In patients who underwent subtotal laryngectomy, residual anatomical elements to which the sphincter function is entrusted, a prerequisite for airway protection during swallowing and voice production, are arytenoids (one or both) posteriorly and epiglottis or base of the tongue anteriorly. When the ariteno-epiglottic or ariteno-lingual opposition does not allow a complete closure of the neoglottic lumen, there is a neoglottic insufficiency with a variable impact on phonation and swallowing [1].

To better understand the causes that could lead to the neoglottic insufficiency, reconstructive techniques and following compensation mechanisms need to be explained.

In supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) [42, 43] reconstruction is done by pexy between the cricoid cartilage, hyoid bone, and the suprahyoid epiglottis. In partial laryngectomy with cricohyoidopexy (CHP) [44, 45], even the epiglottis is removed and the reconstruction is done by pexy between the cricoid cartilage and hyoid bone with a transfixed suture that includes a portion of the base of the tongue.

The subtotal laryngectomy with tracheohyoidoepiglottopexy (THEP) or with tracheohyoidopexy (THP) [46] is indicated for glottic carcinomas with subglottic involvement greater than 5 mm and inferior paraglottic space invasion. Compared to supracricoid laryngectomy, with this technique the larynx is removed comprising the entire anterior or anterolateral subglottic space, preserving one or both cricoarytenoid units.

In all these surgical procedures, an arytenoid could be removed or preserved.

The causes of neoglottic insufficiency may be linked to the intervention, to an inadequate rehabilitation process, to postsurgical adjuvant treatments.

The surgical technique in reconstructive laryngectomies must necessarily be carried out following all the precautions necessary to achieving a satisfactory postoperative organ function.

Preservation of the inferior laryngeal nerves is important for arytenoids motility, but also the preservation of the superior laryngeal nerves for hypopharyngeal visceral sensitivity that is fundamental during the pharyngeal phase of swallowing to trigger the adduction laryngeal reflex. During surgery then is identified the superior neurovascular laryngeal pedicle with preservation of the external portion of the internal branch of the nerve.

Another technical device not to be overlooked is to not place, during pexy performation, the anterior hyoid bone margin in front of the cricoid or tracheal ring (depending on type of reconstruction), in order to obtain an anatomical conformation of the neolarynx which facilitates the opposition of the base of the tongue or the epiglottis to the residual arytenoid (one or both).

In case of CHP and THP, pexy suture must include a portion of base of the tongue, which is thus compacted towards the hyoid bone assuming a convex curvature that allows to better protect the neoglottic aditus during swallowing.

The speech rehabilitation must be carried out properly and completely. Outpatient rehabilitation after discharge is also very important because it aims mainly to arytenoid motility exercises that contribute to refine swallowing and strengthen the quality and intensity of voice.

Patients who undergo adjuvant chemoradiotherapy may show significant regression of functions acquired with postoperative rehabilitation because of postradiation edema, cricoarytenoid ankylosis, decrease of pharyngeal mucosa, and neoglottic sensitivity.

Since the patient with glottic cancer has dysphonia (from mild to severe) as main symptom, which has been gradually established, he tends to accept without much difficulty the postoperative kind of voice that will be breathy, particularly hoarse (with noise as main spectrum component), produced with considerable difficulty for a short duration (few seconds). The critical aspect is constituted by swallowing and persistence, despite rehabilitation treatment, of a neoglottic insufficiency (Fig. 3.2) that determines swallowing alterations that can lead to aspiration pneumonia. The mechanism that assures a neoglottic competence is the movement of one or both arytenoids horizontally toward the midline and anteriorly towards the epiglottis, if present, or, alternatively, towards the base of the tongue with a complete and energic contact. Retropulsion of the base of the tongue is another important protective mechanism especially in CHP and THP.

The vocal production is fundamentally linked to the vibration of arytenoid mucosa, which sometimes is associated with the vibration of other structures such as the mucosal flap that is formed where there was the removed arytenoid, the epiglottis, and the ariepiglottic fold.

Glottic insufficiency determines an alteration of the voice as it causes an incomplete closure of the vocal cords during the phonatory vibration, with an air leak more or less significant. The two main consequences are:

In cases of marked glottic insufficiency, as for example in the outcomes of arytenoidectomy, of enlarged cordectomy or unilateral cordal paralysis in abducted position, dysphagia can also occur with aspiration of foods (especially liquids) during the pharyngeal phase of swallowing.

The evaluation of the patient with glottic insufficiency is performed both at the time of the preoperative clinical-instrumental diagnosis at posttreatment control. For a correct diagnosis and a correct evaluation of the therapeutic (medical, speech therapy, phonosurgery) results, it is essential that the speech pathologist uses a protocol of clinical and instrumental investigations internationally widespread and shared, in order to compare the data obtained from the same patient before and after treatment and the data obtained in other centers with the same therapeutic method or with different methods.

The protocol of essential clinical and instrumental investigations adopted in Italy and in Europe for the evaluation of the patient with dysphonia from glottic insufficiency, as well as for other voice disorders, has been proposed by the European Society of Laryngology (ELS) in 2001 [47], and adopted, with some modifications, by the Italian Phoniatrics and Logopedics Society (SIFEL) and the Italian Society of Otorhinolaryngology (SIO) in 2002 [48, 49] with further modifications [50–52].

The surveys provided by the “SIFEL protocol” to which we refer are “subjective” and “objective.” The ideal condition would be to be able to assess the dysphonia through a unique “objective” – investigation – but phonation is a “multidimensional” phenomenon [53] and cannot be properly assessed through a single examination.

The clinical and instrumental investigations contained in the ELS protocol and in the SIFEL protocol are:

The Italian protocol also includes the phoniatric medical history and logopedic assessment (agreement pneumo-phono-articulatory, posture, muscular tensions).

Cards for collection of data obtained from clinical and instrumental investigations are different for the “common” adult dysphonic patient and for dysphonic children or singers [54–56].