Laser excision and voice

Laser excision for early glottic carcinoma is one alternative to radiotherapy protocols. Cure rates are considered to be comparable for these modalities, ranging from 66% to 95% for patients undergoing radiotherapy and 76% to 96% for patients undergoing endoscopic laser excision . Frequently, radiotherapy has been favored over laser excision due to reduced impact on the voice after treatment . Extent of voice impact after resection is heavily dependent on the depth of the resection, with resections limited to the superficial layer of the lamina propria, Reinke’s space, and the vocal ligament resulting in near normal voice production in most cases . Deeper resections extending to the vocalis muscle can result in a significant increase in postoperative dysphonia . Surgical interventions to address dysphonia after such deep resection may include microlaryngoscopic lipoinjection, medialization thyroplasty, and anterior commissure laryngoplasty . Many patients will also require voice therapy following these procedures to maximize voice potential .

Common complaints regarding voice after laser excision include increased vocal effort, the need to take frequent breaths, and difficulty with pitch and loudness control . Videostroboscopic assessment of these patients may reveal glottic incompetence, decreased mucosal wave, and vocal fold stiffness . Despite complaints regarding voice after such procedures, patient-perceived voice handicap as measured by the Voice Handicap Index (VHI) is relatively low in contrast to other voice disorders. In a recent study by Brondbo and Benninger , patients after laser resection provided an overall score of 13 out of a possible 120 points on this measure indicating a low level of perceived limitation. Other authors report higher scores for dysphonia due to muscle tension dysphonia and unilateral paralysis .

Voice therapy for patients after laser excision will depend on their specific deficits and personal goals. In the immediate postoperative period, patients should be encouraged to comply with a period of total voice rest to facilitate healing. A recent study using a canine model is supportive of a rapid reestablishment of the basement membrane zone when a period of vocal rest is compared with a voice use condition . Following the immediate postoperative period, a typical voice therapy protocol will include information regarding vocal hygiene and direct voice work. Use of voice therapy to improve both acoustic parameters and patient perceived handicap has been supported, although the specifics of the therapy protocol are not provided . In this study an average improvement of 15 points on the VHI was reported after a course of voice therapy for a group of patients who had either a laser excision or radiotherapy. Despite improvement in functional outcomes, return to normal function was not observed.

Vocal hygiene recommendations are typically reviewed with patients during the education portion of treatment. Patients are advised to improve systemic and direct hydration; to avoid phonotraumatic behaviors such as yelling, shouting, and throat clearing; and to reduce laryngeal irritants such as acid reflux or smoke. Although vocal hygiene approaches have not been directly evaluated with this patient population, they have been validated in a number of studies involving teachers and professional voice users .

Voice intervention strategies are chosen based on the individual’s deficits. Postoperatively, hyperfunction and hypofunction are possible. In general, treatment targets include improved glottic closure, reduced supraglottic tension, improved balance between airflow and muscular forces, and increased mobility of the laryngeal musculature. A number of techniques may be useful in this population including resonant voice therapy and vocal function exercises . In resonant voice therapy, the patient uses a barely adducted/abducted laryngeal posture to gain maximal vocal results with minimal impact stress and vocal effort. The vocal function exercises are a holistic approach to achieving air-muscle balance during phonation. Furthermore, these exercises directly modify vocal fold flexibility and can lead to improved vocal performance and endurance. Because of direct stretching accomplished with these exercises, they may contribute to improved flexibility of established scar tissue. When direct voice modification does not yield desired results in patients with hypofunction, use of small, personal voice amplifiers can be effective.

Laser excision and swallowing

The impact of endoscopic laser excision for laryngeal cancer on swallowing is similarly minimal. Preservation of laryngeal and pharyngeal movement and sensation with endoscopic procedures offers clear advantages over open procedures, radiotherapy, or chemoradiation. Size and location of tumor are important factors, however . Reports of dysphagia after minimally invasive treatment for laryngeal cancer usually discuss T2-T4 glottic cancer, as treated T1 tumors have little to no effect on swallowing . The need for a nasogastric (NG) feeding tube is usually temporary and duration of use correlates with size of tumor/extent of resection, but is generally less than 3 weeks . In a study of 210 patients with laryngeal and hypopharyngeal cancer, Bernal-Sprekelsen and colleagues report that 3.8% required a postoperative tracheotomy and 6.2% required a gastrostomy tube for dysphagia including aspiration. Postoperative radiation was related to more severe dysphagia in this and other studies . Despite the trend toward worse functional outcomes on swallowing with adjuvant radiation and minimally invasive surgery, the study by Jepsen and colleagues found important advantages with combined treatment modalities (surgery and radiation). In this group, no patients required tracheostomy or permanent gastrostomy and only 17% needed temporary nonoral feeding tubes. Comparable results have been noted across the age span .

