from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, ListFlowable, ListItem
from reportlab.lib.enums import TA_JUSTIFY, TA_CENTER

output_path = "/home/daytona/workspace/laryngectomy-essay/Swallowing_Rehabilitation_After_Laryngectomy_ENT_PG_Essay.pdf"

doc = SimpleDocTemplate(
    output_path,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2*cm,
    bottomMargin=2*cm
)

styles = getSampleStyleSheet()
styles.add(ParagraphStyle(name='TitleCenter', parent=styles['Title'], alignment=TA_CENTER, fontSize=16, spaceAfter=12))
styles.add(ParagraphStyle(name='Heading', parent=styles['Heading2'], fontSize=12, spaceBefore=10, spaceAfter=6))
styles.add(ParagraphStyle(name='BodyJ', parent=styles['BodyText'], alignment=TA_JUSTIFY, leading=15, fontSize=10.5, spaceAfter=6))

story = []

story.append(Paragraph("Swallowing Rehabilitation After Laryngectomy", styles['TitleCenter']))
story.append(Paragraph("Essay Answer for ENT Postgraduate Examination", styles['TitleCenter']))
story.append(Spacer(1, 8))

intro = """
Swallowing rehabilitation after laryngectomy is a critical component of head and neck oncologic care. Although total laryngectomy permanently separates the airway from the food passage and therefore usually prevents aspiration, many patients still develop clinically significant dysphagia due to postoperative edema, pharyngocutaneous fistula, pharyngoesophageal stricture, stenosis, cricopharyngeal dysfunction, reduced tongue-base propulsion, fibrosis after radiotherapy, and poor general nutritional status. Rehabilitation is therefore not merely dietary progression, but a structured, multidisciplinary process aimed at restoring safe oral intake, maintaining nutrition and hydration, improving quality of life, and integrating speech restoration.
"""
story.append(Paragraph(intro, styles['BodyJ']))

story.append(Paragraph("1. Aims and Principles of Swallowing Rehabilitation", styles['Heading']))
text1 = """
The primary goals are: (1) safe return to oral feeding, (2) adequate caloric and fluid intake without long-term tube dependence, (3) early recognition and treatment of complications, and (4) restoration of patient confidence and social eating. Rehabilitation must be individualized according to type of surgery (total laryngectomy versus laryngopharyngectomy), reconstruction used (primary closure, free flap, visceral flap), prior radiotherapy/chemoradiotherapy, and patient factors such as diabetes, renal insufficiency, hypothyroidism, and baseline frailty.
"""
story.append(Paragraph(text1, styles['BodyJ']))

story.append(Paragraph("2. Team-Based Approach", styles['Heading']))
text2 = """
Optimal outcomes require coordinated care by the ENT surgeon, speech and language pathologist (SLP), swallowing therapist, dietitian, specialist nurse, and where required, reconstructive surgeon and gastroenterologist. The SLP is central in assessing swallow mechanics, advising compensatory strategies, and supervising long-term functional training. Regular follow-up is essential because dysphagia may appear early (edema/fistula-related) or late (fibrosis/stricture-related).
"""
story.append(Paragraph(text2, styles['BodyJ']))

story.append(Paragraph("3. Postoperative Phases of Swallowing Rehabilitation", styles['Heading']))
phase_intro = "Rehabilitation can be discussed in phased fashion:"
story.append(Paragraph(phase_intro, styles['BodyJ']))

phases = [
    "<b>Immediate postoperative phase (day 0 to day 7):</b> Enteral feeding is usually maintained via nasogastric tube or gastrostomy while pharyngeal closure heals. Airway care, humidification, secretion management, and stoma care are prioritized.",
    "<b>Early oral intake phase (around day 7 onward):</b> In uncomplicated non-irradiated patients, oral intake is commonly started around postoperative day 7. In previously irradiated patients, a more cautious delay (often around or after day 14) is preferred due to higher fistula risk.",
    "<b>Progression phase:</b> Once saliva swallow is adequate and no leak is suspected, diet is advanced from liquids/soft foods to normal diet as tolerated. Edentulous patients require caution with solids.",
    "<b>Late rehabilitation phase:</b> Focuses on detection and management of strictures, functional stenosis, cricopharyngeal spasm, and long-term dietary adaptation."
]

story.append(ListFlowable([ListItem(Paragraph(p, styles['BodyJ'])) for p in phases], bulletType='1', start='1'))

story.append(Paragraph("4. Evaluation of Dysphagia in Laryngectomized Patients", styles['Heading']))
text4 = """
If oral intake is poor or progressively worsening, systematic assessment is required. Important causes include pharyngeal stricture, pharyngoesophageal stenosis, recurrent tumor, tongue weakness, and cricopharyngeal spasm. Modified barium swallow and/or videofluoroscopic methods (including manofluorography where available) help localize dysfunction. Endoscopy and biopsy are mandatory when recurrence is suspected. Clinically, pain-associated dysphagia with odynophagia raises concern for recurrence, while painless progressive dysphagia more often suggests cicatricial stenosis or functional narrowing.
"""
story.append(Paragraph(text4, styles['BodyJ']))

