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Tracheoesophageal voice restoration with total laryngectomy
Otolaryngol Clin N Am 37 (2004) 531–545
Tracheoesophageal voice restoration with total laryngectomy Anna M. Pou, MD, FACS Department of Otolaryngology, University of Texas Medical Branch, 301 University Blvd., JSA Rm. 7.104, Galveston, TX 77555-0521, USA
The larynx is the second most common site for cancer in the upper aerodigestive tract, of which squamous cell carcinoma is the predominant type (95%). There are about 136,000 new cases diagnosed worldwide per year, with an estimated overall 5-year survival rate of 68%, making it one of the more curable cancers of the upper aerodigestive tract. Although organ preservation protocols and conservation laryngeal surgeries are in use today, patients with advanced or recurrent squamous cell carcinoma of the larynx continue to undergo total laryngectomy in the course of their treatment. Total laryngectomy profoundly alters speech, 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 to the rehabilitation of these patients. There are three methods of alaryngeal speech: electrolarynx, esophageal speech, and tracheoesophageal (TE) speech. Historically, 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 approximately 26% of patients are able to use this method in daily communications [1]. Those who could not master esophageal speech used the electrolarynx. Although the electrolarynx is the most common method of alaryngeal speech and the easiest method to learn, this device produces an unnatural, mechanical sound. It also relies on the use of batteries and is often not covered by insurance policies. The creation of a successful, surgical voice restoration technique did not occur until the introduction of the TE puncture (TEP) by Singer and Blom in 1979. It was proposed as a secondary salvage technique for those who E-mail address: [email protected] 0030-6665/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2004.01.009
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failed esophageal speech or those who were displeased with the electrolarynx voice [2]. The guidelines that were used to create this revolutionary method for voice restoration included (1) no oncologic compromise; (2) normal swallowing without aspiration; (3) reliable voice; (4) surgical simplicity, reliability, and reproducibility; (5) inclusion of an uncomplicated, costeffective prosthetic valve to prevent stenosis and aspiration; and (6) viability in irradiated tissue [3]. TE speech has evolved over the past 24 years and has gained worldwide acceptance. TEP, pioneered by Singer and Blom [2], is not very different from the selfinflicted 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 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. 1). Airflow is only limited by the vital capacity of the lungs. Various modifications and improvements have been made to the prosthesis since 1978 [2]. Other prostheses have also been introduced (Provox, Groningen, The Netherlands). Maves and Lingeman [4] and Hamaker et al [5] were the first to introduce TEP as a primary technique at the time of laryngectomy.
Primary voice restoration Selection criteria 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 separation occurs when 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, then abscess formation, sloughing of the posterior tracheal wall, and possibly mediastinitis can occur. Relative contraindications to primary TEP include the complexity of the reconstruction (see the article by Deschler and Gray elsewhere in this issue) and the patient’s inability to use and care for the prosthesis because of 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 caregiver. Other relative contraindications to primary TEP include bilateral severe sensorineural hearing loss (due to the patient not hearing the TE voice) and limited pulmonary function (limited pulmonary air restricts the fluency and volume of speech) [6]. Preoperative radiation therapy or the need for postoperative radiation therapy is not a contraindication for this procedure [5–7]. Studies have shown that there is no difference in complication rates between groups of
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Tracheoesophageal Voice Prosthesis
Speech
Location of tissue vibration for voice Tracheoesophageal Puncture and Blom-Singer® Voice Prosthesis
Stoma closure with thumb. (Low pressure prosthesis pictured)
Esophagus Trachea and Air from Lungs Adjustable tracheostoma valve for hands-free operation. (Indwelling prosthesis pictured)
Fig. 1. Anatomy and physiology of TE speech. (Courtesy of In Health Technologies, Carpinteria, California; with permission.)
patients who did and did not undergo radiation [6,8]. In addition, the rates of pharyngocutaneous fistula, wound breakdown, stomal stenosis, and esophageal stenosis are similar to those reported in patients who underwent total laryngectomy without primary TEP [8]. 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.
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This procedure allows the use of the catheter for feeding until the pharyngeal closure is healed and obviates the need for placement of a nasogastric tube through the fresh pharyngeal closure, which may reduce the pharyngocutaneous fistula rate [8]. 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 (see the article by Gress elsewhere in this issue). Primary TEP is believed to be safer than secondary TEP, in that there is less risk of mediastinal dissection and posterior esophageal perforation and there is elimination of additional anesthesia [8]. Surgical technique The technique for primary voice restoration includes five basic steps that 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 tracheoesophageal party wall [5]. Following laryngectomy, the stoma is constructed. The optimal tracheal diameter is 3 cm or greater to prevent stenosis. The midline inferior skin flap is sewn to the midline anterior tracheal ring using half vertical mattress sutures that allow coverage of the cartilage. Interrupted sutures are placed at 5-mm intervals on either side of the midline, pulling the trachea laterally. This process creates a straight, horizontal membranous trachea that is sewn to the superior skin flap. If the trachea is smaller than 3.0 cm, then a stomaplasty is performed [9]. The trachea is incised bilaterally for a vertical distance of 1 cm (two tracheal rings in length) between the midline and the most posterolateral aspect. An ‘‘X’’ is drawn in the midline of the inferior skin flap at the proposed stoma site. The skin and subcutaneous tissues of the superior and inferior areas of the ‘‘X’’ incision are discarded. The lateral triangles of skin are sewn into the apex of the lateral tracheal ring incisions, causing the trachea to enlarge (Fig. 2) [9]. The TEP is then performed using a ruler, a right-angled clamp, and a No. 15 scalpel blade (Figs. 3 and 4). The puncture is made 1.0 to 1.5 cm below the posterior cut edge of the stoma. A right-angled hemostat is placed in the esophagus through the pharyngotomy and pushed against the posterior tracheal wall. A 4-mm horizontal incision is made over the tip of the hemostat, and the hemostat is pushed into the tracheal lumen (Fig. 5A). The jaws of the hemostat are opened and a 16 French (F) Silastic Foley catheter is grasped and pulled through the party wall and fed down into the esophagus (Fig. 5B). Care should be taken at this step to ensure that the catheter is firmly grasped by the hemostat so that it does not slip while it is being pulled through the party wall. The catheter is sewn to the superior
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Fig. 2. Cadaveric stomaplasty: the lateral triangles of neck skin are sewn into the apex of the lateral tracheal incisions.
skin flap after the skin is closed and can be used to feed the patient in the immediate postoperative period (Fig. 6) [5,9]. Alternatively, the prosthesis can be primarily placed and the patient fed through a nasogastric tube. Management of the pharyngeal constrictor muscles to prevent pharyngeal spasm is key to successful TE speech (see the article by Bayles and Deschler elsewhere in this issue). The most reliable method for preventing spasm, if done properly, is a pharyngeal constrictor myotomy. The pharynx is rolled over a tubular structure, most often a finger or dilator, and the muscles are incised vertically in the posterior midline of the pharynx from the level of the puncture to the tongue base. The muscles are cut to the level of the submucosa.
