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.     

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.     

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.     

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.     

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).     

The acceptability of secondary tracheo-oesophageal fistula creation in long standing laryngectomees.

The use of a tracheo-oesophageal voice prosthesis was introduced to the Glasgow Royal Infirmary Otolaryngology, Head and Neck Surgery unit in 1986. Although it was the authors' impression that most total laryngectomees since then had been offered this method of voice restoration, it was thought that long standing laryngectomees were seldom offered tracheo-oesophageal fistula (TOF) speech. Therefore all 58 total laryngectomees currently attending the combined head and neck surgery/radiotherapy clinic were assessed. Thirty-two had a tracheo-oesophageal fistula with voice prosthesis. All of these patients had undergone their total laryngectomy since 1986 and 83 per cent had achieved TOF speech. The remaining 26 patients (who mostly had their laryngectomy before 1986) had not been offered TOF speech. An outpatient consultation was arranged for these patients and 63 per cent of those offered, accepted TOF creation and a voice prosthesis. When compared to those who refused, it was found that good oesophageal speech, age or interval since laryngectomy were not good predictors of likely refusal. This study indicates that all fit long standing laryngectomees should be offered secondary TOF creation.     

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.     

The pharyngo-oesophageal sphincter after laryngectomy. A manometric investigation.

The function of the pharyngo-oesophageal sphincter in patients subjected to total laryngectomy has been evaluated by manometric measurement, and the results related to the patient's ability to speak with an oesophageal voice, as well as to the occurrence of dysphagia. Seventeen totally laryngectomized patients were studied. The intelligibility of the patient's oesophageal voice was classified according to the scale: good (group IV), middle (group III), poor (group II) and unintelligible (group I). The manometric investigation was carried out with a continuously perfused low compliance system with three side holes, and the results of the patient investigation were compared with those from a normal material. It was possible in three patients only to demonstrate a resting tone corresponding to the pharyngo-oesophageal sphincter. The pressure was lower in these patients than in the normal material. No correlation was found between any of the three parameters: sphincter pressure, intelligibility, and the presence of dysphagia.     

Rehabilitation after major head and neck surgery—the patients' view

Forty-nine patients who were free of tumour 5 months to 14 years (mean 30 months) after total laryngectomy or a commando precedure were given questionnaires designed to obtain the patient's assessment of their resulting disability. Sixteen areas of disability were studied grouped under five main headings: speech, eating, cosmetic, employment and social. Following laryngectomy more than half of the patients achieved successful communication by oesophageal speech. Success in this was usually associated with minimal problems in other areas. The disabilities after commando procedures were more varied and complex. more patients reported severe disability in more than one area. Difficulties with chewing and swallowing were prominent. The results aere illustrated with patients comments. Ways in which rehabilitation might be improved are considered.     

Effect of cricopharyngeus myotomy on postlaryngectomy pharyngeal contraction pressures

After total laryngectomy, the cricopharyngeus muscle, when intact, appears to inhibit the free flow of saliva and secretions past the pharyngeal repair into the upper esophagus. The authors hypothesize that cricopharyngeus myotomy reduces sphincteric pressure, thereby diminishing forces against the pharyngeal suture line. Peak pharyngeal pressures were recorded in patients who underwent total laryngectomy with and without cricopharyngeus myotomy. In patients without concurrent myotomy, peak pharyngeal pressures were all greater than 60 mm Hg. With concurrent myotomy, peak pharyngeal pressures averaged less than 40 mm Hg. Concurrent myotomy carries with it the potential for minimizing postoperative fistulization, eliminating dysphagia of cricopharyngeus spasm, and improving the acquisition of alaryngeal speech.     

Endothelial cell growth factor (ECGF) application to irradiated soft tissue

After total laryngectomy, the cricopharyngeus muscle, when intact, appears to inhibit the free flow of saliva and secretions past the pharyngeal repair into the upper esophagus. The authors hypothesize that cricopharyngeus myotomy reduces sphincteric pressure, thereby diminishing forces against the pharyngeal suture line. Peak pharyngeal pressures were recorded in patients who underwent total laryngectomy with and without cricopharyngeus myotomy. In patients without concurrent myotomy, peak pharyngeal pressures were all greater than 60 mm Hg. With concurrent myotomy, peak pharyngeal pressures averaged less than 40 mm Hg. Concurrent myotomy carries with it the potential for minimizing postoperative fistulization, eliminating dysphagia of cricopharyngeus spasm, and improving the acquisition of alaryngeal speech.     

