TITLE: VOICE REHABILITATION AFTER LARYNGECTOMY
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: December 10, 1996
RESIDENT PHYSICIAN: Deborah Paige Wilson, M.D.
FACULTY: Christopher H. Rassekh, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.

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"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."

Introduction:

Restoring communication by speech following total laryngectomy has been a great challenge for speech pathologists and head and neck surgeons ever since Billroth performed the first laryngectomy over one hundred years ago. A number of voice rehabilitation procedures have been attempted over the years. This paper serves to briefly review the history of voice rehabilitation techniques and evaluate the therapeutic options that are currently offered to the laryngectomy patient.

Brief history

In 1874, Gussenbauer devised the first artificial larynx for Billroth's total laryngectomy patient. Billroth had created a diverting pharyngostoma to prevent aspiration. Gussenbauer used the artificial larynx (Figure 1) to connect the pharyngostoma to the tracheostoma. It was reported that the patient spoke with an intelligible voice. In the late 1800's, Gluck and Sorensen introduced primary reconstruction of the pharynx. The diverting pharyngostoma was eventually eliminated which greatly improved deglutition. Artificial instruments were introduced by Western Electric and esophageal voice became better understood as a means of voice rehabilitation. Voice restoration by the fistula technique was reintroduced by Asai in 1965. He proposed a tracheo- esophageal skin tube shunt (Figure 2) that was established over three stages. However, this technique was plagued with problems including disruption of the shunt, stenosis, and aspiration. Taub and Spiro developed a prosthetic method in 1972 using a valved prosthesis called a VoiceBakTM.

The VoiceBak was the first commercially available laryngeal prosthesis. Unfortunately, it was expensive, required frequent maintenance, and was awkward for the patient. In 1972, Serafini proposed construction of a "neolarynx" during the laryngectomy procedure by preserving portions of the larynx. His technique was complicated with inability to decannulate, serious aspiration, and recurrence. Pearson in 1981 then questioned the need for total laryngectomy to obtain adequate surgical margins. This lead to partial, near-total, and conservation laryngectomy for select patients, which will not be discussed in this paper. In 1979, Singer and Blom introduced the tracheoesophageal puncture (TEP) and silicone prosthesis. Since their introduction, variations on the procedure and of the prosthesis have been proposed but the general principles remain the same today.

Total laryngectomy - the anatomy and closure of the surgical defect

To fully understand the methods used for voice rehabilitation following total laryngectomy, it is necessary to comprehend the surgical defect and closure of this defect.. Widefield total laryngectomy results in removal of the entire larynx including the thyroid and cricoid cartilages, the hyoid bone, partial pharynx, strap muscles, one to three rings of the trachea, and possibly the ipsilateral lobe of the thyroid gland. The defect consists of pharyngeal mucosa and constrictor muscle remnants. Meticulous closure of the pharyngeal mucosa is performed using an inverting Connell stitch 3. Closure of the constrictor muscle remnants is an area of controversy. Non-muscle closure appears to help prevent spasm of the pharyngoesophageal segment, which is a notable cause of speech failure following total laryngectomy. Olsen and Callaway4 illustrated relative safety of a non-muscle closure for total laryngectomy. Clevens et al 5 demonstrated that the safety of this non-muscle closure persists even when accompanied by either primary or secondary TEP.

Voice rehabilitation options

The patient who has undergone, or preferably is about to undergo, total laryngectomy is usually offered three options: the artificial larynx or electrolarynx, esophageal voice, and tracheoesophageal voice. Artificial Larynx There are two types of artificial larynges, an external type that is placed against the neck and an oral type. Both types are electrically driven and produce a mechanical sound. This sound is articulated by the tongue, lips, and teeth as understandable speech. The most common type is the external type. The intraoral type is indicated for patients whose cervical tissues cannot transmit the sound such as those that have received radiation to the neck. The advantages of the artificial larynx or electrolarynx are it's short learning time, ability to use immediately postop, and relative availability and low cost. The disadvantages include the mechanical sound, dependence on batteries, and maintenance of the intraoral tubes. Esophageal Speech Esophageal speech has been used as a method of voice restoration for over 100 years.

