Current status of laryngectomee rehabilitation: I. Results of therapy

Original Contributions Am ] Otolaryngol 3 : 1 - 7 , 1982

Current Status of Laryngectomee Rehabilitation: I. Results of Therapy GEORGEA. GATES, M.D.,* WILLIAMRYAN, PH.D.,t J. C, CooPER,JR., PH.D.,$ G. FRANKLAWLIS,PH.D.,w Evm CANTU, M.ED.," TONIHAYASHI, M.A., II EDMUNDLAUDER,M.A.,82RICHARDW. WELCH,M.D.,** AND ERWINHEARNE,PH.D.tt Of 103 people with the clinical diagnosis of laryngeal cancer studied by the authors, 53 eventually were treated by total laryngectomy and, in some cases, radical neck dissection (43), preoperative radiation therapy (15), postoperative radiation therapy (29), and postoperative chemotherapy (7). All were entered into a comprehensive rehabilitation program. Six months following completion of their cancer therapy 47 were re-evaluated. Of these, 12 (26 per cent) used esophageal speech as the dominant mode of communication, 16 (34 per cent) the electrolarynx, and the remainder either wrote (16 [34 per cent]) or signed (3 [6 per cent]). Twenty-six (55 per cent) were considered to be successfully rehabilitated overall and 21 (45 per cent) were not. These data indicate that the rehabilitative needs of today's laryngectomee are not being met successfully with traditional methods.

Recovery from any type of cancer surgery is affected by three elements: cancer control, physiologic alterations, and psychosocial adjustment; laryngectomy is no exception. Postlaryngectomy recovery differs quantitatively from recovery from other cancer operations in that disease control is better (60 per cent) and the

physiologic handicaps--difficulty in swallowing, shoulder drop, and anosmia--are generally not incompatible with a vigorous life. Since removal of the cancerous larynx leaves patients without their primary means of communication and emotional expression, efforts to rehabilitate the laryngectomee have, understandably, centered on restoration of vocal communication by the a c q u i s i t i o n of esophageal speech. The psychosocial effects of voice loss are substantial. In the words of Greene, 1 in a choice between early death and loss of voice the patient " . . . suffers a shock from which he never completely rallies." Other consequences of laryngectomy, particularly its effects on emotional health, social interaction, and self-image, have received less attention. Esophageal speech, when successful, provides most laryngectomees with a harsh voice of low pitch and loudness that is adequate for communication in small groups and quiet settings. Only a few exceptional esophageal speakers have sufficient versatility and dynamic vocal range to approximate the normal voice. Not all laryngectomees are able to acquire esophageal sl~eech--reported percentages range from 432 to 98, 3 with an average of 6 4 - 6 9 per cenP--and the proportion of those who fail to acquire it appears to us to be increasing. In spite of many studies of laryngectomee rehabilitation, the extent of recovery after

Received March 31, 1981. Accepted for publication August 21, 1981. Supported by a grant {R18 CA18629-02) from the National Institutes of Health. * Professor and Head, Division of Otorhinolaryngology, The University of Texas Health Science Center, San Antonio, Texas, t Chief of Audiology and Speech Pathology, Veterans Administration Medical Center, Albuquerque, New Mexico. # Associate Professor and Chief of Audiology, Division of Otorhinolaryngology, The University of Texas Health Science Center, San Antonio, Texas. wProfessor, Department of Psychology, North Texas State University, Denton, Texas. "Research Associate, Division of Otorhinolaryngology, The University of Texas Health Science Center at San Antonio, Texas. Clinical Assistant Professor, Department of Physical Medicine, and Rehabilitation, The University of Texas Health Science Center at San Antonio, Texas. ** Associate Professor, Division of GastRoenterology, The University of Texas Health Science Center at San Antonio, Texas. t t Assistant Professor (Biostatistics), Division of Otorhinolaryngology, The University of Texas Health Science Center, San Antonio, Texas. Address correspondence and reprint requests to Dr. Gates: Division of Otorhinolaryngology, Department of Surgery, University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284.