In the cited articles, specific descriptions of dysphagia other than aspiration were not included. One study mentions that reduced pharyngeal constrictor motility and impaired pharyngeal and laryngeal sensation due to scarring and edema can account for dysphagia after endoscopic laser procedures for laryngeal cancer . Specifics of dysphagia treatment are not common in the literature regarding patients undergoing minimally invasive procedures for larynx cancer. Medical/surgical management including autologous fat injection (AFI) has been described as helpful for dysphagia due to glottic insufficiency. Because of resorption of the fat, this may need to be repeated after several months, but in a study of 11 patients, 100% were found to have improved swallowing 1 year after AFI . Because of the risk of reduced sensation, instrumental procedures, such as videofluoroscopy (VFSS) or fiber-optic endoscopic evaluation of swallowing (FEES), are recommended to evaluate swallowing and plan appropriate treatment.

Laser excision and voice

Laser excision for early glottic carcinoma is one alternative to radiotherapy protocols. Cure rates are considered to be comparable for these modalities, ranging from 66% to 95% for patients undergoing radiotherapy and 76% to 96% for patients undergoing endoscopic laser excision . Frequently, radiotherapy has been favored over laser excision due to reduced impact on the voice after treatment . Extent of voice impact after resection is heavily dependent on the depth of the resection, with resections limited to the superficial layer of the lamina propria, Reinke’s space, and the vocal ligament resulting in near normal voice production in most cases . Deeper resections extending to the vocalis muscle can result in a significant increase in postoperative dysphonia . Surgical interventions to address dysphonia after such deep resection may include microlaryngoscopic lipoinjection, medialization thyroplasty, and anterior commissure laryngoplasty . Many patients will also require voice therapy following these procedures to maximize voice potential .

Common complaints regarding voice after laser excision include increased vocal effort, the need to take frequent breaths, and difficulty with pitch and loudness control . Videostroboscopic assessment of these patients may reveal glottic incompetence, decreased mucosal wave, and vocal fold stiffness . Despite complaints regarding voice after such procedures, patient-perceived voice handicap as measured by the Voice Handicap Index (VHI) is relatively low in contrast to other voice disorders. In a recent study by Brondbo and Benninger , patients after laser resection provided an overall score of 13 out of a possible 120 points on this measure indicating a low level of perceived limitation. Other authors report higher scores for dysphonia due to muscle tension dysphonia and unilateral paralysis .

Voice therapy for patients after laser excision will depend on their specific deficits and personal goals. In the immediate postoperative period, patients should be encouraged to comply with a period of total voice rest to facilitate healing. A recent study using a canine model is supportive of a rapid reestablishment of the basement membrane zone when a period of vocal rest is compared with a voice use condition . Following the immediate postoperative period, a typical voice therapy protocol will include information regarding vocal hygiene and direct voice work. Use of voice therapy to improve both acoustic parameters and patient perceived handicap has been supported, although the specifics of the therapy protocol are not provided . In this study an average improvement of 15 points on the VHI was reported after a course of voice therapy for a group of patients who had either a laser excision or radiotherapy. Despite improvement in functional outcomes, return to normal function was not observed.

Vocal hygiene recommendations are typically reviewed with patients during the education portion of treatment. Patients are advised to improve systemic and direct hydration; to avoid phonotraumatic behaviors such as yelling, shouting, and throat clearing; and to reduce laryngeal irritants such as acid reflux or smoke. Although vocal hygiene approaches have not been directly evaluated with this patient population, they have been validated in a number of studies involving teachers and professional voice users .

