Voice rehabilitation after laryngectomy with voice prostheses. Results of a prospective follow-up study]

Although the results of surgical rehabilitation by means of voice prostheses are on the average better than rehabilitation via oesophageal speech, the tracheoesophageal puncture (TEP)-technique has so far not been widely used in Germany. The majority of hospitals still prefer the "traditional" method of voice rehabilitation using oesophageal speech. The present prospective study was undertaken to compare the results of postlaryngectomy vocal rehabilitation, if patients were offered the surgical voice rehabilitation via voice prosthesis as an alternative to oesophageal speech. Taking into account all the patients who underwent laryngectomy from 1989 until 1990 in Tübingen, primary surgical voice rehabilitation was performed in 44 out of 54 patients (81.5%). Interestingly enough, 34 patients who underwent laryngectomy were able to perform communication via the telephone on the day of their discharge. Moreover, one-third of the laryngectomised patients showed a significant increase in speech intelligibility within the first six months after laryngectomy. 36 patients with laryngectomy were able to attain proficiency 6 months after surgery. In 12 patients the prosthesis had to be removed, since either phonation was impossible or patients successfully learned and preferred oesophageal speech. In conclusion, independent of the method of voice rehabilitation (prosthesis, electrolarynx, oesophageal speech), our results support the hypothesis that a voice rehabilitation regimen will yield a higher rehabilitation rate of patients if rehabilitation via surgical voice is offered as an alternative to learning the oesophageal voice. Therefore, it seems to be advisable that patients are allowed to have the choice between surgical rehabilitation and oesophageal speech restoration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Voice prosthesis in patients after total laryngectomy

The aim of the study is to present the role of voice prostheses in the voice rehabilitation in patients who underwent total laryngectomy. 7 patients with laryngeal cancer were included in the study. All patients are males aged 41-72 years (mean age 58) treated in the Department of Otolaryngology Medical Academy of Bialystok from November 2001 to March 2002. The voice prostheses were placed during the total laryngectomy in 5 patients. In 2 patients the voice prosthesis was placed in the period of 1.5 to 2 years after laryngectomy. The voice prostheses type Provox 2 were used in all cases. In 2 cases the prosthesis was in size of 8 mm, in 5 cases--10 mm. The control group included 7 patients after total laryngectomy without placing the voice prostheses. These patients developed oesophageal speech. All patients underwent phoniatric measurements during 12 to 30 days after the surgical procedure. The data indicate that patients who developed oesophageal speech, their voice in the range of subjective measurements is understandable but it is necessary to emphasize that the voice is harsh, low without fluency of the speech result from the intervals essential to accumulate the air in the oesophagus. The patients with voice prostheses have dull voice but more fluent and louder. The clarity of the voice of the patients with voice prostheses is significantly higher. According to the objective measurements all parameters are better in the oesophageal speech.     

The use of the vocal prosthesis Provox 2 for speech rehabilitation after total laryngectomy

The authors have presented the application and usage the alloplastic vocal prosthesis Provox 2 to serve for rehabilitation speech after total laryngectomy. Surgical technique of implantation of vocal prosthesis was discussed. The authors estimated in 6 patients following parameters of speech; fundamental frequency, maximum phonation time of vowel "a", maximum intensity and degree of dysphonia. In all 6 cases post-operative course was uncomplicated. Above mentioned parameters of voice were measured in order to comparison quality of oesophageal speech to tracheo - oesophageal speech. The authors assessed speech at 6 patients with voice prosthesis and 6 with good oesophageal speakers as a control group. The results of our investigations showed, that quality of tracheo - esophageal speech obtained with usage vocal prosthesis Provox 2 is more like normal speech than oesophageal speech. Social efficiency and quality of tracheo - oesophageal voice is better than oesophageal voice.     

The role of a psychologist in a rehabilitation of the patients with laryngeal cancer after total laryngectomy with implantation of the voice prostheses

The new possibilities of voice rehabilitation in patients with laryngeal cancer who undergo total laryngectomy have been opened with the surgical insertion of voice prostheses after performing of the tracheoesophageal shunt. This method enables to achieve a voice of better quality which leads to improved patients' general well-being. The cornerstone of the rehabilitation after an implantation of voice prosthesis is an appropriate psychosocial attitude of a patient towards combating of a cancer and his motivation for a verbal communication. In this review we have characterized both a role of the psychologist in the diagnostic and therapeutic team and psychological attitudes of the patients with cancer. These problems were illustrated by the clinical cases.     