Fig. 3. A ruler is used to measure the location of the planned puncture. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
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Fig. 4. A No. 15 scalpel blade is used to make a horizontal incision over the right-angle hemostat in the party wall. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
If bleeding occurs, then careful use of bipolar cautery is recommended. If an inadvertent pharyngotomy is made, the mucosa is repaired at this time. If flap reconstruction of the pharynx is performed, then the segment of muscle from the puncture site to the inferior flap is myotomized [5,9]. An alternative method that can be performed to prevent pharyngeal spasm is a unilateral pharyngeal plexus neurectomy [10]. After laryngectomy, the pharyngeal muscles lay medially at the level of the superior thyroid artery. The plexus is found within the middle constrictor muscle. A nerve stimulator is used to identify three to five nerve braches by eliciting muscle contraction. The nerve branches are then cut and coagulated. If poor muscle contraction is seen following stimulation, then this method is abandoned and a myotomy is performed. This method is also useful when the pharynx is already closed and a myotomy was inadvertently omitted. The party wall usually separates about 3 to 5 mm above the site of the puncture. The party wall is buttressed using interrupted sutures of 3-0 chromic or 4-0 vicryl (Fig. 7), which obliterates the space. This prevents the collection of saliva in this area if a fistula develops, and helps to maintain the integrity of the posterior stoma. If separation of the party wall extends below the area of the planned puncture, then the puncture is delayed because this can lead to pocket formation with abscess and loss of the posterior tracheal wall [5,9]. The voice prosthesis can be placed anytime after the patient is taking per oral feeds. Voicing, however, is delayed until 2 weeks postoperatively to allow the hypopharyngeal closure to heal. Voicing before this time may place too much air pressure on the new closure, disrupting the suture line. If the patient is discharged from the hospital with the Foley catheter in place, then the balloon is filled with 2 mL of normal saline to prevent accidental dislodgement of the catheter from the puncture site [6]. The patient is also
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Fig. 5. (A) The right angle hemostat is pushed through the party wall into the tracheal lumen. (B) The 16 French foley catheter is grasped with the right angle hemostat, pulled through the party wall, and guided into the esophagus. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
given varying sizes of red rubber catheters and instructed how to replace the catheter if it becomes dislodged. Primary TEP results in development of successful TE speech in 50% to 93% of patients, depending on patient selection criteria and the use of an indwelling prosthesis [5–8,11]. During postoperative radiation therapy, voicing may become interrupted due to mucositis or the patient’s inability to occlude the stoma due to pain. Although not used, the prosthesis may remain in place during this time [5]. Despite an overall excellent success rate, some clinicians are still hesitant to perform primary TEP based on lack of experience and fear of complications. When not performed primarily, TEP is rarely done as a secondary procedure, which likely is due to a patient’s bias toward his or her initial form of speech and reluctance to undergo another surgical procedure [8].
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Fig. 6. The catheter is secured to the upper skin flap in the midline.
Secondary tracheoesophageal puncture Patient selection and timing The few factors that guide patient selection are similar to those listed for primary TEP. The timing of secondary puncture depends on the extent of resection, the complexity of reconstruction, and the need for postoperative radiation therapy. Secondary voice restoration should be delayed until 6 weeks following laryngectomy, 6 to 8 weeks following postoperative radiation therapy, or until the peristomal skin has recovered from radiation toxicity and at least 1 month following recovery from reconstruction of a total laryngopharyngectomy or total laryngopharyngoesophagectomy defect and adjunctive therapies (see the article by Deschler and Gray elsewhere in this issue). These patients should also undergo barium swallow to evaluate the reconstructive changes and 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 [9].
Fig. 7. The party wall is buttressed using 4-0 vicryl.
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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, then 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 and whose tissues appear to be at risk are better managed by the former method. If a laryngectomy tube is used, then it can be fenestrated posteriorly and simultaneously worn with the prosthesis in place. When necessary, the stomaplasty is performed before the puncture, leaving the posterior wall intact. The stoma is enlarged using a Z-plasty technique on each side [9]. For fluent TE speech to occur, there must be sufficient relaxation of the pharynx. There is a subset of patients (20%–40%) who present with hypertonic or spastic speech, indicating spasm of the cricopharyngeus, inferior, and middle constrictor muscles when speech is attempted. A hypopharyngeal bar corresponding to these muscles can be seen with a 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 before puncture using the transnasal esophageal insufflation test [9]. 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 [12]. 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, which 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 are obtained following the insufflation test: (1) fluent, sustained voice production with minimal effort, indicating relaxed pharyngoesophageal muscles; (2) a breathy, hypotonic voice, indicating the absence of pharyngeal constrictor muscle tone; (3) hypertonic voice characterized by intermittent production of effortful speech, with gastric distension and posttrial burping; or (4) spasm that is characterized by no production of voice, even with substantial pulmonary air flow. Insufflation testing also is done after flap reconstruction or gastric pull-up to determine the quality of voice [9]. 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 and patient errors 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
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esophagus. Patient errors can be prevented by having the patient selfmonitor using a mirror [9]. Surgical procedure This procedure was first described by Singer and Blom in 1979 [2]. The following procedure is performed in the operating room under general anesthesia. The Blom-Singer tracheostoma puncture kit (InHealth Technologies, Carpinteria, California) 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 can be palpated. The position of the esophagoscope also protects the posterior esophageal wall from penetration. A No. 14 sheathed catheter is introduced into the bevel of the esophagoscope approximately 5 mm below the mucocutaneous junction. The needle is withdrawn, leaving the sheath in place. 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 and can be used for feeds if a secondary pharyngeal constrictor myotomy is performed, resulting in a fistula [9]. This kit can be replaced by using a curved 18-gauge needle, a 24-gauge wire, a red rubber catheter, a No. 15 scalpel blade, and a hemostat. This technique has been modified by many clinicians over the years to include the use of local anesthesia, transnasal esophagoscopy, and the use of the potassium titanyl phosphate laser, among other methods [13–17]. The prosthesis generally is placed in 48 hours but can be placed immediately. In patients who present with a stricture or fibrosis of the neck tissues following radiation therapy, 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. Cannon [18] described a technique that uses an endotracheal tube and a flexible bronchoscope. An appropriately sized endotracheal tube is passed through the esophageal lumen. A 7.4- to 10-mm window is cut at the junction of the middle and distal third of the endotracheal tube. A flexible bronchoscope that is passed inside the lumen of the endotracheal tube allows for a concomitant esophagoscopy. Light from the bronchoscope illuminates the puncture site. An Intracath venous needle (Deseret Co., Sandy, Utah) with an attached catheter is directed through the posterior tracheal wall into the lumen of the endotracheal tube. If necessary, forceps are used to grasp the catheter and pull it through the mouth. A red rubber catheter is then sutured to the catheter and delivered through the TEP site. When the insufflation test reveals hypertonic or spastic speech, a secondary pharyngeal constrictor myotomy or the injection of botulinum