Voice intervention strategies are chosen based on the individual’s deficits. Postoperatively, hyperfunction and hypofunction are possible. In general, treatment targets include improved glottic closure, reduced supraglottic tension, improved balance between airflow and muscular forces, and increased mobility of the laryngeal musculature. A number of techniques may be useful in this population including resonant voice therapy and vocal function exercises . In resonant voice therapy, the patient uses a barely adducted/abducted laryngeal posture to gain maximal vocal results with minimal impact stress and vocal effort. The vocal function exercises are a holistic approach to achieving air-muscle balance during phonation. Furthermore, these exercises directly modify vocal fold flexibility and can lead to improved vocal performance and endurance. Because of direct stretching accomplished with these exercises, they may contribute to improved flexibility of established scar tissue. When direct voice modification does not yield desired results in patients with hypofunction, use of small, personal voice amplifiers can be effective.

Laser excision and swallowing

The impact of endoscopic laser excision for laryngeal cancer on swallowing is similarly minimal. Preservation of laryngeal and pharyngeal movement and sensation with endoscopic procedures offers clear advantages over open procedures, radiotherapy, or chemoradiation. Size and location of tumor are important factors, however . Reports of dysphagia after minimally invasive treatment for laryngeal cancer usually discuss T2-T4 glottic cancer, as treated T1 tumors have little to no effect on swallowing . The need for a nasogastric (NG) feeding tube is usually temporary and duration of use correlates with size of tumor/extent of resection, but is generally less than 3 weeks . In a study of 210 patients with laryngeal and hypopharyngeal cancer, Bernal-Sprekelsen and colleagues report that 3.8% required a postoperative tracheotomy and 6.2% required a gastrostomy tube for dysphagia including aspiration. Postoperative radiation was related to more severe dysphagia in this and other studies . Despite the trend toward worse functional outcomes on swallowing with adjuvant radiation and minimally invasive surgery, the study by Jepsen and colleagues found important advantages with combined treatment modalities (surgery and radiation). In this group, no patients required tracheostomy or permanent gastrostomy and only 17% needed temporary nonoral feeding tubes. Comparable results have been noted across the age span .

In the cited articles, specific descriptions of dysphagia other than aspiration were not included. One study mentions that reduced pharyngeal constrictor motility and impaired pharyngeal and laryngeal sensation due to scarring and edema can account for dysphagia after endoscopic laser procedures for laryngeal cancer . Specifics of dysphagia treatment are not common in the literature regarding patients undergoing minimally invasive procedures for larynx cancer. Medical/surgical management including autologous fat injection (AFI) has been described as helpful for dysphagia due to glottic insufficiency. Because of resorption of the fat, this may need to be repeated after several months, but in a study of 11 patients, 100% were found to have improved swallowing 1 year after AFI . Because of the risk of reduced sensation, instrumental procedures, such as videofluoroscopy (VFSS) or fiber-optic endoscopic evaluation of swallowing (FEES), are recommended to evaluate swallowing and plan appropriate treatment.

Vertical hemilaryngectomy and voice

In a standard vertical partial/hemilaryngectomy, one vertical half of the larynx is removed, transecting the thyroid cartilage and typically including one false vocal fold, one ventricle, and one true vocal fold. As a result, glottic incompetence and subsequent dysphonia are common. Preservation of the arytenoid, hyoid, and epiglottis is common . Common findings following vertical hemilaryngectomy include incomplete glottic closure, assistance of the the supraglottic structures (ventricular folds, arytenoids) for abutement of the remaining fold, reduced maximum phonation time, high and more variable pitch, and restricted vocal intensity range. These patients often undergo additional procedures to improve glottic valving including medialization and reconstructive procedures. Despite elimination of glottic insufficiency, these patients often continue to report dysphonia secondary to alteration of their vibratory characteristics .

After vertical hemilaryngectomy, voice rehabilitation is geared toward compensation for deficits. In addition to surgical options to narrow the glottic gap, digital or external compression of the thyroid laminae can be used for improved glottic closure. A head turn to the affected side can also be useful. Other strategies can be implemented to reduce the functional impact of the dysphonia including use of amplification and environmental manipulation.