The influence of early speech rehabilitation with voice prostheses on the psychological state of laryngectomized patients

This survey assessed how early speech rehabilitation influences the emotional state and psychological adjustment of 43 male laryngectomy patients, at three different chronological stages. The first assessment occurred 2–3 days before the operation. The patients filled out a stress questionnaire (SVF) which assessed coping strategies. Exactly 2 weeks after the operation the patients were given a list of adjectives (EWL) which measured their actual emotional state. One day before leaving the hospital the patients were given the Post-laryngectomy Telephone Test (PLTT) which ascertained the quality of speech intelligibility. In addition, patients filled out a questionnaire on postoperative stress and anticipated stigmatisation with regard to their changed voice. Results demonstrated that patients who had early speech rehabilitation felt significantly more active and, in general, felt considerably better than patients who had not received speech rehabilitation training. Patients assessed voice loss as extremely distressing. The postoperative stress and the anticipated stigmatisation on the basis of the changed voice was significantly higher in those patients with good speech intelligibility than in patients with poor speech articulation at hospital discharge. The coping strategies “Giving up and resignation” and “Need for social support” correlated positively with postoperative stress and anticipated stigmatisation. Results show that early speech rehabilitation with voice prostheses had a positive effect on the emotional state of laryngectomy patients. However, the early speech rehabilitation leads to distress in the initial phase in laryngectomy patients. Moreover, patients who habitually tend towards resignation, or need lots of social support should receive psychological support during the early phase of speech rehabilitation training. Received: 27 April 2001 / Accepted: 5 July 2001     

Vocal rehabilitation after total laryngectomy using the Provox voice prosthesis

Vocal rehabilitation in laryngectomized patients can be attained by surgical (tracheoesophageal speech) or conservative methods (oesophageal speech or artificial larynx). We prospectively studied voice restoration in 37 patients who underwent total laryngectomy in the period from February 1991 to February 1993. The patients were given the opportunity to assess both non-shunt oesophageal speech and shunt oesophageal speech using the Provox voice prosthesis. The Provox low resistance, self-retaining voice prosthesis is a biflanged device made of silicon rubber. A primary tracheoesophageal puncture was made in 28 patients, while a secondary puncture was performed in another nine patients. The results were assessed according to criteria established at the ‘Third International Congress on Voice Prosthesis’ in Groningen (1988). Functional tracheoesophageal speech after primary puncture was achieved in 95% of patients 12 months after puncture, while oesophageal voice was acquired by 55%. Only minor surgical and prosthesis-related complications were encountered during this follow-up period in 29% of the patients. The device lifetime varied from 3 months to at least 2 years (mean 5.4 months).     

History of voice rehabilitation following laryngectomy

INTRODUCTION: The history of voice rehabilitation following laryngectomy is as long as the history of laryngectomy itself. The multitude of methods which have been employed to reduce the disability associated with the loss of the larynx, illustrate the difficulty of finding an optimal method of reestablishing verbal communication while preserving the ability to breathe and swallow. MATERIAL AND METHODS: The world literature was reviewed using various Internet and medical search engines and library facilities. Landmark articles were identified and summarized. RESULTS: A coherent history of voice rehabilitation following laryngectomy was constructed. DISCUSSION: The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts to create lung powered voice with and without the use of prosthetic devices to prevent aspiration, "near-total" resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound which is then transmitted through the oral cavity and pharynx. CONCLUSION: For the past two decades, simple shunt devices inserted either primarily, at the time of laryngectomy, or later as a secondary procedure, have mainly supplanted the other methods of voice rehabilitation, with the exception of an occasional patient who has acquired good esophageal speech, or for whom external devices may be the only practical method of voice production.     

Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience

We describe the speech rehabilitation outcome of patients treated with total laryngectomy or total laryngopharyngectomy and insertion of Provox voice prostheses (Atos Medical AB, H?rby, Sweden) at the Helsinki University Central Hospital. We performed a retrospective chart review of 95 patients (88 men and 7 women; mean age, 63.5 years) who underwent insertion of a voice prosthesis in the period 1992 to 2002. Eighty-one percent (77/95) of the patients underwent a primary prosthesis insertion at the time of laryngectomy. A head and neck surgeon, a laryngologist, and a speech therapist rated the long-term tracheoesophageal speech of 78% (74/95) of the patients as good or average. The main causes for replacement of the device were obstruction, leakage or inadequate size of the prosthesis, and granulation or leakage around the fistula. According to our 10-year experience, use of the Provox prosthesis is an effective method of postlaryngectomy voice rehabilitation, and it continues to be our preferred method of voice restoration in the majority of cases.     

Dislokation von Stimmprothesen

Tracheoesophageal voice prostheses after total laryngectomy are infrequently the cause of severe complications. We report on a patient with threefold dislocation of a Provox® prosthesis, each with suspected oesophageal loss. The patient came to our hospital with acute dyspnoea. An urgent bronchoscopy showed two prostheses in the right and one in the left main bronchus, which had caused inflammation with extensive occlusion of the bronchus. All three prostheses could be recovered.     

Tracheoesophageal speech failure in the laryngectomee: The role of constrictor myotomy

Drs. Singer and Blom pioneered the development of a valved voice prosthesis and controlled fistula between the tracheal and esophagcal wall to generate fluent esophageal speech in laryngectomy patients. Since then numerous voice prostheses with different performance capacities have entered the marketplace. In spite of optimal choices and fitting of devices, there remains a population of patients refractory to this type of rehabilitation. It is our experience that a number of patients ultimately benefit from middle and inferior constrictor myotomy with marked improvement in their speech. Patient selection, evaluation, and operative techniques are discussed. Five patients who were unable to speak even after introduction of various commercially available devices showed marked improvement after middle and inferior constrictor surgical myotomy. Minimal complications were encountered even in irradiated patients. These patients were preoperatively injected with Xylocaine to produce a partial blockade. Their speech improved dramatically for the duration of Xylocaine blockade. Esophageal video fluoroscopy of attempted speech with the voice prosthesis in place confirmed constrictor spasm that opposed air flow to the oropharynx. Inferior and middle constrictor myotomy appears to be very beneficial in rehabilitation of failed alaryngeal speakers who demonstrate pharyngeal constrictor spasm.     

The long-term indwelling tracheoesophageal prosthesis for alaryngeal voice rehabilitation

OBJECTIVE: To analyze the initial experience at Oregon Health Sciences University, Portland, with the use of long-term indwelling tracheoesophageal voice prostheses. DESIGN: Retrospective case series. SETTING: Tertiary referral academic medical center. PATIENTS: Thirty patients undergoing speech rehabilitation after laryngectomy during a period of 18 months. INTERVENTION: Insertion of a long-term indwelling tracheoesophageal voice prosthesis. MAIN OUTCOME MEASURES: Duration of use, complications. RESULTS: The mean duration of placement for a single prosthesis was 4.9 months (148 days), with a range of 14 to 330 days. Sixteen of the 30 patients encountered problems with leakage because of fungal colonization, the majority of which (15 of 16 cases) were solved with either oral or topical application of nystatin. Size matching in terms of prosthesis length and tract length was critical, and problems of this nature were encountered in 11 of 30 patients. The incorporation of a second system of prostheses that offered an increased number of size options solved these problems in all of these patients. Ultimately, 27 of 30 patients were able to successfully wear these prostheses. CONCLUSIONS: The indwelling tracheoesophageal voice prosthesis offers patients all the advantages of tracheoesophageal speech rehabilitation after laryngectomy without the inconvenience of frequent prosthesis changes. With careful attention to the details of fitting and care, it can be worn by the majority of patients successfully.     

