Post-Laryngectomy

Voice Rehabilitation
Abigail Schnieders, MD
Matthew Page, MD

Overview

Overview of Alaryngeal Speech

Options for Post-Laryngectomy Communication
Physiology of TEP
Surgical Considerations in TEP
Troubleshooting TEP
Complications of TEP

The Saga Continues

After being laryngectomized by the infamous Dr. Goodwin, the
previously discussed patient returns to clinic 3 months post op
for cancer surveillance. He is found to be free of disease.
However, he wishes to discuss options for being able to
communicate againother than with his pencil and paper.
What are some of his options and what are the pros and cons
of each?

Life expectancy of patients who

previously underwent laryngectomy

Importance of focusing on improved quality of life in postlaryngectomy patients.

Hotz, MA. Success and Predictability of Provox Prosthesis Voice Rehabilitation. Arch Otolaryngol Head and Neck Surg 2002; 128:687-691

Vocabulary
The first thing that I learned when researching for this topic
The following are actual words:
Laryngectomized
Having undergone the process of a laryngectomy
Laryngectomised
Brittish spelling

Laryngectomee
One who has previously undergone a laryngectomy

History of Alaryngeal Speech

1873 Billroth
performed first total
laryngectomy
Artificial larynx used post
operatively with good
success
Issues of diplophonia and
wound infection
Figure 113-1. Drawings from the original paper by Gussenbauer. Note the almost complete
obstruction of the subglottic space within the cricoid cartilage. On the left are the first and second
versions of the artificial larynx. In the center the postoperative situation is depicted, with a
pharyngostoma to hold the pharyngeal extension of the artificial larynx

Cummings Otolaryngology, 5th edition. Chapter 113

Anatomy Quiz

Physiology of Speech
Airflow causing vibrations of the vocal cord mucosa is best
described as which phenomena?

Bernoulli Effect

Physiology of Speech
Needed for Speech
Bellows
Sound source
Vocal tract

The least affected by

TL?

Anatomy
Suprahyoid
musculature separated
from superior border
of hyoid
Separation of
pharyngeal
constrictors at oblique
line of thyroid cartilage
Closure of these
muscles as the external
layer

Baileys Head and Neck Surgery. Chapter 123

Post-TL voice restoration

Artificial Larynx

Esophageal Speech

TEP

Mechanism

Mechanical sound
introduced into the
vocal tract

Air injected into

esophagus and then
propelled into PE
segment

Tracheal air exhaled

into pharynx through
fistulous tract

Advantage

Rapid learning; does

not interfere with
acquisition of other
forms of speech; low
cost; loud

Less conspicuous; hands

free; natural sound;
patient independent of
devices

Natural phrasing of
voice; more
acoustically normal
speech;

Disadvantage

Dependence on
batteries; mechanical
sound; loss of hands
free
speech;appearance;
lack of insurance

Low fundamental
frequecy (~65 Hz); short
duration; low acquisition
rate; extended learning
period

Tract can be difficult to

maintain; salivary
reflux into trachea

5-30%

40-90%

Successful use ~100%

Esophageal Speech
Air injected into esophagus
or stomach
Expelled into PE segment
causing mucosal vibrations
~80 mL of air compared to
3+ liters of air
1-2 sec of phonation time
compared to ~ 20 sec
Success rates ~ 40-60%

Cummings Otolaryngology, 5th edition. Chapter 113

Mechanical Speech
Electrolarynx
Electrically generated
vibrations pass through skin
Vibrations formed into
speech within the vocal
tract

Cummings Otolaryngology, 5th edition. Chapter 113

TEP
Tracheoesophageal
puncture
One way valve allowing
exhaled air to pass into
pharynx. This airstream
vibrates the mucosa of the
upper PE segment.
Similar physiologic
principles of normal
speech
Efficient air flow source
Natural phrasing and varied
voice efforts

When the air souce

subsides, the valve closes
and prevents aspiration of
secretions
Emedicine. Laryngectomy Rehabilitation.

TEP
Tracheostoma valve
Closes the stoma
when phonating
Higher airflows for
voice close a valve
diaphragm

Hands free speech

Cannot be used in
patients with COPD
Effective in only 25%
of laryngectomy
patients

Voice Prostheses
1970-1980
Creation of surgical fistula between trachea and neopharynx
Aspiration problems
Trade off between voice quality and aspiration
1972
Mozolewski published results from first voice prostheses
1980
first Blom-Singer prosthesis
duckbill

Baileys Head and Neck Surgery. Chapter 123

Low flow TEP

Reduction in airflow
resistance requires
less effort for voicing
Increased diameter
of prosthesis
Increased loudness
20 Fr

Fine line between

voice quality and
aspiration
Baileys Head and Neck Surgery. Chapter 123

Voice Prostheses
Indwelling
Provox
Replaced by clinician
Robust construction ensures
longer life span
Determined by leakage of
fluids around prosthesis or
increased airflow
resistance
Success independent of
patient age and general health

Non-indwelling
Duckbill; Panje prostheses
Removed by patient
Daily maintenance includes
cleaning and flushing
Need manual dexterity

