Voice Rehabilitation Following Laryngectomy
Anna M. Pou
The larynx is the second most common site for cancer in the upper aerodigestive tract, of which squamous cell carcinoma (SCCA) is the predominant type (95%) (see Chapters 123 and 124). Although organ preservation protocols and conservation laryngeal surgeries are in use today, patients with advanced or recurrent SCCA of the larynx continue to undergo total laryngectomy in the course of their treatment.
The operative procedure of total laryngectomy results in separation of the aerodigestive tract, establishing a permanent tracheostoma at the base of the neck. The pharynx is closed by simply closing the mucosa or, in more complex cases, by placing a flap to preserve an adequate lumen for swallowing. Total laryngectomy profoundly alters speech, lung function, respiration, and sense of smell and taste. It is the loss of voice that is most responsible for the psychosocial and economic consequences following laryngectomy. Effective voice restoration is essential for the rehabilitation of these patients.
Total laryngectomy includes removal of the entire larynx, hyoid bone, portions of the pharynx, the strap muscles, one or more rings of the trachea, and part or all of the thyroid gland. The resection may include neck dissection, upper mediastinal lymph node dissection, and dissection of portions of the tongue base. In order to resect the larynx, entrance into the pharynx away from the epicenter of the tumor is required. The resulting defect, a pharyngotomy, consists of varying amounts of pharyngeal and esophageal mucosa, constrictor muscle remnants, and tongue base. The closure of this defect depends upon the amount of remaining mucosa; it is closed using continuous or interrupted Connell sutures in a vertical or “T” fashion. Flap reconstruction (free fasciocutaneous flap; pectoral major flap) is used when there is insufficient mucosa to close the pharynx.
The usual approach to laryngectomy separates the pharyngeal constrictor muscles at the oblique line of the thyroid cartilage (Fig. 125.1). Specifically this includes the inferior pharyngeal constrictor and cricopharyngeus muscles. The junction of the pharynx and esophagus has been studied by speech pathologists as the sound source for alaryngeal speech and is called the “PE” segment. It is difficult to predict resultant voice or quality because of variations in anatomy, tumor extent, muscle bulk, and operative technique. Pharyngeal closure after laryngectomy is generally concerned with controlling secretions, swallowing, and prevention of fistula formation. In addition, attention has been directed to alaryngeal voice acquisition and the possibilities for maximizing voice results.
There are three methods of alaryngeal speech: electrolarynx speech, esophageal speech, and tracheoesophageal (TE) speech. Historically speaking, esophageal speech was the method of choice by which all others were compared. In this method, air is injected into the cervical esophagus and immediately expelled causing the vibration of the opposing mucosal surfaces of the pharyngoesophagus, which is then articulated into speech by structures of the oral cavity. This method is very difficult to learn, and only about 26% of patients are able to use this method in daily communications (1). Consequently, tracheoesophageal puncture (TEP) has replaced esophageal speech as the gold standard. All methods of alaryngeal speech are taught by a speech pathologist.
The characteristic esophageal voice is low in fundamental frequency (-65 Hz), is of short duration, and requires some effort to produce. The most common method involves trapping air in the mouth or pharynx and then injecting it into the esophagus by the propulsive action of the tongue. With diaphragmatic effort, the air refluxes through the esophagus and crosses the upper esophageal sphincter. The mucosa of this region is vibrated by the released air and produces a characteristic belch-like
sound. This sound is then articulated into speech using the tongue, lips, and teeth. Rapid repetitive movements of injection and release produce fluent and understandable speech.
sound. This sound is then articulated into speech using the tongue, lips, and teeth. Rapid repetitive movements of injection and release produce fluent and understandable speech.
 Figure 125.1 Separation of the pharyngeal constrictors from the larynx. E, esophagus; Ic, inferior constrictor; Mc, middle pharyngeal constrictor. |
The artificial larynx is an instrument that serves as a voicing source. It introduces a mechanical sound into the tissues and air spaces of the vocal tract. This sound, emanating from the mouth, is again articulated into speech by structures in the oral cavity. The most common types of electrolarynx include one that is placed against a supple point on the neck or one that uses a tube adapter to direct the sound to the oral cavity, where it can be articulated with some reduction in intelligibility. The oral adapter is useful for patients whose necks do not transmit the electrical sound or in the immediate postoperative period when the neck is healing. A newer device consists of an electric sound source that is housed in a denture and is activated by a hand control or by the tongue (2).
