Chapter 9 PROSTHETIC TRACHEOESOPHAGEAL VOICE

Transcription

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Chapter 9
PROSTHETIC
TRACHEOESOPHAGEAL VOICE
RESTORATION FOLLOWING
TOTAL LARYNGECTOMY
Corina J. van As-Brooks and Dennis P. Fuller
Excerpt from Head and Neck Cancer: Treatment, Rehabilitation, and Outcomes
By Elizabeth C. Ward and Corina J. van As Brooks.
Visit www.pluralpublishing.com for more information.
CHAPTER OUTLINE
Introduction
Historical Review: Tracheoesophageal Speech
The First Total Laryngectomy and Artificial
Larynx
Tracheoesophageal Shunt Procedures
Voice Prostheses for Tracheoesophageal Speech
Surgical Techniques and Factors Influencing
Voice Production
Pharyngeal Closure
Primary or Secondary Tracheoesophageal
Puncture
Primary or Delayed Placement of the Voice
Prosthesis
Surgical Techniques to Influence the Tonicity of
the Neoglottis
Pharyngeal Reconstruction
Pectoralis Major Flap
Radial Forearm Flap
Jejunal Graft
Free Lateral and Anterolateral Thigh Flap
Gastric Pull-Up
Tracheostoma Construction
Tracheoesophageal Speech
Voice Prostheses
Development of Different Types of Voice
Prostheses
Indwelling versus Non-Indwelling
Special Purpose Voice Prostheses
Tracheoesophageal Voice Rehabilitation
Patient Selection
Preoperative Visit
Prosthesis Measurement, Fitting, Maintenance,
and Change
Measurement
Placement of a Non-Indwelling Prosthesis
Placement of an Indwelling Prosthesis
Patient Education
Postoperative Voice and Speech Training
The First Session
Training Sequence
Basic Aspects to Address
Stoma Occlusion
Posture
continues
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HEAD AND NECK CANCER: TREATMENT, REHABILITATION, AND OUTCOMES
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continued
Pulmonary Support
Muscle Tension
More Specific Aspects to Address
Voice Quality
Fluency
Intonation and Inflection
Intelligibility
Speech Rate
HME and Attachment
Hands-Free Speech and Attachment
Troubleshooting
Leakage of Fluid through the Lumen of the
Prosthesis
Excessive Candida Growth Leading to Early
Valve Failure
Leakage of Fluid around the Prosthesis
Introduction
While the former chapter focused on nonprosthetic
forms of voice rehabilitation, the current chapter will
focus on voice rehabilitation using a voice prosthesis.
During a total laryngectomy the entire larynx,
including the hyoid bone, epiglottis, thyroid cartilage,
cricoid cartilage, and the first two or three tracheal rings
are removed. After removal of the larynx, the trachea
is diverted forward to the neck and sutured into the
original skin incision or a separately created skin incision. The inferior pharyngeal constrictors (previously
attached to the larynx) and pharyngeal mucosa are
closed to reestablish the digestive tract. Figure 9–1
schematically shows the anatomical situation before and
after total laryngectomy, and during phonation after
total laryngectomy with a voice prosthesis in situ.
In addition to providing preoperative information
and postoperative voice and speech training, in most
countries the speech-language pathologist (SLP) also
plays an important role in fitting and replacing the
voice prosthesis and in troubleshooting problems that
may occur with the voice prosthesis. Although at times
it seems that selecting and fitting the prosthesis is the
primary focus of rehabilitation, fitting a voice prosthesis is only a first step. In analogy to the voice and
speech training provided to nonprosthetic speakers,
the prosthetic speakers also require dedicated rehabilitation of voice and speech beyond simply the insertion of the prosthesis, in order for them to achieve
optimal voice quality and speech intelligibility. The
current chapter focuses on both the rehabilitation of
voice and speech and on the voice prosthesis.
Historical Review:
Tracheoesophageal speech requires an opening between
the trachea and esophagus. This opening enables the
patient to speak by closing off the tracheostoma
(stoma) and thereby causing the air to divert through
the opening between the trachea and the esophagus
into the esophagus. Historically, various techniques
have been used to establish this opening between the
trachea and esophagus. At present, tracheoesophageal
voice prostheses are the method of choice.
