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Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 99-104 Review Article A brief review of voice restoration following total laryngectomy M Kapila, N Deore, RS Palav, RA Kazi, RP Shah, MV Jagade Department of ENT and Head and Neck Surgery, Grant Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, India Correspondence Address: Code Number: cn11016
Abstract Despite advances in conservative laryngeal surgery and radiotherapy, total laryngectomy still remains the procedure of choice for advanced-stage (UICC T3 and T4) laryngeal carcinoma, around the world. The functional rehabilitation of the laryngectomized patients has been a concern of head and neck surgeons and speech therapists. Significant developments in speech rehabilitation over the past three decades have led to substantial improvements in the quality of life of these patients. The tracheoesophageal (TE) voice prosthesis has become the gold standard in various centers for voice rehabilitation since its introduction in 1980. Successful tracheoesophageal voice restoration in laryngectomy patients can be very rewarding and patients no longer have to live in silence while they await the results of their cancer treatments. They can face the challenges of life with the knowledge that a near normal quality of life is very much possible.In this article, we present a brief review of voice restoration following laryngectomy.Keywords: Tracheoesophageal speech, voice prosthesis, surgical voice restoration Introduction With the advances in voice conservative surgeries and radiotherapy techniques, most patients of cancer of the larynx can be cured. [1] However, for those who do not respond or present with recurrent or advanced disease, total laryngectomy is the only curative approach that can be offered. [2] The prognosis of laryngectomized patients has remained relatively favorable over the years, with five-year survival rates of 65 - 75%. [3] However, the procedure has various functional and physiological consequences. In addition to the loss of voice, there is loss of olfaction sense, a poor cough reflex, swallowing difficulties, lung function changes, and complications associated with a permanent tracheostoma. [4] The importance of the loss of speech is not appreciated until it is lost. Speech forms an important part of day-to-day life this world, where one relies heavily on verbal communication. [5] The functional rehabilitation of laryngectomized patients has been the major concern of head and neck surgeons and speech therapists. Various developments in speech rehabilitation over the past three decades have led to improvements in the quality of life of these patients. Physiology of Voice Production Voice is produced by the respiratory tract with the lungs acting as bellows. The air passes by the adducted vocal cords and voice is produced on expiration. The larynx is the voice generator, vibrating from the air column and producing a sound. A traveling mucosal wave is generated on the surface of the membranous vocal cords during active adduction. Understandable speech is then created when the articulators, lips tongue, and teeth, form the sound emanating from the larynx into words. The voice resonator formed by the oral cavity and pharynx transmits or suppresses certain frequencies of the sound wave and speech is produced. With the larynx removed, the basis of speech rehabilitation is to replace the voice generator. [5] Voice restoration for laryngeal speakers can be attained with any of the three speech options namely esophageal speech, electrolarynx, and now surgical voice restoration (SVR), using the valve. Non-Surgical Methods of Speech Rehabilitation The non-surgical methods of communication that can be used by laryngectomy patients are esophageal speech, writing, gestures, pneumatic, and electronic larynges. Esophageal speech Seeman, in 1922, found that the cervical esophagus acted as a vibratory source and the rest of the esophagus and stomach acted as an air reservoir and produced speech in certain patients of laryngectomy. [6] This technique of esophageal speech was widely adopted. It is produced by swallowing air, which is then released in a controlled manner so as to vibrate the soft tissues of the pharyngoesophageal segment, and the sound thus produced is modified into words in the normal manner. This form of speech may have effects such as severe heartburn on swallowing air, causing the patients to discontinue it. The speech produced is of low volume and low pitch and is unpopular with females. It also requires support and motivation from family members. All these factors are responsible for a success rate of 14 to 76% in patients acquiring esophageal speech. [7] The advantages lie in the lack of a prosthesis, requiring maintenance and risks of surgical procedures. Artificial larynx Patients who have failed other methods of speech rehabilitation post radiation or with disorders that do not allow adequate care of valves, are candidates for the artificial larynx. The pneumatic larynx consists of a metal or plastic tube that transmits respiratory air from the tracheal stoma to the mouth. They achieve fundamental frequencies approaching normal speech, but are not accepted widely as they are cumbersome. The electronic larynx consists of a diaphragm that is vibrated by an electromechanical vibrator, which when held over the