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toxin (Botox) into the pharyngeal constrictor muscles is performed (see the articles by Bayes and Deschler and by Hoffman elsewhere in this issue). The secondary pharyngeal constrictor myotomy is done at the same time as the puncture and stomaplasty if necessary. A No. 34 to 40 Maloney dilator (Piling, Horsham, Pennsylvania) is inserted to confirm the location of the pharynx and esophagus. An incision is made between the pharynx and the carotid artery down to the level of the prevertebral fascia. The carotid is retracted laterally and the pharyngeal muscles are rolled over the dilator, which is pushed medially by the assistant. A complete myotomy is made from the level of the tongue base to the esophageal inlet. The muscles are incised until the submucosa is reached [9]. The fistula rate is 10% to 20%. Tube feedings are begun through the puncture catheter if a fistula occurs. When the fistula is healed, oral feeds may begin and voicing is delayed for an additional 2 weeks. Complications The most common complications encountered following primary and secondary TEP include (1) loss of the puncture site by dislodgment of the catheter placed at the time of puncture, (2) partial or complete extrusion of the prosthesis, (3) migration of the puncture site, (4) formation of granulation tissue, (5) aspiration of the prosthesis, (6) cellulites, (7) stomal stenosis, and (8) pharyngoesophageal stenosis (see the articles by Bunting and by Lewin elsewhere in this issue) [6,19–21]. Sternoclavicular arthritis and manual pressure necrosis have also been reported [22]. Violation of the posterior esophageal wall, passage of the catheter through a false passage, and esophageal perforation are unique to secondary TEP and can result in epidural abscess, vertebral osteomyelitis, and mediastinitis. Stricture dilatation has been associated with an increase in complication rate in secondary TEP [23]. Previous radiation [24,25], diabetes mellitus, chronic obstructive pulmonary disease, alcoholism, and extended laryngectomy have not been found to be significant risk factors for complications [23]. Postoperative rehabilitation Postoperative TE voice rehabilitation usually is taught by a speech and language pathologist. There are three basic treatment goals following TEP. The first is to dilate and measure the puncture, followed by placement of the prosthesis; the second goal is to instruct the patient and family in routine care of the prosthesis; and the third goal is to instruct the patient in finger occlusion of the tracheostoma and to apply and use a tracheostomal valve [26]. Briefly, the puncture must be dilated to the appropriate size to accommodate the prosthesis (eg, 22F for a 20F prosthesis). A measuring device is then placed into the puncture and slowly withdrawn until the retention collar sits against the inner surface of the esophageal wall and the length of
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the prosthesis is measured. If the length lies between sizes, then the longer size is chosen to prevent underfitting, which can cause the puncture to heal from behind. The type of prosthesis to be used is chosen. The duckbill and lowpressure prostheses are removable prostheses that the patient learns to clean and replace in the puncture. The indwelling low-pressure prosthesis is placed and removed by the physician or speech and language pathologist. Before placing the voice prosthesis, an ‘‘open-tract’’ test is performed. The patient is asked to voice without the prosthesis in place. Poor voicing is due to pharyngeal constrictor spasm or to excessive finger pressure occlusion of the stoma (see the article by Bunting elsewhere in this issue). The life of any prosthesis, in general, is about 3 to 6 months. It is the colonization of yeast that usually destroys the integrity of the valve, which causes leakage of saliva and foods and decreases the life expectancy of the prosthesis [9]. The next steps include patient and family education regarding care of the prosthesis and patient instruction regarding finger occlusion of the prosthesis. It is usually necessary to assist the patient with accurate occlusion of the stoma at the initial visit while the patient watches in the mirror. About six sessions are required for the average patient to master removal, cleaning, and reinsertion of the standard voice prosthesis. The indwelling prosthesis is used in patients who cannot or prefer not to use the removable prosthesis. For those patients who find finger occlusion unacceptable, a hands-free valve can be used [9]. Predictors of successful tracheoesophageal speech Many variables have been studied by various clinicians to predict which patients will achieve successful TE speech with primary or secondary puncture [8,21,25,27,28]. The results of these studies are varied, although age, sex, and tumor size/stage appear to have no influence. Alcohol abuse and lack of transportation to follow-up visits correlated well with TE speech failure in some studies [8,25] but were not significant in others [27,28]. Many clinicians, however, can anecdotally report alcohol abuse as a contributor to rehabilitation failure. In a study by Cantu et al [28], 36 patients undergoing either primary or secondary TEP were evaluated for long-term success and predictors of successful TE speech. Nearly two thirds of the patients had successful communication at an average of 4 years post puncture. For the remaining patients who were judged as unsuccessful, reduced vision, limited hand and arm movement, and history of radiation therapy (but not timing of radiation therapy) were found to be significant. There were, however, patients with good vision and hand coordination who did not develop good speech and patients with previous radiation therapy who developed successful speech. Therefore, the presence of these factors does not necessarily predict lack of success. The introduction of the indwelling prosthesis has reduced the problems associated with decreased function of
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the patient, and it is believed that the lack of radiation therapy may predict higher success. The timing of TEP did not appear to influence communication effectiveness [28], and the absence of pharyngeal stricture was the only significant predictor of good-to-excellent speech results in secondary TEP found in one study [29]. Due to variable results found in multiple studies, it has been suggested that studying a combination of factors using multiple regression or analysis of covariance will better identify predictors of success than studying a specific factor in isolation [28].