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Strained, Tight, or Effortful Voice, or No Voice
Sound At All
Soft, Weak, Breathy Voice
The Tracheal Flange Seems to Be Angled
Forward
The Tracheal Flange Is Discolored or Shows
Signs of Candida Growth
Appearance of a Pink or Raised Ring of Tissue
around the Fistula
TEP Is Situated Too Low or Too High
Prosthesis Is Missing from Fistula
Prosthesis Turned Sideways in Fistula
Infection of the TEP
Gastric Filling/Bloating
Conclusion
References
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PROSTHETIC TRACHEOESOPHAGEAL VOICE RESTORATION FOLLOWING TOTAL LARYNGECTOMY
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Figure 9–1. Schematic drawing of the anatomical situation before total laryngectomy with the red
dotted line showing the structures that will be removed during surgery A., of the anatomical
situation after total laryngectomy B., and of prosthetic tracheoesophageal speech C.
The First Total Laryngectomy and
Artificial Larynx
The Viennese surgeon Billroth is credited for performing the first total laryngectomy secondary to laryngeal
carcinoma in 1873. His fellow, Gussenbauer, described
the procedure and also described the artificial larynx
that was used in this patient (Gussenbauer, 1874).
In this early procedure, for reasons of surgical safety,
the anterior pharyngeal wall was not closed, leaving
the patient with a large, unrepaired defect above the
tracheostoma. Already at the time of this first laryngectomy, concerns were expressed about vocal and pulmonary rehabilitation and an artificial larynx was
developed for this patient. Specifically, the artificial larynx was connected to the pharyngeal defect and to
the tracheostoma, and it contained a metallic reed for
voice production and a respirator for pulmonary rehabilitation. The report says that “the patient was able to
speak with a clear voice that was loud enough to be
heard at the other side of a large hospital room.”
This first artificial larynx was based on a design
from the Czech physiologist Johann Czermak (Luchsinger & Arnold, 1965) who designed a “sound produc-
Tracheoesophageal Shunt Procedures
Reportedly, the first tracheoesophageal “puncture” was
made by a patient himself. Guttman (1932) detailed a
laryngectomized patient who used a hot ice pick to
create an opening between the trachea and hypopharynx. This enabled the patient to force air through the
puncture by closing off the tracheostoma with a finger.
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ing” prosthesis for an 18-year-old female who had suffered “closure of her larynx” and required a tracheotomy. The Czermak design was a tube that was placed
over the tracheal stoma upon exhalation which routed
the pulmonary air over a metal reed and then through
a hollowed rubber tube that was placed in the mouth.
Pulmonary airflow through the reed produced the
“artificial voice,” the user simply articulated, and intelligible speech was created. In 1894 Gluck and Sorensen
succeeded in primary closure of the pharyngeal defect,
which subsequently ended the need for artificial larynges such as the one described above and enabled the
use of esophageal speech (for more on esophageal
speech, see Chapter 8).
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Over the years, a number of surgical tracheoesophageal shunt procedures have been described.
Asai (1972) introduced a dermal tube shunt procedure. When successful, the speaker inhaled through
the stoma, occluded the stoma with a thumb or finger,
and then exhaled. The pulmonary air was consequently
routed from the trachea, through the dermal tube, into
the esophagus and resulted in esophageal pseudo-voice.
When completed successfully, this type of tracheoesophageal voice resulted in a length of phonation and
vocal prosody that approached that of laryngeal speakers. Similar but surgically unique procedures followed,
reported by Montgomery and Toohill (1968), McGrail
and Oldfield (1971), Serafini (1972), Amatsu (1980), and
Staffieri (1981). Although the voice sound was often
good, patients often presented with a high incident of
aspiration, dermal tube stenosis, spontaneous dermal
tube closure, and/or poor air flow into the esophagus.
Over the course of the following decade, fewer of
these procedures were completed and at the same
time a relatively simple prosthesis was developed that
achieved the same physical use and routing of pulmonary air without any of the tracheoesophageal
shunt complications.
