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Voice Restoration after Laryngectomy
Anna M. Pou
Effective voice restoration is essential for the rehabilitation of individuals undergoing total laryngectomy. Three methods are available: the electrolarynx, esophageal speech, and tracheoesophageal (TE) speech. Historically, esophageal speech is the method by which all others are 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. This method is very difficult to learn. The electrolarynx is the most common and the easiest method to learn. However, many patients do not like the unnatural, mechanical sound of voice produced. TE voice restoration is currently the preferred method of postlaryngectomy speech.
- There are no absolute contraindications to secondary tracheoesophageal puncture (TEP). Specifically, radiation therapy is not a contraindication.
- Relative contraindications include the patient’s inability to use and care for the prosthesis due to impaired mental status or decrease in manual dexterity, bilateral severe sensorineural hearing loss (patient cannot hear the TE voice), and limited pulmonary function (restricts the fluency and volume of speech). The introduction of the indwelling prosthesis and the hands-free valve has eliminated many of the relative contraindications.
- TEP is performed 4 to 6 weeks following total laryngectomy, 6 to 8 weeks following postoperative radiation therapy or until the peristomal skin has recovered from radiation toxicity, and at least 4 weeks following recovery from reconstruction of a total laryngopharyngectomy or total laryngopharyngoesophagectomy defect and adjunctive therapies.
- Transnasal esophageal insufflation testing is performed to assess the pharyngeal constrictor muscle response to esophageal distention. Insufflation testing is also done after flap reconstruction or gastric pull-up to determine the quality of voice.
- When hypertonic or spastic speech is present, a secondary pharyngeal constrictor myotomy (PCM) or the injection of Botox (botulinum toxin A) into the pharyngeal constrictor muscles is performed; the latter is the preferred method. The secondary PCM is done at the same time as the puncture and stomaplasty if indicated.
- Barium swallow: the stoma is marked radiographically, and the proposed puncture site is determined in relationship to the pharyngoesophageal segment. This is particularly useful following flap reconstruction. Esophageal stricture can also be identified.
- Stoma size must be at least 2 cm to allow prosthesis placement and to avoid airway compromise.
- Microstomia is treated with serial dilatation using silicone laryngectomy tubes (recommended for irradiated patients) or stomaplasty.
- Stomaplasty is performed prior to TEP, leaving the posterior wall intact during the same operation.
- An endoscopic puncture is made through the TE party wall through which a one-way silicone valve is placed. This tubular prosthesis 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 (Fig. 15-1
