Laryngectomy RehabilitationIntroductionTotal laryngectomy (TL) significantly alters speech production. For a speechproduction system to be functional, the following 3 basic elements are necessary:(1) a power source,(2) a sound source, and(3) a sound modifier.For laryngeal speakers, lung air is the power source, the larynx is the sound source,and the vocal tract (i.e., pharynx, oral cavity) is the sound modifier. During totallaryngectomy (TL), the sound source is removed and the lungs are disconnectedfrom the vocal tract. Successful voice restoration following total laryngectomy(TL) requires identification of an alternative sound source with a viable powersource.1An image depicting laryngectomy rehabilitation can be seen below.
Diagram of tracheoesophageal puncture and prosthesis placement.The 3 basic options for voice restoration after total laryngectomy (TL) are (1) artificiallarynx speech, (2) esophageal speech, and (3) tracheoesophageal speech. Selection of amethod should be based on input from the surgeon, speech pathologist, and patient.The decision is best made keeping in mind the patients communicative needs, physicaland mental status, and personal preference.Esophageal speech • Principle: Esophageal speech is produced by insufflation of the esophagus and controlled egress of air release that vibrates the pharyngoesophageal (PE) segment for sound production. Anatomic structures for articulation and resonance are usually unaltered.
• Techniques: The 2 basic approaches to esophageal insufflation are injection and inhalation. Both techniques are based on the pressure differential principle that air flows from areas of higher pressure to areas of lower pressure. Injection involves using the articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. Inhalation involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax so air insufflates the esophagus. Proficiency in esophageal speech typically requires several months of speech therapy. • Advantages: No apparatus must be purchased or maintained, and no further surgery is required. • Disadvantages: Speech acquisition is delayed because of the learning curve, and difficulties with phrasing and loudness are possible.Artificial larynx speech • Principle: An external mechanical sound source is substituted for the larynx. Anatomic structures for articulation and resonance are usually unaltered. • Techniques: Two general types of electrolarynges are available, the neck type and the intraoral type. The neck type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted into the oropharynx and articulated normally. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. A small tube is placed toward the posterior oral cavity, and the generated sound is then articulated. The tube has minimal effect on articulatory accuracy if the patient is taught properly and learns to use it well. A third type of electrolarynx has been developed using an electromyograph (EMG) transducer in the strap muscles to activate a sound source for hands-free use.2 • Advantages: Voice restoration after surgery is immediate, and the maintenance for the electrolarynx is minimal (may last 2-10 y). • Disadvantages: The voice quality sounds mechanical.Tracheoesophageal speech • Principle: A surgical fistula is created in the wall separating the trachea and esophagus. This puncture tract can be created primarily, at the time of total laryngectomy (TL), or secondarily, weeks or years following the total laryngectomy (TL). Several days after surgery, a one-way valved prosthesis is placed in the puncture tract, allowing lung air to pass into the esophagus. The lung air induces vibration of the PE segment for sound production. The
mechanics of the one-way valve allow lung air to pass into the esophagus without food and liquids passing into the trachea. • Technique: During the initial evaluation, a speech pathologist measures the length of the puncture tract and selects a size and style of prosthesis for placement. Once in place, the patient digitally occludes the tracheostoma to direct air through the prosthesis into the esophagus for phonation. Hands-free external airflow valves are also available as accessories. • Advantages: The air supply for speech is pulmonary, phonation sounds natural, and voice restoration occurs within 2 weeks of surgery. • Disadvantages: Additional surgery is required for secondary punctures, the prosthesis must be maintained, and aspiration may occur if liquids leak through a malfunctioning valve.Evaluating Tracheoesophageal SpeechAssessing the integrity of the pharyngoesophageal segmentTracheoesophageal punctures can be created primarily, at the time of totallaryngectomy (TL), or secondarily, days to years after surgery. If the plan is for asecondary puncture, a simple insufflation test can be performed preoperatively bythe speech pathologist to assess the integrity of the PE segment and potential voicequality. Results indicate whether further surgical intervention is necessary duringthe puncture procedure. If the puncture is performed primarily, insufflation testingis not an appropriate preoperative assessment because the cricopharyngeus will bereconstructed during the laryngectomy.Insufflation testingA catheter is placed through the nose and inserted until the end is just below the PEsegment, ie, approximately 25 cm of the catheter length. Air is channeled throughthe catheter to insufflate the esophagus, simulating tracheoesophageal speech. Ifinsufflation is monitored using manometry, the indication for adequate PE segmentintegrity is a phonation pressure less than 22 mm Hg. For perceptual assessment,the patient performs speech tasks, such as sustained phonation and/or counting forevaluation of phonatory quality and duration. The patient should be able to sustainphonation of /a/ for at least 10 seconds or produce 10-15 syllables per breath.If the insufflation test is performed correctly and phonation is not achieved or is ofpoor quality and duration, the 4 possible conditions of the PE segment that shouldbe considered are (1) hypotonicity, (2) hypertonicity, (3) spasticity upon egress of