Voice Prostheses for
During 1973 Taub and Bergner introduced a surgical
procedure with a prosthetic fitting that used pulmonary air to vibrate the new voice source. They circumvented the earlier reported dermal tube difficulties by
surgically developing a fistula on the lateral neck just
anterior to the external carotid artery. After fistula healing, they connected the tracheostoma to the surgical
fistula with a prosthesis that, with increased pulmonary
flow and pressure, closed a flutter valve and routed air
through the surgical fistula and into the esophagus to
produce pulmonary driven esophageal voice. Although
some patients reported some complaints about the
weight and bulk of the prosthesis, Taub did report a
greater than 90% success rate of pulmonary driven
esophageal voice production (Taub, 1975).
Singer and Blom (1980) developed an endoscopic
procedure with prosthetic fitting that, with continued
variations and modifications to both the procedure
and the prosthesis, is still considered state of the art
Surgical Techniques and Factors
Influencing Voice Production
Not all total laryngectomy procedures are carried out
in a similar way. For example, the surgeon will choose
a specific type of pharyngeal closure, may or may not
choose to create a primary TE puncture, may or may
not place a voice prosthesis, may carry out additional
procedures that influence the tonicity of the neoglottis, may have to remove more tissue causing the need
for reconstruction, may construct the tracheostoma
differently, and may attempt to create a flatter peristomal area. All of those techniques may influence
voice, speech, swallowing, and the use of devices for
rehabilitation. In the following sections each of these
additional surgical aspects is discussed.
Figure 9–2. Photograph of the first Blom-Singer
duckbill voice prosthesis initially without esophageal retention collar (right) and later with
esophageal retention collar (left).
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over two and a half decades later. They proposed puncture of the tracheoesophageal wall, dilation of the
puncture and fitting with a so-called duckbill silicone
voice prosthesis (see Figure 9–2). This seemed an
improvement over the Taub and Bergner procedure.
The prosthesis was smaller and lighter than previous
designs, and the prosthesis puncture was also smaller
and located within the trachea, away from the carotid
artery. Singer, Blom, and Hamaker (1981) were soon to
report a success rate of tracheoesophageal voice production as high as Taub and Bergner with larger numbers
of patients and fewer postoperative complications.
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Pharyngeal Closure
Usually the pharynx is closed in three layers: mucosa,
submucosa, and muscle. Some surgeons prefer a onelayer (mucosa) or two-layer (mucosa and submucosa)
closure and leave the muscular layer unclosed or halfclosed (see next section for more on this topic).
The pharynx can be closed in a vertical line
(I-shape) or in a T-shape; this often depends on the
preference of the surgeon and the remaining tissue
available for closure. During a T-shape closure, the surgeon starts at one lateral side and sutures the lateral
side of the pharynx to the base of tongue until the
midline is reached; subsequently, the same is done for
the contralateral side. Then, the remaining part of the
pharynx is sutured together vertically resulting in a
T-shape. During a vertical or I-shaped closure the lateral sides of the pharynx are sutured together in the
midline. The occurrence of a pharyngeal pouch is
lower when a T-shape closure is used (Davis, Vincent,
Shapshay, & Strong, 1982). It is sometimes hypothesized that patients with a T-shape closure have better
voice/pitch control and better swallowing due to the
connection between the pharynx and base of tongue.
See Chapter 10 for aspects related to postlaryngectomy dysphagia.
Primary or Secondary
Tracheoesophageal Puncture (TEP)
The term primary puncture is used when the puncture
is created at the time of surgery. The term secondary
puncture is used when the procedure is done as a separate procedure any time from weeks to years after the
total laryngectomy has been completed.