Assessment of irregular voices after total and laser surgical partial laryngectomy

OBJECTIVES: To assess the merits of computer-aided voice analysis procedures for very irregular voices of patients after total and laser surgical partial laryngectomy, and to characterize qualitative differences in speech and voice function between these 2 groups of patients. DESIGN: Cross-sectional study. SETTING: University hospital in G?ttingen, Germany PATIENTS: Twenty-nine patients with advanced laryngeal carcinomas (T3-T4; according to the Union Internationale Contre le Cancer, TNM staging system, stages III-IVa) were examined: 18 patients with tracheoesophageal speech (voice prosthesis) after total laryngectomy and 11 patients who underwent partial transoral resection of the larynx (by means of laser microsurgery without surgical voice rehabilitation). MAIN OUTCOME MEASURES: Speech intelligibility was measured by a standardized and validated telephone test, and voice quality was determined by 2 computerized voice analysis systems (multidimensional voice program and G?ttingen hoarseness diagram). RESULTS: The telephone test demonstrated a significantly better speech performance of the patients who had undergone organ-preserving surgery. The voices of both patient groups were too irregular for a qualitative differentiation with the multidimensional voice program. The multidimensional voice program results also failed to show significant correlations to speech intelligibility. The G?ttingen hoarseness diagram showed significantly more regular voices in patients with partial laryngectomy than total laryngectomy. These results were correlated with speech intelligibility. CONCLUSIONS: The G?ttingen hoarseness diagram is suitable for a qualitative assessment even of irregular voices. Voice prosthesis offers a voice quality that at best approaches that of patients with partial laryngectomy.     

Blom-Singer发音管在喉全切除术后的临床应用

目的观察喉全切除术后应用Blom-Singer发音管重建喉发声功能的效果。方法回顾性分析1994年9月～2003年8月15例喉全切除术后行Blom-Singer发音管重建喉发声功能患者的临床资料。结果15例患者中12例行Ⅰ期发音管重建术，10例手术成功(10／12，83．33％)；3例行Ⅱ期发音管重建术，其中2例手术成功，两种术式的总成功率为80％(12／15)。Ⅰ期手术失败2例，与气管食管壁分离过多有关；Ⅱ期手术失败1例，系环咽肌切断不完全所致。结论喉全切除术后应用Blom-Singer发音管重建喉发声功能是一种有效的发声重建方法，环咽肌切断及保留气管食管壁的完整是手术成功的美键。     

Electromyography of Cricopharyngeal Muscles in Patients with Oesophageal Speech

Subject for the examination were 30 patients who during total laryngectomy had had two silver clips for haemostasis inserted into the cricopharyngeous muscle about 3 cm from the sewing place in the midline, faciliating the location of the muscle and the placing of a needle electrode. Twelve to 18 months after laryngectomy and Phoniatric rehabilitation, electromyographic examinations were performed. Each EMG recording was evaluated as to amplitude, discharge frequency and time duration of muscle electric activity. EMG recordings made during deglutition and phonation proved dependences of cricopharyngeous muscle activity on quality of oesophageal voice production and higher activity of muscle during phonation than deglutition in patients who developed very good and good oesophageal speech.     

Electromyography of cricopharyngeal muscles in patients with oesophageal speech.

Subject for the examination were 30 patients who during total laryngectomy had had two silver clips for haemostasis inserted into the cricopharyngeous muscle about 3 cm from the sewing place in the midline, facilitating the location of the muscle and the placing of a needle electrode. Twelve to 18 months after laryngectomy and phoniatric rehabilitation, electromyographic examinations were performed. Each EMG recording was evaluated as to amplitude, discharge frequency and time duration of muscle electric activity. EMG recordings made during deglutition and phonation proved dependences of cricopharyngeous muscle activity on quality of oesophageal voice production and higher activity of muscle during phonation than deglutition in patients who developed very good and good oesophageal speech.     

