Care for Adults Following Laryngectomy

Key Message

What Is the Issue?

• Total laryngectomy is a surgical procedure to remove the larynx which significantly impacts a patient's ability to swallow, breathe and speak, thereby having a great impact on their overall quality of life (QoL).
• Voice rehabilitation or using a voice prosthesis are options for restoring voice communication in adults following total laryngectomy. However, prostheses are usually expensive and require self-care and/or regular visits to health care personnel to maintain function.
• The effectiveness and health economic evaluation of using voice prostheses (indwelling and non-indwelling devices) and heat moisture exchangers for adults following laryngectomy is unclear.

What Did We Do?

• To inform decisions on the appropriate use of voice prostheses (indwelling and non-indwelling devices) and heat moisture exchangers for adults following laryngectomy, CDA-AMC sought to identify and summarize related evidence or recommendations from clinical studies, health economic evaluations, and evidence-based guidelines.
• We searched key resources, including journal citation databases, and conducted a focused grey literature search for relevant evidence published since January 2019.

What Did We Find?

• One systematic review compared tracheoesophageal voice (TEV) using voice prostheses and esophageal voice (EV) and that meta-analysis revealed that the mean difference between the 2 groups was not statistically significant for voice handicap index (VHI) and voice-related QoL. The overall quality of evidence was assessed as very low.
• One systematic review compared 10 voice prostheses (8 indwelling and 2 non-indwelling) and ranked these devices based on P-scores. This review did not compare indwelling and non-indwelling devices as 2 distinct groups. Most comparisons between various VPs showed no statistically significant differences in device replacements, device lifetime, airflow resistance, leakage, speech rate, maximum phonation time, patient device preference, phonatory effort, fundamental frequency, voice loudness, speech intelligibility, stoma stenosis, dislodgement, fistula problems, granulation, prosthesis inaccurate size, prosthesis deterioration, and survival rate.
• One systematic review reported using heat moisture exchangers significantly reduced several clinical outcomes including mucus production, coughing, forced expectorations, the number of days requiring chest physiotherapy after surgery, tracheobronchitis or pneumonia episodes and improved patient satisfaction. There were no statistically significant differences between heat moisture exchangers and control groups in quality of life (QoL), sleep quality, speech quality, or social contacts.
• No evidence regarding cost-effectiveness of voice prostheses versus no prostheses, indwelling versus non-indwelling prostheses, or comparisons among different non-indwelling prostheses for adults following laryngectomy was identified.
• Heat moisture exchangers were reported as cost-effective compared to alternative stoma covers (ASC) from US perspectives.
• For laryngectomized patients with periprosthetic leakage, switching from Provox Vega to its modified versions (Provox XtraSeal or Provox ActiValve) was reported as cost-effective.
• One evidence-based guideline recommended replacing the prosthesis with a double-flanged one, such as Provox XtraSeal, adjusting the diameter and length, or placing a silicone sheet on the tracheal side of the prosthesis can be used to manage periprosthetic leakage. This report did not identify any evidence-based guidelines regarding the use of heat moisture exchanger (HME) for adults following laryngectomy.

What Does it Mean?

• Initial decisions regarding the choice of voice prostheses should consider patients’ values and preferences, accessibility, affordability, and other factors such as physical and mental capabilities, caregiver support, and patient motivation.
• For laryngectomy patients experiencing periprosthetic leakage, it may be reasonable to switch to a modified version.
• Adding heat moisture exchangers might be beneficial in several clinical outcomes, such as mucus reduction and reported patient satisfaction yet some studies reported similar scores in QoL, sleep quality, speech quality, and social contacts compared to no heat moisture exchangers.
• Further high-quality research is necessary to confirm whether voice prostheses (indwelling or non-indwelling devices) or heat moisture exchangers can be routinely used for adults following laryngectomy.