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1

LARYNGECTOMEE REHABILITATION [

laryngectomy is not known because: 1) most reports have been retrospective, 2) the population bias of those studies has been high (usually only those who survive their cancer and who are willing to participate have been used as study subjects), and 3) the conclusions of published reports have been contradictory. To investigate the current status of laryngectomee rehabilitation, we initiated a prospective study entitled "Comprehensive Rehabilitation of the Laryngectomee," based on the premise that only a composite and comprehensive view of the ]aryngectomee could provide insight into the problems of rehabilitation. The study design was based on three assumptions: 1. That information about multiple aspects of patients with laryngeal cancer obtained prior to surgery could provide a data base with which to compare similar information obtained postoperatively; . 2. That such comparisons would permit: a) an accurate assessment of the impact of laryngectomy; b) identification of factors that promote success or mitigate failure; c) delineation of those factors that adversely affect rehabilitation; and 3. That to insure that m a x i m u m benefits could be obtained all subjects would have available to them a dedicated rehabilitation team capable of the best state-of-the-art treatment. Accordingly we assembled a team consisting of an audiologist (J.C.C.), an otolaryngic head and neck surgeon (G.A.G.), clinical psychologists (F.L., T.H.), speech pathologists (E.C., E.L., W.R.) a gastroenterologist (R.W.), and a statistician (E.H.). We chose to examine five major aspects of these patients--personal, biologic, speech, psychosocial, and economic--using 65 independent and 44 dependent variables. METHODS

General SUBJECT SELECTION. The patients were recruited from the otolaryngology services of the four

American Journel of Otoloryngology

teaching hospitals in San Antonio (Audie Murphy Veterans Administration Medical Center, Bexar County Hospital District, Brooke Army Medical Center, and Wilford Hall U.S. Air Force Medical Center), and from private physicians in the community. Every patient with a clinical diagnosis of cancer that could potentially necessitate laryngectomy for treatment was eligible to

be a prospectively studied subject (designated by the symbol PS) unless informed consent was not given or the patient's condition was too poor to permit testing. A second group of patients who had undergone laryngectomy previously or had otherwise not been included in the PS group was s t u d i e d retrospectively. These subjects were designated by the symbol RS. INSTITUTIONAL REVIEW. The consent forms, procedures, and protocol were approved by the institutional review boards of The University of Texas Health Science Center at San Antonio and of the participating hospitals. Patient confidentiality was assured. Procedural Overview The study consisted of three phases: preoperative evaluation, rehabilitative measures, and a postoperative evaluation six months after completion of cancer therapy. PREOPERATIVE EVALUATION. Patients were requested to provide information about themselves, their feelings, and their concerns. A series of psychologic tests was conducted, a videotaped interview was made to record speech characteristics, an audiogram was done, and esophageal manometry was requested. The patient was offered a visit by a laryngectomee. A criterion learning test was administered to assure the patient's k n o w l e d g e about l a r y n g e c t o m y and its sequelae. REHABILITATION MEASURES. The PSs were visited in-hospital by the study team to provide support, counseling, instructions in the use of the electrolarynx, and other measures as necessary. Esophageal speech lessons were "offered to all PSs and were carried out until maximum benefit had been reached or the patient discontinued the lessons. POSTOPERATIVE EVALUATION. Six months after completion of their cancer therapy the PSs

were requested to have a repeat interview, a speech recording, an audiogram, psychological tests, and e s o p h a g e a l m a n o m e t r y . The RSs underwent these procedures also. Specific Test Measures AUDIOMETRY. Air and bone pure-tone thresholds and speech discrimination scores were recorded by certified audiologists in a sound-attenuating chamber using American National Standards Institute (ANSI) 1969 calibrated equipment.

GATES ET AL.

TABLE 1. Demographic Characteristics of 53 Subjects Studied Prospectively Age Sex Race Number of hamemates Income Employment Smoking Alcohol use Education Language Intelligence

60 • 1.1 years* (range 41-75) 40 men; 13 women 38 Anglo; 12 Mexican-American; 3 black 1.5 • 0.1' (8, none; 29, one; 9, three ormore) $6,746 • 787* (range $2,000-21,600) 30 employed; 9 unemployed; 22 retired 53 • 5* pack-years (range 20-75) 5 seldom or none; 25 daily; 23 no comment 18 none to eighth grade; 15 high school; 20 college (1-6 years) 41 English only', 5 Spanish only; 7 bilingual 108 -+ 3* WAIS-FS+ (range 74-118)

* Mean - standard error of the mean. t Wechsler Adult Intelligence Scale, full scale.

