voice rehabilitation following laryngectomy

Voice Rehabilitation following Laryngectomy

Balasubramanian Thiagarajan

An initiative of drtbalu's otolaryngology online

Introduction

Total Laryngectomy is still the preferred management modality in advanced laryngeal malignancies

Advances in medical oncology and radiation oncology combined with traditional surgical methods has increased longevity of these patients

TEP (Tracheo-oesophageal puncture) is considered gold standard among various voice rehabilitation procedures

A good percentage of patients undergoing total Laryngectomy regain esophageal voice

The current 5 yr. survival rate of patients following total Laryngectomy is about 80%


Functional alterations following total Laryngectomy Loss of smell Changes in normal swallowing mechanism Changes in the pattern of respiration Most importantly Loss of speech. The importance of this function is not

realized till it is lost


Components of phonation

Lung (Bellows

)

Larynx (Vibrat

or)

Articulators (Lips, tongue, teeth)


Requirements for normal phonation

Active respiratory support Adequate glottic closure Normal mucosal covering of vocal cord Adequate vocal cord length and tension control


Glottic cycle

One opening and one closing incident of glottis is known as glottic cycle The frequency of glottic cycle is determined by subglottic air pressure This frequency is unique for each individual


Vocal fold vibratory phases

During phonation two types of vibratory phases occur (Open and closed phases)

In open phase glottis is at least partially open Open phase can be divided into opening and closing phases In opening phase the vocal cords move away from one another In closing phase the vocal folds move closer to each other in unison Closed phase indicate complete closure of glottic chink


Vocal folds vibratory patterns

Falsetto Modal voice Glottal fry


Falsetto vibration

Vocal cord closure is not complete There is minimal air leak between the cords Only upper edge of vocal fold vibrates Also known as light voice


Modal voice

This is the basic frequency at which a pt. phonates Complete glottal closure occurs during this phase Vocal fold mucosa vibrates independently of the underlying vocalis

muscle Modal frequency in adult males is around 120 Hz Modal frequency in adult females is around 200 Hz


Glottal fry

Low frequency phonation In this type of vocal fold vibration closed phase is longer when compared

with that of open phase The vocal fold mucosa and vocalis muscle vibrate in unison


Mucosal wave

Very important physiological parameter to be noted during vocal fold motion

It is the undulation that occurs over vocal fold mucosa This wave travels in infero superior direction The speed of this wave 0.5 – 1 m/sec Symmetry of these waves between both sides should be evaluated.

Even mild degrees of asymmetry is pathological


Methods of speech following Laryngectomy Also known as alaryngeal speech Esophageal speech Electro larynx TEP (Tracheo-oesophageal puncture)


Esophageal speechAlaryngeal speech


Contd…

All pts. Develop some degree of esophageal speech following Laryngectomy

All alaryngeal speech modalities are compared with this modality Till 1970’s this was the gold standard for all other post Laryngectomy

speech rehabilitation procedures


Esophageal speech - Physiology

Air is swallowed into cervical esophagus This swallowed air is expelled out causing vibrations of pharyngeal

mucosa These vibrations along with articulations of tongue cause speech to

occur The exact vibrating portion of pharynx is the pharyngo-oesophageal

segment The vibrating muscles and mucosa of cervical oesophagus and

hypopharynx cause speech


Oesophageal speech – PE segment

This segment is made up of musculature and mucosa of lower cervical area (C5-C7 segments).

Vibration of this segment causes speech in pts. Without larynx Cricopharyngeal area is important Cricopharyngeal spasm in these pts. Can lead to failure in developing

Oesophageal speech Cricopharyngeal myotomy may help these pts. in developing

Oesophageal speech


Pumping air into cervical oesophagus

Injection method Inhalational method


Injection method

Enough positive pressure is built inside oral cavity to force air into cervical oesophagus

Lip closure and tongue elevation against palate causes increase intraoral pressure

Air is injected into the cervical oesophagus by voluntary swallowing This method is also known as tongue pumping / glossopharyngeal

press / glossopharyngeal closure This method is really useful before uttering plosives / fricatives /

affricatives


Inhalational method

Uses the negative pressure used in normal breathing to allow air to enter cervical oesophagus

Air pressure in the cervical oesophagus below Cricopharyngeal sphincter is the same negative pressure as that of thoracic cavity

Pts. Learn how to relax Cricopharyngeal sphincter during inspiration allowing air to flow into cervical oesophagus as it enters the lungs

Pts. Are encouraged to consume carbonated drinks which facilitates air entry into cervical oesophagus helping in generation of Oesophageal speech