Voice quality It is important for potential TE speech users to have realistic expectations. The goal of voice restoration is to provide fluent, effortless, and intelligible speech. The quality of voice cannot be controlled. TE voice quality is usually harsh and often loses its sexual characterization [30]. Patients undergoing total laryngectomy, however, already have varying degrees of dysphonia, and TE voice quality should be compared with preoperative voice quality. In a study by Cantu et al [28], one third of patients (or their significant others) judged the success of their TE speech at a lower level than that of the primary investigator. This finding indicates that the clinician and patient may be using different standards of success; the patient and significant other may be using an ‘‘idealized’’ voice standard that cannot be produced using TEP. Patients should realize that there is a learning curve associated with TE speech; TE speech generally improves over time [21]. In addition, TEP does not preclude the use of other methods of alaryngeal speech. On the contrary, a functionally rehabilitated TE prosthesis user may find it easier to switch to esophageal speech [21]. Acoustic analysis of TE speech has been compared with laryngeal, esophageal, and electrolarynx speech by many investigators [31–34]. The fundamental frequency, intensity, and rate of TE speech approximates that of normal speech. In a study by Robbins et al [31], esophageal and TE speakers were analyzed for intensity, frequency, and rate of speech production. TE speech was found to be more similar to laryngeal speech than esophageal speech. When compared with esophageal speech, TE speech gives superior voice quality in reference to volume and phrase length and is much easier to learn. Also, the rate of speech is faster and the intelligibility is superior to that acquired using the artificial larynx or esophageal speech [34–36]. In the presence of noise, however, there is a lower rate of listener intelligibility of TE speech compared with laryngeal speech [33]. The prevention of pharyngeal spasm is paramount to the production of successful TE speech. Acoustic analysis of TE speech was studied following three different surgical methods used to address the pharynx: pharyngeal plexus neurectomy, pharyngeal constrictor myotomy, and unilateral pharyngeal plexus neurectomy with a drainage myotomy limited to the
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cricopharyngues. Patients undergoing pharyngeal plexus neurectomy had the highest fundamental frequency, which may be due to the residual resting tone in the pharyngoesophageal segment [32]. Management of the pharynx with neurectomy may be desirable in women who are undergoing laryngectomy with voice restoration. TE speech has been rated the most desirable form of alaryngeal speech by speech pathologists and patients [37] and is the preferred method of alaryngeal speech by naı¨ ve listeners [34]. Summary The introduction of TE voice restoration in 1979 revolutionized postlaryngectomy speech and has emerged as the method of choice. It offers rapid recovery of fluent, high-quality speech that facilitates the rehabilitation of laryngectomy patients, allowing them to return to normal activities of life and work. Continual improvement in prosthesis design has expanded patient use and satisfaction. References [1] Gates GA, Ryan W, Cooper JC Jr, Lawlis GF, Cantu E, Hayaski T, et al. Current status of laryngectomy rehabilitation: results of therapy. Am J Otolaryngol 1982;3:1–7. [2] Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;89:529–33. [3] Blom ED. Current status of voice restoration following total laryngectomy. Oncology 2000;14(6):915–22. [4] Maves MD, Lingeman RE. Primary vocal rehabilitation using the Blom-Singer and Panje voice prosthesis. Ann Otol Rhinol Laryngol 1982;1:458–60. [5] Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol 1985;111:182–6. [6] Silverman AH, Black MJ. Efficacy of primary tracheoesophageal puncture in laryngectomy rehabilitation. J Otolaryngol 1994;23(5):370–7. [7] Kao WW, Mohr RM, Kimmel CA, Getch C, Silverman C. The outcome and techniques of primary and secondary tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 1994;120:301–7. [8] Karlen RG, Maisel RH. Does primary tracheoesophageal puncture reduce complications after total laryngectomy and improve patient communication? Am J Otolaryngol 2001; 22(5):324–8. [9] Blom ED, Hamaker RC. Tracheoesophageal voice restoration following total laryngectomy. In: Myers EN, Suen JY, editors. Cancer of the head and neck. 3rd edition. Philadelphia: WB Saunders; 1996. p. 839–52. [10] Singer MI, Blom ED, Hamaker RC. Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope 1986;96:50–3. [11] Singer MI, Blom ED, Hamaker RC, Yoshida GY. Application of the voice prosthesis during laryngectomy. Ann Otol Rhinol Laryngol 1989;98:921–5. [12] Blom ED, Singer MI, Hamaker RC. An improved esophageal insufflation test. Arch Otolaryngol 1985;111:211–2. [13] Desyatnikova S, Caro JJ, Cohen JI, Andersen PE, Wax MK. Tracheoesophageal puncture in the office setting with local anesthesia. Ann Otol Laryngol 2001;110:613–6.
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[14] Bach KK, Postma GN, Koufman JA. In-office tracheoesophageal puncture using transnasal esophagocospy. Laryngoscope 2003;113(1):173–6. [15] Eerenstein SE, Schouwenburg PF. Secondary tracheoesophageal puncture with local anesthesia. Layngoscope 2002;112(4):634–7. [16] Koch W. A failsafe technique for endoscopic tracheoesophageal puncture. Laryngoscope 2001;111(9):1663–5. [17] Shaw GY, Searl JP. Secondary tracheoesophageal puncture using a KTP laser. Laryngoscope 2000;110(9):1574–7. [18] Canon CR. Using an endotracheal tube in difficult secondary tracheoesophageal puncture: a novel technique. Otolaryngol Head Neck Surg 2001;125(1):117–9. [19] Fukutake T, Yamashita T. Speech rehabilitation and complications of primary tracheoesophageal puncture. Acta Otolaryngol (Stockh) 1993;(Suppl) 500:117–20. [20] Ramirez MJF, Domenech FG, Durban SB, Llatas MC, Ferriol EE, Maritnez RL. Surgical voice restoration after total laryngectomy: long-term results. Eur Arch Otorhinolaryngol 2001;258:463–6. [21] Hotz MA, Baumann A, Schaller I, Zbaren P. Success and predictability of Provox voice rehabilitation. Arch Otolaryngol Head Neck Surg 2002;128(6):687–91. [22] Mehle ME, Lavertu P. Sternoclavicular joint arthritis and manual pressure necrosis: two potential complications of tracheoesophageal puncture. Otolaryngol Head Neck Surg 1991;105:130–3. [23] Mehle ME, Lavertu P, Meeker SS, Tucker HM, Wood BG. Complications of secondary tracheoesophageal puncture: the Cleveland Clinic Foundation experience. Otolaryngol Head Neck Surg 1992;106:189–92. [24] LaBruna A, Klatsky I, Huo J, Weiss MH. Tracheoesophageal puncture in irradiated patients. Ann Otol