The ability to speak and communicate vocally is a unique human characteristic that is often taken for granted but is fundamental to many activities of daily living. Loss of voice after total laryngectomy can lead to a serious decrease in quality of life and can precipitate significant frustration over the inability to communicate effectively. There are 3 main methods of voice restoration: esophageal speech, usage of the electrolarynx, and tracheal-esophageal puncture for tracheal-esophageal speech, which can be performed primarily or secondarily. Although all 3 methods have potential benefits, the gold standard is tracheal-esophageal speech.
Key points
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Loss of voice after total laryngectomy can lead to a significant decrease in a patient’s quality of life, which can be improved with voice restoration.
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The 3 main modalities of voice restoration are esophageal speech, electrolarynx, and tracheoesophageal puncture.
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Esophageal speech is the most difficult to teach and for patients to learn; however, it is the most economical.
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Speech with the electrolarynx is easier to learn than esophageal speech, but requires the purchase and maintenance of an electrolarynx device.
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Tracheoesophageal puncture with voice prosthesis placement is the gold standard for voice restoration and can be done at the time of total laryngectomy or as a secondary procedure afterward.
| EMG | Electromyography |
| PCF | Pharyngocutaneous fistula |
| QOL | Quality of life |
| SIP | Sickness Impact Profile |
| TEP | Tracheoesophageal puncture |
| TL | Total laryngectomy |
| UWQOL | University of Washington Quality of Life scale |
| VHI-10 | Voice Handicap Index 10 |
History of voice restoration
Achieving voice in the absence of a functional larynx has been described for more than 150 years. In 1859, Czermak and colleagues described a girl with laryngeal stenosis who achieved voice by deflecting airflow from a tracheostomy to the tongue base. In 1874 at the third Congress of the German Company of Surgeons in Berlin, the first case of creating intelligible speech after total laryngectomy (TL) was described by Gussenbauer when he fitted Billroth’s first TL patient with a reedlike device mounted onto a double-lumen tracheostomy tube with a port extending into the pharynx. Since then numerous surgical modifications and devices have been described, including esophageal speech in the mid-nineteenth century, electrical devices for sound generation in the early nineteenth century, and then creation of mucosal or skin fistulas directing air from the lungs to the upper esophagus and pharynx and implantation of unidirectional prosthetic valves between the trachea and upper esophagus in the mid-twentieth century.
History of voice restoration
Achieving voice in the absence of a functional larynx has been described for more than 150 years. In 1859, Czermak and colleagues described a girl with laryngeal stenosis who achieved voice by deflecting airflow from a tracheostomy to the tongue base. In 1874 at the third Congress of the German Company of Surgeons in Berlin, the first case of creating intelligible speech after total laryngectomy (TL) was described by Gussenbauer when he fitted Billroth’s first TL patient with a reedlike device mounted onto a double-lumen tracheostomy tube with a port extending into the pharynx. Since then numerous surgical modifications and devices have been described, including esophageal speech in the mid-nineteenth century, electrical devices for sound generation in the early nineteenth century, and then creation of mucosal or skin fistulas directing air from the lungs to the upper esophagus and pharynx and implantation of unidirectional prosthetic valves between the trachea and upper esophagus in the mid-twentieth century.
Overview of voice restoration
What is voice restoration? According to the Merriam-Webster dictionary, human voice is defined as sound produced by means of the lungs and larynx or the faculty of utterance. Three elements are necessary for voice production with an anatomically normal vocal tract ( Fig. 1 ):
- 1.
An air generator: during expiration, the lungs generate a burst of air, which is channeled though the larynx
- 2.
A vibrating apparatus: vibrations produced by vocal fold adduction allow sound production to occur
- 3.
