Introduction:
Functional rehabilitation of post-laryngectomy patients is a challenging task; this includes achieving optimal speech and swallowing outcomes. Common problems in these patients relate to either the hypertonicity of the pharyngoesophageal (PE) segment, PE segment spasm or stricture formation(1). Many of these patients would have received radiotherapy/chemo-radiotherapy as a definitive therapy (before surgery) or as adjuvant therapy, and radiation induced fibrosis further worsens the functional outcomes. Inadequate myotomy probably increases the risk of hypertonicity and spasm.
Pharyngeal constrictor myotomy(2), pharyngeal plexus neurectomy and various methods of surgical closure at the time of the operation(1)can all mitigate the risk of these complications. Once established, stenosis can be treated by dilatation with balloon or bougie, or augmenting the neopharynx surgically. Hypertonicity and spasm, however, can be treated with the use of Botulinum toxin (Botox) injections, which has been shown to be efficacious(3). This chemically denervates the hypertonic pharyngoesophageal segment by blocking the release of acetylcholine at the neuromuscular junction. This reduced tone can lead to permanent improvements in speech in the majority of patients. These are usually injected under videofluoroscopic control but in patients with significant fibrosis it can be difficult to get sufficient injection directly into the muscle fibres and so is undertaken under direct vision under general anaesthetic, including if an anaesthetic is required for another procedure such as dilatation or secondary puncture.(4) Other methods of injecting botulinum toxin include electromyographic (EMG) guided(2) and ultrasound-guided. However, rigid endoscopy guided injection of the Botox remains a helpful approach in some patients with failed prior transcutaneous injections. This can however prove difficult in post-radiotherapy patients, particularly those with limited neck extension.
We propose a novel and efficacious technique using a portable video-laryngoscope, GlideScope®, to directly visualise the injection of botulinum toxin in total laryngectomy patients with severe radiation-induced changes. This gives a more stable view than that from a flexible laryngoscope.