Blom and Singer’s first TE punctures were done as
secondary procedures (Singer et al., 1980). Only a few
years later, TEP as a primary technique at the time of
laryngectomy was introduced (Maves & Lingeman,
1982). Although the TEP was developed at the time of
the larynx removal, the placement of the actual voice
prosthesis still occurred at a later stage. The advantages of primary TEP are that it eliminates the need for
a second surgical procedure (together with accompanying risks and cost) and that the catheter used to
maintain the puncture can be used as a feeding tube
(Maves et al., 1982). Another advantage is that with pri-
Primary or Delayed Placement of
the Voice Prosthesis
With the introduction of indwelling voice prostheses,
primary insertion of the voice prosthesis was introduced (Manni, Van den Broek, de Groot, & Berends,
1984; Hilgers & Schouwenburg, 1990). Instead of
stenting the TEP with a catheter or feeding tube, the
prosthesis is placed at the time of surgery. During the
surgery, after removal of the larynx but before final closure of the pharyngeal defect the TEP fistula is created
and a prosthesis inserted. After a period of healing, the
prosthesis can be changed like usual.
Research shows that in general this first indwelling voice prosthesis that is placed at the time of surgery lasts as long and often even longer than average
(Op de Coul et al., 2000; Elving, Van Weissenbruch,
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mary TEP the patient will produce voice sooner. Also
emotionally it is important for the patient to be able to
communicate in the early postoperative period.
Complication rates between primary and secondary puncture procedures have been shown to be
no different (Silverman & Black, 1994). Postoperative
radiotherapy is not considered a contraindication
for primary puncture (Kao, Mohr, Kimmel, Getch, &
Silverman, 1994; Silverman et al., 1994). The only contraindication for primary puncture is separation of the
tracheoesophageal wall at the puncture site, for example, when the patient undergoes a laryngopharyngoesophagectomy with gastric pull-up (Pou, 2004). In
those patients a secondary puncture will have to be
carried out after a period of wound healing. Other reasons for secondary puncture are that some patients initially may choose a communication option other than
a voice prosthesis and decide at a later date that they
now desire this option. In rare situations, a primary
TEP fistula may have to be altered or allowed to close,
or closes inadvertently due to accidental removal of
the prosthesis.
A primary or secondary procedure can be the
result of institution tradition/policy, physician choice,
clinician choice, and/or patient choice. For most
patients, the timing of the creation of the TEP fistula
does seem to be more convenient for the patient
and all professionals if done at the time of the total
laryngectomy.
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Busscher, Van Der Mei, & Albers, 2002). On the contrary, prostheses that are fitted a few (2–6) days postoperatively after secondary puncture (after removal of
the catheter) seem to last a shorter duration due to the
need for resizing (Leder & Sasaki, 1995). In fact, Leder
and Sasaki (1995) report that the most common reason
for voice prosthesis resizing after initial fitting is that
the prosthesis is protruding too far into the trachea.
The first voice prosthesis after initial fitting lasted on
average 26 days and the main reason for replacement
was the need for resizing: 78% required resizing to two
full sizes (8 mm) shorter (Leder et al., 1995). For the
indwelling voice prostheses placed at the time of surgery the first prosthesis exchange is usually for leakage
through the device and occurs around a median of
135 days (Op de Coul et al., 2000). The reason(s) for
this difference between the two methods are not clear.
It is sometimes speculated that the presence of a
catheter or nasogastric (NG) feeding tube in the fistula
may cause irritation with subsequent edema, or angulation of the fistula, while the presence of a voice prosthesis could possibly prevent edema and maintain a
stable puncture site. The most important argument for
primary TEP with “delayed” fitting of the prosthesis is
that the TEP can be used for the NG tube, thus eliminating the need for uncomfortable placement of the
NG tube through the nose. However, some surgeons
choose to insert the prosthesis at the time of surgery
and pass the feeding tube through the lumen of the
voice prosthesis.
As with the choice for primary or secondary
puncture, whether or not the prosthesis is placed
at the time of surgery can be the result of institution
tradition/policy, physician choice, clinician choice, and/
or patient choice. In any case the SLP should be aware
of these differences to provide optimal treatment to
the patient. Usage of a prosthesis that is too long or too
short may lead to a variety of problems and should
therefore be avoided by proper management.