neck, transmits vibrations that are modified by the mouth to produce speech. [8] The voice produced is monotonous and mechanical sounding. Surgical Methods of Voice Restoration The aim of surgical voice restoration procedures is to use the lungs as an airflow source and prevent the aspiration of ingested material. Taub and Spiro proposed the ′Voice-Back′ technique of voice restoration, which involved the construction of a secondary, skin lined esophagostoma, in which was placed a one-way silicon valve connected to the tracheostoma. [9] Problems included maintenance, need for a secondary procedure, and difficulty in construction of a stoma in post radiation necks. This technique fell into disuse. This was followed by attempts at biological valving of the pharynx. Arslan and Serafini reported a technique of ′ epiglottohyoidopexy′. [10] This method had a serious complication of aspiration. Staffieri and Serafini described a technique of primary tracheopharyngeal shunt, using the pharyngeal musculature as a sphincter.[11] Good speech fluency was achieved by the procedure, but problems of shunt closure and lack of evidence of use of this technique in a post radiation setup led to the decline of this technique. To develop an effective voice post surgery, the mucous folds in the pharyngoesophageal segment must be vibrated by the airflow. This has to be done in such a way that the swallowed material does not enter the airway. This has been better achieved by an artificial valve than by a biological valve. [12] Tracheoesophageal voice using voice prosthesis The first voice rehabilitation technique was used by Gussenbauer, Billroth′s assistant, in 1873. He placed a reed valve into a temporary pharyngostome allowing air to vibrate the valve and then travel through the pharynx for speech production. [13] The primary purpose of the pharyngostome was to prevent pulmonary complication as a result of wound breakdown. As the operative techniques improved, the complications decreased, and the necessity for a temporary pharyngostome was no longer needed and the voice rehabilitation technique was lost. Various techniques were developed and refined since that time. Up until the 1970s, esophageal speech and electronic larynx were the popular and existing methods of voice rehabilitation. [5] The first reported use of a valved prosthesis was by Eric Blom, a speech therapist, and Mark Singer a surgeon, in 1978, when they secondarily inserted a specially designed valved prosthesis into a surgically created tracheoesophageal fistula. [12] The one-way valve of the prosthesis allowed air during expiration to enter the pharynx and produced sound by vibrating the mucosa of the pharyngoesophageal segment. The valve closed while swallowing preventing the salivary soiling of the airway. This prevented pulmonary aspiration and also helped in voice production with the help of pulmonary air. By the mid-1980s, a variety of prostheses were developed by various workers across the world, such as, Panje, Groningen, Nijdam, Herrman, Traissac, Algaba, and Bonelli among others. The first prostheses to be developed were designed as ex-dwelling devices - to be cared for by the patient. Then hands-free devices were developed - to be followed by low pressure devices. The non-indwelling or ex-dwelling devices had to be removed, cleaned, and re-inserted by the patient. The in-dwelling prostheses need less dexterity on the part of the patient and can be cleaned in situ. They are periodically replaced by the otolaryngologist or the speech language pathologist. The earlier prostheses had a duckbill valve and a tapered tip to facilitate easier insertion; they, however, presented more resistance to airflow. The newer valves present lesser material into the esophagus and function at a lower resistance - the ′low-pressure′ prosthesis. Today, the Provox; voice prostheses developed by the Netherlands Cancer Institute and the Blom-Singer; voice prosthesis by In-Health Technologies Ltd. are the most commonly used prostheses worldwide. [12],[14] With the advent and the use of bio-compatible materials, the indwelling prostheses that are maintained by the clinician have become increasingly popular. The reported fluency rates achieved by this method are 90%. [12] The technique of tracheoesophageal speech rehabilitation involved the creation of a simple puncture between the posterior wall of the tracheostome and the upper esophagus, into which a one-way silicone valve was inserted. The valve prevented the entry of swallowed material into the airway, while the prosthesis conducted the expired air, when the tracheostoma was occluded, into the pharyngoesophageal segment. This air was then used to vibrate the mucosal folds and the sound conducted was modified into speech by the oral cavity. [12] Hamaker et al., in 1985, were the first to use the procedure as a primary puncture during a laryngectomy.