全喉切除术后安装Blom-Singer发音管术28例

目的 为无喉者恢复发音功能。方法 用气管食管穿刺术、内窥镜手术建立气管食道通道,安装Ｂｌｏｍ－Ｓｉｎｇｅｒ发音管。结果 ２８例中２５例发音成功,成功率为８９．２９％。结论 气管食管造瘘安装Ｂｌｏｍ－Ｓｉｎｇｅｒ发音管,方法简单,并发症少,是全喉切除术后获得Ｂｌｏｍ－Ｓｉｎｇｅｒ发音重建的一种有效途径。     

应用发音钮发音重建出现发音障碍的原因分析

喉癌病人施行喉全切除术后,恢复发音功能的方法很多。临床证明其各有所长,但亦有不足。我们以医用硅橡胶研制的发音钮,又叫发音管(图1),1900年2月至1994年5月,临床应用于75例本病患者发音重建,其中12例不能发音。为提高发音钮的临床应用效果,现对应用发音钮后出现发音障碍的原因进行分析,报告如下。     

气管食管裂隙状瘘发音重建术的声学分析

目的 客观评价气管食管裂隙状瘘发音重建术后的发音效果，并以此指导临床工作。方法 对喉全切除术后I期与Ⅱ期气管食管裂隙状瘘发音患者、食管发音患者、安装Blom—Singer发音钮患者以及健康人分别进行语音测试，分析7项客观声学参数，比较发音效果。结果 经统计学t检验，气管食管裂隙状瘘语音最长发音时间短于健康人，明显长于食管音，但和Blom—Singer发音钮语音差异无显著性；其声音的强度和健康人及Blom—Singer发音钮差异无显著性，明显高于食管音；其基频明显低于健康人；其频率微扰和振幅微扰明显高于健康人，而明显低于食管发音，与Blom—Singer发音钮语音差异无显著性；其共振峰频率和能量仅在F1共振峰能量上明显高于食管音，其余各频率上差异均无显著性。虽然喉全切除I期气管食管裂隙状瘘发音重建术中制作帽状气室，而Ⅱ期发音重建术中不制作帽状气室，但两者语音声学分析各参数间差异均无显著性。结论气管食管瘘语音比食管音接近健康人语音，能满足日常生活需要。气管食管裂隙状瘘发音重建术中不制作帽状气室不影响术后的发音。     

两步发音训练法在喉全切除Groningen发音钮置放术的应用体会

目的 总结喉全切除患者,应用Groningen发音钮,通过两步发音训练法进行发音训练的体会.方法 本组32例患者,男25例,女7例,年龄46～78岁,平均64.5岁,一期置放发音钮30例,二期置放2例,后者均为男性,上述患者均接受喉全切除手术治疗,术后随诊均为1年以上.结果 能进行言语交流31例,其中优秀者可以连续数35个数,并能进行电话交流,发音失败1例,患者为发音钮脱落.结论 喉全切除放置低阻力Groningen发音钮是喉全切除术后恢复发音功能的一种简便、效果可靠的方法.     

克罗尼根发音钮置放后脱落一例

患者,男,57岁,因喉鳞状细胞癌（声门型,T3N0M0）行喉全切除、右侧局限性颈淋巴结清扫和克罗尼根发音钮置放术.术中于气管断端下约1.5 cm处用置放器械穿透气管食管并置放低阻力型号发音钮（轴直径7 mm,长度11 mm,荷兰Medin Instruments B.V.）.术后7天切口拆线，13天后患者出院。经过言语训练，患者能连续说十几个字，能进行生活中简单语言交流，但发声像“鸭声”，无进食呛咳。     

气管食管语言与食管语言的声学分析

全喉切除术后恢复发育的两种最重要方法是食管语言与气管食管语言（应用低阻力瓣，Provox瓣）。两种再造喉语言的声振源是相同的，为咽食管段（PE段）；但其发音动力不同，一种为由肺呼出的气体排出到咽，另一种是由食管排出的气体。众所周知，由于发音的强度大，持续时间长以及可理解性和可接受性强，气管食管语言较食管语言好。该文通过研究两种语言的声波和频谱，进行了详细的声学分析。病人分两组，均为男性，l组由12例食管发音良好者组成，另1组为12例应用Provox发音装置至少2个月的气管食管发音者。病人在适当大声和适宜时间发“a”…     

全喉切除应用发音钮获得满意效果（摘要）

全喉切除后，病人失去发音能力，精神上十分痛苦．生活中十分不便。我科自1991年始已对10例全喉切除后的病人，行气管食管间造瘘，安装硅橡胶发音钮，除2例失败外，8例均获满意的效果，报告如下。     

