Eur Arch Otorhinolaryngol (2009) 266:1305–1308
DOI 10.1007/s00405-008-0861-z
HEAD AND NECK
Estimation of inXuence of myofascial release techniques
on esophageal pressure in patients after total laryngectomy
Siawomir Marszaiek · Anna ôebryk-Stopa ·
Jacek Kramny · Andrzej Obrdbowski ·
Wojciech Golusijski
Received: 20 August 2008 / Accepted: 26 October 2008 / Published online: 21 November 2008
© Springer-Verlag 2008
Abstract In patients after total laryngectomy, increased
tension in myofascial neck and arm areas might be
observed. Via fascial continuity it has an adverse impact on
the superior esophageal constrictor forming the “mouth of
the oesophagus”, which hinders learning of esophageal
speech. The aim is to assess the eVect of manual myofascial
release techniques on esophageal pressure in patients after
total laryngectomy. Forty patients (12 F, 28 M), aged 43–
75 (mean 56.8 years), 9 months to 13 years (average
3 years) after total laryngectomy, 35 patients (87.5%) after
neck lymph node resection, 38 patients (95%) after radio-
therapy. Esophageal pressure was assessed using modiWed
Seeman’s method. Manual myofascial release techniques
were applied within head, neck, arms, upper trunk and
upper limb areas. Wilcoxon and Shapiro–Wilk’s test was
used for the purpose of statistical analysis. Statistically sig-
niWcant decrease of the mean esophageal pressure was
observed after the physiotherapy treatment. The average
pressure among the examined patients decreased from 37.9
to 26.6 mmHg. The application of myofascial manual
S. Marszaiek (&)
Department of Athletics,
University School of Physical Education, Poznan, Poland
e-mail: marszaleksl@wp.pl
S. Marszaiek · W. Golusijski
Department Head and Neck Oncology,
Great Poland Cancer Center,
Poznan University of Medical Sciences, Poznan, Poland
W. Golusijski
e-mail: wgolusinski@am.poznan.pl
A. ôebryk-Stopa · J. Kramny · A. Obrdbowski
Department of Phoniatrics and Audiology,
Poznan University of Medical Sciences, Poznan, Poland
techniques decreases esophageal pressure, thus allowing
patients to learn esophagus speech at a faster pace.
Keywords Cancer · Head and neck · Oncology ·
Physical therapy · Muscles · Otolaryngology · Esophagus
Introduction
One of the basic problems for patients undergoing laryn-
gectomy due to laryngeal cancer is the loss of ability of
sound communication. There are many functional distur-
bances developing in the head and neck area after the sur-
gery. During the surgery, muscles from superWcial and deep
layers (supra- and infra-hyoid muscles) are removed, either
partially or totally, including hyoid bone. As a result, exten-
sive scars form in the neck area, accompanied by dysfunc-
tion of muscles responsible for physiological range of
motion of this area, including reduced stability of the upper
body. Decreased elasticity of anterior cervical soft tissues
(such as layers of cervical fascia and platysma muscle)
leads to reduction of physiological motor range during
backward bend of the neck. Strength reduction of the neck
Xexors is also observed. As a result, antagonistic muscles
automatically contract, i.e., posterior neck muscles [1–4].
Muscles Xexing the neck, i.e., prevertebral and scalene
muscles, are phasic muscles. Combination of static and
dynamic overload, together with increased tension of antag-
onistic muscles, leads to their weakening. The descending
part of the trapezius muscle, neck part of the erector spinae,
levator scapulae muscles and suboccipital muscles are tonic
muscles, which means that they tend to reduce their physio-
logical length and to increase their tension. When their
antagonists are impaired and some of them removed, they
are forced to perform excessive, concentric contraction
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(related to static tension), which gradually leads to muscle
contractures. This elevated tension of tonic muscles auto-
matically inhibits and weakens the function of their antago-
nists, phasic muscles. Weakening of the phasic muscles
provokes further increase of tonic muscle tension. This pos-
itive feedback mechanism worsens the state of static dis-
equilibrium in the neck and shoulder girdle muscles [2, 3,
5]. Additional factors contributing to increased tonic mus-
cle tension at rest are stress and anxiety resulting from lar-
yngectomy, as a major surgical treatment [6, 7].
Stress reaction in these patients results from both the
physical consequences of their diseases as well as from
their awareness of lost life opportunities. They suVer from