Surgical Techniques to Influence
the Tonicity of the Neoglottis
During the procedure of total laryngectomy there are
a variety of surgical techniques that can be employed,
which can potentially influence postsurgical voice
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and swallowing. It is presently well known that the
neoglottis consists of the muscles of the upper
esophageal sphincter and/or the inferior and middle
pharyngeal constrictor muscles. Among other aspects,
the tonicity of the neoglottis plays an important role in
voice production. The tension in the PE segment may
be too high (hypertonicity or spasm) leading to the
inability to produce voice, or a strained, squeezed,
intermittent voice sound (See CD, Chapter 9: Audio:
“Hypertonicity”), or too low (hypotonicity) resulting
in voice quality that is soft, weak, breathy, whispery,
aphonic, and sometimes intermittently “bubbly” (see
CD, Chapter 9: Audio: Hypotonicity).
Singer and Blom (1981) found that 12% of their
patients failed to achieve tracheoesophageal voice
because of pharyngoesophageal spasm. They successfully carried out a secondary myotomy (cutting the
muscle) to prevent the spasm from occurring. In the
same study they describe myotomy carried out as a
primary intervention immediately during surgery. All
patients achieved fluent postoperative voice.
A myotomy may be carried out as a “long”
myotomy, including the upper esophageal sphincter
and pharyngeal constrictor muscles, or as a “short”
myotomy, including the upper esophageal sphincter
only (see CD, Chapter 9: Video: Myotomy). Other
methods that may be carried out at the time of the
laryngectomy to prevent hypertonicity or spasm of
the neoglottis are unilateral neurectomy (cutting the
nerve) of the pharyngeal plexus (Singer, Blom, &
Hamaker, 1986), nonclosure of the pharyngeal constrictor muscles (Olson & Callaway, 1990), and half closure of the pharyngeal constrictor muscles (Deschler,
Doherty, Reed, Hayden, & Singer, 2000). Currently, it
is common practice to carry out a myotomy, neurectomy, or modified closure to prevent postoperative
voice problems due to hypertonicity or spasm (Bayles
& Deschler, 2004).
Despite using the preventive measures mentioned
above, some patients may still present with pharyngoesophageal spasm. Hoffman et al. (1997) introduced
the use of Botox for chemical denervation of the
pharyngoesophageal segment to treat pharyngoesophageal spasm. Currently, the use of Botox has
replaced secondary myotomy as a treatment for
postoperative spasm of the neoglottis (Hamaker &
Blom, 2003).
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Pharyngeal Reconstruction
In addition to surgical removal of the larynx, depending on the size and location of the tumor, a part of the
pharynx (total laryngectomy with partial pharyngectomy), the entire pharynx (pharyngolaryngectomy), or
the entire pharynx and esophagus (laryngopharyngoesophagectomy) may have to be removed and reconstructed as well. The surgeon has various options
available for reconstruction. The tissues that are most
often used for reconstruction are a pedicled myocutaneous (muscle and skin) pectoralis major flap, free
radial forearm flap, free jejunal graft, lateral or anterolateral thigh flap, and full or tubed gastric pull-up.
The amount of tissue removed and the type of
reconstruction may have an impact on postsurgical
speech and swallowing (see Chapter 10). In most of
the reconstructive cases, the pharyngoesophageal segment that serves as the voice source after standard
total laryngectomy may have been resected. The
neoglottis will now consist of some part of the reconstructive tissue. Patients who have undergone one of
the forms of extensive pharyngeal reconstruction
often are not able to use esophageal speech (see also
Chapter 8). However, an electrolarynx can be used,
and tracheoesophageal speech by means of a voice
prosthesis is a viable option for many (Hilgers et al.,
1995; Ward, Koh, Frisby, & Hodge, 2003).
In the following sections, the surgical reconstructions that are most often used are described briefly. For
a more detailed description of the procedures and the
corresponding impact of these reconstructions on
swallowing, the reader is referred to Chapter 10.
Pectoralis Major Flap
The pectoralis major (PM) flap is a myocutaneous flap
consisting of muscle and skin of the chest. The flap is
pedicled, which means that it remains attached to the
feeding vessels under the clavicle and it is rotated into
the pharyngeal defect (see Figure 9–3). The PM flap is
an important tool for the repair of specific pharyngeal
defects after partial or full pharyngectomy and was
first introduced in 1981 (Baek, Lawson, & Biller, 1981).