Esophageal speech - Advantages

Patient’s hands are free No additional surgery / prosthesis needed. Hence no extra cost for the

pt. Pts. Get easily adapted to esophageal voice


Esophageal speech - Disadvantages

Nearly 40% of pts fail to develop esophageal speech Quality of voice generated is rather poor Pt. may not be able to continuously speak using esophageal voice

without interruption. They will be able to speak only in short bursts Significant training is necessary Loudness / pitch control is difficult Fundamental frequency of esophageal speech is 65 Hz which is lower

than that of male and female frequencies


Esophageal speech development causes for failure Presence of cricopharyngeal spasm Presence of reflux esophagitis Abnormalities involving PE segment – like thinning of muscle wall in that

area Denervation of muscle in the PE segment Poorly motivated patient


Cricopharyngeal spasm

Cricopharyngeal myotomy Botulinum toxin injection – 30 units can be injected via the

tracheostome over the posterior pharyngeal wall bulge


Electrolarynx

These are battery operated vibrating devices It is held in the submandibular region Muscle contraction and changes in facial muscle tension causes

rudiments of speech Initial training to use this equipment should begin even before surgery


Electrolarynx - Types

Pneumatic – Dutch speech aid, Tokyo artificial speech aid Neck Intraoral type


Electrolarynx - Contd

Neck type is commonly used Hypoesthesia of neck during

early phases of post op period can cause difficulties

If neck type cannot be used intraoral type is the next preferred one


Intraoral artificial larynx

Intraoral cup should form a tight seal over the stoma. There should not be any air leak

Oral tip should be placed in the oral cavity

Pts exhaled air rattles the cup placed over the stoma

Changes in exhaled pressure can vary the quality of sound generated


Electrolarynx - advantages

Can be easily learnt Immediate communication is possible Additional surgery is avoided Can be used as a interim measure till the patient masters the technique

of esophageal speech or gets a TEP inserted


Electrolarynx - Disadvantages

Expensive to maintain Speech generated is mechanical in quality Difficult while speaking over telephone


Types of voice restoration surgeries

Neoglottic reconstruction Shunt technique


Neoglottis procedure

Performing trachea hyoidopexy This can restore voice function in alaryngeal patients Abandoned due to increased incidence of complications like aspiration


Shunt technique

Developed by Guttmann in 1930 Involves creation of shunt between trachea and esophagus Lots of modifications of this procedure is available, Basic principle is the

same Aim is to divert air from trachea into the esophagus


Types of shunts

High trachea-esophageal shunt (Barton) Low trachea-esophageal shunt (Stafferi) TEP shunts (Guttmann)


Causes of failure of shunt procedure

Aspiration through the fistula Closure of the fistula To avoid these problems prosthesis was introduced


Types of Prosthesis


TEP

Was first introduced by Blom and Singer in 1979 One way silicone valve is introduced via the fistula This valve served as one way conduit for air into esophagus while

preventing aspiration This prosthesis has two flanges, one enters the esophagus while the

other rests in the trachea. It fits snugly into the trachea-esophageal wound

Indwelling prosthesis have more rigid flanges when compared to that of non indwelling ones

A medallion ring is attached to the non indwelling prosthesis to prevent aspiration


Types of TEP

Primary TEP – Performed during total laryngectomy Secondary TEP – Performed 6 months after surgery


Anatomical structures TEP

TEP is performed in midline (Less bleeding) Structures that are penetrated during TEP - membranous posterior wall

of trachea, esophagus and its 3 muscle layers and esophageal mucosa Interconnecting tissue in the trachea-esophageal space


Advantages of TEP

Can be performed after laryngectomy / irradiation / chemotherapy / neck dissection

Fistula can be used for esophago-gastric feeding during immediate PO period

Easily reversible Speech develops faster than esophageal speech High success rate Closely resembles laryngeal speech Speech is intelligible


Disadvantages of TEP

Pt should manually cover the stoma during voicing Good pulmonary reserve is a must Additional surgical procedure is needed to introduce it Posterior esophageal wall can be breached Catheter can pass through the posterior wall


TEP – Patient selection

Motivated patient Patient with stable mind Patient who has understood the anatomy & physiology of the process Patient should not be an alcoholic Good hand dexterity Good visual acuity Positive esophageal air insufflation test Patient should not have pharyngeal stricture / stenosis Stoma should be of adequate depth and diameter Intact trachea-esophageal wall


Contraindications of TEP

Extensive surgery involving pharynx, larynx with separation of trachea-esophageal wall

Inadequate psychological preparation Patient with doubtful ability to cope up with prosthesis Impaired hand dexterity Suspected difficulty during PO irradiation


Primary - TEP

Hamaker first performed in 1985 Primary TEP should be attempted where ever possible In this procedure puncture is performed immediately after laryngectomy

and prosthesis is inserted Prosthesis of sufficient length should be used


Primary TEP - Advantages

Risk of separation of trachea – esophageal wall is minimized Tracheo – esophageal wall is stabilized to some extent by the prosthesis Flanges of prosthesis protects trachea from aspiration Stomal irritation is less Patient becomes familiar with prosthesis immediately following surgery Post op irradiation is not a contraindication