[16] In a retrospective study of 75 patients who underwent a primary tracheoesophageal puncture (TEP) and 18 secondary TEPs, there was no statistically significant difference in the success rate on assessment using the Harrison-Robillard-Schultz Rating Scale (HRSS). [17] The authors concluded that a primary TEP should be preferred in view of the requirement for a secondary procedure and he psychological impact in secondary TEP. Brown et al. [18] found no difference in patients undergoing primary or secondary TEP. The procedure can be done in post-radiotherapy patients, who have undergone a neck dissection or have previously undergone a laryngectomy. The puncture can be utilized for postoperative esophagogastric feeding in the postoperative period. Patients can start speaking within a few days of surgery, which is helpful for the patient′s psychological state. [17] Closure of the fistula can easily be achieved if the patient so desires. It is more easily attained than esophageal speech. The tracheoesophageal speech utilizes he pulmonary air supply to produce sound. [15] It is closer to laryngeal speech when compared to voice parameters such as fundamental frequency, words per minute, and maximum phonation time. [Table - 1] In tracheoesophageal speech more air is available for speech as the entire tidal volume of expired air, which is 500 ml, is much more in comparison to esophageal speech, which is around 40 - 70 ml. As the speech is lung powered, the speech is louder, more fluent in quality, and more sustained when compared to esophageal speech. [Table - 2] Disadvantages of tracheoesophageal speech include a finger that is required to occlude the tracheostoma, patients are dependent on the physician for the change of the prosthesis, and a second surgery is required if the patient is undergoing a secondary insertion. A retrospective multicenter study conducted to study the complications of tracheoesophageal voice restoration, involving 95 patients, found complications that ranged from mild to severe, and included problems with predictive values obtained during insufflation, fistula retention, TEF angulation shifts, fungal colonization of the prosthesis, valve retention problems, difficulty with digital occlusion, pressure necrosis, postradiation necrosis, dysphagia, phonatory gagging, emesis, gastric distention, pouching, stenosis, infection, hypertrophy, shunt insufficiency, persistent spasm, myotomy, inadvertent fistula closure, and aspiration of the prosthesis. [19] Complications that may occur during a secondary puncture include violation of the posterior pharyngeal wall, passage of the catheter into a false passage, and esophageal perforation. [20] Advances in the manufacture of the valve have tried to tackle these problems with the introduction of hands-free valves, low-pressure, and indwelling and fungal-resistant valves. [14] Types of Valves The types of valves available include the ′ex-dwelling′ and the ′indwelling′ valves. The ′ex-dwelling′ valves have straps or tapes to secure the prosthesis to the neck. The ex-dwelling prostheses have smaller flanges in comparison to the newer indwelling prostheses. They have to be cared for by the patient, by routine removal, cleaning, and re-insertion. The ′indwelling′ valves are cleaned in-situ and replaced at intervals by a qualified speech-language pathologist or otolaryngologist. The ′indwelling′ voice prostheses of the low pressure type have larger and thicker retention collar dimensions, which secure it without the need for straps. [14] Selecting a Prosthesis When selecting a valve for a patient, attention has to be paid to certain important issues, which include candidate dexterity, phonatory effort, party wall thickness, durability, and cost of the prosthesis. An indwelling prosthesis is ideal for patients unwilling to change their valve independently. [21] Patients with good phonatory effort with an open puncture tract prior to insertion of prosthesis can have a trial of higher-resistance durable valves. [22] The length of the fistula or party wall thickness needs to be estimated accurately, to obtain a snug fit for the prosthesis. [21] Problems with Surgical Voice Restoration and Troubleshooting The problems and complications with relation to the use of the tracheoesophageal prosthesis are manageable when recognized early and with appropriate treatment plans. [23],[24] Leakage Leakage of fluids causing coughing when swallowing could be due to leakage either through or from around the prosthesis. Leakage through the prosthesis could be caused due to a faulty valve, valve distortion, debris blocking the valve, or end of the natural lifespan of the valve. A faulty valve is usually evident immediately after insertion. An inadequately dilated tract results in distortion of the valve after insertion, as in a 20Fr valve used for a tract dilated only to 16Fr. This can be avoided by slow dilatation of the tract over several hours or overnight. Leakage can occur if there is debris blocking the valve. The natural lifespan of the valve can vary enormously from a few weeks to over a year and this can be prolonged by careful cleaning of the valve either in-situ or after removal. [23] Fungal colonization with candida albicans is one of the most common causes of leakage, which is caused by distortion of the valve mechanism. Use of nystatin suspension (500 000 units swished around in the mouth twice daily) reduces colonization and increases the lifespan of the valve. [24] Leakage from around the prosthesis could be due to a long prosthesis causing it to move in and out like a piston. Patients who are cachectic or thin, post radiotherapy, have a thin party wall that is freely mobile and wide. These patients should not be fitted with a larger prosthesis, but it should be down-sized and fitted with a silicon anti-leakage ring. [25] Remacle and Declaye have reported good results with the use of Type I