Despite improvements in chemoradiation therapy and the adoption of organ preservation for some head and neck cancers, total laryngectomy remains the treatment often providing best survival chances for advanced laryngeal cancer. This article reviews the causes of dysphagia post-laryngectomy and the use of evaluation tools. The authors describe the incidence of dysphagia between 50-72% following laryngectomy; often under-reported and resulting in psychosocial limitations. Assessment of swallow is most commonly associated with videofluoroscopy. Fibreoptic endoscopic evaluation of swallowing (FEES) identifies secretions and residue post swallow. It is useful in those who are not medically fit for videofluoroscopy, but direct visualisation of the oral and oesophageal stages of swallowing are not possible. A study of manometry, measuring bolus pressure and timing of the contractile wave during swallowing at anatomical points, such as upper or lower oesophageal sphincter, demonstrated impaired propulsive forces of the reconstructed pharynx after laryngectomy and suggested that biomechanical effects can be influenced by surgical techniques. Like videofluoroscopy, it involves radiation exposure and this technique is not readily available in small centres. Common causes of post-laryngectomy dysphagia are described including pseudodiverticulae, fistulae, strictures, reduced propulsion in the neopharynx, voice prosthesis leakage and reflux. Each of these problems results in dietary modifications and difficulty maintaining a balanced diet. In summary, the authors highlighted that a significant number of post-laryngectomy patients suffer with dysphagia. Its management is facilitated by comprehensive swallowing evaluation. Further research is required to illuminate dysphagia rehabilitation. 

Swallowing after laryngectomy.
Coffey M, Tolley N.
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Anna Slovick

Guy's Hospital, London, UK.

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