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 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)     

Quality of life during the first 3 months following discharge after surgery for head and neck cancer: prospective evaluation

OBJECTIVE: To identify patient groups that are prone to poorer quality of life (QoL) during the first 3 months following discharge from the hospital after surgery for head and neck cancer. DESIGN: Prospective evaluation of the QoL of surgically treated head and neck cancer patients measured with questionnaires at discharge and at 6 weeks and 3 months after discharge. SETTING: Department of Otolaryngology and Head and Neck Surgery of the Erasmus University Medical Centre, a tertiary health care centre in Rotterdam, The Netherlands. PARTICIPANTS: Ninety head and neck cancer patients who had undergone a total laryngectomy, neck dissection, or the commando procedure. MAIN OUTCOME MEASURES: Patients' quality of life in 22 different dimensions. RESULTS: Three patient characteristics associated with poorer QoL during the first 3 months following discharge from the hospital after surgery for head and neck cancer: laryngectomy, lower levels of education, and being single. QoL already improved in eight QoL dimensions during the first 3 months after discharge, but QoL in the dimensions "loss of control" and "physical self-efficacy" worsened during this same period. CONCLUSIONS: It is possible to identify patient groups that are prone to poorer QoL during the first 3 months following discharge from the hospital after surgery for head and neck cancer. The results of this study may help care providers working with head and neck cancer patients to tailor their rehabilitation programs.     

Partial laryngectomy for recurrent laryngeal carcinoma

From July 1975 to January 1998, 33 patients underwent partial laryngeal resection for residual or recurrent tumour after primary radical radiotherapy. Sixteen patients had T1 tumours on presentation, 14 were T2 and three were T3. Six patients underwent a supraglottic (horizontal) laryngectomy, 24 had a vertical partial laryngectomy, two had an endoscopic laser resection and one had an endoscopic laser resection followed by a vertical partial laryngectomy. The median time interval between radiotherapy and salvage surgery was 10 months (range 2-188 months). The median follow-up period was 41 months (range 12-185 months). There were five major postoperative complications (15%); two patients developed a pharyngeal fistula and three required further surgery for laryngo-tracheal stenosis. Twenty-five patients (76%) retained their larynx with satisfactory speech and swallowing. Eight patients (24%) had to be converted to a total laryngectomy, seven for recurrent disease and one for laryngeal stenosis. Of the eight patents converted, seven had normal swallowing and six developed good tracheo-oesophageal speech. Seven patients (21%) developed recurrent tumour after partial laryngectomy and were subjected to total laryngectomy; six of these seven were salvaged. Only one of the 33 patients died with recurrent tumour, giving an ultimate disease-related survival of 97%. Conservation laryngeal surgery for salvage of selected patients who fail radical radiation therapy is safe, effective, and results in reasonable preservation of laryngeal function.     

Estimation of influence of myofascial release techniques on esophageal pressure in patients after total laryngectomy

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 effect 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 radiotherapy. Esophageal pressure was assessed using modified 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 significant 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 techniques decreases esophageal pressure, thus allowing patients to learn esophagus speech at a faster pace.     

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.     

Reasons for success or failure in surgical voice restoration after total laryngectomy: an Australian study.

Over the past 20 years, use of tracheo-oesophageal puncture (TEP) speech after total laryngectomy has resulted in reported success rates of 90-93 per cent worldwide. Despite this, data collected from major acute hospitals in Victoria, Australia indicated that, of 38 patients who underwent total laryngectomy in 1997, only 10 (26 per cent) were using TEP speech as their primary mode of communication at 12 months post-operatively. This paper describes how a quantitative research methodology was used to investigate why so few patients in Victoria were successfully using TEP speech as their chosen mode of rehabilitation after total laryngectomy. Patients, speech pathologists and ENT surgeons were interviewed. Their thoughts and beliefs regarding speech rehabilitation were mapped, and themes were identified, coded and analysed. This paper describes and discusses the results of this research and its possible implications for future patient management, through establishing a model for 'ideal' speech rehabilitation.     

Oesophageal speech after laryngectomy: a study of possible influencing factors.

52 patients with laryngeal carcinoma were studied before and after laryngectomy with regard to what factors might influence the development of oesophageal speech. The investigations consisted of oesophageal manometry, a follow-up interview and a review of surgical approaches and radiotherapy. 43% of the patients achieved socially acceptable oesophageal speech, 22% were able to speak single words, and 35% had no oesophageal speech at all. 61% had post-operative dysphagia. Age was the only factor which significantly correlated to intelligible speech. The intraoesophageal pressure during oesophageal phonation exceeded in all cases the low PO-HPZ pressure after operation. The extension of surgery and radiation field, severity of dysphagia, alcohol and smoking habits, and mental condition did not differ between the 3 groups of oesophageal speech. It was concluded that the rather complicated process of acquiring oesophageal speech is much more dependent on learning ability which decreases with age than on various kinds of motor dysfunction after laryngectomy.     

