COMPREHENSIVE MANAGEMENT OF THE PATIENT WITH LARYNGEAL AND HYPOPHARYNGEAL CANCER. PHONIATRIC ASPECTS.

Abstract

Multidisciplinary treatment of head and neck tumors influences both survival and quality of life after treatment. Before the introduction of organ preservation and partial surgery, the main treatment for laryngeal cancer was total laryngectomy. This procedure implies a separation of upper digestive and respiratory tracts, and loss of the phonatory organ. These patients may recover their communication ability through erigmophony or the use of a voice prosthesis. As a result, they get a lower toned voice and short phonation time. If these fail, they may use a laryngophone, but the sound obtained has a robotic quality and short duration. Although the main objective of treatment is to obtain complete control of the disease, organ preservation strategies aim to preserve laryngeal function by decreasing morbidity. Oncologic committees propose the most adequeate strategy for each patient, from an array of options including partial surgery, chemotherapy and radiotherapy. Phoniatric intervention will depend on the location of the disease and the applied treatment. Our objective will be to obtain a functional larynx, able to communicate effectively, swallow safely and allow breathing withoutthe need of a tracheostomy. Supraglottic tumors usually do not result in dysphonia, but normally modify timbre through alteration of the resonators. Supraglottic laryngectomy affects voice mildly but impairs swallowing, so treatment aims to improve the function of the sphincter, while modifying posture and food texture. Glottic tumors cause dysphonia, and partial laryngectomies the resulting quality of voice will depend on the size and location of the tumor, being worse in cases of deep infiltration or anterior commisure involvement. The objective in these cases is to increase tissue flexibility to improve glottic closure. In certain cases, voice production with the vestibular folds is an acceptable solution. In some other cases, sound produced by contact of the arytenoid with the epiglottis of with some othe mucosal surface. Radiotherapy affects voice quality to a lesser degree, but induces transitory dysphonia due to tissue swelling and fibrosis. Arytenoid mobilization exercises prevent stiffness, and laryngeal closure excersices improve vocal fold tone and flexibility.