esophageal voice electrolarynx tracheo-esophageal fistula

1. VOICE REHABILITATION AFTER
TOTAL LARYNGECTOMY
Dr Safika Zaman
PGT, Dept of ENT & Head neck surgery
VIMS, RKMSP

2. INTRODUCTION
Patients may regard the loss of their voice as a loss of part of their identity.
Multidisciplinary team effort in order to achieve optimal results.

3. VOICE
 In the broad sense, voice refers to the sound we produce to
communicate meaning, ideas, opinions, etc.
 Laryngeal voice refers to sounds produced by vocal fold vibration, or
voiced sounds.

4. PHYSIOLOGY OF PHONATION & PHONATING SYSTEM
 Aerodynamic power generation / the power house : chest ,
diaphragm, abdominal muscles.
 Vibration of vocal fold: buzzing sound.
 Resonating system/ suprglottic vocal tract: amplification of
the sound.
 Articulating system : lips, tongue, teeth, mandible, palate .
https://www.researchgate.net/profile/Shakti-
Saurabh/publication/330546181/figure/fig1/AS:718216326303745@1548247524275/Stages-of-
voice-production-Source-Anatomy-and-Physiology-John-Hopkins-Voice-Center.png

5. INDICATION FOR TOTAL LARYNGECTOMY
 T4 tumours.
 Subglottic extension with invasion of the cricoid cartilage.
 Laryngeal dysfunction in laryngeal cancer patient.
 Post radiotherapy or post chemotherapy patient with severely dysfunctional
larynx.
 Laryngeal cancer patient who can not with stand chemotherapy or radiotherapy.
 Completion laryngectomy for failed initial laryngeal conservation surgeries.
 Advanced thyroid tumour with laryngeal extension.

6. HISTORY OF VOICE REHABILITATION
Rehabilitation after Total Laryngectomy—A Tribute to the Pioneers of Voice Restoration in the
Last Two Centuries
Kai J. Lorenz1,*

8. COMPARISON
Text book of Stell & Maran – chapter 59

9. PSEUDO-WHISPERING
 Pseudo-whispering is a mode of phonation that exclusively uses the
air that is present in the oral and pharyngeal space.
 Appropriate articulation movements allow patients to produce a
weak and aphonic voice that enables them to communicate only in a
quiet place.

10. OESOPHAGEAL SPEECH
 Air intake from the oral and pharyngeal space into
the upper oesophagus.
 The pharyngo-esophageal (PE) segment to vibrate
for the production of speech.
 Injection method: Builds up enough positive pressure
in the oral cavity, forcing air into the cervical
oesophagus.
 Inhalational method: Uses the negative pressure used
in normal breathing to allow air to enter the cervical
oesophagus.

11. ADVANTAGE & DISADVANTAGE
 Advantage: Hands-free speech and requires no extra equipment or repairs.
 Disadvantage:1. Significant speech therapy training is required to become a
proficient oesophageal speaker.
 2.Controlling pitch, loudness, and rate of speech can be difficult for oesophageal
speakers.

12. ELECTRONIC ARTIFICIAL LARYNX
 There are two types of EL: the neck
type/external and the intraoral type.
 The neck-type EL is the most widely used in
laryngectomy because it is easy to handle and
is hygienic.

14. ADVANTAGE AND DISADVANTAGES OF
ELECTROLARYNX
 Advantages: 1.Relatively short learning time.
2.Ability to use it immediately postoperatively.
3.Relative low cost and its minimal maintenance.
 Disadvantages:1.Mechanical monotonous sound quality,
2.Use a hand to operate the control.
3.Dependence on batteries.

15. TRACHEOESOPHAGEAL VOICE
 Technique: creating a simple tracheo-oesophageal
puncture between the posterior wall of the tracheostome
and the upper oesophagus , into which a one-way
silicone valve is inserted.
 Occlusion of the stoma allows air during exhalation to
be shunted into the pharynx.
 Sound is then produced by vibrating the mucosa of the
pharyngo-oesophageal segment.

16. PRIMARY VS SECONDARY PUNCTURE
Text book of Stell & Maran – chapter 59

17. CRITERIA FOR SECONDARY VOICE RESTORATION
Text book of Stell & Maran – chapter 59

18. ADVANTAGE OF TEP
Can be performed after laryngectomy, neck dissection, and/or
radiotherapy.
Speech is attained more quickly.
The success rate of prosthetic vocal rehabilitation is high.
Fair-to-excellent voice quality .
It is similar to laryngeal speech on a range of voice parameters
Indwelling valve in place

19. DISADVANTAGE
Need to manually cover the stoma when voicing.
Adequate pulmonary reserve is necessary.
Additional surgery for secondary punctures.
Violation of the posterior oesophageal wall.
Inadvertent passage of the catheter through a false passage, and
esophageal perforation

20. INDWELLING PROSTHESIS
Advantage :No replacement required by patient
 Shorter learning curve.
 More robust design & longer device life.
Disadvantage : it is more prone to yeast colonization which
destroys its function.
Provox speaking valve

21. Rehabilitation after Total Laryngectomy
1Arsheed Hussain Hakeem, 2Imtiyaz
Hussain Hakeem, 3Anubha Garg
1Consultant, Department of Head and
Neck Surgery and Surgical Oncology,
Prince Aly Khan Hospital, Mumbai
Maharashtra, India
2Resident, Department of Internal
Medicine, Florida Hospital Medical
Center, Orlando, Florida, USA
3Fellow, Department of Oncology,
Prince Aly Khan Hospital, Mumbai,
Maharashtra, India

22. PROVOX 1& 2

23. COMPLICATIONS WITH PROSTHESIS
 Leakage through the prosthesis.
 Leakage around the valve
 blocked lumen with granulation tissue.
 Fibrous ring around the prosthesis..
 Valve extrusion.
 Aphonia

24. CONT..
 Hypertonicity or spasm
 Pseudovallecula formation
 Stenosis of stoma
 Hypotonic voice

25. HEAT AND MOISTURE EXCHANGE SYSTEMS
 heat and moisture exchanger effectively protects the
trachea and the lower airway from drying and cooling and
considerably reduces the burden of air-conditioning .on the
lower respiratory tract.
 Another function is providing resistance to airflow. Raising
airway resistance has a positive effect on tissue oxygen
saturation in the laryngectomizedpatient.

26. HANDS-FREE TRACHEOSTOMA VALVES
 An external housing and an adjustable valve.
 The valve remains open during quiet
respiration and automatically closes in
response to an increase in expiratory flow to
allow speech production

27. Thank you