TABLE 2. Demographic Characteristics of 40 Subjects Studied Retrospectively Age Sex Race Number of homemates Income Employment Smoking Alcohol use Education Language Intelligence

58 - 1.4 years* (range 36-79) 39 men; 1 woman 36 Anglo; 3 Mexican-American; 1 black 1.47 • 0.3* (6, none; 21, one; 9, three or more) $7,598 -+ $884* (range 0-27,500) 19 employed; 19 unemployed; 22 retired 52 _+ 6* pack-years (range 10-99) 5 seldom or none; 12 daily; 33 no comment 9 none to eighth grade; 20 high school; 8 college [1-6 years) 37 English only; 1 Spanish only; 2 bilingual 108 _ 3* WAIS-FS~ (range 85-1271

* Mean • standard error of the mean. ~rWechsler Adult Intelligence Scale, full scale. SPEECH EVALUATION. Preoperatively, each PS w a s asked to sustain the v o w e l / a / a s long as possible, a t t e m p t e s o p h a g e a l s o u n d p r o d u c t i o n , r e a d a list of 50 w o r d s t a k e n f r o m the Modified R h y m e Test or S p a n i s h l a n g u a g e equivalent/5 a n d read the first p a r a g r a p h of the Grandfather Passage w h i l e being r e c o r d e d in a standardized f o r m a t on videotape. Postoperatively, the subjects w e r e r e - r e c o r d e d u n d e r the s a m e conditions while p r o d u c i n g a s u s t a i n e d / a / f o l l o w i n g a single air injection into the e s o p h a g u s , repeating / p a / a s m a n y times as possible following a single air charge, m a k i n g 20 a t t e m p t s to s a y / p a / by e s o p h a g e a l speech, and, w h e n possible, reading f r o m the word lists a n d the G r a n d f a t h e r Passage. N a i v e listeners j u d g e d the intelligibility and acc e p t a b i l i t y of t h e s p e e c h p r o d u c e d . S p e e c h p a t h o l o g i s t s j u d g e d p h o n a t i o n time, n u m b e r of syllables, consistency, t y p e of air injection, and c o m m u n i c a t i o n effectiveness. PSYCHOLOGICAL TESTS. The subjects were requested to take the Bender-Gestalt test (Hutt adaptation), s the A t t i t u d e T o w a r d Disabled Pers o n s Scale, 7 t h e S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e (Form E for p e r s o n s of limited e d u c a t i o n a l and cultural b a c k g r o u n d ) d e v e l o p e d b y Cattell, s the F u n d a m e n t a l Interpersonal Relations Orientation Behaviour Test, 9 a nineq u e s t i o n Criterion L e a r n i n g T a s k and an Exis-

tential Evaluation (both developed by us), a n d the Wechsler Adult Intelligence Scale, 1~ and to respond to a biographical questionnaire. ESOPHAGEAL MANOMETRY, The pressure and length of the upper esophageal sphincter were recorded as a force-summing probe was pulled through the zone of high pressure in the pharyng o e s o p h a g e a l area at a c o n s t a n t speed. T h i s probe, c o m p o s e d of a glycerin-filled t o m s in contact with a titanium strain gauge, records the average pressure regardless of its radial orientation. 11 A second p u l l - t h r o u g h u s i n g an eightl u m e n radially perfused probe in the same m a n ner p e r m i t t e d c o m p u t e r reconstructions to be made in three dimensions. '2

Data Analysis All data were r e c o r d e d on the a p p r o p r i a t e f o r m s a n d edited. I t e m s were t r a n s f e r r e d to s u m m a r y data sheets, w h i c h were keypunched. The data were entered and analyzed on a Digital E q u i p m e n t C o m p a n y DEC-20 C o m p u t e r using the Statistical Program of the Social Sciences SPSS-20 of the University of Pittsburgh, w h i c h i n c l u d e d appropriate statistical tests: Chi-square test, Student's t test, one-way analysis of variance, and Pearson p r o d u c t - m o m e n t correlations.

Volume 3 Number 1 January 1982

LARYNGECTOMEEREHABILITATIONI RESULTS

Format In the following sections, the data are presented in descriptive format and by crosscorrelations. The descriptive statistics use the means _ standard errors of the means, ranges, proportions and percentages as appropriate. Correlations that are not statistically significant (P/> 0.051 are not listed, with the exception of variables that are commonly held to be important. Where 0.01 ~< P ~< 9.05, the actual P value is not stated. However, where P ~< 0.001 it is stated in the text.