TEP: Patient Candidacy

Relative concerns that may reduce the success of voice restoration
Pharyngeal stricture with symptomatic dysphagia
Radiation therapy exceeding 6,500 cGy
Malnutrition
Diabetes
Dementia
Severe COPD

Baileys Head and Neck Surgery. Chapter 123

TEP: Patient selection

Relative contraindications

Impaired mental status

Decreased manual dexterity
Bilateral severe SNHL
Limited pulmonary function

TEP: Preoperative evaluation

Esophageal insufflation test
Placement of catheter
through nose into upper GI
Air insufflated and released
as speech

Estimates the possibility of

pharyngeal constrictor
spasm
Esophageal distension occurs
with air ingestion
Reflexive increase in tone in
constrictor muscles
Air trapping can result in
gastric filling, distension

However, no reliable data

showing the incidence of
patients who will succeed
Baileys Head and Neck Surgery. Chapter 123

Four scenarios:
Fluent, sustained speech
Indicates relaxed musculature

Breathy, hypotonic voice

Absence of muscle tone

Intermittent production of
effortful speech
Hypertonicity
Gastric distension

Aphonia
Complete spasm

Surgical Considerations in
Voice Rehab

Primary prosthetic voice

restoration: surgical considerations
Refinements in total laryngectomy techniques for
optimizing prosthetic voice restoration
Cricopharyngeal myotomy to prevent hypertonicity of PE segment
Suturing of trachea in separate fenestra in inferior skin flap to create stable
stoma
Sectioning of sternal heads of SCM to prevent deep stoma

Low-tension closure of pharyngeal mucosa to prevent pseudo-vallecula

formation

Intra-operative measures to
improve prosthetic voice
Prevention of
hypertonicity
Excess tone in
constrictors
Tone exacerbated with
inflation of air,
blocking overall
airflow
Anterior myotomy of
CP

Intra-operative measures to improve prosthetic voice

Creation of optimally contoured
stoma
Ideal stoma
Same diameter as trachea
Adequate to access prosthesis
Avoid laryngetomy tube

Stoma stenosis
Dehiscence of trachea from skin
Separate fenestra avoids trifurcations

Cranial tracheal ring should remain

intact
Distribution of collagen fibers act as
spring to stent the trachea open
If disrupted, trachea will collapse

Contraction of tracheocutaneous
suture
Meticulous suturing
Optimal coverage of exposed cartilage

Intra-operative measures to
improve prosthetic voice
Prevention of a deep
stoma
Some rehabilitation
devices rely on
peristomal
attachments
Heat and moisture
exchanger
Automatic speaking
valve

Cutting SCM heads will

allow for flat
peristomal area

Intra-operative measures to
improve prosthetic voice
Pharyngeal mucosa
closure
Avoidance of tension
on closure
T shaped closure
Reinforcement of
trifurcation prevents
fistula
Avoid
pseudovallecula
which can occur with
vertical closure

Timing of TEP placement

Primary vs Secondary Prosthetic

Voice Rehabilitation
When is the ideal time to place the TEP?
During initial surgery
vs

Delayed procedure

Timing of TEP placement in radiated patients undergoing TL

30 patients underwent
laryngectomy after failing
chemoRT
20 underwent primary TEP
10 underwent secondary
procedure

10/20 fistulized in the

primary TEP group
Compared to 1/10 in the
secondary group

Median time to fluent

speech
63 days in primary group
125 days in secondary group

100% of patients acquired

fluent speech

Primary TEP

Secondary TEP technique

Endoscopic technique
Puncture location 5mm
from superior trachea
14 gauge needle inserted
under direct visualization
Puncture through posterior
esophageal wall
Wire inserted and guided
through oral cavity
Dilation of puncture site
Threading of urethral
catheter retrograde

Fitting of prosthesis in 2
days

TEP placement
Measurement of
distance across
puncture site
Insertion of
prosthesis and
securement above
tracheostoma

Complications of Voice
Prostheses
Epidural abscess or vertebral
osteomyelitis secondary to
violation of posterior
esophageal wall during
secondary TEP
Mediastinitis secondary to
dissection of party wall
Loss of the puncture site by
dislodgment of the catheter
placed at the time of
puncture
TEP dilation

Partial or complete extrusion

of the prosthesis
Migration of the puncture site
Formation of granulation
tissue
Stomal or
pharyngoesophageal stenosis
Aspiration of saliva and foods
through puncture site
Esophageal prolapse
Tracheostoma prolapse
Aspiration of prosthesis
3-5%

Tracheoesophageal Speech
Similar to laryngeal speech, pulmonary driven
Air driven through one way valve into PE segment
Maximum phonation times ~ 16-17 seconds

Acoustic analysis
Comparison of TE speech with laryngeal speech
Fundamental frequency, intensity, frequency and rate are similar

TE speech superior to esophageal speech in volume, phrase

length, ease of use
Rated most desirable form of alarygneal speech by SLP, patients and
listeners

In the presence of noise, TE speech has a lower rate of listener

intelligibility

Tracheoesophageal Speech
True or False
There is no gender difference in post-laryngectomy anatomy and
physiology of the sound source.