Rhinol Laryngol 1995;104(4 pt 1):279–81. [25] Trudeau MD, Schuller DE, Hall DA. The effect of radiation on tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 1989;115:1116–7. [26] Blom ED. Tracheoesophageal speech. Semin Speech Lang 1995;16(3):191–204. [27] Lavertu P, Scott SE, Finnegan EM, Levine HL, Tucker HM, Wood BG. Secondary tracheoesophageal puncture for voice rehabilitation after laryngectomy. Arch Otol Head Neck Surg 1989;115(3):350–5. [28] Cantu E, Ryan WJ, Tansey S, Johnson CS Jr. Tracheoesophageal speech: predictors of success and social validity ratings. Am J Otolaryngol 1998;9(1):12–7. [29] Lavertu P, Guay ME, Meeker SS, Kmiecik JR, Secic M, Wanamaker JR, et al. Secondary tracheoesophageal puncture: factors predictive of voice quality and prosthesis use. Head Neck 1996;18(5):393–8. [30] Mendelsohn M, Morris M, Galllagher R. Speaking proficiency after primary tracheoesophageal puncture. J Otolaryngol 1993;22(6):435–7. [31] Robbins J, Fisher HA, Blom ED, Singer MI. Selected acoustic features of tracheoesophageal, esophageal and laryngeal speech. Arch Otolaryngol 1984;110:670–2. [32] Blom ED, Pauloski BR, Hamaker RC. Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part I: speech characteristics. Laryngoscope 1995;105:1093–103. [33] McColl D, Fucci D, Petrosino L, Martin DE, McCaffrey P. Listener ratings of the intelligibility of tracheoesophageal speech in noise. J Commun Disord 1998;31(4):279–89. [34] Merwin GE, Goldstein LP, Rothman HB. A comparison of speech using artificial larynx and tracheoesophageal puncture with valve in the same speaker. Laryngoscope 1985;95:730–4. [35] Pindzola R, Cain B. Acceptability rating of tracheoesophageal speech. Laryngoscope 1988; 98:394–7. [36] Williams S, Watson B. Speaking proficiency variation according to method of alaryngeal voicing. Laryngoscope 1987;97:737–9. [37] Culton GL, Gerwin JM. Current trends in laryngectomy rehabilitation: a survey of speechlanguage pathologists. Otolaryngol Head Neck Surg 1998;118:458–63.
Tracheoesophageal voice restoration with total laryngectomy Anna M. Pou, MD, FACS Department of Otolaryngology, University of Texas Medical Branch, 301 University Blvd., JSA Rm. 7.104, Galveston, TX 77555-0521, USA
The larynx is the second most common site for cancer in the upper aerodigestive tract, of which squamous cell carcinoma is the predominant type (95%). There are about 136,000 new cases diagnosed worldwide per year, with an estimated overall 5-year survival rate of 68%, making it one of the more curable cancers of the upper aerodigestive tract. Although organ preservation protocols and conservation laryngeal surgeries are in use today, patients with advanced or recurrent squamous cell carcinoma of the larynx continue to undergo total laryngectomy in the course of their treatment. Total laryngectomy profoundly alters speech, 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 to the rehabilitation of these patients. There are three methods of alaryngeal speech: electrolarynx, esophageal speech, and tracheoesophageal (TE) speech. Historically, 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 approximately 26% of patients are able to use this method in daily communications [1]. Those who could not master esophageal speech used the electrolarynx. Although the electrolarynx is the most common method of alaryngeal speech and the easiest method to learn, this device produces an unnatural, mechanical sound. It also relies on the use of batteries and is often not covered by insurance policies. The creation of a successful, surgical voice restoration technique did not occur until the introduction of the TE puncture (TEP) by Singer and Blom in 1979. It was proposed as a secondary salvage technique for those who E-mail address: [email protected] 0030-6665/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2004.01.009
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failed esophageal speech or those who were displeased with the electrolarynx voice [2]. The guidelines that were used to create this revolutionary method for voice restoration included (1) no oncologic compromise; (2) normal swallowing without aspiration; (3) reliable voice; (4) surgical simplicity, reliability, and reproducibility; (5) inclusion of an uncomplicated, costeffective prosthetic valve to prevent stenosis and aspiration; and (6) viability in irradiated tissue [3]. TE speech has evolved over the past 24 years and has gained worldwide acceptance. TEP, pioneered by Singer and Blom [2], is not very different from the selfinflicted 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 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. 1). Airflow is only limited by the vital capacity of the lungs. Various modifications and improvements have been made to the prosthesis since 1978 [2]. Other prostheses have also been introduced (Provox, Groningen, The Netherlands). Maves and Lingeman [4] and Hamaker et al [5] were the first to introduce TEP as a primary technique at the time of laryngectomy.
Primary voice restoration Selection criteria 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 separation occurs when 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, then abscess formation, sloughing of the posterior tracheal wall, and possibly mediastinitis can occur. Relative contraindications to primary TEP include the complexity of the reconstruction (see the article by Deschler and Gray elsewhere in this issue) and the patient’s inability to use and care for the prosthesis because of 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 caregiver. Other relative contraindications to primary TEP include bilateral severe sensorineural hearing loss (due to the patient not hearing the TE voice) and limited pulmonary function (limited pulmonary air restricts the fluency and volume of speech) [6]. Preoperative radiation therapy or the need for postoperative radiation therapy is not a contraindication for this procedure [5–7]. Studies have shown that there is no difference in complication rates between groups of
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Tracheoesophageal Voice Prosthesis
Speech
Location of tissue vibration for voice Tracheoesophageal Puncture and Blom-Singer® Voice Prosthesis
Stoma closure with thumb. (Low pressure prosthesis pictured)
Esophagus Trachea and Air from Lungs Adjustable tracheostoma valve for hands-free operation. (Indwelling prosthesis pictured)
Fig. 1. Anatomy and physiology of TE speech. (Courtesy of In Health Technologies, Carpinteria, California; with permission.)
patients who did and did not undergo radiation [6,8]. In addition, the rates of pharyngocutaneous fistula, wound breakdown, stomal stenosis, and esophageal stenosis are similar to those reported in patients who underwent total laryngectomy without primary TEP [8]. 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.