Preoperative Personal Characteristics

American Journal of Otolaryngology

The age, sex, race, number of homemates, income, employment, and personal characteristics of the PSs just prior to hospitalization are summarized in Table 1. The age ranges of the men and women were similar. The majority of the patients (29/53) lived in a household with one other person besides themselves; eight lived alone. Of the 22 listed as employed, 15 had fulltime and 1 part-time salaried jobs, 4 were selfemployed, and 2 were housewives. All patients smoked cigarettes. Alcohol use was common--25 patients reported drinking daily, and five seldom or never. However, 23 patients did not report on alcohol use. Women stayed in speech therapy significantly longer than men. W o m e n used alcohol less commonly and earned less money. Age did not correlate with any o u t c o m e variable. The Mexican-American subjects were older and had lower family incomes. The blacks used alcohol less often, and more were women. More of the whites were male, had gone to school longer, and used more alcohol. Education correlated strongly with income (P = 0.001) and with performance on the Wechsler Adult Intelligence Scale (P = 0.091). The members of the RS group did not differ statistically from the PSs in age, education, income, intelligence scores, cigarette and alcohol consumption, or proportion employed. However, more RSs were unemployed than retired, and there were fewer Mexican-Americans (3 vs. 12) and women (1 vs. 13). The demographic characteristics of the RS group were obtained postoperatively and are summarized in Table 2,

Biologic Data The sites and stages of the n e o p l a s m s are tabulated in Table 3. 'rumor staging follows the recommendations of the 1978 American Joint Commission. Every patient had histologic confirmation of the presence of squamous cell carcinema following e n d o s c o p i c evaluation and biopsy. Fifty-three per cent (28/53) of the lesions were classified as glottic in origin; there was one case of primary subglottic carcinoma that is tabulated in the glottic group. Ten lesions (19 per cent) were classified as supraglottic cancer and 15 (28 per cent) as pyriform sinus cancer. Treatment policies were not part of the study protocol; treatment decisions were the responsibility of the p a t i e n t s ' p h y s i c i a n s . As such, choices of treatment based on stage and site were not uniform among the participating physicians. The patients were nearly evenly divided among the private (16), veterans (12), military (13), and medically indigent (11) sectors. Surgical care was provided by the otolaryngology staffs of three institutions, ten private otolaryngologists, and one general surgeon. All PSs had total laryngectomy (with partial pharyngectomy as appropriate for the pyriform sinus group, n = 15). Radical neck d i s s e c t i o n was p e r f o r m e d u n i l a t e r a l l y in 40 a n d b i l a t e r a l l y (simultaneously) in 3; 10 (19 per cent) did not have a radical neck dissection. Forty-four patients (83 per cent) had radiotherapy, 15 preoperatively and 29 postoperatively. Seven of the PSs had chemotherapy for recurrent disease; none received preoperative chemotherapy. The overall determinate disease control rate at the sixth posttreatment month was 33/53 (62 per cent). Failure to control the cancer occurred in 1/9 (11 per cent) p a t i e n t s n o t r e c e i v i n g radiotherapy, in 10/29 (34 per cent) receiving postoperative radiotherapy, and in 7/15 (47 per cent) receiving preoperative radiotherapy. Failure of surgical control in the preoperative radiotherapy group occurred in 2/5 patients (40 per cent) who were initially treated by irradiation for cure (a salvage-surgery six-month control rate of 60 per cent), and in 6/11 patients (55 per cent) w i t h a d v a n c e d l e s i o n s w h o r e c e i v e d planned combined therapy. The status of two patients was undetermined. Four patients died of persistent disease before the sixth posttreatment month. The six-month control rates 'by stage were: Stage I, 0 per cent (n = 2); Stage II, 100 per cent

GATES ET AL,

TABLE 3,

Tumor Sites and Stages in Patients Studied Prospectively S~TE Glottic

n Stage I Stage II Stage III Stage IV

Suprag/ottic

Pyriform Sinus

TlNoMo T2NoMo TaNoMo TaNI~.,M. T4NoMo

2 7 25 ~ 5

1 4 17* 2 3

0 0 5 2 1

1 3 3 2 1

T4N1-3M0

8

1

2

5

TOTAL

53(100%)