喉全切除后Blom—Singer技术发音重建的应用

从1997年开始，对9例喉全切除后行发音重建术，其中4例采用Blom-Singer技术，5例在Blom-Singer技术基础上进行改良，即在行气管食管穿刺术的同时，立即装上发音管。结果所做9例发音全部成功，随访6－27月，平均20个月后，采用听距法评定发音效果，行Blom-Singer技术者，Ⅰ级：2例：Ⅱ级：2例。改良法者，Ⅰ级：人例；Ⅱ级：3例。改良法缩短了手术时间，减少手术步骤，降低费用，发音效果一致。     

用Provox发音钮进行全喉切除后的发音重建

传统的发音重建有人工喉和食管发音。人二：喉发音不自然，州外繁＊。；食管发音不易掌握且声音小，语音低。发音钮是声音重建较新的方法，具有语言流畅易懂，容易掌握等优点。但一般发音或均存在两个弱点，气流通过发音钮及食道人口段的高阻力及使用寿命短。文所采用的Provo。发音钮系低阻力自固定，式发音钮，通过瓣膜的改良降低阻力，同时行单侧咽缩肌切开或咽丛神经切断术降低气流阻力，其效果满意。该作者发现真菌感染为影响发音钮寿命的主要原因，所以认为局部用抗真菌药可延长其使用时间。对37例全喉切除后行Provox发音或声音重建的…     

喉切除术后3种发音重建术的发音强度测定

目的 测定喉切除术后的3种发音重建术的发音强度。方法 用声级计测定发音强度。结果 全喉切除术后安装发音钮14例，发音强度达55-65db者6例（42.8%）；全喉切除后气管上端食道粘膜声门重建9例，发音强度达55-65dB者2例（22%）；次全喉术后气管咽发音管成形31例；发音强度达55-65dB者19例（61%）。结论 喉切除3种发音重建术，以次全喉切除气管咽发音管成形术的发音强度较好。     

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).     

Prothetische Stimmrehabilitation nach Laryngektomie

BACKGROUND: Indwelling voice prostheses are state of the art for post-laryngectomy voice rehabilitation. The aim of this study was to identify the impact of radiation prior to tracheoesophageal puncture on success rate and complications. PATIENTS AND METHODS: We undertook a retrospective study of 145 patients who had undergone prosthetic voice restoration between 1990 and 2002 (Provox) and Provox2). Risks of functional failure and complications in 17 patients with previous radiation therapy were compared to those of 128 patients without such therapy. RESULTS: Previous radiation increased not only the risk of functional failure by 2.9 (P=0.023), but also the risk of shunt-related complications such as aspiration around the prosthesis (1.51; P=0.046), widening of the shunt (2.32; P=0.014), esophageal (2.51; P=0.013) or tracheal (3.29; P=0.0023) dislocation of the prosthesis and spontaneous (2.51; P=0.047) or surgical closure (3.76; P=0.037) of the shunt. CONCLUSION: Primary tracheoesophageal puncture during laryngectomy is recommended in cases without previous radiation therapy, especially when post-laryngectomy radiation is likely. In patients with previous radiation therapy, generally good success rates decrease, however, without absolute contraindication of tracheoesophageal puncture. These results may affect salvage surgery concepts.     

Insertion of Provox2 voice prosthesis using the anterograde technique immediately after the secondary tracheoesophageal puncture

Insertion of a voice prosthesis through the tracheoesophageal puncture (TEP) is one way to restore the voice after total laryngectomy. The second generation Provox voice prosthesis is presently one of the most popular devices. Although TEP can be done primarily, there are many centres that prefer it to be done at a second stage for various reasons. However, secondary TEP for retrograde replacement of prosthesis can be difficult and general anaesthesia is very often necessary. Moreover, the presence of neck stiffness and fibrosis from the surgery or previous radiotherapy could affect the neck extension for proper positioning of the trocar. Similarly, it is difficult to insert the prosthesis if there is stenosis at the pharyngoesophageal segment. We describe a technique in which creation of secondary TEP and insertion of Provox2 is done with local anaesthesia under the same setting. The procedure is well tolerated and can be safely performed on an out-patient basis.     

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.     

Speech rehabilitation using Provox voice prosthesis

The first voice prosthesis was described in 1972 by Mozolewski. Eight years later Blom and Singer constructed the first commercial prosthesis. In 1988 another prosthesis was presented as Provox system prosthesis. The aim of the study was to describe the technique of tracheoesophageal puncture (TEP) and to present two years results of the technique performed in 21 patients. Primary TEP with immediate implantation of the Provox 2 prosthesis was applied in 16 (76%) patients. In five patients (24%) secondary TEP was performed. All the patient with primary TEP had cricopharyngeal myotomy. In 7 patients the vocal prosthesis was exchanged. In five because of leakage through the valve and in two patients the vocal prosthesis was extruded. Leakage around the prosthesis occurred in two patients with secondary TEP. The mean device-related lifetime was 216 days and ranged from 30 to 540 days. In non-radiated patients the lifetime of the prosthesis was 255 days and in patients after radiotherapy the lifetime was 150 days. In all the patients the prosthetic voice was more similar to normal voice than in patients with esophageal speech. The implantation of the voice prosthesis is a simple method of restoring of a good quality voice enabling communication.     

