Introduction. Round Table S.I.O. National Congress.

Since the advent of laryngeal surgery, practitioners have recognised the need for the rehabilitation of the two essential functions of the laryngeal system: swallowing, which for obvious reasons is necessary for survival; and speech, our main means of communication and, consequently, essential for interpersonal relationships. Although the first true laryngectomy, performed by Billroth, is conventionally thought to have been conducted in 1873 phonatory rehabilitation techniques were described for the first time in the early 1900s and involved the use of aids such as the artificial larynx devised by Gussenbauer and Caselli and those involving nasal or oral tubes (used by Gluck, Caselli and Tapia ): by suitably arranging the upper resonators and appropriately deviating the flow of exhaled air, patients who had undergone total laryngectomy were able to produce an articulated, yet audible voice 1. In the early decades of the 20th Century, in addition to rehabilitation techniques involving implanted aids, speech therapy rehabilitation techniques aimed at producing a belched voice were devised and later developed. The first attempts at combined surgical-implant rehabilitation were made by Delavan (in 1924) and Briani (in 1952) . Like their predecessors, these Authors used implants, this time integrating them with the patient’s tissues in surgical procedures .

At the same time, to overcome the significant functional consequences of laryngectomy, important progress was made in laryngeal surgery techniques by primarily European Authors starting in the 1950s, with the introduction of the vertical partial laryngectomy and supraglottic laryngectomy -. Whereas most modern laryngologists have abandoned the vertical technique on account of its high post-operative stenosis rates and subsequent frequent impossibility of decannulation, horizontal supraglottic laryngectomy, on the other hand, has become part of daily practice in the head and neck surgery field and as it spares the glottis, it poses far less important issues with regards to rehabilitation, the true focus of this Round Table.

In the early 1970s, Italian Authors, particularly Staffieri and Serafini, established further milestones in conservative laryngeal surgery . The technique introduced by Staffieri involved the creation of a phonatory neoglottis during total laryngectomy procedures: this brought significant benefits for patients, making it possible to obtain a perfectly audible voice simply by closing the tracheostomy stoma during expiration to allow the air to vibrate the surgically-furnished valve between the trachea and the neo-hypopharynx. In 1970, Serafini , on the other hand, presented the results of a laryngectomy with tracheohyoidopexy reconstruction: which, together with Mayer’s experience (1959) , was the first attempt at avoiding a permanent tracheostomy in subtotal laryngectomy subjects. Although Staffieri’s laryngectomy technique frequently gave unsatisfactory results with belched voice production and Serafini’s technique was characterised by a high post-operative pulmonary aspiration rate, these procedures, nevertheless, represented attempts that stimulated later surgeons to improve their methods and led us to the results we have today. Undoubtedly, Serafini can be credited with having believed in the potential of subtotal surgery, encouraging many laryngologists in Italy and worldwide to adopt the technique. A number of changes were later introduced to Serafini’s original procedure: the tracheohyoidopexy technique thus evolved and, as experience developed, increasingly precise oncological indications were classified and, once the main aim of decannulation was achieved, increasingly safe and encouraging results were obtained in cancer patients. Indeed, in 1971, Alaimo, Labayle and Bismuth published their reports on the cricohyoidopexy technique, and, in 1974, Piquet, Desaulty and Decroix published the results of their experience with a cricohyoidoepiglottopexy procedure . Despite involving the removal of most of the laryngeal structures, preserving just the cricoid and at least one of the arytenoids, these procedures were a success from both an oncological and a functional standpoint. These Authors observed that the swallowing competence of the neoglottis was guaranteed even with just one arytenoid that by “bowing” towards the epiglottis or base of the tongue was able to adequately protect the respiratory tract. The same mobility of the residual arytenoid or arytenoids made it possible to obtain “compensation” voices perfectly adequate for normal interpersonal relationships, by allowing the arytenoid mucosa to vibrate against the residual epiglottis or base of the tongue.

Subtotal laryngectomy procedures remained substantially unchanged from the 1970s, until Rizzotto et al. (2006) reviewed the tracheohyoidopexy and tracheohyoido-epiglottopexy techniques. By observing the importance of the functional cricoarytenoid unit (unlike Authors such as Serafini and Mayer who previously used similar techniques but overlooked this aspect), these Authors performed subtotal laryngectomies even in unilateral hypoglottic tumours: the tracheohyoidopexies described in the paper by Rizzotto et al. involved the removal of significant portions of cricoid on the tumour side, but preserved at least one arytenoid unit, the portion of cricoid below, the superior laryngeal nerve, lateral internal branch (plus, the recurrent laryngeal nerve), and by performing the reconstruction directly between the trachea and hyoid bone (with or without the residual epiglottis): in their paper, they reported functional results comparable with conventional subtotal procedures.

Those who work in the laryngeal surgery field constantly have to manage the deglutition and phonatory rehabilitation of laryngectomised patients, fully aware of all the medical, nutritional, psychological, organisational and even economical issues that face both patients and medical practitioners. It goes without saying that the greater the efforts to spare the larynx, the more diffuse conservational laryngeal surgery techniques and the more important the vocal and deglutition rehabilitation techniques become. The purpose of this Round Table is, therefore, to focus attention on the issues of post-laryngectomy speech and swallowing rehabilitation, in the light of contemporary surgical techniques, which primarily aim to spare the organ and respect function and quality of life.