| BackgroundLaryngeal carcinoma is a common malignant cancer, which ranked second in the head and neck tumor. Surgery is the most effective way to treat laryngeal carcinoma. The supracricoid partial laryngectomy (SCPL) has been established as a main surgical method in the treatment of the supraglottic or glottic carcinoma of larynx, which is widely used, because its postoperative 5-year survival reached 75%-95%, similar to those with single total laryngectomy. The SCPL also preserves the respiration and vocal function, so it is widely used in middle-late laryngeal cancer.SCPL has removed the bilateral vocal cords, false vocal cord and (or) epiglottis, even a side arytenoid, so that the swallowing protective barrier is damaged, which consist of laryngeal vestibule closures, false vocal cord and vocal cords adduction. What’s more, part of the sublingual muscle group, such as thyroglossal skeletal muscle, were cut off, lead to decrease of height and velocity of larynx elevation, reduction of opening width of cricopharyngeal muscle. Therefore, aspiration has become the inexorable trend after the operation.Aspiration is an important problem to be urgently solved in the SCPL post-operation, which seriously affect the patient’s postoperative rehabilitation and quality of life. According to the literature, the rates of aspiration of SCPL post-operative could reach 32% to 89%, with the silent aspiration up to 26.7%, and the rates of aspiration pneumonia could reach 4.3% to 23%, which could lead to death. Thus, to accurately evaluate swallowing function of patients in SCPL postoperative, and supply dieting mode and related rehabilitation training, have the actual clinical significance for reducing the level of aspiration and aspiration related complications.To evaluate the swallowing function of patients who underwent supracricoid partial laryngectomy in six months post-operation, the modified barium swallow (MBS) and fiberoptic endoscopic evaluation of swallowing (FEES), combined with modified penetration aspiration scale (MPAS), were used. We used the evaluation results to guide patients to eat and related rehabilitation training. Furthermore, the feasibility, reliability and accuracy of these two methods were compared.Methods and materials Clinical DataBetween January 2013 and February 2014,11 cases of laryngeal cancer patients who underwent supracricoid partial laryngectomy in six months post-operation had dynamically accepted the assessment of swallowing function, including 10 male and 1 female. The age range was between 44 and 71 yeas old, with the median age of 55. All case were diagnosed as squamous carcinoma, including 9 cases with CHEP and 2 cases with CHP. Bilateral arytenoid was preserved in 6 cases, and unilateral arytenoid was preserved in 5 cases. Bilateral neck dissection was operated in 2 cases, and unilateral neck dissection was operated in 5 cases. Preoperative chemotherapy was performed in 1 case, and postoperative radiotherapy was performed in 2 cases. The TNM system was defined according to the UICC standard (Union InternationaleAgainst Cancer) in 2002, including 4 cases of stages Ⅱ,4 cases of stages Ⅲ,3 cases of stages IVA. All cases included 9 glottis cancer and 2 supraglottis cancer.EquipmentThe fiberoptic endoscopic evaluation of swallowing was performed using a electronic laryngoscope and endoscopic graphic display system (PENTAX EPM-3500, Japan). The modified barium swallow was performed using a digital stomach intestine machine and a fluoroscopy unit (Iconos R200, Siemens, Germany). They were connected to a video recorder, and each examination was recorded.Time of evaluationNo obvious infection of incision,the swallowing function would be evaluated at day 7-15,day 16-30, day 31-45, day 46-90, day 91-180 post-operation, respectively.Evaluation methods(1) Modified barium swallow (MBS):All patients were examined in both a lateral and an anteroposterior view. Each case attempted solid food (62.34% ultravist paste), semiliquid food (62.34% thick ultravist) and liquid food (5ml,10ml of 62.34% ultravist). Compensatory strategies and therapeutic intervention were selected and attempted on the basis of the patient’s swallowing response to each food type during the MBS study. Whether or not food boluses go into the laryngeal vestibule, passes below the glottis, stimulates cough reflex and is ejected completely from the airway. The diagnoses of aspiration were confirmed together by an experienced radiologists and two evaluators who undergo training in assessing dysphagia, and they repeatedly checked the video back again, combined with modified penetration aspiration scale (MPAS). The aspiration level is defiend from 1 to 6 score, ranked by normal, penetration, aspiration, silent aspiration. Normal is defined as score 1,penetration as score 2 and 3, aspiration as score 4 and 5, and silent aspiration as score 6.