An articulating tract: sound is channeled and modified through an articulating apparatus (pharynx, oral cavity) to produce an audible, understandable voice
After TL, patients maintain their air generator and articulating tract (to varying degrees depending on the extent of concomitant pharyngeal or tongue base resection). However, they lose their ability to make sound ( Fig. 2 ). The goal of voice restoration is to artificially create a sound source and, more specifically, to create vibratory motion of air that can be projected through and modified by the vocal tract. The 3 primary modalities of voice restoration are esophageal speech, the electrolarynx, and tracheoesophageal puncture (TEP).
Importance of voice restoration after total laryngectomy
Numerous studies have shown that psychosocial quality of life (QOL) decreases dramatically after TL. A study of 150 patients by Babin and colleagues suggests that there are significant increases in feelings of solitude after TL and that voice deprivation is a limiting factor in social relationships, tending to push individuals into social withdrawal. Reduced sexual enjoyment and libido are also common problems after laryngeal and hypopharyngeal cancer surgery. Thus, successful treatment of laryngeal cancer cannot be measured by survival rates alone.
Rapid, effective restoration of voice and speech is one of the primary focuses of postoperative TL rehabilitation and is pivotal to the prevention of potential psychosocial and economic consequences. One study showed that indwelling vocal prostheses improved QOL, self-esteem, and sexual function ( P <.05) via several validated tests, including the World Health Organization Quality of Life–BREF, Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Arizona Sexual Experience Scale. In another study on 113 patients in a developing world community, QOL scores on the European Organisation for Research and Treatment of Cancer QOL Questionnaire were significantly higher in those patients with voice restoration after TL compared with those without voice restoration. Some studies also suggest that posttreatment QOL in patients who have undergone TL with vocal rehabilitation is comparable with that of patients who have undergone laryngeal preservation (chemo) radiation therapies. A study by Finizia and Bergman suggests that successful speech rehabilitation with a TEP after laryngectomy may be as effective as conservative treatment with radiotherapy for laryngeal cancer with regard to psychosocial adjustment and functional ability, as measured with generic QOL instruments. In a study by Schuster and colleagues that evaluated TL patients with TEP voice restoration, patients’ social functioning, vitality, and mental health were not excessively limited; overall mental health and vitality were significantly better than for patients with other chronic diseases, such as heart or renal failure or hepatitis C, and general health was similar to that of a standard population. Another study by Eadie and colleagues suggests that patients had a high level of self-perceived QOL after TEP in the domains of communication, eating, pain, and emotion that was empirically better than results found in a previous study involving individuals who had undergone TL without voice restoration. Possible reasons cited for the improved self-reported QOL among patients having voice restoration included use of tracheoesophageal speech for postlaryngectomy communication, a higher level of education, and membership in a support group.
Overall, the ability to communicate and converse with others is essential to an individual’s QOL and spans the gambit of people’s activities of daily living. Voice restoration after TL enables a significant portion of such patients’ QOL to be returned to them.
Patient evaluation overview
All patients who are to be evaluated for voice restoration after TL should have a preoperative speech therapy assessment. The role of the speech therapist is pivotal in all 3 modalities of voice rehabilitation because there is a learning curve for all techniques. Patients need to be taught how to perform esophageal speech, use an electrolarynx, or use their TEP, and a speech therapist trained in vocal rehabilitative techniques is best equipped to provide that training. It is essential for patients to plan for a specific voice rehabilitation method preoperatively with their speech therapists and then implement that technique after TL. Financial considerations should also be taken into account because the different vocal rehabilitation methods all have variable costs, especially in the developing world.
Preoperative and postoperative vocal dysfunction should be longitudinally documented using one or more of several voice rating scales. Popular scales include the Voice Handicap Index 10 (VHI-10) as well as the University of Washington Quality of Life scale (UWQOL). A study by Eadie and colleagues investigated potential relationships between speech intelligibility, acceptability, and self-reported QOL after TL and compared the UWQOL and VHI-10 scales. Speech acceptability and intelligibility varied across the samples, with acceptability only moderately related to intelligibility ( r = 0.41; P <.05). The only statistically significant, but moderate, relationship was found between speech acceptability with the UWQOLQOL speech subscore ( r = 0.46; P <.05) suggesting that it may be a more appropriate rating scale for voice assessment after TL than the VHI-10.