feelings of regret, loss and fear from suVering and disease
recurrence. They are worried for their relatives fate after
their death. Psychological stress resulting from the fact of
having cancer leads to automatic hypertension of muscles
at rest, especially in the areas of the head, neck and upper
body. Some have tried to describe the characteristics of
body posture of patients, depending on the emotions domi-
nating their life, comparing it to “coat-hanger” through
excessive fear of dependence, to “meat hook” due to accu-
mulation of anger, to “hanging on the noose” by patients
trying to suppress their emotions with rational thinking, and
to “scarecrow” in the case of overwhelming feelings of
guilt [6, 8]. The resulting static and dynamic overload in
neck and arm muscles hinders rehabilitation and further
negatively inXuences motor functions in patients after total
laryngectomy [4, 8].
Moreover, cervical lymphadenectomy, often performed
together with total laryngectomy, intensiWes the process of
scar formation and leads to increase in myofascial tension,
which limits movements in the neck and shoulder girdle,
sometimes causing even dysphagia.
Increased myofascial tension in the neck and arm areas,
via fascial continuity and connection with cricopharyngeal
muscle, has an adverse impact on muscles forming the
“mouth of the oesophagus” (cricopharyngeal muscle, supe-
rior esophageal constrictor). Predominantly, it is the
“mouth of the oesophagus”, where the pseudoglottis for
esophageal speech is formed. Seeman [9] has already
pointed to the fact that one of the most important factors
hindering esophageal speech learning in some laryngec-
tomy patients is the increase of pressure in the “mouth of
the oesophagus” resulting form hypertension of the crico-
pharyngeal muscle.
Aim
The aim of the present study is to assess the eVect of man-
ual myofascial release techniques on the esophageal pres-
sure in patients after total laryngectomy.
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Eur Arch Otorhinolaryngol (2009) 266:1305–1308
Material and methods
Forty patients were studied. The study group included 12
female and 28 male subjects, aged 43–75. Mean age was
53.3 for women and 58.3 for men. The patients were
9 months to 13 years (average 3 years) after total laryngec-
tomy. In 35 patients (87.5%) neck lymph nodes were also
resected, in 38 (95%) adjuvant radiotherapy was per-
formed.
In all subjects one session of physiotherapeutic treatment
was applied using manual myofascial release techniques in
the upper body, shoulders, arms, neck and head areas [1, 2,
10–17]. Directly before and directly after the treatment ses-
sion esophageal pressure was measured using Seeman’s
method [9].
Esophageal pressure was measured 2–3 times before and
after the physiotherapeutic procedure. For statistical analy-
sis, mean values from the three measurements were used.
Distribution analysis of the results revealed that the values
did not show the characteristics of a normal distribution.
This is why the non-parametric Wilcoxon test for paired
samples was used to assess the level of signiWcance in both
parameters variability. In graphical analysis, the Shapiro–
Wilk test was used.
Results
Seventeen patients reported swallowing problems of vari-
ous degrees, especially when swallowing larger or dry
chunks of food. In one patient gastrostomy was performed.
Seventeen patients (42%) communicated using esophageal
speech, among those nine very well, seven well and one
moderately well. The remaining 23 (58%) patients used
oropharyngeal pseudowhisper.
Twenty-three (58%) complained of sensory disturbances
and feeling of tension at the surgery site: 14 subjects
reported stiVness and tension, 2 pain and 2 burning. Five
patients (12.5%) reported feeling stiVness in soft tissues in
the front of the neck; 6 reported (15%) pain and stiVness in
the neck and shoulder girdle.
After the physiotherapy treatment, a statistically signiW-
cant decrease in the mean esophageal pressure was
observed (P = 9.05E-07) (Table 1; Fig. 1). Mean esopha-
geal pressure decreased from 37.9 before, to 26.6 mmHg
after the treatment.
In Table 1 and Figs. 1 and 2 it is shown that after com-
paring the before and after results a tendency towards nor-
malization of the distribution of values could be observed.
The maximal value of esophageal pressure decreased from
180 to 85 mmHg. The values of the lower and upper quar-
tiles decreased from 24.2 to 17.8 and from 37.1 do
30 mmHg, respectively. Standard deviation decreased from
Eur Arch Otorhinolaryngol (2009) 266:1305–1308 1307