collagen injections into the posterior tracheal wall. [26] Perie et al. [27] has reported success with the use of the autologous fat injection for the leakage around the prosthesis. Surgical closure of the fistula is rarely performed; if done it is conducted by using a non-irradiated muscle flap between the trachea and esophagus and a three-layer closure is carried out with a secondary puncture performed three months later. An inferiorly based sternomastoid muscle flap or if there is loss of excessive mucosa then a pedicled myocutaneous flap can be used for reconstruction. [23] Granulations Early valves were frequently blocked due to an inferiorly placed opening being blocked by granulations; this is no longer a problem. However, granulations may arise from the posterior wall of the trachea due to a valve that is too tight or placed at an angle. The granulations may be cauterized and removed and the valve position corrected. [24] Fibrous ring On long-term use, the tracheal end of the valve becomes surrounded by a doughnut-shaped fibrous ring, which gradually increases the length of the tract and causes failure of the voice. If the ring is not too prominent then resizing can be done, else it has to be excised. [28] Valve extrusion The valve can be dislodged during cleaning or coughing and the tract may close down. If the valve is inhaled it has to be retrieved by bronchoscopy. The tract tends to close down immediately after extrusion. It can be maintained by a catheter or dilator till the prosthesis is replaced. If the tract has not closed down completely it can be serially dilated by soft urethral catheters or by curved metal male urethral dilators by an experienced clinician. [28] Aphonia Aphonia due to incomplete insertion requires resizing and re-insertion and aphonia due to closure requires a re-puncture. [28] Hypertonicity Hypertonicity or spasm of the pharyngeal constrictors causes voice failure. This can be corrected by injection of botulinum toxin or by a long myotomy. [29] A transcutaneous pharyngeal plexus block can be tried as an office-based procedure, to identify this problem. If effective relaxation follows the block, the problem can be relieved by a constrictor myotomy. A selective neurectomy at the time of total laryngectomy can eliminate this problem. [15] Hypotonicity Hypotonic voice, usually due to a reconstructed hypopharynx may be corrected with digital pressure or with an elastic band worn over the pharynx in the neck. [24] Excessive flatulence Air may be ingested across the valve due to the negative pressure in the esophagus during inspiration and a hypotonic or hypertonic pharyngoesophageal segment. This may be corrected by a high resistance valve such as the duck-bill valve. [24] Stomal stenosis The stoma has a natural tendency to contract till the peristomal scar tissue stabilizes. Patients may need to wear stoma buttons or laryngectomy tubes to prevent stenosis. Managing a prosthesis becomes difficult when the stoma is smaller than 2 cm and breathing difficulty occurs if it is less than 1 cm. A well-established stenosis of the stoma needs to be managed by a stomaplasty technique such as V-Y advancement. [24] Macrostomia The stoma may occasionally be too large for the patient to be able to achieve an air tight closure with finger occlusion and in such cases the patient may need to use a laryngectomy tube or a hands-free valve. [14] Mucous discharge If excessive mucous discharge from the stoma is a problem it can be managed by a heat moisture exchanger system. [30] Heat moisture exchange and hands-free systems During expiration heat moisture exchangers (HME) collect heat and moisture from the expired air and heat, filter, and moisten the inspired air. Their constant use has a positive effect on the pulmonary function, quality of life, and voice quality. [30] Tracheostoma breathing valves provide housing for heat moisture exchangers and allow hands-free speech. Housing is either intra-luminal or peristomal, the former consists of a soft silicon rubber conforming to the patient′s stoma and the latter is usually fixed by an adhesive disk, to the peristomal skin. The valve is open during quiet respiration and closes automatically during an increase in expiratory flow, required for speech production. [31] Conclusion Various advances have tried to tackle the loss of voice associated with laryngectomy, including voice conservation surgeries and restoration. All of them aim to give a better quality of life to the patient. The tracheoesophageal voice prosthesis has become the gold standard in various centers for voice rehabilitation, since its introduction in 1980. The other options of rehabilitation, however, should not be forgotten, as no single option is best for every patient. While selecting prostheses, attention must be paid to details such as the integrity of the pharyngoesophageal segment, valve size, and troubleshooting. Leakage and fungal infestation continue to remain a problem, despite the advances in the prosthesis design. The cost and maintenance of a prosthesis are still a major concern in third-world countries. It is, however, rewarding to be able to successfully provide speech rehabilitation via a voice prosthesis in a laryngectomized patient. References
Copyright 2011 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn11016t2.jpg] [cn11016t1.jpg] |
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