Esophageal speech
Overview
Esophageal speech is produced by insufflation of air into the esophagus, essentially by swallowing air. The air is then released in a controlled manner back through the esophagus allowing the mucosa of the upper esophagus/neopharynx to vibrate. Using the vibrations of the pharyngeal/esophageal mucosa as a sound source, the vibratory air column is channeled through the articulatory apparatus of the upper pharynx and oral cavity, where it can be modified and modulated to produce understandable voice ( Fig. 3 ).
Patient Evaluation
According to several studies, esophageal speech is more difficult than other methods to learn to use. However, advantages compared with other voice rehabilitation methods include low cost (no need to purchase an external vibratory device such as a tracheal-esophageal prosthesis or an electrolarynx) and no need for additional surgeries. All TL patients who have access to a professional trained in teaching esophageal speech would qualify for this technique, although patients with tight cricopharyngeal musculature or who develop esophageal or pharyngeal stenoses postoperatively have difficulty with voice production by this method. This technique is used most commonly in developing countries secondary to its low cost.
Management Goals
The main goal for esophageal speech is to restore voice with minimal surgical intervention. For patients who do not wish further surgery or the possible complications associated with a TEP, esophageal speech may be a viable alternative. In addition, as stated previously, no external devices need to be purchased or maintained. As stated by Staffieri and colleagues, there is a steep learning curve and many patients find it difficult to learn initially, but it remains the most economical option of all voice restoration techniques.
There are many difficulties in learning esophageal speech. In addition to patient difficulty in learning how to perform esophageal speech, there are often obstacles for primary speech therapists in teaching esophageal speech. Most speech therapists do not use esophageal speech as their primary communication modality because they all have larynges. Because they have not had TL, any attempt at showing esophageal speech by the speech therapist allows the swallowed air to pass through the laryngeal apparatus, making it innately different than for someone who has had a TL.
Because surgery is not performed, there are no surgical complications. The main nonsurgical complications are failure to learn how to perform esophageal speech and potential loss of voice should esophageal or pharyngeal stenosis or significant cricopharyngeal muscle spasms evolve. Cricopharyngeal spasm can be managed conservatively with exercises supervised by a speech therapist (in mild to moderate cases) or, if this fails, chemically with botulinum toxin–induced muscle paralysis or surgically by division of the cricopharyngeus muscle. Division of the cricopharyngeus muscle at the time of TL is advisable if esophageal speech is to be considered and care must be taken to divide all visible muscle fibers. Effects of botulinum toxin for cricopharyngeal spasm last approximately 4 to 6 months before the patient needs to be reinjected. Surgical cricopharyngeal muscle division is associated with risks of bleeding, perforation, and recurrence from inadequate muscle division.
Treatment
Esophageal speech can be performed through 2 techniques, both based on the principle of pressure gradients and how matter flows from areas of higher pressure to areas of lower pressure. One method is to use the oral cavity/lip muscles to increase air pressure in the oral cavity. Once the pressure in the oral cavity is greater than that exerted by the cricopharyngeal sphincter, the esophagus is insufflated as air flows from the high-pressure oral cavity into the esophagus. The second method is by decreasing the pressure in the esophagus with inhalation. If a rapid breath is taken, the thorax expands rapidly, allowing the pressure within the thoracic cavity, and hence the esophagus, to decrease dramatically. Atmospheric pressure would be greater than the pressure in the esophagus, allowing air from the atmosphere to enter the esophagus via the vocal tract. Both methods require extensive training and perseverance with speech therapy is essential.
Electrolarynx
Overview
Voice restoration with an electrolarynx occurs by producing vibrations in the oral cavity or pharyngeal mucosa with an external vibrating apparatus ( Fig. 4 ).
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