Table 1 Basic statistical values before and after physiotherapy treatment in the study group
Mean Median Minimum Maximum Lower quartile Upper quartile Standard deviation Skewness Kurtosis V%

Before 37.9 30.0 14 180 24.2 37.1 30.6 3.6 14.0 0.81
After 26.6 21.7 11 85 17.8 30.0 15.4 2.5 6.9 0.58

40 37,9
Oesophageal pressure [mm Hg]

35
**
30
26,6
25

20

15

10

0
Before physiotherapy After physiotherapy

Fig. 1 Mean oesophageal pressure values in patients after total laryn-

gectomy before and after physiotherapy treatment (P = 9.05E-07, Wil-
coxon test for paired samples)

Fig. 3 Distribution of esophageal pressure values in laryngectomy pa-

tients after the physiotherapy treatment

In patients after total laryngectomy an increase of myo-

Fig. 2 Distribution of esophageal pressure values in laryngectomy pa-
tients before the physiotherapy treatment
30.6 to 15.4, skewness from 3.6 to 2.5 and kurtosis from
14.0 to 6.9 (Fig. 3).
Discussion
There have been reports in the available literature pointing
to the inXuence of superior esophageal constrictor tension
on esophageal speech quality [18, 19]. Attempts have been
made to reduce the tension using myorelaxants. However,
up until now physiotherapeutic options have not been suY-
ciently tried.
fascial neck and arm area tension might be observed [2].
Due to anatomical and functional closeness, as well as
through undergoing post-operational changes in neuronal
pathways, tension also increases in the muscles of the lower
pharynx and esophagus, which take part in production of
esophageal speech.
Manual myofascial release techniques also aVect
branches of the pharyngeal plexus, which innerve cricopha-
ryngeal muscle. Neuromobilization of these structures auto-
matically reduces pathologically increased muscular
tension [10, 20].
Similar observations have been made regarding transfer
of myofascial tension in neck, mandible and shoulders in
hyperfunctional voice disorders [21–23]. Rubin et al. [24]
noted that the neck muscles do not work separately; they
cooperate in various movements. Increased tension of neck
and shoulder muscles negatively inXuences the function of
the larynx and esophagus [21–23].
Total laryngectomy leads to numerous structural
changes in the cervical soft tissues. Scars and postsurgical
adhesions (so-called cross links) interfere with movements
of the pharynx, and of the cervical portion of the esopha-
gus. Manual relaxation techniques applied to the neck and
shoulder girdle areas allow reduction of tension in the
“mouth of the oesophagus” through their inXuence on myo-
fascial tension. This eVect should enable laryngectomy
patients to achieve better quality of esophageal speech.

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Spontaneous remarks of our patients following the physio-
therapeutic session seem to conWrm this hypothesis: “I can
swallow the air better and my speech got better”, “I can
speak more easily”, “My voice is better and stronger now”,
“I feel relaxed”. It is worth noting that the patients making
those remarks achieved values below 20 mmHg after the
therapy.
Many authors suggest that the optimal esophageal pres-
sure for the process of learning of esophageal speech ranges
from 20 to 40 mmHg [9, 18, 19]. However, our observa-
tions and the remarks of our patients seem to show that val-
ues below 20 mmHg are even better in improving the
quality of esophageal speech.
Conclusions
1. The application of myofascial manual techniques in
laryngectomy patients decreases the tension of pharynx
and esophagus muscles, which in turn reduces the val-
ues of esophageal pressure.
2. The model of motoric rehabilitation presented here
should be an integral part of a complex rehabilitation
process after laryngectomy. It may accelerate the pro-
cess of learning of esophageal speech, as well as
improve patients quality of life.
3. Preliminary results suggest that physiotherapists
should be included in the rehabilitation teams working
with patients after total laryngectomy.
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