The role of the upper oesophageal sphincter in voice rehabilitation after laryngectomy and Staffieri's procedure

The Staffieri method was used for voice rehabilitation after total laryngectomy in our patients. Leakage of saliva has been a problem in some. It has been suggested that aspiration could be due to specific pressure relations in the pharynx, upper oesophageal sphincter and cervical oesophagus during deglutition (Mann et al., 1980). Regarding voice production, the upper oesophageal sphincter is probably the main sound source, functioning in essentially the same way as in oesophageal speech. Intraluminal pressure recordings at rest and during swallowing were used in 16 Staffieri speakers and 9 oesophageal speakers. Upper oesophageal sphincter dysfunction was seen more often in Staffieri speakers with aspiration problems than in Staffieri speakers without aspiration problems, but the relation is not clearly understood. A definite relation could be established between upper oesophageal sphincter function in terms of relaxation and coordination and aerodynamic pressure measured in the tracheostoma, necessary to sustain phonation. After dilatation of the oesophagus, produced by the inflow of air, a reflex rise in the upper oesophageal sphincter pressure is thought to occur. The pressure necessary to sustain phonation probably depends on the extent to which this reflex mechanism occurs and on the ability of the patient to induce a relaxation of the upper oesophageal sphincter before air expulsion. Selective myotomy will possibly lower the necessary pressure and enhance vocal rehabilitation. Whether this will solve a part of the aspiration problems in Staffieri speakers is completely unpredictable, as the relation of the motor function of the upper oesophageal sphincter and the aspiration problems is not well understood.     

Factors influencing pharynx' and pharyngoesophageal sphincter's morphology and their function after total laryngectomy

The usefulness of the videolaryngoscopy in patients after total laryngectomy/laryngopharyngectomy was discussed. They serve for: a) evaluation of the pharynx and of the pharyngoesophageal sphincter (pes) morphology, b) prognosis of the esophageal speech developing. In the study videolaryngoscopy was done in 82 patients (7 female and 75 male). In 62 of them total laryngectomy was done (among them in 50/62--with standard pharynx suture, in 9/62--with the pes plasty, and 3/62--with simple pes myotomy). In 20 case of laryngopharyngectomies--4/20 standard pharynx suture was done, 12/20 were reconstructed with tongue flap, 3/20--with pes plasty, and in 1/20 simple myotomy was performed. The investigations were carried out between 1 to 36 months after total laryngectomy and 24 month after laryngopharyngectomy. The analysis of the videolaryngoscopy imagings revealed that the pharynx and pes morphology after laryngectomy/laryngopharyngectomy (shape, thickness of the mucose, weakened wall peristalsis, secretion retention, lack or presence of the pes relaxation at the time of examination) correlates with the rest pressure in the pes area, measured by Seeman's method and with the occurrence of the esophageal speech mastering. The most significant changes in morphology and function of the pharynx (irregular shape, weakened wall peristalsis, retention of secretion) as well as the highest pressure in the area (5.1 +/- 3.33 kPa-38 +/- 25 mm Hg) was found after pharyngolaryngectomy. The shape of the pharynx in all the patients after laryngectomy with plasty or simple myotomy of the pes was regular, with thin and smooth mucosa while the rest pressure was low (3.0 +/- 1.18 kPa(-)+/- 22.5 +/- 8.8 mm Hg). In the analyzed material at the rest pressure in the sphincter area from 0.7 to 4kPa (from 5 to 30 mm Hg), 93% (41/44) of the patients have mastered the esophageal speech. It was stressed that videolaryngoscopy is entirely sufficient for the approximate assessment of the rest pressure in the pes area and prognosis of the esophageal speech development process.     

Swallowing difficulties caused by a voice prosthesis in a laryngectomee

IntroductionThe role of voice prosthesis (VP) in causing swallowing difficulties has not been thoroughly evaluated. A laryngectomee with dysphasia caused by a VP is presented.Case ReportA 77-year-old laryngectomee presented with dysphagia. He had hypo pharyngeal squamous cell carcinoma, which was treated with intensity-modulated radiotherapy 13 years earlier. Cancer recurrence 2 years later required laryngectomy and forearm free flap restoration. The patient used trachea-oesophageal speech for communication using Provox® Vega 22.5/Fr 6 mm. Diagnostic endoscopy revealed significant oesophageal stenosis at the upper portion of the flap immediately below the VP. The VP was replaced with a 22.5 Fr/4 mm Provox® Vega that was modified by cutting out its distal hood that protruded into the oesophageal lumen. The patient noted an immediate improvement in his dysphagia that persisted through the 14-month follow-up.ConclusionsThis report underscores the need to evaluate the role of VP in laryngectomees with swallowing difficulties. Obstruction generated by oesophageal protrusion of the VP can be alleviated by installing a thinner prosthesis and/or when possible by changing the location of the puncture to a new site.     

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.     

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.     

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.     

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy was studied in 42 patients. A significant reduction was found in the mean daily frequency of sputum production, forced expectoration in order to clean the airway and stoma cleaning after use of the HME for 6 weeks. Symptoms of fatigue and malaise decreased significantly, while social contact improved. Patients using oesophageal speech or an electrolarynx benefited more than patients using a voice prosthesis. The findings indicate that respiratory problems after total laryngectomy can be reduced significantly with the use of a device with heat and moisture exchanging properties. In turn, reduction of respiratory symptoms results in an improved quality of life.