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This procedure allows the use of the catheter for feeding until the pharyngeal closure is healed and obviates the need for placement of a nasogastric tube through the fresh pharyngeal closure, which may reduce the pharyngocutaneous fistula rate [8]. 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 (see the article by Gress elsewhere in this issue). Primary TEP is believed to be safer than secondary TEP, in that there is less risk of mediastinal dissection and posterior esophageal perforation and there is elimination of additional anesthesia [8]. Surgical technique The technique for primary voice restoration includes five basic steps that 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 tracheoesophageal party wall [5]. Following laryngectomy, the stoma is constructed. The optimal tracheal diameter is 3 cm or greater to prevent stenosis. The midline inferior skin flap is sewn to the midline anterior tracheal ring using half vertical mattress sutures that allow coverage of the cartilage. Interrupted sutures are placed at 5-mm intervals on either side of the midline, pulling the trachea laterally. This process creates a straight, horizontal membranous trachea that is sewn to the superior skin flap. If the trachea is smaller than 3.0 cm, then a stomaplasty is performed [9]. The trachea is incised bilaterally for a vertical distance of 1 cm (two tracheal rings in length) between the midline and the most posterolateral aspect. An ‘‘X’’ is drawn in the midline of the inferior skin flap at the proposed stoma site. The skin and subcutaneous tissues of the superior and inferior areas of the ‘‘X’’ incision are discarded. The lateral triangles of skin are sewn into the apex of the lateral tracheal ring incisions, causing the trachea to enlarge (Fig. 2) [9]. The TEP is then performed using a ruler, a right-angled clamp, and a No. 15 scalpel blade (Figs. 3 and 4). The puncture is made 1.0 to 1.5 cm below the posterior cut edge of the stoma. A right-angled hemostat is placed in the esophagus through the pharyngotomy and pushed against the posterior tracheal wall. A 4-mm horizontal incision is made over the tip of the hemostat, and the hemostat is pushed into the tracheal lumen (Fig. 5A). The jaws of the hemostat are opened and a 16 French (F) Silastic Foley catheter is grasped and pulled through the party wall and fed down into the esophagus (Fig. 5B). Care should be taken at this step to ensure that the catheter is firmly grasped by the hemostat so that it does not slip while it is being pulled through the party wall. The catheter is sewn to the superior
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Fig. 2. Cadaveric stomaplasty: the lateral triangles of neck skin are sewn into the apex of the lateral tracheal incisions.
skin flap after the skin is closed and can be used to feed the patient in the immediate postoperative period (Fig. 6) [5,9]. Alternatively, the prosthesis can be primarily placed and the patient fed through a nasogastric tube. Management of the pharyngeal constrictor muscles to prevent pharyngeal spasm is key to successful TE speech (see the article by Bayles and Deschler elsewhere in this issue). The most reliable method for preventing spasm, if done properly, is a pharyngeal constrictor myotomy. The pharynx is rolled over a tubular structure, most often a finger or dilator, and the muscles are incised vertically in the posterior midline of the pharynx from the level of the puncture to the tongue base. The muscles are cut to the level of the submucosa.
Fig. 3. A ruler is used to measure the location of the planned puncture. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
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Fig. 4. A No. 15 scalpel blade is used to make a horizontal incision over the right-angle hemostat in the party wall. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
If bleeding occurs, then careful use of bipolar cautery is recommended. If an inadvertent pharyngotomy is made, the mucosa is repaired at this time. If flap reconstruction of the pharynx is performed, then the segment of muscle from the puncture site to the inferior flap is myotomized [5,9]. An alternative method that can be performed to prevent pharyngeal spasm is a unilateral pharyngeal plexus neurectomy [10]. After laryngectomy, the pharyngeal muscles lay medially at the level of the superior thyroid artery. The plexus is found within the middle constrictor muscle. A nerve stimulator is used to identify three to five nerve braches by eliciting muscle contraction. The nerve branches are then cut and coagulated. If poor muscle contraction is seen following stimulation, then this method is abandoned and a myotomy is performed. This method is also useful when the pharynx is already closed and a myotomy was inadvertently omitted. The party wall usually separates about 3 to 5 mm above the site of the puncture. The party wall is buttressed using interrupted sutures of 3-0 chromic or 4-0 vicryl (Fig. 7), which obliterates the space. This prevents the collection of saliva in this area if a fistula develops, and helps to maintain the integrity of the posterior stoma. If separation of the party wall extends below the area of the planned puncture, then the puncture is delayed because this can lead to pocket formation with abscess and loss of the posterior tracheal wall [5,9]. The voice prosthesis can be placed anytime after the patient is taking per oral feeds. Voicing, however, is delayed until 2 weeks postoperatively to allow the hypopharyngeal closure to heal. Voicing before this time may place too much air pressure on the new closure, disrupting the suture line. If the patient is discharged from the hospital with the Foley catheter in place, then the balloon is filled with 2 mL of normal saline to prevent accidental dislodgement of the catheter from the puncture site [6]. The patient is also
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Fig. 5. (A) The right angle hemostat is pushed through the party wall into the tracheal lumen. (B) The 16 French foley catheter is grasped with the right angle hemostat, pulled through the party wall, and guided into the esophagus. (From Myers EN, Carrau RL, editors. Operative otolaryngology: head and neck surgery. Elsevier, 1997; with permission.)
given varying sizes of red rubber catheters and instructed how to replace the catheter if it becomes dislodged. Primary TEP results in development of successful TE speech in 50% to 93% of patients, depending on patient selection criteria and the use of an indwelling prosthesis [5–8,11]. During postoperative radiation therapy, voicing may become interrupted due to mucositis or the patient’s inability to occlude the stoma due to pain. Although not used, the prosthesis may remain in place during this time [5]. Despite an overall excellent success rate, some clinicians are still hesitant to perform primary TEP based on lack of experience and fear of complications. When not performed primarily, TEP is rarely done as a secondary procedure, which likely is due to a patient’s bias toward his or her initial form of speech and reluctance to undergo another surgical procedure [8].
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Fig. 6. The catheter is secured to the upper skin flap in the midline.
Secondary tracheoesophageal puncture Patient selection and timing The few factors that guide patient selection are similar to those listed for primary TEP. The timing of secondary puncture depends on the extent of resection, the complexity of reconstruction, and the need for postoperative radiation therapy. Secondary voice restoration should be delayed until 6 weeks following laryngectomy, 6 to 8 weeks following postoperative radiation therapy, or until the peristomal skin has recovered from radiation toxicity and at least 1 month following recovery from reconstruction of a total laryngopharyngectomy or total laryngopharyngoesophagectomy defect and adjunctive therapies (see the article by Deschler and Gray elsewhere in this issue). These patients should also undergo barium swallow to evaluate the reconstructive changes and 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 [9].
Fig. 7. The party wall is buttressed using 4-0 vicryl.