The artificial larynx is rapidly learned and does not delay or interfere with the acquisition of other forms of alaryngeal speech. It has the advantages of low cost, availability, short learning time, and loudness. Its disadvantages are dependence on batteries (cost often not covered by insurance), mechanical sound, conspicuous appearance, loss of hands-free speech, and hygiene of the intraoral tubes or dental appliance. It also relies on the use of batteries and is often not covered by insurance policies. Nevertheless, many laryngectomized patients use the artificial devices as the primary method for speech communication.
SHUNTS AND VALVES
From the time of the first laryngectomies, it was known that tracheal air during exhalation can be shunted to the pharynx or esophagus through a planned fistula or tract, and this pulmonary-driven insufflation can produce effective speech. The same principles of speech production apply with articulation at the oral cavity and sound produced in the upper esophageal sphincter. The shunts, however, persisted with problems: shunt closure due to stenosis at the level of the trachea or pharynx and leakage of esophageal contents into the trachea through the patent shunt with resultant aspiration. For these reasons, some investigators developed mechanical valves to divert the secretions from the trachea or attempted to devise biologic valves (sphincters) for airway protection, but most of them failed.
The creation of a successful, surgical voice restoration technique did not occur until the introduction of the TEP by Singer and Blom in 1979. It was proposed as a secondary salvage technique for those who failed esophageal speech or those who were displeased with the electrolarynx voice (3). The guidelines used to create this revolutionary method for voice restoration were no oncologic compromise; applicability in an irradiated field; normal swallowing without aspiration; reliable voice; surgical simplicity; rapid recovery; reliability and reproducibility; inclusion of an uncomplicated, cost-effective prosthetic valve to prevent stenosis and aspiration; and limited cost (4). TE voice restoration has gained worldwide acceptance over the past 32 years and is the preferred method of postlaryngectomy speech. TEP is safe, reliable, and reproducible and should be considered in all patients undergoing total laryngectomy and in those who have failed to master other methods of alaryngeal speech.
The TEP pioneered by Singer and Blom (3) is not very different from the self-inflicted TEP made by a laryngectomy patient using an ice pick in 1931. An endoscopic puncture is made through the party wall through which a one-way silicone valve is placed. This tubular prosthesis (silicone) maintains the puncture site, protects the airway from aspiration of saliva and foods, and allows pulmonary air to be directed across the pharyngoesophageal mucosa for voice production. Airflow is only limited by the vital capacity of the lungs. The prosthesis is biologically compatible, removable, and inexpensive. Various modifications and improvements have been made on the prosthesis since 1978 (3). Other prostheses have also been introduced (Provox, Groningen).
SECONDARY TRACHEOESOPHAGEAL PUNCTURE
Patient Selection and Timing
There are a few factors that guide patient selection and they are similar to those listed for primary TEP. The timing of secondary puncture depends upon the extent of resection,
the complexity of reconstruction, and the need for postoperative radiation therapy. Secondary voice restoration should be delayed at least 8 weeks following postoperative radiation therapy or until the peristomal skin has recovered from radiation toxicity and at least 6 weeks following recovery from reconstruction of a total laryngopharyngoesophagectomy defect in order to allow healing of the flap to the posterior tracheal wall. Patients undergoing flap reconstruction for pharyngeal defects should also undergo barium swallow to evaluate the reconstructive changes and for the presence of a stricture. The stoma is outlined with a radiopaque marker, and the site for the proposed puncture is determined in relationship to the pharyngoesophageal segment. Pharyngoesophageal dilatation is performed if necessary (5).
the complexity of reconstruction, and the need for postoperative radiation therapy. Secondary voice restoration should be delayed at least 8 weeks following postoperative radiation therapy or until the peristomal skin has recovered from radiation toxicity and at least 6 weeks following recovery from reconstruction of a total laryngopharyngoesophagectomy defect in order to allow healing of the flap to the posterior tracheal wall. Patients undergoing flap reconstruction for pharyngeal defects should also undergo barium swallow to evaluate the reconstructive changes and for the presence of a stricture. The stoma is outlined with a radiopaque marker, and the site for the proposed puncture is determined in relationship to the pharyngoesophageal segment. Pharyngoesophageal dilatation is performed if necessary (5).
Stoma size is critical to successful use of the voice prosthesis. Stoma size under 2 cm is suboptimal; this small size makes it difficult to place the prosthesis and may compromise the airway due to the prosthesis size. If microstomia is present, the stoma can be serially dilated using silicone laryngectomy tubes, or a stomaplasty can be performed at the time of puncture. Patients who have undergone radiation therapy whose tissues appear to be at risk are better managed by the former method. If a laryngectomy tube is used, it can be fenestrated posteriorly and simultaneously worn with the prosthesis in place. When necessary, the stomaplasty is performed prior to the puncture leaving the posterior wall intact. The stoma is enlarged using a Z-plasty technique on each side (5).