Figure 9–3. Pectoralis major flap reconstruction after total laryngectomy and partial pharyngectomy A. The pedicled flap is harvested, remains attached to the feeding vessels at the clavicle,
and is passed through under the skin to the neck A., sutured in place B., restoring the digestive
tract C.
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Tracheoesophageal voice quality after this type of
reconstructive surgery does not differ significantly
from voice after standard total laryngectomy for loudness, pitch, and jitter measurement, but perceptual
evaluation on 10 parameters has shown that the
patients with standard total laryngectomy scored better on all parameters (Deschler, Doherty, Reed, &
Singer, 1998).
Radial Forearm Flap
A radial forearm flap is a free, revascularized fasciocutaneous (fascia and skin) flap of the forearm. This flap
is usually tubed and used for reconstruction of circumferential defects of the pharynx after total laryngopharyngectomy (also called pharyngolaryngectomy) (see
Figure 9–4) (Harii et al., 1985). With this reconstruction, an acceptable voice can be achieved, but percep-
tual parameters of the voice quality with the radial
forearm flap are found to be significantly different from
the voice quality after standard total laryngectomy.
Both naïve and trained raters found that intelligibility,
pitch usage, fluency, communicative effectiveness, and
pleasantness were worse in the radial forearm group;
the trained raters also rated the radial forearm group
worse for loudness usage, wet voice, and extraneous
noise while the naïve raters found it to be worse for
speaking rate and loudness usage (Deschler, Doherty,
Reed, Anthony, & Singer, 1994).
Jejunal Graft
A jejunal graft is a free revascularized transplant of the
jejunum that can be used to reconstruct circumferential defects after total laryngopharyngectomy (see
Figure 9–5) (McConnel, Hester, Jr., Nahai, Jurkiewicz,
Figure 9–4. Free radial forearm reconstruction after total laryngopharyngectomy A. The free flap
is harvested with attached feeding vessels, a tube is created, and it is transferred to the neck B.
and sutured in place to restore the digestive tract C.
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Figure 9–5. Jejunal graft reconstruction after total laryngopharyngectomy A. The graft is
harvested and transferred to the neck B. and sutured in place to restore the digestive tract C.
& Brown, 1981). After this type of reconstruction, the
patient may experience trouble in voice and swallowing due to the peristaltic activity of the graft. The voice
is regularly blocked by the autonomous peristalsis,
and sounds “wet” due to the continuous production
of intestinal secretions (Haughey & Forsen, 1992). In
comparison to total laryngectomy speakers, studies have
shown that tracheoesophageal speech following jejunal transplant is less intelligible, and of reduced vocal
quality; however, patients are satisfied with their voice
outcomes and achieve functional speech (McAuliffe,
Ward, Bassett, & Perkins, 2000). In spite of the wetsounding voice quality, patients prefer the use of a
voice prosthesis over other forms of communication
(Mendelsohn, Morris, & Gallagher, 1993).
Free Lateral and Anterolateral
Thigh Flap
The lateral thigh flap consists of the skin and subcutaneous tissue overlying the lateral thigh. It often supplies a large amount of tissue and can therefore be
Gastric Pull-Up
This type of surgery is usually necessary in patients
who need a total laryngopharyngoesophagectomy.
Either the complete stomach is pulled up to replace
the pharynx and esophagus (see Figure 9–6) (Silver,
1976) or the stomach is surgically formed into a tube
and then pulled up (Marmuse, Guedon, & Koka, 1994).
Hilgers et al. (1995) found that the voice results after
tube reconstruction were more often judged to be
good than the voice results after full stomach transfer.
After the latter the voice more often sounded
amphoric, with little strength.
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used for larger defects of the neopharynx (Hayden &
Deschler, 1999). The anterolateral thigh flap is harvested
from the anterior part of the lateral thigh and has similar characteristics to the lateral thigh flap. Lewin et al.
(2005) showed that in comparison with jejunal graft
reconstruction the anterolateral thigh flap resulted in
similar complication rates and better speech and swallowing outcomes.