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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, then 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 and whose tissues appear to be at risk are better managed by the former method. If a laryngectomy tube is used, then it can be fenestrated posteriorly and simultaneously worn with the prosthesis in place. When necessary, the stomaplasty is performed before the puncture, leaving the posterior wall intact. The stoma is enlarged using a Z-plasty technique on each side [9]. For fluent TE speech to occur, there must be sufficient relaxation of the pharynx. There is a subset of patients (20%–40%) who present with hypertonic or spastic speech, indicating spasm of the cricopharyngeus, inferior, and middle constrictor muscles when speech is attempted. A hypopharyngeal bar corresponding to these muscles can be seen with a 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 before puncture using the transnasal esophageal insufflation test [9]. 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 [12]. 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, which 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 are obtained following the insufflation test: (1) fluent, sustained voice production with minimal effort, indicating relaxed pharyngoesophageal muscles; (2) a breathy, hypotonic voice, indicating the absence of pharyngeal constrictor muscle tone; (3) hypertonic voice characterized by intermittent production of effortful speech, with gastric distension and posttrial burping; or (4) spasm that is characterized by no production of voice, even with substantial pulmonary air flow. Insufflation testing also is done after flap reconstruction or gastric pull-up to determine the quality of voice [9]. 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 and patient errors 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
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esophagus. Patient errors can be prevented by having the patient selfmonitor using a mirror [9]. Surgical procedure This procedure was first described by Singer and Blom in 1979 [2]. The following procedure is performed in the operating room under general anesthesia. The Blom-Singer tracheostoma puncture kit (InHealth Technologies, Carpinteria, California) 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 can be palpated. The position of the esophagoscope also protects the posterior esophageal wall from penetration. A No. 14 sheathed catheter is introduced into the bevel of the esophagoscope approximately 5 mm below the mucocutaneous junction. The needle is withdrawn, leaving the sheath in place. 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 and can be used for feeds if a secondary pharyngeal constrictor myotomy is performed, resulting in a fistula [9]. This kit can be replaced by using a curved 18-gauge needle, a 24-gauge wire, a red rubber catheter, a No. 15 scalpel blade, and a hemostat. This technique has been modified by many clinicians over the years to include the use of local anesthesia, transnasal esophagoscopy, and the use of the potassium titanyl phosphate laser, among other methods [13–17]. The prosthesis generally is placed in 48 hours but can be placed immediately. In patients who present with a stricture or fibrosis of the neck tissues following radiation therapy, 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. Cannon [18] described a technique that uses an endotracheal tube and a flexible bronchoscope. An appropriately sized endotracheal tube is passed through the esophageal lumen. A 7.4- to 10-mm window is cut at the junction of the middle and distal third of the endotracheal tube. A flexible bronchoscope that is passed inside the lumen of the endotracheal tube allows for a concomitant esophagoscopy. Light from the bronchoscope illuminates the puncture site. An Intracath venous needle (Deseret Co., Sandy, Utah) with an attached catheter is directed through the posterior tracheal wall into the lumen of the endotracheal tube. If necessary, forceps are used to grasp the catheter and pull it through the mouth. A red rubber catheter is then sutured to the catheter and delivered through the TEP site. When the insufflation test reveals hypertonic or spastic speech, a secondary pharyngeal constrictor myotomy or the injection of botulinum
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toxin (Botox) into the pharyngeal constrictor muscles is performed (see the articles by Bayes and Deschler and by Hoffman elsewhere in this issue). The secondary pharyngeal constrictor myotomy is done at the same time as the puncture and stomaplasty if necessary. A No. 34 to 40 Maloney dilator (Piling, Horsham, Pennsylvania) is inserted to confirm the location of the pharynx and esophagus. An incision is made between the pharynx and the carotid artery down to the level of the prevertebral fascia. The carotid is retracted laterally and the pharyngeal muscles are rolled over the dilator, which is pushed medially by the assistant. A complete myotomy is made from the level of the tongue base to the esophageal inlet. The muscles are incised until the submucosa is reached [9]. The fistula rate is 10% to 20%. Tube feedings are begun through the puncture catheter if a fistula occurs. When the fistula is healed, oral feeds may begin and voicing is delayed for an additional 2 weeks. Complications The most common complications encountered following primary and secondary TEP include (1) loss of the puncture site by dislodgment of the catheter placed at the time of puncture, (2) partial or complete extrusion of the prosthesis, (3) migration of the puncture site, (4) formation of granulation tissue, (5) aspiration of the prosthesis, (6) cellulites, (7) stomal stenosis, and (8) pharyngoesophageal stenosis (see the articles by Bunting and by Lewin elsewhere in this issue) [6,19–21]. Sternoclavicular arthritis and manual pressure necrosis have also been reported [22]. Violation of the posterior esophageal wall, passage of the catheter through a false passage, and esophageal perforation are unique to secondary TEP and can result in epidural abscess, vertebral osteomyelitis, and mediastinitis. Stricture dilatation has been associated with an increase in complication rate in secondary TEP [23]. Previous radiation [24,25], diabetes mellitus, chronic obstructive pulmonary disease, alcoholism, and extended laryngectomy have not been found to be significant risk factors for complications [23]. Postoperative rehabilitation Postoperative TE voice rehabilitation usually is taught by a speech and language pathologist. There are three basic treatment goals following TEP. The first is to dilate and measure the puncture, followed by placement of the prosthesis; the second goal is to instruct the patient and family in routine care of the prosthesis; and the third goal is to instruct the patient in finger occlusion of the tracheostoma and to apply and use a tracheostomal valve [26]. Briefly, the puncture must be dilated to the appropriate size to accommodate the prosthesis (eg, 22F for a 20F prosthesis). A measuring device is then placed into the puncture and slowly withdrawn until the retention collar sits against the inner surface of the esophageal wall and the length of
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the prosthesis is measured. If the length lies between sizes, then the longer size is chosen to prevent underfitting, which can cause the puncture to heal from behind. The type of prosthesis to be used is chosen. The duckbill and lowpressure prostheses are removable prostheses that the patient learns to clean and replace in the puncture. The indwelling low-pressure prosthesis is placed and removed by the physician or speech and language pathologist. Before placing the voice prosthesis, an ‘‘open-tract’’ test is performed. The patient is asked to voice without the prosthesis in place. Poor voicing is due to pharyngeal constrictor spasm or to excessive finger pressure occlusion of the stoma (see the article by Bunting elsewhere in this issue). The life of any prosthesis, in general, is about 3 to 6 months. It is the colonization of yeast that usually destroys the integrity of the valve, which causes leakage of saliva and foods and decreases the life expectancy of the prosthesis [9]. The next steps include patient and family education regarding care of the prosthesis and patient instruction regarding finger occlusion of the prosthesis. It is usually necessary to assist the patient with accurate occlusion of the stoma at the initial visit while the patient watches in the mirror. About six sessions are required for the average patient to master removal, cleaning, and reinsertion of the standard voice prosthesis. The indwelling prosthesis is used in patients who cannot or prefer not to use the removable prosthesis. For those patients who find finger occlusion unacceptable, a hands-free valve can be used [9]. Predictors of successful tracheoesophageal speech Many variables have been studied by various clinicians to predict which patients will achieve successful TE speech with primary or secondary puncture [8,21,25,27,28]. The results of these studies are varied, although age, sex, and tumor size/stage appear to have no influence. Alcohol abuse and lack of transportation to follow-up visits correlated well with TE speech failure in some studies [8,25] but were not significant in others [27,28]. Many clinicians, however, can anecdotally report alcohol abuse as a contributor to rehabilitation failure. In a study by Cantu et al [28], 36 patients undergoing either primary or secondary TEP were evaluated for long-term success and predictors of successful TE speech. Nearly two thirds of the patients had successful communication at an average of 4 years post puncture. For the remaining patients who were judged as unsuccessful, reduced vision, limited hand and arm movement, and history of radiation therapy (but not timing of radiation therapy) were found to be significant. There were, however, patients with good vision and hand coordination who did not develop good speech and patients with previous radiation therapy who developed successful speech. Therefore, the presence of these factors does not necessarily predict lack of success. The introduction of the indwelling prosthesis has reduced the problems associated with decreased function of
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the patient, and it is believed that the lack of radiation therapy may predict higher success. The timing of TEP did not appear to influence communication effectiveness [28], and the absence of pharyngeal stricture was the only significant predictor of good-to-excellent speech results in secondary TEP found in one study [29]. Due to variable results found in multiple studies, it has been suggested that studying a combination of factors using multiple regression or analysis of covariance will better identify predictors of success than studying a specific factor in isolation [28].