In order for fluent TE speech to occur, there must be sufficient relaxation of the pharynx. There was a subset of patients (20% to 40%) identified early on who presented with hypertonic or spastic speech. It was determined that failure to maintain fluent speech was due to spasm of the cricopharyngeus and inferior and middle constrictor muscles when speech was attempted (6,7). A hypopharyngeal bar corresponding to these muscles can be seen using barium swallow. A column of air distends the esophagus proximal to the bar when phonation is attempted. The status of the pharynx can be evaluated prior to puncture using the transnasal esophageal insufflation test (5).
The transnasal esophageal insufflation test is a subjective test that is used to assess the pharyngeal constrictor muscle response to esophageal distention in the laryngectomy patient (8). The test is performed using a disposable kit consisting of a 50-cm-long catheter and tracheostoma tape housing with a removable adaptor. The catheter is placed through the nostril until the 25-cm mark is reached. This should place the catheter in the cervical esophagus adjacent to the proposed TEP. The catheter and the adaptor are taped into place. The patient is then asked to count from 1 to 15 and to sustain an “ah” for at least 8 seconds without interruption. Multiple trials are performed to allow the patient to produce a reliable sample.
One of four responses is obtained following the insufflation test: fluent, sustained voice production with minimal effort indicating relaxed pharyngoesophageal muscles; a breathy, hypotonic voice indicating the absence of pharyngeal constrictor muscle tone; hypertonic voice characterized by intermittent production of effortful speech with gastric distension and posttrial burping; and spasm, which is characterized by no production of voice even with substantial pulmonary airflow. Insufflation testing is also done after flap reconstruction or gastric pull-up to determine the quality of voice (5). The voice quality is usually “wet” following jejunal reconstruction and hollow or breathy following gastric pull-up. Compression of the neck with an elastic band can enhance voice quality in the latter situation.
Examiner error can obscure the results of the test. Common errors include improper placement of the catheter (not inserted 25 cm into the cervical esophagus), too much digital pressure exerted by the patient or examiner on the tracheostoma, and attempting to swallow saliva or inject air from the mouth into the esophagus while simultaneously insufflating the esophagus. The patient errors can be prevented by having the patient self-monitor using a mirror (5).
Surgical Procedure
This procedure was first described by Singer and Blom in 1979 (3) and has been modified over the years. The following procedure is performed in the operating room under general anesthesia. The Blom-Singer tracheostoma puncture kit (InHealth Technologies, Carpinteria, CA) allows the surgeon to perform the secondary puncture in less than 30 minutes. Following esophagoscopy, the esophagoscope (surgeon’s choice) is withdrawn to the level of the stoma with the bevel positioned against the posterior wall of the trachea so that the light can be seen and the bevel palpated. The position of the esophagoscope also protects the posterior esophageal wall from penetration. A number 14 sheathed catheter is introduced into the bevel of the esophagoscope about 5 mm below the mucocutaneous junction. The needle is withdrawn leaving the sheath in place (Fig. 125.2). A wire on a tapered catheter is threaded through the sheath and pulled out of the mouth of the esophagoscope. The wire is cut from the end of the catheter, which is then directed down the scope into the esophagus. The catheter is secured into place at the stoma (5). This kit can be replaced by using a curved 18-gauge needle, a 24-gauge wire, red rubber catheter, number 15 scalpel blade, and hemostat. The prosthesis can be placed immediately, but most clinicians wait 48 hours.
This technique has been modified by many clinicians over the years to include the use of local anesthesia, transnasal esophagoscopy (TNE), and the use of the KTP laser, among other methods (9,10,11,12). In patients who present with a stricture, fibrosis of the neck tissues following radiation therapy, or cervical spine deformity, it is often impossible to perform a secondary TEP using a rigid esophagoscope.
Many surgeons have developed their own techniques for dealing with this problem, but the most common way to deal with this now is using flexible esophagoscopy in the office under local anesthesia (11,12). In a study performed by LeBert et al. (11), the overall success rate of TNE-assisted TEP was 97%. Only 1/39 patient attempts was unsuccessful. Regarding previous radiation therapy, myotomy, and type of reconstruction, there was no statistically significant difference among patients regarding difficulty with placement of prosthesis, development of complications, use of TEP prosthesis, or speech intelligibility.
