngectomy
resulted in a significantly longer period of immediate postoperative nonoral
nutrition and delays to the commencement of oral feeding compared with the
laryngectomy group. The present study also revealed that the pharyngolaryngectomy
patients experienced a significantly higher incidence of early complications
related to swallowing dysfunction than the laryngectomy patients during the
early postsurgical phase. The prominent complications observed in the group
included nasal regurgitation and fistula formation, which have been reported
in the literature as frequently occurring following pharyngolaryngectomy surgery
with jejunal graft reconstruction.17-18
Beyond the early postsurgical phase, however, the incidence of complications
affecting swallowing function in the long-term did not differ between the
2 surgical groups, with less than 40% of patients experiencing some complication
that developed beyond 1 month postsurgery.
The swallowing impairments noted in both patient groups impacted negatively
on patients' quality of life. In particular, laryngectomy patients who presented
with persistent dysphagia reported significantly higher levels of disability
than those patients who could tolerate a normal diet. Those patients with
a perceived disability reported an inability to manage normal dietary consistencies,
the need to implement compensatory strategies to facilitate their swallowing,
or the dependence on additional nutritional supplements. For laryngectomy
patients with persistent swallowing impairments, the results also reflected
poor quality of life with the perception of higher levels of handicap and
distress than the laryngectomy patients who experienced normal long-term swallowing
function. Laryngectomy patients with dysphagia reported that the prolongation
of swallowing impairments following the postoperative phase had affected their
ability to fulfill certain social, educational, and/or family roles; decreased
their self-confidence and self-esteem; and resulted in poor ability to achieve
their potential in certain situations. Considering that eating is a crucial
component not only in sustaining nutritional needs, but also in socializing
and enjoying lifelong traditions, all of these patients experienced impaired
quality of life as a result of prolonged swallowing dysfunction.5
Furthermore, reduced quality of life was also evident in the increased reports
of anger, frustration, embarrassment, concern, and withdrawal in laryngectomy
patients with dysphagia, which was consistent with some reports that patients
with cancer find eating to be more distressing than nourishing.19
At present, there is a sparsity of literature detailing the functional
recovery of swallowing following pharyngolaryngectomy procedures with free
jejunal graft reconstruction in the long-term or the impact of persistent
dysphagic impairments on quality of life. This may be the result of a number
of factors, including poor survival rates, which have been reported to fall
as low as 15% to 35% following a 5-year period.20-21
Poor longevity is further exacerbated by patient dropout from longitudinal
studies, which can be expected following head and neck surgery.22
These 2 factors were demonstrated to affect the present study because insufficient
patient numbers were available for follow-up in the pharyngolaryngectomy patient
group to allow a definitive statistical analysis of the impact of long-term
swallowing dysfunction on quality of life to be reported. Evaluation of the
descriptive statistics revealed pharyngolaryngectomy patients who presented
with long-term swallowing dysfunction, however, reported higher levels of
perceived disability, handicap, and distress on average. This finding suggests
that pharyngolaryngectomy patients with persistent dysphagia also experienced
impaired social functioning and emotional repercussions as a result of poor
swallowing ability.
Interestingly, in the present data some patients who presented with
the ability to manage a normal diet at follow-up and reported no swallowing
disability perceived that they continued to experience a mild level of handicap
and distress related to their swallowing function. The interviews with these
patients revealed that although the patients could manage a normal diet, compensations
such as taking additional time to complete a meal or drinking increased amounts
of liquids were viewed as negative changes. Other psychological and emotional
issues (eg, the lack of "taste" of foods) was also reported by some as still
impacting negatively on the social and pleasurable aspects of swallowing and
eating postsurgery. These findings demonstrate that even mild alterations
to normal eating and swallowing behaviors can alter a patient's perceptions
about their quality of life. They also highlight how levels of disability
do not always correspond to the perceived levels of handicap and distress.
CONCLUSIONS
Through the use of more stringent criteria that classified dysphagia
as any inability to resume normal dietary status, the present study demonstrated
a higher incidence of dysphagia at discharge and long-term follow-up in both
the laryngectomy and pharyngolaryngectomy groups than was previously reported.
The present study identified characteristic differences between the total
laryngectomy and pharyngolaryngectomy patients with respect to the higher
incidence of early postoperative complications and the extended duration to
initial postsurgical dietary intake recorded in the pharyngolaryngectomy group.
The incidence of dysphagia at discharge and long-term follow-up, however,
was comparable for both groups.
The persistence of long-term swallowing impairments was noted to negatively
affect a patient's quality of life, with more significant levels of disability,
handicap, and distress reported by patients with dysphagia in both surgical
groups. In addition, although the laryngectomy and pharyngolaryngectomy patients
without dysphagia had resumed premorbid dietary status, some still perceived
that they experienced increased levels of handicap and distress due to factors
such as increased time required to complete a meal of normal consistency.
This finding, and the results of the disability, handicap, and distress measures
of the patients with dysphagia highlight that any degree of alteration to
normal swallowing function can have a negative impact on a patient's quality
of life. Consequently, it is important not to underestimate the postsurgical
significance of any degree of swallowing impairment and its potential effect
on a patient's level of well-being.
AUTHOR INFORMATION
Accepted for publication August 29, 2001.
We would like to acknowledge the assistance of Melissa Timm, BspPath,
Lynda Waymouth, BspPath, and Megan Bell, BspThy, for their assistance with
the data collation and Barbara McCosker for her assistance with the medical
records.
Corresponding author: Elizabeth Ward, PhD, Department of Speech Pathology
and Audiology, The University of Queensland, St Lucia 4072, Australia (e-mail: Liz.Ward{at}mailbox.uq.edu.au).
From the Department of Speech Pathology and Audiology, The University
of Queensland, St Lucia, Australia (Dr Ward and Ms Bishop); and the Departments
of Speech Pathology (Ms Frisby) and Ear, Nose, and Throat (Dr Stevens), Royal
Brisbane Hospital, Brisbane, Australia.
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