Post-LaryngectomyVoice Rehabilitation

Abigail Schnieders, MD

Matthew Page, MD

Overview

• Overview of Alaryngeal Speech

• Options for Post-Laryngectomy Communication

• Physiology of TEP

• Surgical Considerations in TEP

• Troubleshooting TEP

• Complications of TEP

The Saga Continues…

• After being laryngectomized by the infamous Dr. Goodwin, the previously discussed patient returns to clinic 3 months post op for cancer surveillance. He is found to be free of disease.

• However, he wishes to discuss options for being able to communicate again…other than with his pencil and paper.

• What are some of his options and what are the pros and cons of each?

Life expectancy of patients who previously underwent laryngectomy

• Importance of focusing on improved quality of life in post-laryngectomy patients.

Hotz, MA. Success and Predictability of Provox Prosthesis Voice Rehabilitation. Arch Otolaryngol Head and Neck Surg 2002; 128:687-691

Vocabulary

• The first thing that I learned when researching for this topic…

• The following are actual words:

• Laryngectomized

• Having undergone the process of a laryngectomy

• Laryngectomised

• Brittish spelling

• Laryngectomee

• One who has previously undergone a laryngectomy

History of Alaryngeal Speech

• 1873 – Billrothperformed first total laryngectomy

• Artificial larynx used post operatively with good success

• Issues of diplophonia and wound infection

Figure 113-1. Drawings from the original paper by Gussenbauer. Note the almost complete obstruction of the subglottic space within the cricoid cartilage. On the left are the first and second versions of the artificial larynx. In the center the postoperative situation is depicted, with a pharyngostoma to hold the pharyngeal extension of the artificial larynx

Cummings Otolaryngology, 5th edition. Chapter 113

Anatomy Quiz

Physiology of Speech

• Airflow causing vibrations of the vocal cord mucosa is best described as which phenomena?

• Bernoulli Effect

Physiology of Speech

• Needed for Speech

• Bellows

• Sound source

• Vocal tract

• The least affected by TL?

Anatomy

• Suprahyoidmusculature separated from superior border of hyoid

• Separation of pharyngeal constrictors at oblique line of thyroid cartilage

• Closure of these muscles as the external layer

Baileys Head and Neck Surgery. Chapter 123.

Post-TL voice restoration

Artificial Larynx Esophageal Speech TEP

Mechanism Mechanical sound introduced into the vocal tract

Air injected into esophagus and then propelled into PE segment

Tracheal air exhaled into pharynx through fistulous tract

Advantage Rapid learning; doesnot interfere with acquisition of other forms of speech; low cost; loud

Less conspicuous; hands free; natural sound; patient independent of devices

Natural phrasing of voice; more acoustically normal speech;

Disadvantage Dependence on batteries; mechanical sound; loss of handsfree speech;appearance; lack of insurance

Low fundamental frequecy (~65 Hz); short duration; low acquisition rate; extended learning period

Tract can be difficult to maintain; salivary reflux into trachea

Successful use ~100% 5-30% 40-90%

Esophageal Speech

• Air injected into esophagus or stomach

• Expelled into PE segment causing mucosal vibrations

• ~80 mL of air compared to 3+ liters of air

• 1-2 sec of phonation time compared to ~ 20 sec

• Success rates ~ 40-60%

Cummings Otolaryngology, 5th edition. Chapter 113

Mechanical Speech

• Electrolarynx

• Electrically generated vibrations pass through skin

• Vibrations formed into speech within the vocal tract

• Cummings Otolaryngology, 5th edition. Chapter 113

TEP

• Tracheoesophagealpuncture• One way valve allowing

exhaled air to pass into pharynx. This airstream vibrates the mucosa of the upper PE segment.

• Similar physiologic principles of normal speech • Efficient air flow source• Natural phrasing and varied

voice efforts

• When the air soucesubsides, the valve closes and prevents aspiration of secretions

Emedicine. Laryngectomy Rehabilitation.