Vertical hemilaryngectomy and swallowing

Functional swallowing results after hemilaryngectomy are generally good relative to other partial laryngectomy procedures, with some initial difficulties in the early postoperative period. Most patients regain normal swallowing within 1 month of surgery . With classical hemilaryngectomy, aspiration during the swallow is most prevalent, with some patients aspirating after the swallow or during and after .

Ideally, the operated side will abut against the intact side to achieve adequate laryngeal closure, allowing for safe swallowing. Some temporary postures or maneuvers may be necessary until this occurs consistently. If the primary problem is airway entrance closure, a chin tuck posture may reduce this risk by narrowing the potential opening. If both airway entrance and glottic closure are problematic, head turn to the damaged side with or without chin tuck may be helpful. The head rotation places extrinsic pressure on the thyroid cartilage, increasing adduction of the vocal fold to the reconstructed side of the larynx . If postures alone are not sufficient in reducing aspiration, the supraglottic or super supraglottic swallow maneuvers can be attempted under fluoroscopy with or without the head postures to determine the best technique for maximal airway closure .

If surgery extends anteriorly to include the anterior commissure or part of the contralateral vocal fold or posteriorly to include the opposite arytenoid cartilage, patients may have more severe swallowing safety issues, requiring more intense and longer duration of swallowing therapy . Jacob and colleagues report on long-term functional outcomes after Laccourreye hemipharyngectomy-hemilaryngectomy for 22 patients. After a mean of 43 months, 14 reported normal eating and drinking while 6 could only eat soft foods, and 2 needed a permanent gastrostomy tube. If other deficits are identified during the evaluation, these should be addressed appropriately, as discussed in the following section of this article.

Supraglottic laryngectomy and voice

Supraglottic carcinoma has been traditionally treated with open supraglottic or horizontal laryngectomy with good functional recovery of voice and swallowing in most patients . Traditional open supraglottic laryngectomy (SGL) removes the epiglottis, both aryepiglottic folds, both false vocal folds, and one or both superior laryngeal nerves and preserves both true vocal folds, both arytenoids, the base of tongue, and hyoid bone . In the SGL, resection of the supraglottic larynx often results in alteration of the resonant characteristics of the voice. This results in a muffled voice that is difficult to project . As a result, patients may be inclined to strain to produce a louder voice. Use of amplification may be helpful, particularly for patients who regularly have to project their voice.

Supraglottic laryngectomy and swallowing

With traditional open SGL, patients can begin eating some foods within 1 month of surgery but may take up to 3 months to return to a full oral diet . Extension of the SGL inferiorly or superiorly can prolong recovery, and dysphagia tends to be more severe, lasting 2 to 6 months and up to 2 years for some patients . Higher T-stage of supraglottic tumors is also correlated with longer duration of feeding tubes . Postoperative radiotherapy can further increase morbidity. Occasionally, safe swallowing is never achieved, requiring permanent means of nonoral feeding such as a gastrostomy tube or offering the patient conversion to total laryngectomy for chronic intractable aspiration/airway protection purposes . Certainly, larger, more extensive, and more invasive resections, as well the addition of postoperative radiation therapy increase the possibility and severity of dysphagia symptoms. Subjective quality of life judgments after supraglottic laryngectomy show that dysphagia is directly related to size and extent of tumor .

Conversely, endoscopic laser resection of supraglottic tumors results in less dysphagia with more rapid return to normal swallowing, sometimes as rapidly as 2 to 7 days postoperatively . One possible reason for improved outcomes in patients undergoing endoscopic SGL versus an open procedure is the preservation of the superior laryngeal nerve. Sasaki and colleagues report an intact glottic closure reflex in six patients within 72 hours of surgery as demonstrated by testing with fiberoptic endoscopic evaluation of swallowing with sensory testing. In contrast, seven of eight patients post–open SGL had persistent loss of glottic closure reflex even up to 12 years.

With any of the SGL procedures, dysphagia is largely a function of airway protection problems . Kreuzer and colleagues performed videofluoroscopy on 120 laryngeal surgery patients and found aspiration to be common. In 61 partial laryngectomy patients who aspirated, 5 did so before the swallow, 32 during the swallow, 9 after the swallow, and 15 at more than one phase. The nature of aspiration was attributed to incomplete airway closure, sphincter dysfunction, or pharyngeal pooling. If the surgery is extended to include part or all of the hyoid bone, laryngeal elevation may be affected, contributing to reduced airway protection before or during the swallow. If the base of the tongue is involved, oropharyngeal transit and/or bolus control may be affected as well as bolus propulsion, resulting in residue after the swallow and/or risk of penetration and aspiration after the swallow .