Voice quality It is important for potential TE speech users to have realistic expectations. The goal of voice restoration is to provide fluent, effortless, and intelligible speech. The quality of voice cannot be controlled. TE voice quality is usually harsh and often loses its sexual characterization [30]. Patients undergoing total laryngectomy, however, already have varying degrees of dysphonia, and TE voice quality should be compared with preoperative voice quality. In a study by Cantu et al [28], one third of patients (or their significant others) judged the success of their TE speech at a lower level than that of the primary investigator. This finding indicates that the clinician and patient may be using different standards of success; the patient and significant other may be using an ‘‘idealized’’ voice standard that cannot be produced using TEP. Patients should realize that there is a learning curve associated with TE speech; TE speech generally improves over time [21]. In addition, TEP does not preclude the use of other methods of alaryngeal speech. On the contrary, a functionally rehabilitated TE prosthesis user may find it easier to switch to esophageal speech [21]. Acoustic analysis of TE speech has been compared with laryngeal, esophageal, and electrolarynx speech by many investigators [31–34]. The fundamental frequency, intensity, and rate of TE speech approximates that of normal speech. In a study by Robbins et al [31], esophageal and TE speakers were analyzed for intensity, frequency, and rate of speech production. TE speech was found to be more similar to laryngeal speech than esophageal speech. When compared with esophageal speech, TE speech gives superior voice quality in reference to volume and phrase length and is much easier to learn. Also, the rate of speech is faster and the intelligibility is superior to that acquired using the artificial larynx or esophageal speech [34–36]. In the presence of noise, however, there is a lower rate of listener intelligibility of TE speech compared with laryngeal speech [33]. The prevention of pharyngeal spasm is paramount to the production of successful TE speech. Acoustic analysis of TE speech was studied following three different surgical methods used to address the pharynx: pharyngeal plexus neurectomy, pharyngeal constrictor myotomy, and unilateral pharyngeal plexus neurectomy with a drainage myotomy limited to the
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cricopharyngues. Patients undergoing pharyngeal plexus neurectomy had the highest fundamental frequency, which may be due to the residual resting tone in the pharyngoesophageal segment [32]. Management of the pharynx with neurectomy may be desirable in women who are undergoing laryngectomy with voice restoration. TE speech has been rated the most desirable form of alaryngeal speech by speech pathologists and patients [37] and is the preferred method of alaryngeal speech by naı¨ ve listeners [34]. Summary The introduction of TE voice restoration in 1979 revolutionized postlaryngectomy speech and has emerged as the method of choice. It offers rapid recovery of fluent, high-quality speech that facilitates the rehabilitation of laryngectomy patients, allowing them to return to normal activities of life and work. Continual improvement in prosthesis design has expanded patient use and satisfaction. References [1] Gates GA, Ryan W, Cooper JC Jr, Lawlis GF, Cantu E, Hayaski T, et al. Current status of laryngectomy rehabilitation: results of therapy. Am J Otolaryngol 1982;3:1–7. [2] Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;89:529–33. [3] Blom ED. Current status of voice restoration following total laryngectomy. Oncology 2000;14(6):915–22. [4] Maves MD, Lingeman RE. Primary vocal rehabilitation using the Blom-Singer and Panje voice prosthesis. Ann Otol Rhinol Laryngol 1982;1:458–60. [5] Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol 1985;111:182–6. [6] Silverman AH, Black MJ. Efficacy of primary tracheoesophageal puncture in laryngectomy rehabilitation. J Otolaryngol 1994;23(5):370–7. [7] Kao WW, Mohr RM, Kimmel CA, Getch C, Silverman C. The outcome and techniques of primary and secondary tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 1994;120:301–7. [8] Karlen RG, Maisel RH. Does primary tracheoesophageal puncture reduce complications after total laryngectomy and improve patient communication? Am J Otolaryngol 2001; 22(5):324–8. [9] Blom ED, Hamaker RC. Tracheoesophageal voice restoration following total laryngectomy. In: Myers EN, Suen JY, editors. Cancer of the head and neck. 3rd edition. Philadelphia: WB Saunders; 1996. p. 839–52. [10] Singer MI, Blom ED, Hamaker RC. Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope 1986;96:50–3. [11] Singer MI, Blom ED, Hamaker RC, Yoshida GY. Application of the voice prosthesis during laryngectomy. Ann Otol Rhinol Laryngol 1989;98:921–5. [12] Blom ED, Singer MI, Hamaker RC. An improved esophageal insufflation test. Arch Otolaryngol 1985;111:211–2. [13] Desyatnikova S, Caro JJ, Cohen JI, Andersen PE, Wax MK. Tracheoesophageal puncture in the office setting with local anesthesia. Ann Otol Laryngol 2001;110:613–6.
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