TEP

• Tracheostoma valve• Closes the stoma

when phonating• Higher airflows for

voice close a valve diaphragm

• Hands free speech

• Cannot be used in patients with COPD

• Effective in only 25% of laryngectomypatients

Voice Prostheses• 1970-1980 • Creation of surgical fistula between trachea and neopharynx• Aspiration problems• Trade off between voice quality and aspiration

• 1972• Mozolewski published results from first voice prostheses

• 1980• first Blom-Singer prosthesis• “duckbill”

Baileys Head and Neck Surgery. Chapter 123

Low flow TEP

• Reduction in airflow resistance requires less effort for voicing

• Increased diameter of prosthesis

• Increased loudness

• 20 Fr

• Fine line between voice quality and aspiration

Baileys Head and Neck Surgery. Chapter 123

Voice Prostheses

• Indwelling

• Provox

• Replaced by clinician

• Robust construction ensures longer life span

• Determined by leakage of fluids around prosthesis or increased airflow resistance

• Success independent of patient age and general health

• Non-indwelling

• Duckbill; Panje prostheses

• Removed by patient

• Daily maintenance includes cleaning and flushing

• Need manual dexterity

Hotz MA. Success and Predictability of Provox Prosthesis Voice Rehabiliation. Arch Otolaryng Head Neck Surg 2002; 128:687-691

TEP: Patient Candidacy

Relative concerns that may reduce the success of voice restoration

Pharyngeal stricture with symptomatic dysphagia

Radiation therapy exceeding 6,500 cGy

Malnutrition

Diabetes

Dementia

Severe COPD

Baileys Head and Neck Surgery. Chapter 123

TEP: Patient selection

• Relative contraindications

• Impaired mental status

• Decreased manual dexterity

• Bilateral severe SNHL

• Limited pulmonary function

TEP: Preoperative evaluation• Esophageal insufflation test

• Placement of catheter through nose into upper GI

• Air insufflated and released as speech

• Estimates the possibility of pharyngeal constrictor spasm

• Esophageal distension occurs with air ingestion

• Reflexive increase in tone in constrictor muscles

• Air trapping can result in gastric filling, distension

• However, no reliable data showing the incidence of patients who will succeed

• Four scenarios:• Fluent, sustained speech

• Indicates relaxed musculature

• Breathy, hypotonic voice • Absence of muscle tone

• Intermittent production of effortful speech• Hypertonicity• Gastric distension

• Aphonia• Complete spasm

Baileys Head and Neck Surgery. Chapter 123

Surgical Considerations in Voice Rehab

Primary prosthetic voice restoration: surgical considerations

Refinements in total laryngectomy techniques for optimizing prosthetic voice restoration

Cricopharyngeal myotomy to prevent hypertonicity of PE segment

Suturing of trachea in separate fenestra in inferior skin flap to create stable stoma

Sectioning of sternal heads of SCM to prevent “deep” stoma

Low-tension closure of pharyngeal mucosa to prevent “pseudo-vallecula” formation

Intra-operative measures to improve prosthetic voice

• Prevention of hypertonicity

• Excess tone in constrictors

• Tone exacerbated with inflation of air, blocking overall airflow

• Anterior myotomy of CP

Intra-operative measures to improve prosthetic voice

• Creation of optimally contoured stoma• Ideal stoma

• Same diameter as trachea• Adequate to access prosthesis

• Avoid laryngetomy tube

• Stoma stenosis• Dehiscence of trachea from skin

• Separate fenestra avoids trifurcations

• Cranial tracheal ring should remain intact• Distribution of collagen fibers act as

“spring” to stent the trachea open

• If disrupted, trachea will collapse

• Contraction of tracheocutaneoussuture• Meticulous suturing

• Optimal coverage of exposed cartilage

Intra-operative measures to improve prosthetic voice• Prevention of a deep

stoma• Some rehabilitation

devices rely on peristomalattachments• Heat and moisture

exchanger

• Automatic speaking valve

• Cutting SCM heads will allow for flat peristomal area

Intra-operative measures to improve prosthetic voice• Pharyngeal mucosa

closure

• Avoidance of tension on closure

• T shaped closure• Reinforcement of

trifurcation prevents fistula

• Avoid “pseudovallecula” which can occur with vertical closure

Timing of TEP placement

Primary vs Secondary Prosthetic Voice Rehabilitation• When is the ideal time to place the TEP?