Swallowing therapy can address each of the deficits listed above. As with any patient experiencing dysphagia, thorough clinical and instrumental examination, preferably videofluoroscopy, is performed to objectify deficits and plan treatment accordingly. Trial therapy techniques can be implemented and evaluated during the examination. These are necessary components for treatment planning with this population of patients .

Bolus control, lingual resistance, and other oral exercises can improve oral phase problems encountered . Base of tongue exercises can improve retraction of the tongue base to the posterior pharyngeal wall. There are several voluntary maneuvers that achieve this, including effortful swallow, super-supraglottic swallow, Mendelsohn maneuver, and tongue-hold maneuver . Specifically, the tongue-hold maneuver improves anterior movement of the posterior pharyngeal wall. Patients are instructed to protrude their tongue and hold it between their teeth while attempting to swallow. Additional therapy exercises used to improve tongue base retraction include yawn/sigh exercises, gargling, and simply instructing patients to retract their tongues as an exercise . These are typically initiated during the postoperative evaluation and performed daily for 2 to 4 weeks. If no improvement is seen, continuing for another 4-week period is advisable .

The supraglottic swallow maneuver (SG) and the super-supraglottic swallow maneuver (SSG) are often indicated as both compensatory airway protection strategies and exercises . Both teach the patient to maintain airway closure before and during the swallow. The SSG adds a voluntary Valsalva maneuver, increasing contact of the base of tongue to the arytenoids. The Mendelsohn maneuver is one way to improve laryngeal elevation and also increases and prolongs cricopharyngeal opening . The Shaker exercise has been shown to improve upper esophageal opening associated with residue and aspiration after the swallow , although this can be difficult for patients having undergone surgery to the neck region. For persistent pharyngeal residue and aspiration after the swallow, which is not eliminated with above-described postures and maneuvers, side-lying posture may be effective. This posture eliminates the gravitational effect on pharyngeal residue, keeping it on one side of the pharynx . Patients will usually need to implement a posture for 1 to 2 months and can return to normal eating without use of the posture after reassessment under videofluoroscopy to ensure that adequate improvement has occurred. Occasionally, postures may need to be used permanently .

Occasionally delayed pharyngeal swallow initiation occurs after SGL, further increasing the risk of aspiration, especially of thin liquids. This can be treated by having the patient compensate by volitionally holding liquids in the mouth briefly before swallowing. Some studies show reduced swallow delay using gustatory, mechanical, temperature (cold), and combined stimulation and temperature and texture variation of foods .

Medical/surgical procedures have a role in swallowing function with partial laryngectomy procedures. Both cricopharyngeal myotomy and pharyngeal plexus neurectomy at the time of partial laryngectomy have been shown to reduce dysphagia related to cricopharyngeal muscle spasm in supraglottic laryngectomy patients . Electrical stimulation is emerging as a potential for dysphagia therapy. Although much more research needs to be completed, a promising intervention to date is the use of intramuscular hooked wire electrodes delivering paired stimulation to laryngeal elevation muscles. This shows the ability to induce laryngeal elevation and potentially improve patients with dysphagia due to reduced or delayed laryngeal elevation .

Supracricoid laryngectomy and voice

Voice quality is significantly altered as a result of the supracricoid laryngectomy. Sound production depends on abutment of the remaining arytenoid against the epiglottis or tongue base . Overall vocal quality was judged to be breathy-hoarse with a low fundamental frequency . Despite the irregularity of voice after SCL, overall intelligibility is judged to be quite good (average score of 4 out of 5 possible by a blinded listener). Dworkin and colleagues did not find any significant difference in the overall quality or intelligibility of voice produced after supracricoid laryngectomy in contrast to total laryngectomy with tracheoesophageal voice prosthesis (TEP). Of note, markedly lower neoglottal air forces were required for the SCL patients than the TL patients (16 versus 31 cm H ₂ O), which may indicate lower vocal effort requirements in the SCL group. Vocal quality is expected to improve over time, although characteristics such as reduced frequency range, low fundamental frequency, and increased breathiness are expected to persist .

