1. Voice Rehabilitation following Laryngectomy
Balasubramanian Thiagarajan

2. 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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3. 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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4. Components of phonation
Lung (Bellows)
Larynx (Vibrator)
Articulators (Lips, tongue, teeth)
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5. 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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6. 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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7. 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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8. Vocal folds vibratory patterns
Falsetto
Modal voice
Glottal fry
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9. 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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10. 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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11. 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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12. 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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13. Methods of speech following Laryngectomy
Also known as alaryngeal speech
Esophageal speech
Electro larynx
TEP (Tracheo-oesophageal puncture)
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15. Esophageal speech Alaryngeal speech
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16. 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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17. 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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18. 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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19. Pumping air into cervical oesophagus
Injection method
Inhalational method
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20. 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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21. 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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22. 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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23. 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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24. 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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25. 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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26. 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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27. Electrolarynx - Types
Pneumatic – Dutch speech aid, Tokyo artificial speech aid
Neck
Intraoral type
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28. 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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29. 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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30. 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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31. Electrolarynx - Disadvantages
Expensive to maintain
Speech generated is mechanical in quality
Difficult while speaking over telephone
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32. Types of voice restoration surgeries
Neoglottic reconstruction
Shunt technique
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33. 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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34. 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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35. Types of shunts High trachea-esophageal shunt (Barton)
Low trachea-esophageal shunt (Stafferi)
TEP shunts (Guttmann)
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36. 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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37. Types of Prosthesis
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38. 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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39. Types of TEP Primary TEP – Performed during total laryngectomy
Secondary TEP – Performed 6 months after surgery
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40. 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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41. 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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42. 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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43. 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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44. 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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45. 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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46. 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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47. 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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48. 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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49. 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 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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50. 12 – 0 clock position of tracheostoma
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51. Yanker’s suction tube inserted
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52. TEP - Incision
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53. TEP - widened
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54. Prosthesis introduced
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55. Prosthesis used in TEP Blom-Singer prosthesis Panje button
Gronningen button
Provox prosthesis
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56. 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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57. 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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58. 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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59. 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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60. Indwelling versus 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
Oesophageal insufflation test should be positive
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61. Problems with TEP insertion
Leak through the prosthesis
Leak around the prosthesis
Immediate aphonia / dysphonia
Hypertonicity problems
Delayed speech
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62. 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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63. 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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64. 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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65. Location of TEP 12-0 clock position of stoma
About 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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66. 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
Prosthesis to be cleaned
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67. 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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68. Thank you
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