28(53%)

10(19%)

15(28%)

* Includes one tumor arising in the subglottic site. (n = 7); Stage III, 65 per cent (n = 31); Stage IV, 53 per cent (n = 13). The control rate for patients with To;4 No lesions was 23130 (77 per cent); for patients with clinically evident neck metastasis (T3/4) NI-,~ it was 5/14 (36 per cent). In general, the effects of cancer treatment had stabilized by the sixth month. To characterize the overall physical strength and vigor of the subjects at that time, we employed a 1 - 5 rating scale, with 5 being equivalent to premorbid status and 1 indicating a preterminal condition. The mean score was 2.5 _+ 0.1. Fourteen PSs were rated in categories 1 and 2, and only four (8 per cent) received a 5 rating. In contrast, the physical vigor of the 25 RSs who had been operated on one to 23 years prior to evaluation was 3.52 _ 0.3. The difference between these means was highly significant (P = 0.0005). A fistula occurred in ten PSs during their hospitalization and in three after discharge. Forty (75 per cent) healed without a fistula. The presence or absence of a fistula did not correlate with success in acquiring or the quality of esophageal speech. Postoperative dysphagia necessitating periodic dilations was experienced by 10/53 (19 per cent) patients. Eleven had slight difficulty that did not require treatment and the remainder had no difficulty. The presence of swallowing diffic u l t y correlated w i t h the failure to acquire esophageal speech. As reported previously," the mean pressure measured preoperatively with the force-summing probe in the upper esophageal sphincters of 12 patients with laryngeal cancer was 130 -+ 24 mm Hg; postoperatively, the mean pressure in 19 patients was 66 - 8 mm Hg. In only one patient was it possible to record both proand postoperative pressures; none of the other subjects consented to repeat manometry, The manometric findings did not correlate with any of the outcome variables, Following laryngectomy the pattern of radial and axial asymmetry

of the upper esophageal sphincter was lost and replaced by a nearly circular configuration. 12 Hearing was not affected by the cancer treatment. The mean speech reception threshold preoperatively was 14.7 dB, and it was 15.4 dB six months postoperatively.

Communication

All patients were offered i n s t r u c t i o n in esophageal speech and electrolarynx use. Two thirds were visited preoperatively by a laryngectomized speech teacher from the American Cancer Society. Twelve refused instruction or returned to their home areas where instruction was not available. Current state-of-the-art speech instruction was given by experienced lay-laryngectomees from the American Cancer Society and speech pathologists at the masters and doctoral levels, including a laryngectemized speech pathologist. The PSs received an average of 5.3 months of speech therapy (range 1 - 6 months), with an average of 12.5 lessons (range 1-62). The majority (57 per cent) used an electrolarynx for communication during the period in which they were learning or attempting to learn esophageal speech. Women received more months of speech therapy (10 vs. 4) than did men. The total numbers of lessons differed among institutions: The Veterans' Administration Hospital patients received an average of 24; the military, 7; private patients, 11; and the patients in the municipal teaching hospital, 8. The RS group received an average of 17 speech lessons (range 1-97) in an average period of three months (range 1-12); 41 per cent used an electrolarynx during their instruction period. Of the 47 PSs available for the sixth posttherapy month evaluation, 12 (26 per cent) used esophageal speech in daily communication; three also used the electrolarynx when tired or when the need for greater loudness or rate arose.

Volume 3 Number 1 January 1982

LARYNGECTOMEE REHABILITATION I TABLE 4. Postoperative Employment Status SUBJECTSSTUDIED RETROSPECTIVELY

SUBIECFS STUDIED PROSPECTIVELY

No. Disabled Able--not seeking work Able--cannot find job Employed--lesser job Employed--comparable job

12 1 1 3 30

Sixteen (34 per cent) used the elecLrolarynx exclusively; 16 (34 per cent) depended on writing, and 3 (6 per cent) on signing, to communicate. Of these 47, only 35 (74 per cent) attempted to learn esophageal speech; thus, the determinate rate of esophageal speech acquisition was 12/35 (34 per cent). In the RS group, 25/40 [62 per cent) used esophageal speech as their primary means of communication.

