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.
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.
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.
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.
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.