Voice therapy after supracricoid laryngectomy is again geared toward increasing function and compensation for deficits. Posterior tongue retraction can result in improved abutment of the arytenoid against the epiglottis or tongue base for increased voice . As with other partial laryngectomy procedures, it is important to ensure that patients avoid strain and overcompensation , although with this population, some degree of overcompensation is necessary for functional outcomes.

Supracricoid laryngectomy and swallowing

Given that airway protection is compromised at the most inferior level of the larynx by the removal of the true and false vocal folds, therapy must focus on improved airway protection before and during the swallow . Studies consistently show return to full oral diets and functional swallowing in 75% to 100% of patients . Time from surgery to removal of feeding tubes has been cited as between 21 and 210 days . Possible reasons for differences in time to recovery of functional swallowing include cricohyoidopexy (CHP) versus cricohyoidoepiglottopexy (CHEP), removal of one arytenoid cartilage in some patients and pre- or postoperative radiotherapy for some patients . Others relate increased duration of nonoral feeding tubes to medical factors such as chronic obstructive pulmonary disease, diabetes mellitus, and increased time to tracheostomy tube removal . Most studies report the importance of regular swallowing evaluation and therapy addressing a variety of oropharyngeal deficits. Characteristics of dysphagia include, but are not limited to, premature spillage, bolus retention, laryngeal penetration, aspiration, and ability to clear aspirated material by coughing . Ruiz and Crevier-Buchman describe a combination chin-down posture with base of tongue retraction in conjunction with a supraglottic swallow, which addresses many of these deficits. Other interventions as described in the previous and following sections of this article should be used as indicated by instrumental assessment.

Electrolaryngeal speech

Electrolaryngeal speech is accomplished by placing the electrolaryngeal device either on the neck, on the cheek, or intraorally. Once vibration is introduced, the patient uses the lips, tongue, teeth, and palate, as usual for articulation. Difficulties with electrolaryngeal speech can arise when the patient has difficulty obtaining adequate vibration due to placement or tissue properties, inadequate articulation, or suboptimal timing characteristics. Treatment for electrolaryngeal speech will address these difficulties using targeted speech drills and functional speech activities.

Esophageal speech

Esophageal speech requires active air injection into the esophagus through the pharyngoesophageal segment (PES). This can be accomplished through positive or negative pressure approaches. The patient then expels the air rapidly in an efferent manner causing vibration of the muscles and tissue of the cervical esophagus and hypopharynx. Postoperative therapy for esophageal speech includes instruction in air injection techniques, articulatory work, improvement of utterance length, and improved naturalness of speech. Esophageal speech, although once the mainstay of alaryngeal voice restoration, has less clinical popularity today because of lower levels of successful acquisition and poorer intelligibility ratings in contrast to tracheoesophageal speech . In fact it is estimated that up to 75% of those attempting esophageal speech are unable to successfully acquire this modality .

Tracheoesophageal speech

The advent of the tracheoesophageal voice prosthesis (TEP) has revolutionized postoperative alaryngeal voice restoration . At the time of the laryngectomy, or at a future date, a puncture is surgically created in the party wall between the trachea and esophagus. A one-way tracheoesophageal voice prosthesis is placed in the tract and when the stoma is occluded, air is shunted into the esophagus. The efferent air travels superiorly, causing the PES to vibrate. This sound source becomes the basis of alaryngeal communication in the TEP user. Recent reports of the successful long-term use of TE speech have revealed a range between 50% and 95% . Voice quality ratings of fair-excellent have been reported in 88% of patients . There are reports of improved outcomes for those undergoing primary puncture at the time of laryngectomy versus those undergoing a secondary puncture at a later date .

Difficulties with successful TEP use may be related to tonicity of the PES, difficulty with stomal occlusion, and prosthesis valve failure. Hypertonicity or spasm of the PES can lead to strained voice, effortful voice, and total inability to produce voice in up to 79% of those patients unable to achieve TE speech . This problem is typically managed through medical/surgical approaches such as myotomy or injection of botulinum toxin . Strictures within the esophagus can also impact voice production and are most often managed through dilatation. Issues with the PES can often be confirmed through videofluoroscopic evaluation.