Relevance of psychosocial factors in speech rehabilitation after laryngectomy

BACKGROUND: Often it is assumed that psychosocial and sociodemographic factors cause the success of voice rehabilitation after laryngectomy. Aim of this study was to analyze the association between these parameters. METHODS: Based on tumor registries of six ENT-clinics all patients were surveyed, who were laryngectomized in the years before (N = 190). Success of voice rehabilitation has been assessed as speech intelligibility measured with the postlaryngectomy-telephone-intelligibility-test. For the assessment of the psychosocial parameters validated and standardized instruments were used if possible. Statistical analysis was done by multiple logistic regression analysis. RESULTS: Low speech intelligibility is associated with reduced conversations (OR 0.970) and social activity (OR 1.049). Patients are more likely to talk with esophageal voice when their motivation for learning the new voice was high (OR 7.835) and when they assessed their speech therapist as important for their motivation (OR 4.794). The risk to communicate merely by whispering is higher when patients live together with a partner (OR 5.293), when they talk seldomly (OR 1.017) and when they are not very active in social contexts (OR 0.966). CONCLUSIONS: Psychosocial factors can only partly explain how voice rehabilitation after laryngectomy becomes a success. Speech intelligibility is associated with active communication behaviour, whereas the use of an esophageal voice is correlated with motivation. It seems that the gaining of tracheoesophageal puncture voice is independent of psychosocial factors.     

Vocal restorative surgery: Why wait?

The case histories of 36 laryngectomees with vocal restorative surgery from the Department of Otolaryngology were reviewed to determine the patient's current mode of speech and number and type of complications to recovery and rehabilitation. The patients comprised two groups: 21 with tracheoesophageal fistula (tef) at the time of laryngectomy (primary) and 15 with tef subsequent to laryngectomy (secondary). Results of the review indicated that while approximately 10% fewer patients in the primary group were using a surgically restored voice, none of the surviving primary group remained aphonic. In contrast, 27% of the surviving secondary group failed to develop some form of verbal communication. When the complication rate is identified, vocal restorative surgery at the time of laryngectomy appeared to be very successful in initiating the rehabilitation process without     

改良Amatsu法全喉切除术后的发音重建

目的：对全喉切除术后Ⅰ期气管食管造瘘术式发音重建进行临床评价。方法：用改良Ａｍｓｔｓｕ法对２０例患者实施全喉切除术后Ⅰ期发音重建术。结果：２０例全喉切除术后发音重建术患者随访１￣８年,最终有１６例获得发音功能。结论：全喉切除术后一期完成气管－食管造瘘发音重建术,适用于所有的全喉切除术或同期作根治性颈廓清术及术后放疗的患者,能较好地解决全喉切除术后发音问题。     

Functional speech outcomes after laryngectomy and pharyngolaryngectomy

OBJECTIVE: To compare and contrast functional speech outcomes of patients having undergone total laryngectomy and pharyngolaryngectomy who use tracheoesophageal speech as their primary mode of communication. DESIGN: Group comparison design. SETTING: Adult acute tertiary care hospital. PATIENTS: Thirty patients who underwent total laryngectomy and 13 who underwent pharyngolaryngectomy with free jejunal interposition reconstruction. All patients used tracheoesophageal speech. INTERVENTION: Group comparisons across measures of speech intelligibility, voice quality, tracheoesophageal speech use, voice satisfaction and levels of perceived voice disability, handicap, and well-being/distress. MAIN OUTCOME MEASURE: The existence of any significant differences between the 2 groups on measures of intelligibility, voice quality, tracheoesophageal speech use, and voice satisfaction and levels of voice disability, handicap, and well-being/distress. RESULTS: Statistical comparisons confirmed reduced functional intelligibility (P<.05), reduced vocal quality (P<.01), and higher levels of disability (P<.05) in the pharyngolaryngectomy group. However, no significant difference was observed between the proportion of patients classified as "successful" tracheoesophageal speech users in either group. Low levels of handicap and high levels of patient well-being were recorded in both groups. CONCLUSION: Despite the perceptual differences in voice quality and intelligibility observed between the 2 groups, tracheoesophageal speech that is functional, effective, and perceived by the patients as satisfactory can be achieved after total laryngectomy and pharyngolaryngectomy with free jejunal interposition reconstruction.     

Voice prosthesis — Our experience

Malignancy of the larynx is a large group of malignancies in our country. The advanced stage of laryngeal carcinoma requires total laryngectomy which results in loss of speech along with other psychological and functional damages. Following total laryngectomy, tracheo-oesophageal voice prosthesis offers the most reliable form of voice rehabilitation. At S.M.S. Medical College and Hospital, Jaipur 25 patient underwent speech rehabilitation with voice prosthesis between Dec. 2001 to Dec. 2003. Speech rehabilitation was successful in all patients with few problem associated with indwelling prosthesis.