Psychosocial Changes Denial was common postoperatively: at the sixth month, 47 per cent showed substantial denial, 35 per cent had distorted perceptions of reality, and 18 per cent had no denial. This was in contradistinction to the RSs, in w h o m denial was absent in 36 per cent and substantial in only 15 per cent, with 49 per cent having distorted perceptions of reality. The presence or degree of denial did not correlate with any of the outcome variables except overall rehabilitation failure. Self-image was poorer postoperatively in 69 per cent; 27 per cent felt the same, and two patients (4 per cent) felt better about themselves than they had preoperatively. The RS group was essentially the same. Attitudes to life were poorer in 57 per cent, the same in 41 per cent, and better in only one patient. This person had had an extensive tumor necessitating bilateral radical neck dissection and postoperative radiotherapy. He had learned esophageal speech spontaneously and was rated as one of the better speakers of the PS group. Social activities of 59 per cent were reduced to various extents, while the remaining 4"t per cent noted no change in the number of friends or social contacts. The RSs reported similar findings. These four categories were highly intercorrelated but showed little relationship to success or failure of rehabilitation.

Economic Aspects American journal Employment circumstances (Table 4) were of unchanged for the majority (64 per cent) of the Otolaryng01ogy PSs and for 69 per cent of the RSs. Three patients (6 per cent) had had to take lesser-paying jobs postoperatively, and one was unable to find

% 26 2 2 6 64

No~

%

7 0 2 3 27

18 o 5 8 69

employment although he was physically .capable of working. Fully a fourth of the PSs were disabled by their illness and were unable to work. Losses of income averaging $1,035 were reported by 14 PSs (26 per cent). The remainder stated that treatment of their illness did not impose an economic hardship. The costs of illness, based on the average 1978 charges in San Antonio for hospital room, surgical fees, and radiation therapy, averaged $8,062. The average cost of rehabilitative measures was estimated to be $413.

Rehabilitation Outcome We divided the PSs into two subgroups on the basis of the overall success of rehabilitation at the sixth posttreatment month independent of cancer control. Criteria for success were: effective c o m m u n i c a t i o n a b i l i t y ( r e g a r d l e s s of method), a lifestyle equivalent to the pretreatment situation, and an adequate psychologic adjustment to their disability. Of the original 53 PSs, four died before the six-month evaluation period and two were unavailable for follow-up. Of the 47 determinate cases, 26 (55 per cent) were judged successful and 21 (45 per cent) were judged to be failures. DISCUSSION

The p r o p o r t i o n of p a t i e n t s w h o a c q u i r e d esophageal speech in the PS group (25 per cent) differs sharply from reported proportions, but that of the RS group (60 per cent) is consistent with most reports. '-4 Explanations for this variance can be f o u n d by. e x a m i n i n g the s t u d y population and the methodologic differences between this and other studies. The significant demographic differences between the PS and RS groups are the greater numbers of w o m e n and persons of MexicanAmerican background in the PS group. Otherwise, both are composed of people w h o s e demographic characteristics are very m u c h like those described by Wallen and Webb. *a However, in our PS group neither sex nor race correlated with a n y o u t c o m e variable. We m u s t c o n c l u d e , therefore, that the rehabilitation p o t e n t i a l of