Inadequate stomal occlusion because of stoma size, shape, or general neck topography can lead to air wasting and suboptimal airflow into the esophagus. In addition, excessive force applied by the patient can lead to narrowing of the vibrating region, leading to strained or absent voice. Both inadequate closure and excessive force are issues that can be addressed by the speech pathologist. Use of tracheostoma valves, housings, and intraluminal attachments can improve functional stomal occlusion, thereby facilitating TE speech. Creative management using devices such as the Barton Mayo button and the Provox Larytube and Laryclips can greatly enhance patient outcomes , particularly when paired with hands-free devices.

Voice prosthesis leakage is the most common maintenance issue with the TEP and can lead to reduction in long-term patient satisfaction . Leakage can occur through the shaft of the prosthesis due to forces maintaining flap opening such as microbial colonization, valve deformities, or negative esophageal pressure during speech/swallowing. New prosthesis designs have targeted these issues through use of Candida -resistant materials, inset flap valves, and magnet closure systems . Traditionally, use of Nystatin has been recommended to combat adhesion of Candida on the esophageal aspect of the prosthesis ; however, recent studies suggest that additional materials such as probiotics and Amphoterican B lozenges may have additional benefits for reducing biofilm formation .

Leakage around the prosthesis, although less frequent in occurrence, can be a more difficult issue. Leakage around the prosthesis is often a result of excessive prosthesis length but can also be due to factors such as radiation effects, hypothyroidism, and recurrent cancer . As a result, determination of the underlying cause of this leakage is critical. Remeasuring the length of the puncture tract and proper fitting of a new prosthesis can often eliminate leakage around the prosthesis. This is particularly the case for the first year after laryngectomy when edema and tissue thickness are gradually decreasing. Use of specialty prostheses with enlarged retention collars can also be used to prevent leakage around the prosthesis. Medical/surgical management for this problem can include injection of augmentation materials or, in severe cases, closure of the tract with re-puncture at a subsequent date.

Total laryngectomy and swallowing

Although safety is not a typical concern after total laryngectomy, swallowing efficiency can be compromised by structural abnormalities and pharyngo-esophageal motility issues . Videofluoroscopy is an effective method for detecting postsurgical structural abnormalities including early postoperative fistulas, strictures, and masses suspicious for recurrence , as well as pharyngoesophageal (PE) segment spasms and motility issues. Pharyngocutaneous fistula is an infrequent (17%–18% of patients) but real complication in this population that delays ability to resume oral diets . There is some evidence that this is more common in patients having a salvage laryngectomy for recurrence after primary chemoradiation rather than a primary total laryngectomy and in patients undergoing vertical versus “T” closure .

Other structural causes of dysphagia warrant intervention to directly improve swallowing. A pseudoepiglottis may form at the base of tongue, requiring laser excision if severe enough to cause backflow into the oro- or nasopharynx . Stricture or narrowing of PES or esophagus can cause difficulty swallowing solids. Incidence of stricture after total laryngectomy may be as high as 39% and has been cited as more common with more extensive surgeries such as laryngopharyngectomy with primary TEP . Treatment with careful dilatation brings relief to many. Performing a cricopharyngeal (CP) myotomy at the time of total laryngectomy may avoid problems due to spasm at this site and retention of foods in the upper esophagus. Horowitz and Sasaki measured peak pharyngeal pressures in TL patients with and without CP myotomy and found a significant difference, concluding that the procedure has the potential to minimize postoperative fistulization, eliminate dysphagia related to CP spasm, and improve acquisition of alaryngeal voice.

Without normal pharyngeal musculature, it is not surprising that many laryngectomees complain of increased effort swallowing and prolonged mealtimes. Direct swallowing therapy including base of tongue retraction exercises may improve dysphagia related to bolus transfer and manipulation difficulties . A tongue-holding maneuver may improve anterior motion of the posterior pharyngeal wall , though this has not been studied in the TL population. Alternating liquids and solids and including moist or wet foods in all meals are helpful behavioral strategies.