A comparison of speech using artificial larynx and tracheoesophageal puncture with valve in the same speaker

Postlaryngectomy speech rehabilitation more frequently includes surgical-prosthetic methods since the introduction of a low morbidity tracheoesophageal puncture technique and a one-way airflow valve. This study compares speech using an artificial larynx and, in one case, esophageal speech with speech using a tracheoesophageal puncture and valve in the same speaker. Using nonprofessional listeners, speech was rated for intelligibility and preference. Voice spectrograms were employed for measurement of rate, fundamental frequency, and intensity. While no statistically significant differences were found in mean fundamental frequency or intensity, the rate of post-tracheoesophageal speech was considerably faster. In addition, when individual speakers are compared with themselves, post-tracheoesophageal speech is significantly more intelligible and preferred by naive listeners. We conclude that using the tracheoesophageal puncture with valve should be strongly considered in total laryngectomy patients whose present mode of communication is unsatisfactory.     

Prospective randomized comparative study of tracheoesophageal voice prosthesis: Blom-singer versus provox

Objectives: Compare the most commonly used types of tracheoesophageal voice prostheses, Blom Singer and Provox. Study Design: Prospective study of 113 prostheses placed in 52 patients randomly selected to receive Blom-Singer and Provox. Methods: Postoperative voice was recorded at 1 and 4 months after valve placement. Survival time of the prosthesis and four objective voice parameters were analyzed. Eight judges rated all recordings in a random order for six subjective voice parameters. Subgroup analysis for primary versus secondary placements and type of procedure was performed. In addition, patients were asked for their subjective assessment. Results: Overall, Blom-Singer and Provox prostheses give very similar voice quality, lifetime, and patient satisfaction. Cleaning management is somewhat better for Provox, but there is a trend toward better overall voice quality for the Blom-Singer prosthesis. In subgroup analysis secondarily placed prostheses score somewhat better than primary placements, and patients with total laryngectomy have better voices than patients with extended laryngectomy combined with partial pharyngectomy. Conclusions: Given the equal and good results in terms of voice quality, other factors (e.g., costs, surgery-related factors, maintenance, patient preference) should be taken into account when deciding which type of tracheoesophageal voice prosthesis to use. Laryngoscope, 108:1561–1665, 1998     

Tracheoesophageal voice prostheses complications in north Glasgow

The objectives of this study were to determine (1) the rates of complications, admissions to hospital and requirements for further surgery in patients fitted with tracheoesophageal fistula speech valves, and (2) whether any factors were predictive of complications. A case note review was undertaken of all patients undergoing a laryngectomy at Gartnavel General and Stobhill Hospitals over a 10-year period. One hundred patients were identified. Forty-five patients had complications from their valves, most commonly granulation tissue formation. Thirty-five had a least one admission related to complications and 34 required further surgery. Sixty-seven were vocalizing with the valve. Radiotherapy and valve type were not statistically significant in predicting complications in this study. Primary puncture was associated with a higher rate of complications, although the numbers undergoing secondary puncture were small.     

In-clinic secondary tracheoesophageal puncture and voice prosthesis placement in laryngectomees

Secondary tracheoesophageal puncture (TEP) with voice prosthesis placement represents one of the possibility to restore vocal function after total laryngectomy. However, some patients have comorbidities that contraindicate general anesthesia. In our department, an in-clinic TEP procedure for retrograde voice prosthesis placement was developed. It allows the immediate placement of the prosthesis and the avoidance of the use of dilators. We described our technique with advantages and pitfalls. The Provox Vega Puncture Set was used. Our technique for in-clinic secondary TEP without general anesthesia or target controlled infusion was a safe and effective procedure. It allows the use of the traditional TEP set, with possibility of voice prosthesis placement after previous TEP closure.     

Microflora of the voice prostheses

The study was made of the condition of voice prostheses Provox and Blom-Singer in 27 patients wearing them. The prostheses were to be replaced by new ones as they lost impermeability for water. The prostheses were used for 6 months to 2 years. At the prosthesis removal from the tracheoesophageal bypass it was found that the esophageal flange and protective valve were contaminated with fungi and pathogenic bacteria. The valve was deformed, had limited motility and did not close tightly the esophageal opening of the prosthesis as the result of which liquid leaked into the airways. Bacteriological examination identified C.albicans, C.krusei, C.glabralis in 11 patients. Nistatin, flucostat, fluconasol, amphotericin were used in antifungal therapy. Prophylactic use of these drugs against fungi prolonged use of the prostheses 2-fold.