(2) Fiberoptic endoscopic evaluation of swallowing (FEES):When the patients were lying in relaxed positions, the procedures were executed by the same ENT specialist and a video with the records of each patient. During FEES, the parameters examined included mucous membrane, presence of 1 or both arytenoids, motility of the epiglottis and cricoarytenoid unit. Whether or not the arytenoid become hypertrophy, boluses of various consistencies (colored paste, gelatinous colored water and colored water) were used to evaluate the correct deglutition process or the eventual anatomic and functional alterations. Data were evaluated using a modified penetration aspiration scale (MPAS) by two experienced otolaryngologists who undergo training in assessing dysphagia during the watch and repeatedly checking video back again.Rehabilitation guidance(1) swallowing function training saliva swallows:According to postoperative recovery, the patients start to practice 8-10 the saliva swallows 1 week after surgery 3 times daily.(2) Swallowing methods① effortful swallows:The tongue body has to resist hard palate when swallowing effectively. With the aid of effortful swallows, the mouth can have enough control of boluses, and the movement can increase from the base of tongue to posterior pharyngeal wall. At the same time, effortful swallows can increase the pressure of pharyngeal wall, reduce the pressure of esophageal sphincter, extend the time of the epiglottis in closing and increase airway protection.② chin tuck:It narrows the laryngeal vestibule, so as to reduce the possibility and severity of penetration or aspiration. Therefore, it is used widely by the patients with dysphagia.③ supraglottic swallow:The method involves holding one’s breath to close the airway prior to swallowing, followed by coughing voluntarily immediately after swallowing to clear any residual food or liquid from the airway entrance.④ multiple swallows:The residual food in hypopharynx would be squeezed into esophagus by multiple swallows.(3) postural changeAccording to the MBS results, the appropriate position is selected, for example, to lie down or chin tuck when eating for the patients who have kept the bilateral arytenoid cartilage, and to lie on or head to arytenoid cartilage side and chin tuck when eating for the patients who have kept the unilateral arytenoid cartilage.(4) liquid restrictionIf the patients can eat semiliquid food and solid food, the liquid food, such as water and soup, will be tuned into certain consistencies, so that it will be swallowed with no cough or slight cough.Statistical AnalysisSPSS 16.0 software was used for statistical analysis. Continuity data were showd as mean±sd. Kappa statistic was employed to evaluate the correlation between the MBS and FEES. A p value less than 0.05 was considered significant.Results(1) Eleven patients were enrolled, and MPAS equals score 1 for solid food, semiliquid food, and liquid food was defined as a criteria of normal swallowing function. By MBS evaluation, the numbers of patients with normal swallowing function were two cases at day 16-30 post-operation, two cases at day 31-45 post-operation, five cases at day 46-90 post-operation, and six cases at day 91-180 post-operation, respectively. By FEES evaluation, the above numbers were three cases, four cases, six cases and eight cases, respectively.(2) The MBS was defined as a golden criteria. When the aspiration was minimal and ejected completely, and MPAS was less than or equal to score 4 for solid food, semiliquid food and liquid food, the gastric tube could be removed. According to this standard, the gastric tube was removed in all cases, and the mean time was 21.3±9.8 days.(3) A good correlation was obtained between these two methods when evaluating solid and semiliquid food, and the Kappa values were 0.802 and 0.844, respectively. However, a little agreement was obtained between these two methods when evaluating liquid food, and the Kappa value was 0.529.(4) Eleven patients were enrolled. Nine cases have taken steps to reduce aspiration level by postural change, including 4 cases by heading to arytenoid cartilage side and chin tuck,1 case by lying on arytenoid cartilage side,4 cases by lying flat,7 cases by liquid restriction,7 cases by supraglottic swallow,1 case by effortful swallows.Conclusions(1) 11 patients who underwent supracricoid partial laryngectomy could restore good swallowing function in six months after the operation.(2) Both MBS and FEES methods are valuable procedures for objectively evaluating the swallowing function in patients after supracricoid partial laryngectomy, which could help to determine the time,to remove the gastric tube, and the most suitable food and feeding posture.(3) The FEES is much better than MBS, because FEES is a simple operation performed alone by otolaryngologists with no radiation.(4) The effective swallow strategy and rehabilitation methods can reduce the aspiration levels. Postural change, supraglottic swallow and liquid restriction are the most effective solution. |
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