Voice Rehabilitation following Laryngectomy
Balasubramanian Thiagarajan
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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
Lung (Bellows
)
Larynx (Vibrat
or)
Articulators (Lips, tongue, teeth)
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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 speechAlaryngeal 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 trachea-esophageal 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 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
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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 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
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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
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