Many surgeons have developed their own techniques for dealing with this problem, but the most common way to deal with this now is using flexible esophagoscopy in the office under local anesthesia (11,12). In a study performed by LeBert et al. (11), the overall success rate of TNE-assisted TEP was 97%. Only 1/39 patient attempts was unsuccessful. Regarding previous radiation therapy, myotomy, and type of reconstruction, there was no statistically significant difference among patients regarding difficulty with placement of prosthesis, development of complications, use of TEP prosthesis, or speech intelligibility.
 Figure 125.2 Endoscopic voice restoration (TEP). |
The method of TNE-assisted TEP is described below. Pontocaine and Neo-Synephrine are sprayed into the more patent nare. Up to 1.0 mL of 1% lidocaine with 1:100,000 epinephrine is injected into the posterior tracheal wall at the intended TEP site. Pledgets soaked with 4% lidocaine or 2% lidocaine jelly are placed in the nasal cavity. The TNE scope is also coated with 2% lidocaine jelly. The TNE scope is advanced through the nasopharynx and oropharynx into the hypopharynx to reach the upper esophageal inlet. The anatomic subsites are evaluated for abnormal function and masses. The patient is then asked to swallow to assist with advancement of the scope into the esophagus. Flexible esophagoscopy to the limits of the lower esophageal sphincter is then performed under direct visualization, maintaining the view by air insufflation as needed. The exam is visualized using the video monitor. The endoscope is withdrawn until the light at the tip of the scope transilluminates the site of puncture of the anterior esophageal wall. This site is then confirmed by visualization of the indentation of the posterior tracheal wall by ballottement. A number 11 blade is used to incise the posterior tracheal wall. The esophageal wall is entered under direct visualization. A hemostat is used to dilate the puncture site. A dilator is introduced into the new TEP site and then removed. The prosthesis can be immediately placed if desired or the puncture site can be stented open with a 16-French red rubber catheter until the prosthesis is placed. If there is difficulty transilluminating the TEP site due to a bulky flap or scar tissue, this technique can be modified using the Seldinger guide wire technique (11).
PRIMARY VOICE RESTORATION
Selection Criteria
Maves and Lingeman (13) and Hamaker et al. (14) were the first to introduce TEP as a primary technique at the time of laryngectomy. Primary voice restoration developed from the concepts of secondary voice restoration. The only absolute contraindication to primary voice restoration is separation of the party wall at the puncture site. This occurs if the surgeon inadvertently separates the party wall or when a patient undergoes a total laryngopharyngoesophagectomy with gastric pull-up. If a puncture is performed following separation of the party wall, abscess formation, sloughing of the posterior tracheal wall, and possibly mediastinitis can occur.
Relative contraindications to primary (and secondary) TEP include the complexity of the reconstruction and the patient’s inability to use and care for the prosthesis due to impaired mental status or decrease in manual dexterity due to age, arthritis, or neurologic insult/disease. With the introduction of the indwelling prosthesis and the hands-free valve, most of these obstacles have become manageable with the assistance of a care taker. Bilateral severe sensorineural hearing loss and limited pulmonary function are also relative contraindications to primary TEP due to the fact that the patient cannot hear the TE voice and limited pulmonary air restricts the fluency and volume of speech, respectively (15). Preoperative radiation therapy or the need for postoperative radiation therapy is not a contraindication for this procedure (14,15,16). Studies have shown that there is no difference in complication rates between these groups of patients (15,17). In addition, the rate of
pharyngocutaneous fistula, wound breakdown, stomal stenosis, and esophageal stenosis are similar to those reported in patients undergoing total laryngectomy without primary TEP (17).
pharyngocutaneous fistula, wound breakdown, stomal stenosis, and esophageal stenosis are similar to those reported in patients undergoing total laryngectomy without primary TEP (17).
If a patient is indecisive regarding primary TEP, a puncture can be performed and then allowed to close if the patient does not wish TE speech. This allows the use of the catheter for feeding until the pharyngeal closure is healed. This obviates the need for placement of a nasogastric tube (NGT) through the fresh pharyngeal closure, which may reduce the pharyngocutaneous fistula rate (17). When undecided preoperatively, the patient often commits to this form of alaryngeal speech in the immediate postoperative period after he/she understands stoma care and has had time to psychologically adjust to laryngectomy.
Primary TEP is felt to be safer than secondary TEP in the fact that there is less risk of mediastinal dissection and posterior esophageal perforation and there is elimination of an additional anesthesia (17).
Surgical Technique
The technique for primary voice restoration includes five basic steps, which are to be done in an ordered sequence to provide success without complication. These steps include incision (laryngectomy), followed by tracheostoma construction, TEP, unilateral pharyngeal constrictor myotomy or pharyngeal plexus neurectomy and buttressing the TE party wall (14).
Tracheostoma Construction
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