airflow, or (4) stricture. If perception is uncertain, the PE segment can be furtherevaluated using fluoroscopy with barium swallows and repeated insufflations.If insufflation test results indicate failure, several therapies are available. Ifhypotonicity is present, consider applying digital pressure to the PE segment or anexternal pressure band around the patients neck during phonation. If hypertonicity,spasticity, or both is present, consider pharyngeal constrictor myotomy, pharyngealplexus neurectomy, or botulinum toxin (BOTOX®) injection withelectromyographic or radiographic guidance. If stricture is present, dilatation isindicated.Tracheoesophageal Speech ProsthesesSelecting a ProsthesisSeveral sizes and styles of tracheoesophageal prostheses are available. Selecting avalve should be a conscientious decision. The following 4 main issues should beconsidered when selecting a device:Phonatory effortBefore any prosthesis is inserted, phonation should be sampled with a patentpuncture tract. The perceptual quality and effort of that sample guides decision-making. For example, if the voice quality is effortless, loud, and consistent, thenthe patient may do well with a higher-resistance device with increased durability. Ifthe voice quality is strained and effortful, a lower-resistance device of greaterdiameter (20F) may be appropriate.Candidacy for independent insertionIf the patient and his or her spouse or caregiver appear able and willing toparticipate in prosthesis management, a valve with no restrictions on placementprocedures should be considered. Indwelling devices, although touted for theiradvanced design, must be inserted by a trained professional. This stipulationcreates a situation of patient dependency on the health care professional.Autonomy offered by devices that can be changed without restriction is appealingto many patients. Conversely, if the patient is unable or unwilling to change thevalve independently, an indwelling style device offers more security fromdislodgement.Durability
Occasionally, the device that provides the least phonatory effort also has a patient-specific tendency to malfunction rapidly. If the device recurrently leaks in less thana couple of months with no treatable cause (eg, candidal infection), a device withhigher resistance and durability should be considered.CostPrices for valves vary from $28 (Inhealth 16F duckbill) to $199 (Provox 2indwelling, Atos Medical).Prosthesis ChoicesDuckbill • Size: The prosthesis is 6-28 mm in length and 16F or 20F in diameter. • Advantages: It has good durability, can be changed independently, and is inexpensive. • Disadvantages: Airflow resistance is increased.Low resistance/pressure • Size: It is 6-28 mm in length and 16F or 20F in diameter. • Advantages: It has decreased airflow resistance, has shorter esophageal extension, and can be change independently. • Disadvantages: It has decreased durability and is sensitive to esophageal pressure changes.Indwelling • It is 6-22 mm in length and 20F or 22F in diameter. • Advantages: It has decreased airflow resistance, increased security from dislodgement, and a removable strap. • Disadvantages: It is clinician-dependent and has the potential for gastric distention from excess air insufflation. Also, it is expensive ($130-199).Steps for Fitting a Prosthesis 1. Evaluate phonation with a patent puncture tract and stoma occlusion to rule out technique problems. 2. Measure the length of the puncture tract (see Image 2). 3. Select and prepare a prosthesis.
4. Dilate the puncture tract to slightly wider than the prosthesis. 5. Align the prosthesis with the puncture tract for insertion; alignment is more important than pressure (see Image 4). 6. Have the patient drink liquid, and watch for any leak through or around the prosthesis (see Image 5). 7. Assess patient phonation with stoma occlusion.Hands-free tracheostoma valvesTracheostoma valves provide 2 primary functions: hands-free speech and housingfor heat and moisture filters. These external valves are adhered to the neck, with avalve housing directly over the stoma. For speech, the air pressure generatedduring increased exhalatory effort closes the tracheostoma valve and directs airback through the tracheoesophageal prosthesis. An adequate adhesive seal isessential to generate hands-free speech. Without a tight external seal, stomal airescape reduces the amount of airflow available for speech. Heat-and-moisture–exchange filters are also available to place over, or in lieu of, the tracheostomavalve. These filters modify the inhaled environmental air. Benefits of the filtersinclude decreased airway irritation and maintenance of airway humidification,which may reduce tracheal secretions.Troubleshooting Tracheoesophageal PuncturesProblems related to tracheoesophageal punctures and prosthetic devices arementioned, along with typical causes and corresponding solutions.Leaking through the prosthesis • Deteriorated valve: Replace the prosthesis. • Candidal infection: Administer antifungal medication. • Duckbill tip pressed against esophageal wall: Switch to a low-pressure device. • Thoracic pressure changes: Increase the resistance of the valve.Leaking around the prosthesis • Tracheoesophageal puncture tract expansion: Fit a 20F prosthesis. • Pistoning of prosthesis: Fit a shorter prosthesis. • Radiation effects: Down-stent or perform a repuncture.Difficult or no phonation
