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.