story.append(Paragraph("5. Common Problems and Their Rehabilitation", styles['Heading']))
problems = [
    "<b>Pharyngocutaneous fistula:</b> Usually managed initially with nil per oral, wound care, drainage optimization, antibiotics, nutritional support, and control of contributing factors such as hypothyroidism. Oral feeding is resumed only after adequate healing.",
    "<b>Pharyngoesophageal stricture/stenosis:</b> Treated by graded dilatation (often outpatient balloon dilatation). Refractory cases may need flap-based revision. Adequate lumen is required not only for swallowing but also for tracheoesophageal voice performance.",
    "<b>Cricopharyngeal spasm (functional stenosis):</b> May cause dysphagia and poor tracheoesophageal voice fluency; management includes dilatation, botulinum toxin injection, and selected myotomy.",
    "<b>Radiation fibrosis and neuromuscular weakness:</b> Managed with long-term swallow therapy, repeated stretching/dilatation when indicated, and structured exercises to optimize tongue-base propulsion and bolus transfer.",
    "<b>Nutritional compromise:</b> Early dietetic optimization, temporary tube feeding when needed, and targeted calorie-protein plans reduce morbidity and support wound healing."
]
story.append(ListFlowable([ListItem(Paragraph(p, styles['BodyJ'])) for p in problems], bulletType='bullet'))

story.append(Paragraph("6. Role of Early Oral Feeding", styles['Heading']))
text6 = """
Traditional practice starts oral intake approximately one week after surgery. Selected studies have reported very early oral feeding (as early as day 3) without increased complications in carefully chosen patients; however, this strategy is not universally feasible due to edema, reconstructive complexity, and prior radiation. Therefore, timing should be individualized rather than protocol-driven, with vigilant fistula surveillance around the first postoperative week.
"""
story.append(Paragraph(text6, styles['BodyJ']))

story.append(Paragraph("7. Relationship with Voice Rehabilitation", styles['Heading']))
text7 = """
In contemporary laryngectomy care, swallowing and voice rehabilitation are interdependent. Tracheoesophageal puncture (TEP) with prosthesis is the preferred voice restoration method in many patients and improves overall quality of life. However, pharyngoesophageal segment function affects both swallowing and voice. Cricopharyngeal spasm, stenosis, or poor vibratory segment quality can impair communication and oral intake simultaneously. Hence combined swallow-voice follow-up is essential.
"""
story.append(Paragraph(text7, styles['BodyJ']))

story.append(Paragraph("8. Factors Predicting Poor Swallowing Outcome", styles['Heading']))
text8 = """
Adverse factors include prior radiotherapy/chemoradiotherapy, history of fistula, extensive oropharyngeal resection, narrow pharyngeal lumen, poor tongue-base propulsion, reduced lubrication in reconstructed segment, and velopharyngeal incompetence. Comorbid diabetes, hypothyroidism, and immunosuppression increase postoperative complications and delay oral rehabilitation.
"""
story.append(Paragraph(text8, styles['BodyJ']))

story.append(Paragraph("9. Exam-Oriented Practical Protocol", styles['Heading']))
protocol = [
    "Preoperative counseling regarding expected swallowing course, tube feeding possibility, and rehabilitation timeline.",
    "Baseline nutritional and speech/swallow assessment.",
    "Postoperative tube feeding with stoma and pulmonary care.",
    "Clinical assessment of saliva swallow and wound status before initiating oral intake.",
    "Stepwise diet progression under SLP-dietitian supervision.",
    "Early imaging/endoscopic evaluation for persistent dysphagia.",
    "Treat structural causes promptly: dilatation for stricture, surgery/flap revision for refractory stenosis.",
    "Treat functional causes: swallow exercises, botulinum toxin/myotomy for cricopharyngeal spasm.",
    "Surveillance for recurrence, hypothyroidism, and late radiation effects.",
    "Long-term integrated swallow and voice rehabilitation with quality-of-life focus."
]
story.append(ListFlowable([ListItem(Paragraph(p, styles['BodyJ'])) for p in protocol], bulletType='1', start='1'))

story.append(Paragraph("10. Conclusion", styles['Heading']))
conclusion = """
Swallowing rehabilitation after laryngectomy is a staged, multidisciplinary, complication-sensitive process. Most patients can return to oral intake, but success depends on careful timing, early detection of fistula/stenosis, objective swallow assessment, correction of structural and functional deficits, and ongoing speech-swallow integration. In postgraduate examination answers, emphasis should be placed on individualized timing of oral feeding, role of modified barium swallow, management of strictures and cricopharyngeal dysfunction, and the close relationship between swallowing outcome, reconstruction type, and prior radiation exposure.
"""
story.append(Paragraph(conclusion, styles['BodyJ']))

story.append(Spacer(1, 12))
story.append(Paragraph("Key Source", styles['Heading']))
story.append(Paragraph("Cummings Otolaryngology Head and Neck Surgery, chapter sections on Total Laryngectomy and Rehabilitation (pp. approximately 2112-2113 in the provided text block).", styles['BodyJ']))

doc.build(story)
print(output_path)