• Clogged device: Clean the device. • Duckbill tip lodged in esophageal wall: Change to a low-pressure prosthesis. • Incomplete insertion: Dilate and resize the puncture tract. • Closed puncture tract: Perform a repuncture.Dislodgement of prosthesis • Incomplete insertion: Dilate and resize the puncture tract. • Inadvertent removal: Fit a more stable prosthesis if this situation is recurrent. • Aspiration of device: Remove the device using flexible bronchoscopy.Granulation tissue • Irritation/pistoning of prosthesis: Fit the prosthesis length more securely. • Repeated removal/insertion of prosthesis: Decrease the frequency of prosthesis changing, and perform laser removal of the granulation tissue.Emergent ProceduresWhen a prosthesis is dislodged, patients are instructed to insert a catheter into thepuncture tract as soon as possible to maintain patency and prevent aspiration. Ifthey are unable to place the catheter, they may come to the emergency departmentfor puncture tract stenting. Patients are sometimes unaware that they can phonatewithout the prosthesis. As long as the puncture tract is patent, phonation ispossible. Encouraging tracheoesophageal speech to explain their situation mayease patient anxiety. If the patient cannot speak, have them drink a sip of water,preferably with blue dye. If the water leaks through the puncture tract into theairway, the tract is patent.The role of the emergency department staff is to stent the puncture tract with acatheter (8-20F). If no catheters are readily available, a Duo Tube or nasogastrictube works. The next step is to dilate the puncture tract. Progressively increase thesize of the catheter until a 16F or 20F catheter passes through the tract, dependingon the size of the prosthesis. At this point, the prosthesis can be reinserted.If the patient did not recover the prosthesis, the device may have been aspirated.Some patients report violent coughing after aspirating a valve; however, manypatients are asymptomatic. Therefore, diagnostic imaging should be performed.Most prostheses manufactured by InHealth are radiopaque. The indwelling devicehas only a ring of radiopacity. A chest radiograph should be the first test, followedby a CT scan if a prothesis that is not radiopaque is missing. The final approach
should be bronchoscopy. Typically, a prosthesis lodges in the right mainstembronchi and can be easily retrieved by an otolaryngologist or pulmonologist.ConclusionSuccessful voice restoration for alaryngeal speakers can be attained with any of the3 speech options. Although, no single method is considered best for every patient,the tracheoesophageal puncture has become the preferred method in the pastdecade. Perceptual studies have demonstrated listener and speaker advantages oftracheoesophageal speech. Despite the potential facility of voice production withthe tracheoesophageal puncture, careful attention must be directed to PE segmentintegrity and mucosal density, valve selection, and troubleshooting. Voicerestoration is a process, not a prosthesis.MultimediaMedia file 1: Sizing device used to measure the depth of the tracheoesophageal walland determine the appropriate prosthesis length.Sizing device used to measure the depth of the tracheoesophageal wall anddetermine the appropriate prosthesis length. Media file 2: Comparison photos of an aspirated indwelling-style prosthesis on a chest x-ray film versus a CT scan image. Only the outside ring of the esophageal flange is radiopaque.
Comparison photos of an aspirated indwelling-style prosthesis on a chest x-rayfilm versus a CT scan image. Only the outside ring of the esophageal flange isradiopaque.Media file 3: Insertion of a low-pressure prosthesis with a gelatincapsule.Insertion of a low-pressure prosthesis with a gelatin capsule.Media file 4: Top photo shows leakage of ingested liquids around the device, whichindicates an expanding tracheoesophageal tract possibly due to a prosthesis that is toolong. Bottom photo shows an indwelling-style prosthesis in place.
Top photo shows leakage of ingested liquids around the device, which indicatesan expanding tracheoesophageal tract possibly due to a prosthesis that is toolong. Bottom photo shows an indwelling-style prosthesis in place. %%%%%%%%%%%%%%%%%%%%%%%%%
Laryngectomy [Short Notes]A total laryngectomy is the complete surgical removal of the voice box. It is usually performedfor cancer of the larynx, though in some cases, the larynx may be removed if it has stoppedfunctioning properly. An even more important function than enabling you to speak, your vocalcords (part of your larynx or voice box) close tightly when you swallow, preventing food, fluid,and saliva from entering into lungs.A person who has undergone a total laryngectomy no longer breathes through his nose or mouth,but only through an opening in the neck called a stoma. This opening is the trachea that has beenpermanently brought out to the neck. It connects directly with your bronchus, which leads intolungs.With a tracheostomy or laryngectomy, the air that patient is now breathing is no longer beingwarmed and moistened, as it was when patient breathed through nose. Additional humidity isnecessary, especially at night, and can be provided by an ultrasonic humidifier or home nebulizerunit. The added humidity will help decrease the crust formation in the tracheostomy tube. Oneshould also have 6 to 8 glasses of water a day, either by mouth or through your feeding tube (asdetermined by your doctor). This helps keep mucus thin and easy to cough out of stoma.