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Figure 9–6. Gastric pull-up reconstruction after total laryngopharyngoesophagectomy A. The
stomach is prepared and pulled up into the neck A. and sutured to the pharyngeal defect to restore
the digestive tract B.
Tracheostoma Construction
Construction of the tracheostoma is an important part
of the surgery. Variations in stoma size, shape, and location are the biggest challenges in the restoration of
speech and pulmonary function following total laryngectomy and tracheoesophageal puncture (Lewin,
2004).
A stoma that is too large, irregular, or deep (see
Figure 9–7) may be difficult to occlude for speech and
it may be difficult to apply baseplates or intraluminal
attachments for heat and moisture exchangers (HMEs)
or hands-free speaking valves. A stoma that is too small
may cause difficulty breathing and may cause problems with prosthesis insertion and maintenance.
Although surgical procedures for “stomaplasty” are
available to improve the characteristics of the stoma
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Figure 9–7. Photograph of a laryngectomized
patient with a deep stoma. (Photo provided as a
courtesy of Atos Medical, www.atosmedical.com.)
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(Verschuur, Gregor, Hilgers, & Balm, 1996), it is obviously better to avoid these problems in the first place
(Verschuur et al., 1996). In general, the stoma will be
either created in unity with the surgical incision or
separately (see Figure 9–8). It is thought that the latter
method causes fewer problems with the stoma configuration and that it eliminates the need for a postoperative laryngectomy tube which is thought by some
to cause healing problems of the stoma (Verschuur
et al., 1996).
In addition to the creation of the stoma itself, it is
often proposed to cut the sternal heads of the sternocleidomastoid muscles (see CD, Chapter 9: Video: Cutting the Sternal Heads). This causes no functional
deficits, but results in a flatter peristomal area (see
Figure 9–9), which allows for easier application of
baseplates or intraluminal devices for HMEs and handsfree speaking valves (Hilgers, 2003).
referred to as PE segment or pseudoglottis) into vibration. The success rates for tracheoesophageal speech
are often higher than those reported for esophageal
speech (see also Chapter 8). For tracheoesophageal
speech, success rates of up to 90% are reported (Op de
Coul et al., 2000).
Of the different forms of alaryngeal communication, tracheoesophageal speech most closely resembles
As can be seen in Figure 9–1, tracheoesophageal speech
is pulmonary driven. Upon occlusion of the tracheostoma, the exhaled pulmonary air is diverted through
the lumen of the voice prosthesis into the esophagus.
There, it sets the new voice source, the neoglottis (also
Figure 9–9. Photograph of the flat peristomal
area of a laryngectomized patient of whom the
sternal heads of the sternocleidomastoid muscle
were cut during surgery. (Photo provided as a
courtesy of Atos Medical, www.atosmedical.com.)
Figure 9–8. Illustration of two different methods of stoma construction: separate from the surgical
incision A. and in unity with the surgical incision B.
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the mechanism of normal laryngeal speech production. The only difference lies within the voice source.
In Table 9–1 the initiator, voice source, resonator,
and vocal tract for the different types of alaryngeal
communication and normal laryngeal communication
are shown.
Due to the differences in nature between the different types of alaryngeal speech, differences in voice
and speech can be expected. In general, tracheoesophageal speech is found to be more like normal speech
than esophageal speech (Baggs & Pine, 1983; Pindzola
& Cain, 1988; Robbins, Fisher, Blom, & Singer, 1984) and
is often reported to be superior to esophageal speech
(Debruyne, Delaere, Wouters, & Uwents, 1994; Max,
Steurs, & De Bruyn, 1996) and electrolarynx speech
(Williams & Watson, 1987). However, as stressed in
Chapter 8, the superiority of one type of alaryngeal
speech over the other is not determined by voice and
speech outcome alone. For a more in-depth discussion
on this topic and the choice of alaryngeal speech
method, we refer the reader to Chapter 8.