A speech pathologist or another laryngectomee usually teaches the patient insufflation behavior. This entails trapping air in the mouth or pharynx and propelling it into the esophagus. Approximately 80ml of air can be stored in the esophagus or stomach. The patient can then reflux the air up through his or her esophagus across the upper esophageal sphincter. This produces a belch-like sound that can be articulated by the tongue, lips, and teeth. The patient learns how to rapidly insufflate and eject air through his or her esophagus to produce understandable speech. The advantages of esophageal speech include it is less conspicuous than the artificial larynx, it requires no batteries, does not sound mechanical, and does not require hands. The major disadvantage of it is that very few laryngectomees are successful users. The literature reports success rates of 5-40% with weeks of intensive speech therapy. Esophageal speakers can also only achieve approximately 4-6 words per breath. Tracheoesophageal Speech Tracheoesophageal speech has revolutionized the rehabilitation of the laryngectomized patient over the past ten to fifteen years. Some authors report that greater than 90% of their patients achieve effective conversational speech with in one month after the prosthesis is placed. Some patients develop effective speech within minutes. The basis of tracheoesophageal speech has been known since the first laryngectomy and artificial larynx. That is that tracheal air during exhalation can be shunted to the pharynx through a fistulous tract and produce sound by vibrating the mucosa of the upper esophageal segment. Speech is produced by articulation of this sound at the oral cavity.

Singer and Blom developed a silicone prosthesis that would maintain the tracheoesophageal puncture. The prosthesis served as a one-way valve to prevent salivary soiling of the upper airway. The original valve is called a duckbill prosthesis to describe the action of the slit valve. Singer and Blom later developed a low-pressure voice prosthesis because of the number of voice failures they encountered due to the high effort for voicing required by the duckbill prosthesis. Because it remained necessary to occlude the tracheostoma for voice production, Singer and Blom later developed a second valve for closing the tracheostoma during phonation. They found this produces a more natural voice and does not require the patient to cover his stoma when speaking, however, it requires an adhesive attachment to the peritracheal skin and maintenance is more complicated. It also cannot be used in patients with COPD. Therefore, the low- pressure prosthesis remains the most commonly used. The advantages of tracheoesophageal voice are many. As previously mentioned, it can sometimes be learned within minutes. Tracheoesophageal speech is also more intelligible and can achieve more words with one breath (25-30) as compared to esophageal speakers. TE speech is also more natural sounding as the patient can vary the pitch. In study done by Sweeney et al8, laryngectomy patients were surveyed about their satisfaction with their current method of alaryngeal communication and their effects on quality of life. Dr. Sweeney found that TE speakers experience greater satisfaction with their method of alaryngeal communication and enjoy a higher quality of life than patients using other means, including esophageal speech and electrolarynges. The disadvantages of TE speech include the requirement to manually cover the stoma when voicing and the need for maintenance of a prosthesis.

Techniques of tracheoesophageal puncture

Tracheoesophageal puncture can be performed at the time of laryngectomy (primary TEP) or later as a second procedure. The timing of tracheoesophageal puncture is another area of debate and appears to be the surgeon's preference. Stiernberg et al9 found that primary TEP is successful, offers no increased risk for complications, and convenient if patients are carefully selected preoperatively. Wenig et al10 also demonstrated that primary and secondary TEPs are equally effective in producing TE speech. Wenig et al however found the incidence of post-operative complications to be slightly higher in the primary TEP group( fistula formation and leakage around the prosthesis). Primary TEP offers the advantages of avoiding a secondary procedure, early voice rehabilitation, and the TE fistula can be used temporarily as a feeding esophagostome. Other authors do not perform primary TEP because of unpredictable edema leading to patient discouragement, risk of tracheastomal stenosis due to placement of a valve or catheter, and, as mentioned above, possible increase in risk of fistula formation. Primary TEP is performed after the stoma is constructed and before the pharynx is closed. This is done by placing a Kelly hemostat into the open pharyngeal defect directed down into the cervical esophagus. The tip of the hemostat is palpated through the posterior tracheal wall. An incision is made 8mm below the posterior edge of the tracheal stump. The hemostat is then pushed into the tracheastoma and used to grasp either a 14 gauge red rubber catheter or NG tube. The catheter is directed down towards the stomach. If an NG tube is used, it can stent the TEP as well as serve as a feeding tube. After the skin flaps are sutured, the catheter is secured to the side of the neck.

