Voice rehabilitation following total laryngectomy

Report
Voice Rehabilitation
following Laryngectomy
Balasubramanian Thiagarajan
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%
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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
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Components of phonation
Articulators
(Lips,
tongue,
teeth)
Larynx
(Vibrator)
Lung (Bellows)
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Requirements for normal phonation
 Active respiratory support
 Adequate glottic closure
 Normal mucosal covering of vocal cord
 Adequate vocal cord length and tension control
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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
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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
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Vocal folds vibratory patterns
 Falsetto
 Modal voice
 Glottal fry
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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
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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
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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
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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
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Methods of speech following
Laryngectomy
 Also known as alaryngeal speech
 Esophageal speech
 Electro larynx
 TEP (Tracheo-oesophageal puncture)
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Esophageal speech
Alaryngeal speech
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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
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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
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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
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Pumping air into cervical oesophagus
 Injection method
 Inhalational method
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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
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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
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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
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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
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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
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Cricopharyngeal spasm
 Cricopharyngeal myotomy
 Botulinum toxin injection – 30 units can be injected via the tracheostome
over the posterior pharyngeal wall bulge
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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
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Electrolarynx - Types
 Pneumatic – Dutch speech aid, Tokyo artificial speech aid
 Neck
 Intraoral type
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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
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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
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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
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Electrolarynx - Disadvantages
 Expensive to maintain
 Speech generated is mechanical in quality
 Difficult while speaking over telephone
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Types of voice restoration surgeries
 Neoglottic reconstruction
 Shunt technique
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Neoglottis procedure
 Performing trachea hyoidopexy
 This can restore voice function in alaryngeal patients
 Abandoned due to increased incidence of complications like aspiration
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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
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Types of shunts
 High trachea-esophageal shunt (Barton)
 Low trachea-esophageal shunt (Stafferi)
 TEP shunts (Guttmann)
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Causes of failure of shunt procedure
 Aspiration through the fistula
 Closure of the fistula
 To avoid these problems prosthesis was introduced
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Types of Prosthesis
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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
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Types of TEP
 Primary TEP – Performed during total laryngectomy
 Secondary TEP – Performed 6 months after surgery
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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
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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
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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
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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
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Contraindications of TEP
 Extensive surgery involving pharynx, larynx with separation of tracheaesophageal wall
 Inadequate psychological preparation
 Patient with doubtful ability to cope up with prosthesis
 Impaired hand dexterity
 Suspected difficulty during PO irradiation
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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
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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
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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
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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
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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
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12 – 0 clock position of tracheostoma
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Yanker’s suction tube inserted
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TEP - Incision
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TEP - widened
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Prosthesis introduced
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Prosthesis used in TEP
 Blom-Singer prosthesis
 Panje button
 Gronningen button
 Provox prosthesis
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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
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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
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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
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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
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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
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Problems with TEP insertion
 Leak through the prosthesis
 Leak around the prosthesis
 Immediate aphonia / dysphonia
 Hypertonicity problems
 Delayed speech
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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”
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Insufflation test interpretation
 Fluent voice on minimal effort – normal
 Breathy voice indicating hypotonic cricopharyngeal muscle
 Hypertonic voice – “Cricopharyngeal spasm”
 Spasmodic voice – “Extreme cricopharyngeal spasm”
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Common problems with TEP
 Improper location of puncture
 Inappropriate size of puncture
 Presence of cricopharyngeal spasm
 Leakage through and around the prosthesis
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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
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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
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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
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