Oesophageal speech after laryngectomy: a study of possible influencing factors

52 patients with laryngeal carcinoma were studied before and after laryngectomy with regard to what factors might influence the development of oesophageal speech. The investigations consisted of oesophageal manometry, a follow-up interview and a review of surgical approaches and radiotherapy. 43% of the patients achieved socially acceptable oesophageal speech, 22% were able to speak single words, and 35% had no oesophageal speech at all. 61% had post-operative dysphagia. Age was the only factor which significantly correlated to intelligible speech. The intraoesophageal pressure during oesophageal phonation exceeded in all cases the low PO-HPZ pressure after operation. The extension of surgery and radiation field, severity of dysphagia, alcohol and smoking habits, and mental condition did not differ between the 3 groups of oesophageal speech. It was concluded that the rather complicated process of acquiring oesophageal speech is much more dependent on learning ability which decreases with age than on various kinds of motor dysfunction after laryngectomy.     

Predictive value of objective esophageal insufflation testing for acquisition of tracheoesophageal speech.

This prospective study was undertaken to assess the predictive value of esophageal insufflation on the acquisition of tracheoesophageal (TE) speech. Fourteen total laryngectomy patients were evaluated prior to tracheoesophageal puncture (TEP) using objective esophageal pressure measurements. These patients then were followed prospectively for 6 to 13 months. Speech was assessed at the time of prosthesis fitting, at 1 month, at less than 6 months, and at greater than 6 months post-TEP. No patient underwent pharyngeal myotomy. Pre-TEP esophageal insufflation pressure was associated (P = .065) with successful TE speech at the time of prosthesis fitting, but was not associated with successful TE speech acquisition after 6 months. This study's results suggest that patients with poor pre-TEP esophageal insufflation test results will usually obtain successful TE speech given adequate time and training, even without pharyngeal myotomy.     

Post-laryngectomy speech respiration patterns

OBJECTIVES: The goal of this study was to determine whether speech breathing changes over time in laryngectomy patients who use an electrolarynx, to explore the potential of using respiratory signals to control an artificial voice source. METHODS: Respiratory patterns during serial speech tasks (counting, days of the week) with an electrolarynx were prospectively studied by inductance plethysmography in 6 individuals across their first 1 to 2 years after total laryngectomy, as well as in an additional 8 individuals who had had a laryngectomy at least 1 year earlier. RESULTS: In contrast to normal speech that is only produced during exhalation, all individuals were found to engage in inhalation during speech production, and those studied longitudinally displayed increased occurrences of inhalation during speech production with time after laryngectomy. These trends appear to be stronger for individuals who used an electrolarynx as their primary means of oral communication rather than tracheoesophageal speech, possibly because of continued dependence on respiratory support for the production of tracheoesophageal speech. CONCLUSIONS: Our results indicate that there are post-laryngectomy changes in the speech breathing behaviors of electrolarynx users. This has implications for designing improved electrolarynx communication systems, which could use signals derived from respiratory function as one of many potential physiologically based sources for more natural control of electrolarynx speech.     

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.     

Assessment of shoulder impairment after functional neck dissection: long term results

OBJECTIVE: In this prospective study, we attempted to use objective techniques to measure shoulder disability and evaluate patients who underwent functional neck dissection (FND) procedure. Patients were compared on the basis of preoperative and postoperative range of motion (ROM) measurements, pain and stiffness domains. At the final visit, a Neck Dissection Impairment Index (NDII) questionnaire was applied to all patients. METHOD: Twenty-five patients treated with head and neck cancer who underwent bilateral FND simultaneously with the resection of primary tumor enrolled in this study from April 2001 to July 2004. Flexion, extension, abduction, internal and external rotations of the shoulder have been measured with electronic incliometer preoperatively, and at the 1st, 3rd, 6th, and 18th months postoperatively. A questionnaire modified from neck dissection impairment index was applied to all patients to measure neck and shoulder disability at final visit. Pain and stiffness domains were also assessed preoperatively and at postoperative 18th month. RESULTS: Measurements of abduction at the first and third months were found to be decreased in comparison with preoperative measurements. These differences were statistically significant (p<0.05). The pain and stiffness scores of all patients at the final visit were significantly worse than the preoperative scores (p<0.005). At the final visit NDII of patients who underwent total laryngectomy were significantly worse than of the patients who underwent partial laryngectomy and glossectomy (p=0.002 and 0.043, respectively). All these results did not correlate with age, radiation therapy (RT), operation side, T stage. CONCLUSION: FND is oncologicaly safe procedure and gives rise to less shoulder morbidity. Although, ROM improved after 18 months from surgery, pain and stiffness were found to be worse than preoperative values. The patients with total laryngectomy had lower NDII scores regarding to other patients. Therefore, shoulder disability can be attributed not only to neck dissection but also to primary surgery.     