GATES ET AL. w o m e n or M e x i c a n A m e r i c a n s is no different f r o m that of m e n or a n y other racial group, and look at other aspects of the s t u d y to a c c o u n t for the variance in o u t c o m e s . During the past d e c a d e a major change has e v o l v e d in the t r e a t m e n t of laryngeal cancer that m a y invalidate rehabilitative a s s u m p t i o n s m a d e on the basis of older studies. T h e increasing use of r a d i a t i o n t h e r a p y or c o n s e r v a t i o n surgery for t r e a t m e n t of early lesions has substantially red u c e d the n u m b e r of " i d e a l " c a n d i d a t e s for learning e s o p h a g e a l speech. Indeed, less than h a l f of all the p a t i e n t s w e i n t e r v i e w e d before t r e a t m e n t had total l a r y n g e c t o m y . The frequent c o m b i n a t i o n of e x t e n d e d s u r g e r y plus radiation t h e r a p y for m o r e a d v a n c e d lesions has increased the n u m b e r of less-ideal candidates. Thus, tod a y ' s l a r y n g e c t o m e e is m o r e likely to have had a m o r e a d v a n c e d n e o p l a s m that was treated by m a n y a n d i n t e n s i v e t h e r a p i e s . Logically, one w o u l d a s s u m e that s u c h i n d i v i d u a l s w o u l d be m o r e likely to h a v e a d v e r s e sequelae from their t h e r a p y and, c o r r e s p o n d i n g l y , more functional d i f f i c u l t i e s . M u s c l e a t r o p h y a n d fibrosis are w e l l - r e c o g n i z e d sequelae that m a y occur after intesive t r e a t m e n t a n d can interfere with swall o w i n g and n e c k m o t i o n . This is in contradistinction to the s u p p l e a n d f u n c t i o n a l muscular n e c k of the i n d i v i d u a l w h o has u n d e r g o n e only a s i m p l e l a r y n g e c t o m y . Therefore, unless patient g r o u p s are c o m p a r e d on the basis of stage of disease and extent of t h e r a p y , it is u n l i k e l y that any m e a n i n g f u l c o m p a r i s o n s can be m a d e between older studies a n d the current situation. One could l o g i c a l l y suggest that deficiencies in o u r rehabilitation t e c h n i q u e s could have acc o u n t e d for the l o w p r o p o r t i o n of success, Alt h o u g h n o r m s h a v e n o t b e e n established to judge the quality of r e h a b i l i t a t i o n p r o g r a m s , we can safely state that the a t t e n t i o n and i n s t r u c t i o n g i v e n to our subjects was of h i g h quality. In addition, the m e m b e r s of the rehabilitation t e a m w e r e p e r s o n a l l y and p r o f e s s i o n a l l y c o m m i t t e d to a c h i e v e m e n t of a h i g h degree of success. T i m e a n d financial c o n s t r a i n t s w e r e not limiting factors. Therefore, we c o n c l u d e that our success rate m i g h t have b e e n e v e n l o w e r had it not been for the efforts of our team. T h e m o s t i m p o r t a n t ' difference b e t w e e n this a n d other studies of l a r y n g e c t o m e e rehabilitat i o n is that we i n c l u d e d all patients, a n d Studied their courses p r o s p e c t i v e l y . T h i s d e s i g n allows an accurate a n d comprehensive picture of the p r o b l e m . Because h i g h - r i s k a n d p o o r - o u t c o m e patients tend to be e x c l u d e d f r o m retrospective s t u d i e s , the s e l e c t i o n p r o c e s s artificially imp r o v e s the success rate and, thus, biases the con~ clusions. We conclude, therefore, that our findings are

p r o b a b l y r e p r e s e n t a t i v e of the c u r r e n t "realw o r l d " s t a t e - o f - a f f a i r s in l a r y n g e c t o m e e rehabilitation. One has but to examine the current l i t e r a t u r e ' s e m p h a s i s on n e w t e c h n i q u e s for voice restoration following laryngectomy to affirm the existence of substantial current problems in ]aryngectomee rehabilitation. It is our opinion, therefore, that needs of today's laryngectomees are not being met w i t h traditional a p p r o a c h e s to rehabilitation. Before proceeding to our r e c o m m e n d a t i o n s , we w i s h to examine further the causes of failure, to r e v i e w in more detail the understanding of esophageal speech, and to discuss our thesis that attitudes about laryngectomee rehabilitation should change. These three topics form the subjects of Parts I I - I V of this series of articles.

ACKNOWLEDGMENT The authors thank Shirley Salmon, Ph,D., for her advice on the conduct of this study and for her careful review and comments on the manuscripts.

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10. Wechsler D: WAIS (SATZ-MOGEL Short Form}: The Wechsler Adult Intelligence Scale. New York, Psychological Corporation, 1974 11. Welch RW, Gates GA, Luckmann KF, et al: Change in the force-summed pressure measurements of the upper esophageal sphincter prelaryngectomy and postlaryngectomy. Ann Oral Rhino] Laryngol 88:804-808, 1979 12. Welch RW, Luckmann K, Ricks PM, et ah Manometry of the normal upper esophageal sphincter and its alterations in laryngectomy. J Clin Invest 63'.1036-1041, 1979 13. Wallen V, Webb VP: A survey of the background char~ acteristics of 2,000 laryngectomees: a preliminary report. Milit Med 149:532-534, 1975

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