Secondary TEP can be performed on the previously laryngectomized patient under local or general anesthesia. There are a variety of different modifications of the endoscopic procedure originally described by Singer and Blom in 1980. This method is performed under general anesthesia and can be performed quickly and safely. It is performed by introducing a rigid esophagoscope (or hypopharyngoscope) into the upper thoracic esophagus. The scope is rotated 1800 from introduction at the tracheostoma so that the endoscope window is anterior and the longer portion of the scope lies against the posterior esophageal wall. Identify a puncture location 5mm from the superior trachea and align endoscope window with this location. A 14 gauge needle is used to puncture through the wall of the trachea. The needle is directed into the lumen of the endoscope through the window. Thread a 16 gauge intravenous catheter over the needle, into the esophagoscope, and out the mouth. This catheter is then tied to a 14 gauge red rubber catheter and used to guide the red rubber catheter through the puncture, into the scope, and out the mouth. The esophagoscope is then reinserted and used to redirect the dilating red rubber catheter into the distal esophagus. This procedure can also be performed under local anesthesia in the office with the patient awake. Several methods have been described. The method we commonly use at UTMB involves having the patient swallow a bougie, which serves as a guide for the esophageal lumen. After the posterior tracheal wall is adequately anesthetized, a needle is used to make the TE puncture. Proper placement of the needle is confirmed by motion of the needle with movement of the bougie. A blade is then used to enlarge the punture. The bougie is withdrawn and a red rubber catheter is then placed into the puncture down into the esophagus. It is then secured to the patient's neck. Postoperatively, the patient can resume a normal diet. The catheter is removed in 2-10 days and the speech pathologist fits the patient with a voice prosthesis.

Complications of tracheoesophageal puncture

The most common problem following TEP is voice restoration failure. Studies have shown that failure rates range from 3-15%. Some of the common causes of voice restoration failure following TEP include patient motivation and learning capabilities. In addition, patients with poor vision, arthritis, or neurological disabilities have been found to be poor candidates for the procedure. These conditions should be considered in the pre-operative evaluation of the patient. Another cause of failure is pharyngoesophageal spasm. This spasm appears to be caused by reflex contraction of cricopharyngeal and constrictor muscles when the mid-esophagus is distended with air. It seems to be a cause of TE speech failure in 10-12% of patients. Therapeutic options for pharyngoesophageal spasm include cricopharyngeal and constrictor myotomies and pharyngeal neurectomies. Other complications from TEP include: bleeding from around the tract (usually granulation tissue), air in the stomach, salivary leakage around or through the prosthesis, aphonia during radiotherapy, coughing at night. More serious, though fortunately rare complications include: mediastinitis, cervical cellulitis, cervical spine fracture, and aspiration of the prosthesis.

Conclusion

Head and neck surgeons and speech pathologists have been searching for a substitute for the human voice since Billroth performed the first laryngectomy over 100 years ago. Although not ideal, tracheoesophageal speech appears to be considered the method of choice for voice restoration in the laryngectomized patient.

Bibliography

1.Holinger PH: A Century of Progress of Laryngectomies in the Northern Hemisphere. Laryngoscope 85:322-332. 1975.

2.Singer MI, Blom ED, Hamaker RC: Voice Rehabilitation after Total Laryngectomy. J Otolaryngology 12:329-334. 1983.

3.Wong F: Total Laryngectomy. In: Atlas of Head and Neck Surgery- Otolaryngology; Bailey BJ, Calhoun KH, Coffey, AR, Neely, JG, eds. Philadelphia, Lippencott-Raven; 1996;200-203.

4.Olsen NR, Callaway E: Nonmuscle Closure of Pharyngeal Muscles after Laryngectomy. Ann Otol Rhinol Laryngol 99:507-508. 1990.

5.Clevens RA, Hartshorn DO, Esclamado RM, Lewin JS: Voice Rehabilitation After Total Laryngectomy and Tracheoesophageal Puncture Using Nonmuscle Closure. Ann Otol Rhinol Laryngol 102:792-796. 1993.

6.Singer MI: Voice Rehabilitation After Laryngectomy. In: Head and Neck Surgery- Otolaryngology; Bailey BJ, ed. Philadelphia, Lippencott Company; 1993;1361-1372.

7.Dedo HH: Tracheoesophageal Voice Rehabilitation after Total Laryngectomy. In: Surgery of the Larynx and Trachea; Dedo HH, ed. Philadelphia, B.C. Decker, Inc; 1990; 350-372.

8.Sweeney KD, Rassekh CH, Seikaly H, Hokanson JA: Communication Following Total Laryngectomy: An Assessment of Patient Satisfaction and Quality of Life.

9.Stiernberg CM, Bailey BJ, Calhoun KH, Perez DG: Primary Tracheoesophageal Fistula Procedure for Voice Restoration : The University of Texas Medical Branch Experience; Laryngoscope, 97: 820-824, 1987.

10.Wenig BL, Levy J, Mullooly V, Abramson AL: Voice Restoration Following Laryngectomy: The Role of Primary Versus Secondary Tracheoesophageal Puncture; Ann Otol Rhinol Laryngol, 98; 70-73, 1989.