Primary TEP - Procedure

Because of exposure following laryngectomy it is easy to perform Ideally performed before pharyngeal closure Puncture is performed through pharyngotomy defect Ryles tube can be introduced via the fistula to provide gastric feeding in

the post op period


Secondary TEP

Usually performed 6 weeks following laryngectomy This allows pt time to develop esophageal speech Area of fistula identified using rigid esophagoscope Prosthesis can be inserted immediatly


Modified secondary TEP procedure

Performed under local anesthesia Patient placed in recumbent position with mild extension of neck with a

shoulder roll Tracheostomy tube is removed 12 0 clock position of tracheostoma visualized and infiltrated using 2%

xylocaine with 1 in 100,000 adrenaline Yanker’s suction tube is inserted into the oral cavity till it hitches against

12-0 clock position of tracheostome This area is incised using 11 blade and widened using curved artery

forceps Blom singer prosthesis is then introduced through this fistula


12 – 0 clock position of tracheostoma


Yanker’s suction tube inserted


TEP - Incision


TEP - widened


Prosthesis introduced


Prosthesis used in TEP

Blom-Singer prosthesis Panje button Gronningen button Provox prosthesis


Panje voice button

Biflanged tube with one way valve

Can be inserted through the fistula created for this purpose

It is supplied with an introducer which makes insertion simple

Should be removed and cleaned every two days

Can be removed, cleaned and reinserted by the patient


Gronningen button

Introduced by Gronningen of Netherlands in 1980

Its high airflow resistance delayed speech in some patients

Now low air flow resistance tubes have been introduced


Blom-Singer prosthesis

Introduced by Blom and Singer in 1978 Commonly used prosthesis This prosthesis acts as one way valve

allowing air to pass into the esophagus and prevents aspiration

This prosthesis is shaped like a duck bill hence known as “Duck bill prosthesis”

The duck bill end should reach up to oesophagus

It is an indwelling prosthesis can be left in place for 3 months

This prosthesis is available in varying lengths


Provox prosthesis

Indwelling low air flow pressure prosthesis

It has extended life time. Can last a couple of yeas if used properly

Insertion is easy


Indwelling versus Non indwelling prosthesis

Indwelling prosthesis Non indwelling prosthesisCan be left in place for 3-6 months

Should be removed and cleaned every couple of days

Requires specialist to do the job Pt. Can do it themselvesLess maintenance Periodical maintenance Stoma should be greater than 2 cms

Stoma should be greater than 2 cms

Oesophageal insufflation test should be positive

Oesophageal insufflation test should be positive


Problems with TEP insertion

Leak through the prosthesis Leak around the prosthesis Immediate aphonia / dysphonia Hypertonicity problems Delayed speech


Oesophageal insufflation test

Should be performed before TEP Assesses cricopharyngeal muscle response to esophageal distention A catheter is placed through the nostril up to 25 cm mark. This

indicates probable site of puncture Pt is asked to count numbers or vocalize “Ah”


Insufflation test interpretation

Fluent voice on minimal effort – normal Breathy voice indicating hypotonic cricopharyngeal muscle Hypertonic voice – “Cricopharyngeal spasm” Spasmodic voice – “Extreme cricopharyngeal spasm”


Common problems with TEP

Improper location of puncture Inappropriate size of puncture Presence of cricopharyngeal spasm Leakage through and around the prosthesis


Location of TEP

12-0 clock position of stoma About 1-1.5 cms from trachea-cutaneous junction If located superiorly pt may find it difficult to occlude If located deep into the trachea then it becomes difficult to introduce the

prosthesis


Management of leak through the prosthesis

Cause SolutionValve in contact with posterior wall of esophagus

Replace prosthesis with different length and size

Prosthesis length too short for the puncture “Pinched valve”

Remeasure the puncture and replace with appropriate size prosthesis

Valve deterioration Replace valveFungal colonization of valve with yeast

Treat with nystatin

Back pressure High resistant prosthesisMucous / food lodgment Prosthesis to be cleaned


Management of leak around the prosthesis

Cause SolutionTEP location Remove prosthesis allow

puncture to close and repunctureUnnecessary dilatation during

valve placementTo be avoided

Thin trachea-esophageal wall 6 mm or less

Choose custom prosthesis

Prosthesis of incorrect length and size

Choose correct length

Poor tissue integrity due to irradiation

Custom prosthesis


Thank you

voice rehabilitation following laryngectomy

Documents

vocal fold motionit

vocal cords

type of vocal fold vibration

basic frequency

hzmodal frequency

openopen phase

phasevocal fold mucosa

closing incident of