Although people tend to discuss tracheoesophageal speech as having certain qualities, it is important
to realize that tracheoesophageal voice quality is highly
variable between patients. As outlined previously, the
anatomy and physiology of the neoglottis plays an
important role in tracheoesophageal voice quality (van
As-Brooks, Hilgers, Koopmans-van Beinum, & Pols,
2005; van As, Op de Coul, van den Hoogen, Koopmansvan Beinum, & Hilgers, 2001; Van Weissenbruch, Kunne,
van Cauwenberghe, Albers, & Sulter, 2000). Perceptually,
male and female tracheoesophageal speech appears
not to be significantly different from each other (van
As, Koopmans-van Beinum, Pols, & Hilgers, 2003).
Female tracheoesophageal speakers often have a low
fundamental frequency (115 Hz average), comparable
to that of males (109 Hz average) (van As-Brooks,
Koopmans-van Beinum, Pols, & Hilgers, 2006). See
examples on CD (Chapter 9: Audio: Male Tracheoesophageal Speaker; Audio: Female Tracheoesophageal
Speaker). Also both the surgery and any reconstruction can cause alterations in the vocal tract and alterations at the level of the sound source that may result
in decreased intelligibility (Doyle, Danhauer, & Reed,
1988; Hammarberg, Lündström, & Nord, 1990; Jongmans, Hilgers, Pols, & van As-Brooks, 2006; Lundstrom
& Hammarberg, 2004; Miralles & Cervera, 1995; Searl,
Carpenter, & Banta, 2001). Consequently, not all
patients have the same voice quality or achieve the
same levels of speech intelligibility. In general, patients
that have undergone reconstruction of the pharynx in
combination with the total laryngectomy have less
optimal voice sound (van As et al., 2003). See CD for
speech samples (Chapter 9: Audio: “TE Speech PostJejunal Reconstruction” 1, 2, and 3).
Voice Prostheses
Today, a variety of different voice prostheses is available that can be divided into two main categories: nonindwelling voice prostheses that are replaced by the
patients themselves and that are regularly removed,
cleaned, and reinserted by the patient, and indwelling
prostheses that require replacement by a medical professional and remain in situ until a replacement is necessary. Although all the different voice prostheses that
Table 9–1. Initiator, Voice Source, Resonator, and Articulator for Each of the Three Types of Alaryngeal
Speech, and for Laryngeal Speech
Electrolarynx
Esophageal
Tracheoesophageal
Laryngeal
Initiator
Battery
Esophageal air
reservoir
Pulmonary air
Pulmonary air
Voice Source
Vibrating membrane
Neoglottis
Neoglottis
Glottis
Resonator
Vocal tract
Vocal tract
Vocal tract
Vocal tract
Articulator
Articulatory organs
Articulatory organs
Articulatory organs
Articulatory organs
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are available have their own unique characteristics, the
general design of a voice prosthesis is quite consistent
(see Figure 9–10).
The prosthesis has retaining flanges at each end.
Depending on the type of prosthesis these flanges vary
in dimension. Indwelling prostheses typically have larger
and more rigid flanges than non-indwelling prostheses
to help secure the prosthesis and facilitate long-term
placement. The smaller flanges on the non-indwelling
prosthesis still help secure the prosthesis, but also
facilitate repeated insertion and removal. When the
prosthesis is in position, the tracheal flange will be
located in the trachea and the esophageal flange will
be located in the esophagus. At the time of insertion the
tracheal end of the prosthesis has a safety strap attached.
In indwelling types of prostheses the safety strap will
be removed from the prosthesis after placement.
Figure 9–11 shows an indwelling voice prosthesis in
situ. In non-indwelling types of prostheses the safety
strap (and safety medallion in some models) is retained
to keep the prosthesis secured to the skin of the neck
and to assist removal and reinsertion. Figure 9–12
shows a non-indwelling voice prosthesis with safety
strap in situ and Figure 9–13 shows a non-indwelling
voice prosthesis with safety strap and safety medallion
(to prevent aspiration of the prosthesis) in situ.
The term “voice prosthesis” is a paradox as the
voice prosthesis does not actually generate sound.
. . .
We hope you enjoyed this excerpt from Head and Neck Cancer:
Treatment, Rehabilitation and Outcomes. For more information,
please visit us at www.pluralpublishing.com.
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Chapter 9 PROSTHETIC TRACHEOESOPHAGEAL VOICE

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