voice rehabilitation following laryngectomy balasubramanian thiagarajan

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 prosthesis

Can 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 themselves

Less 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 Solution

Valve 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 valve

Fungal colonization of valve with yeast

Treat with nystatin

Back pressure High resistant prosthesis

Mucous / food lodgment Prosthesis to be cleaned


Management of leak around the prosthesis

Cause Solution

TEP location Remove prosthesis allow puncture to close and repuncture

Unnecessary dilatation during valve placement

To 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 balasubramanian thiagarajan

Documents

phase vocal fold mucosa

vocal cords

vocal fold motion

vocal fold vibratory

open open phase

type of vocal fold vibration

upper edge of vocal

opening phase