• During initial surgery

• vs

• Delayed procedure

Timing of TEP placement in radiated patients undergoing TL

• 30 patients underwent laryngectomy after failing chemoRT• 20 underwent primary TEP• 10 underwent secondary

procedure

• 10/20 fistulized in the primary TEP group• Compared to 1/10 in the

secondary group

• Median time to fluent speech • 63 days in primary group• 125 days in secondary group

• 100% of patients acquired fluent speech

Primary TEP

Secondary TEP technique

• Endoscopic technique• Puncture location 5mm

from superior trachea

• 14 gauge needle inserted under direct visualization

• Puncture through posterior esophageal wall

• Wire inserted and guided through oral cavity

• Dilation of puncture site

• Threading of urethral catheter retrograde

• Fitting of prosthesis in 2 days

TEP placement

• Measurement of distance across puncture site

• Insertion of prosthesis and securement above tracheostoma

Complications of Voice Prostheses• Epidural abscess or vertebral

osteomyelitis secondary to violation of posterior esophageal wall during secondary TEP

• Mediastinitis secondary to dissection of party wall

• Loss of the puncture site by dislodgment of the catheter placed at the time of puncture

• TEP dilation

• Partial or complete extrusion of the prosthesis

• Migration of the puncture site• Formation of granulation

tissue• Stomal or

pharyngoesophageal stenosis• Aspiration of saliva and foods

through puncture site• Esophageal prolapse• Tracheostoma prolapse• Aspiration of prosthesis

• 3-5%

Tracheoesophageal Speech

• Similar to laryngeal speech, pulmonary driven

• Air driven through one way valve into PE segment

• Maximum phonation times ~ 16-17 seconds

• Acoustic analysis

• Comparison of TE speech with laryngeal speech

• Fundamental frequency, intensity, frequency and rate are similar

• TE speech superior to esophageal speech in volume, phrase length, ease of use

• Rated most desirable form of alarygneal speech by SLP, patients and listeners

• In the presence of noise, TE speech has a lower rate of listener intelligibility

Tracheoesophageal Speech

• True or False

• There is no gender difference in post-laryngectomy anatomy and physiology of the sound source.

• TRUE

• Male and female voices do not differ in fundamental frequency post laryngectomy

• 100Hz

Prosthesis Maintenance

• Lifespan of prostheses

• ~10-18 months in US

• Fluid leakage main cause of failure

• Transprosthetic leakage

• Periprosthetic leakage

• A patient comes into clinic 2 months after having a TEP placed, feeling like there is a lot of leakage around the prosthesis.

• Which of the following is the most likely explanation for this leakage?

• Usual wear and tear of valve

• Too-long prosthesis

• Leakage of fluids through the valve due to incomplete closure

• Tumor recurrence

• Which of the following is an appropriate initial treatment for the aforementioned condition?

• Nystatin swish and swallow

• re-fitting prosthesis to puncture site

• Removal of prosthesis and replacement in 6-8 weeks

• Endoscopy with biopsy

Prosthetic leakage

• Transprosthetic

• Most common cause of TEP leakage

• Incomplete valve closure

• Candida

• Negative pressure

• Periprosthetic leakage

• Inappropriate prosthetic length

Candida growth and TEP

• Predominant species

• Candida albicans (41%)

• Antifungals

• No evidence to support routine use

• MIC of isolates suggest pansensitivity to nystatin

• Probiotics

• Prevent growth of candida

• Proven in vivo and in vitro

Negative pressure aerophagia

• Deep breathing creates a negative pressure within the thorax

• Normally, UES prevents air from flowing into the upper GI

• Prosthesis is present beneath the UES

• Valve opens and air enters the esophagus

• Complaints of aerophagia

• Easier valve opening and delayed closure

Provox Acti-Valve

• Teflon like material prevents candida growth

• Built in magnets counteract negative pressure in the esophagus

• Group of patients requiring early replacement due to leakage

• Median life span of 336 days

platonmedical.co.uk

Periprosthetic leakage

• Careful checking of the prosthetic length required prior to replacement

• Pulling at tracheal flange to assess if the prosthetic is correct length

• Typical progression involves shortening of the party wall with healing

• Tissue inflammation and atrophy

• Resolution of tissue edema

• Moving prosthesis 2-3mm in the AP direction is correct amount

• Indicates little to no pressure on the tissue

• > 3mm movement is an indication to shorten length of prosthetic

Diagnosis of TEP failures

• Recommendation for clinical protocol for troubleshooting prosthesis problems

• Adverse events occuring in about 1/3 of patients

• Early intervention can prevent further problems

Diagnosis of TEP failures

• Prosthesis failure:

• Position

• Size

• type

• patency

• Reflex pharyngeal constrictor spasm

• Nonvibrating pharyngoesophageal segment:

• radiation-induced

• edema

• reconstructed segment

• Puncture closure

• Inadequate air supply:

• decreased respiratory support

• improper stoma occlusion

Algorithm for solving TE wall atrophy

• Fistula shrinkage

• Removal of prosthesis and replacement with feeding tube

• Requires cuffed cannula to prevent aspiration

• If wall is thinner than 4mm…

• A 4mm prosthesis will not create adequate seal

• Silicon washer

• Used as a spacer and placed between the tracheal flange and mucosa

• 0.5mm thick

• Adheres to mucosa via surface tension

Algorithm for solving TE wall atrophy• Purse string suture• Used if tissues are not

too atrophic

• 3-0 vicryl used to pursestring the fistula, prosthesis is replaced and suture tightened around to secure

• Good short term success rates

• Long term success variable

Algorithm for solving TE wall atrophy

• Augmentation of party wall

• Bioplastic

• Collagen

• Fat

• Granulocyte/ macrophage colony stimulating factor

• Creation of sterile inflammation

Algorithm for solving TE wall atrophy

• Fistula closure

• If failure of all other measures

• Must dissect and close all 3 layers

• Complete epithelialization within 6 months

• Fascial graft or pedicles SCM flap

• Re-puncture with immediate prosthesis placement after 6 weeks

• Occasionally, pectoralis or free flap must be used to close a large defect

Puncture site infection

• ~10% of patients

• Treatment with broad spectrum antibiotic

• Prosthesis left in place

• Potentially replaced with a longer prosthesis

• Avoid removal so that the fistula does not close

Fistula hypertrophy

• Anterior• Excessive mucosal granulation

• More common in patients requiring a laryngectomytube

• Too-short prostheses

• May lead to overgrowth of tracheal flange• Stoma-plasty or laser resection of scar tissue

• Posterior• “esophageal pocket”• Leading to strained voice or bleeding during

valve cleaning• Diagnosed with a pediatric endoscope through

the valve• Can see mucosal overgrowth on esophageal side

• Insertion of a longer prosthesis • Leading to fistulization of the pocket• May require retrograde insertion

Hypertonicity of PE segment

• Most important reason for failure to develop fluent speech• May be prevented with a CP myotomy

• Evaluation with videofluoroscopy• Treatment with intensive speech

therapy

• Chemodenervation• Identification of hypertonic segment

with videofluoroscopy• Transcutaneous injection into

constrictor• Long lasting effect

• Biofeedback mechanism

• Post injection VFS shows reduction in mass of constrictors

Hypotonicity of PE segment

• Hypotonicity

• Leads to whispered voice

• Excessive bulging of the PE segment

• Seen with plexus pharyngeal neurectomy

• External pressure

• Digital

• SCM sling

Prosthesis Extrusion

• Partial extrusion can result in a false passage

• Can result from pressure necrosis from short prosthesis

• Longer prosthesis can bridge the passage and allow for spontaneous healing

• Complete extrusion

• Inability to locate the prosthesis should prompt CXR

• Endoscopic removal in airway

• Allow for passage if in GI

TEP Emergencies

Emedicine: laryngectomy rehabilitation

TEP emergencies

• Inability to insert the esophageal flange fully

• Results in increased voice resistance

• Tract will close from the esophagus within 24 hours

• May re-dilate and stent with a catheter

• Aspiration

• Commonly when patients attempt to replace TEP

• Most common location is right upper mainstem

• Dyspnea

• Aspiration of secretions

• Detailed instructions should be given in case of aspiration

• Avoidance of deep inhalation

• Retrieval with topical anesthesia and flexible bronch

References

• Hotz, MA. Success and Predictability of ProvoxProsthesis Voice Rehabilitation. Arch Otolaryngol Head and Neck Surg 2002; 128:687-691

• Baileys Head and Neck Surgery. Chapter 123.

• Cummings Otolaryngology. Chapter 113.

• Lombard LE. Emedicine: Laryngectomy Rehabilitation.