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     

Acoustic and perceptual evaluation of voice and speech quality: a study of patients with laryngeal cancer treated with laryngectomy vs irradiation

OBJECTIVE: To compare voice and speech function in patients who underwent laryngectomy with that of 2 control groups. DESIGN: A cross-sectional study comparing acoustic and temporal variables with perceptual evaluations in 3 subject groups. SETTING: University hospital in G?teborg, Sweden. SUBJECTS: Two groups of patients with laryngeal carcinoma were examined: 12 male patients who had laryngectomy and were using a tracheoesophageal prosthesis and 12 male patients treated with radical radiotherapy who had a preserved larynx. The third group consisted of 10 normal controls without laryngeal disease. MAIN OUTCOME MEASURES: Acoustic variables were fundamental frequency, absolute fundamental frequency perturbation, speech rate, and maximum phonation time. Perceptual evaluation included 15 listeners' perceptual evaluation and the patients' self-assessment of speech intelligibility, voice quality, and speech acceptability. RESULTS: No significant acoustic or temporal differences were found between the laryngectomy and radical radiotherapy groups. There was a significant difference between the patient groups in perceptual evaluation. Both groups of patients differed from normal controls in acoustic and temporal measures, where the laryngectomy group generally deviated more from the normal controls than the patient group treated with radiotherapy. There was a weak, but significant, correlation between absolute fundamental frequency perturbation and perceived voice quality. CONCLUSIONS: Perceptual evaluations could indicate significant differences between the patients who underwent laryngectomy and irradiated patients, where the acoustic analysis failed to reflect these differences. Both patient groups could be distinguished according to acoustic and temporal measures when compared with normal controls. The acoustic analyses were more sufficient in voices without severe dysfunction.     

Tracheoesophageal speech in a developing world community.

OBJECTIVES: To determine the tracheoesophageal speech results in a Third World medical practice; to examine the impact of socioeconomic status, literacy, and proximity to specialist services on tracheoesophageal speech; to assess whether these factors should affect patient selection for fistula speech; and to determine guidelines for voice prosthesis selection. DESIGN: Retrospective analysis. SETTING: Groote Schuur Hospital, Cape Town, South Africa, which serves a Third World community. PATIENTS: Ninety-seven consecutive patients who underwent total laryngectomy between January 1, 1996, and October 1, 1998. Patients who undergo total laryngectomy routinely have a primary tracheoesophageal fistula created for speech. MAIN OUTCOME MEASURES: Speech outcomes after total laryngectomy; tracheoesophageal speech in relation to social class, literacy, and proximity to specialist services; and experience with removable and indwelling valves. RESULTS: Fifty-nine (81%) of 73 patients acquired useful speech. Speech outcome was not affected by employment status or proximity to specialist services. Although speech was affected by literacy and housing, several illiterate shack dwellers acquired good speech. Average device life of removable prostheses was 16 weeks (>4 months in 35% [64/183]). Indwelling prostheses had an average life of 28 weeks. CONCLUSIONS: Tracheoesophageal speech results in a Third World community equate with those in the Developed World. All patients who undergo laryngectomy and have adequate manual dexterity and cognitive function should be given a trial of fistula speech. Removable voice prostheses can successfully be used as indwelling prostheses.     

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).     

Surgical voice restoration following ablative surgery for laryngeal and hypopharyngeal carcinoma

Surgical voice restoration is an important part of functional rehabilitation of patients following ablative surgery for laryngeal and hypopharyngeal carcinoma. The aim of this retrospective study was to assess the functional status with regard to speech of a cohort of 100 patients (age ranged 34-84 years), who underwent laryngectomy and laryngopharyngectomy over a 10-year period (1989-1999). Ninety-two patients consented to surgical voice restoration. Primary tracheoesophageal punctures were performed in 70 and secondary punctures in 22 (mainly after jejunal flap reconstruction). Nine patients were excluded from this analysis (seven patients died prior to assessment, one had the prosthesis removed at her request and one patient had insufficient follow-up). Tracheoesophageal speech was assessed in the remaining 83 patients using a rating scale measuring the number of syllables per breath, use of voice and intelligibility by non-professional listeners. Currently, Provox 2 valves are being used in the majority of patients. Overall tracheoesophageal speech results were good in 45/83 (54.2 per cent), average in 22/83 (26.5 per cent) and poor in 15/83 (18 per cent). One patient could not develop tracheoesophageal speech. The majority of laryngectomy patients had good speech but in patients who had complex reconstructions tracheoesophageal speech was mostly rated as average. Average to good speech in more than two-thirds of the cohort of patients show that surgical voice restoration is a highly successful and valuable technique to restore speech functions after ablative surgery for laryngeal and hypopharyngeal carcinoma.     

Speech rehabilitation using a voice prostheses following laryngectomy

The most serious consequence for patients following laryngectomy is the restriction of verbal communication. Since the introduction of laryngectomy significant concerns have already been focused on the field of speech rehabilitation. The operational procedures for the speech rehabilitation include training of the oesophageal voice speech and the voice prostheses. Speech prostheses are available in our hospital since 1983. The speech quality of the speech prostheses is compared with the classical oesophageal voice or to the voice by means of a Provox speech help. Bacteriological and mycological colonisation as a function of the length of implantation are defined. Our approach to the voice rehabilitation after a laryngectomy by use of a spacer during the laryngectomy has proven successful. As a result patients do not fall into a "hole" of non verbal communication. The aim of our efforts is always to create a functioning oesophageal voice after leaving the care of the hospital.     

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.