TRUE
Male and female voices do not differ in fundamental frequency
post laryngectomy
100Hz

Prosthesis Maintenance
Lifespan of prostheses
~10-18 months in US

Fluid leakage main cause of failure

Transprosthetic leakage
Periprosthetic leakage

 A patient comes into clinic 2 months after having a TEP placed,

feeling like there is a lot of leakage around the prosthesis.
Which of the following is the most likely explanation for this
leakage?

Usual wear and tear of valve

Too-long prosthesis
Leakage of fluids through the valve due to incomplete closure
Tumor recurrence

 Which of the following is an appropriate initial treatment for

the aforementioned condition?

Nystatin swish and swallow

re-fitting prosthesis to puncture site
Removal of prosthesis and replacement in 6-8 weeks
Endoscopy with biopsy

Prosthetic leakage
Transprosthetic
Most common cause of TEP leakage
Incomplete valve closure
Candida
Negative pressure

Periprosthetic leakage
Inappropriate prosthetic length

Candida growth and TEP

Predominant species
Candida albicans (41%)

Antifungals
No evidence to support routine use
MIC of isolates suggest pansensitivity to nystatin

Probiotics
Prevent growth of candida
Proven in vivo and in vitro

Negative pressure aerophagia

Deep breathing creates a negative pressure within the thorax
Normally, UES prevents air from flowing into the upper GI
Prosthesis is present beneath the UES

Valve opens and air enters the esophagus

Complaints of aerophagia
Easier valve opening and delayed closure

Provox Acti-Valve
Teflon like material prevents candida growth
Built in magnets counteract negative pressure in the
esophagus
Group of patients requiring early replacement due to leakage
Median life span of 336 days

platonmedical.co.uk

Periprosthetic leakage
Careful checking of the prosthetic length required prior to
replacement
Pulling at tracheal flange to assess if the prosthetic is correct
length
Typical progression involves shortening of the party wall with
healing
Tissue inflammation and atrophy
Resolution of tissue edema

Moving prosthesis 2-3mm in the AP direction is correct

amount
Indicates little to no pressure on the tissue

> 3mm movement is an indication to shorten length of

prosthetic

Diagnosis of TEP failures

Recommendation for clinical protocol for troubleshooting
prosthesis problems
Adverse events occuring in about 1/3 of patients
Early intervention can prevent further problems

Diagnosis of TEP failures

Prosthesis failure:

Position
Size
type
patency

Reflex pharyngeal constrictor spasm

Nonvibrating pharyngoesophageal segment:
radiation-induced
edema
reconstructed segment

Puncture closure
Inadequate air supply:
decreased respiratory support
improper stoma occlusion

Algorithm for solving TE wall atrophy

Fistula shrinkage
Removal of prosthesis and replacement with feeding tube
Requires cuffed cannula to prevent aspiration

If wall is thinner than 4mm

A 4mm prosthesis will not create adequate seal

Silicon washer
Used as a spacer and placed between the tracheal flange and
mucosa
0.5mm thick
Adheres to mucosa via surface tension

Algorithm for solving TE wall

atrophy
Purse string suture
Used if tissues are not
too atrophic
3-0 vicryl used to
pursestring the fistula,
prosthesis is replaced
and suture tightened
around to secure
Good short term
success rates
Long term success
variable

Algorithm for solving TE wall atrophy

Augmentation of party wall
Bioplastic
Collagen
Fat
Granulocyte/ macrophage colony stimulating
factor
Creation of sterile inflammation

Algorithm for solving TE wall atrophy

Fistula closure
If failure of all other measures
Must dissect and close all 3 layers
Complete epithelialization within 6 months
Fascial graft or pedicles SCM flap
Re-puncture with immediate prosthesis
placement after 6 weeks
Occasionally, pectoralis or free flap must be used
to close a large defect

Puncture site infection

~10% of patients
Treatment with broad spectrum antibiotic
Prosthesis left in place
Potentially replaced with a longer prosthesis
Avoid removal so that the fistula does not close

Fistula hypertrophy
Anterior
Excessive mucosal granulation
More common in patients requiring a laryngectomy
tube
Too-short prostheses

May lead to overgrowth of tracheal flange

Stoma-plasty or laser resection of scar tissue

Posterior
esophageal pocket
Leading to strained voice or bleeding during
valve cleaning
Diagnosed with a pediatric endoscope through
the valve
Can see mucosal overgrowth on esophageal side

Insertion of a longer prosthesis

Leading to fistulization of the pocket
May require retrograde insertion

Hypertonicity of PE segment
Most important reason for failure to
develop fluent speech
May be prevented with a CP myotomy

Evaluation with videofluoroscopy

Treatment with intensive speech
therapy
Chemodenervation
Identification of hypertonic segment
with videofluoroscopy
Transcutaneous injection into
constrictor
Long lasting effect
Biofeedback mechanism

Post injection VFS shows reduction in

mass of constrictors

Hypotonicity of PE segment
Hypotonicity
Leads to whispered voice
Excessive bulging of the PE segment
Seen with plexus pharyngeal neurectomy

External pressure
Digital
SCM sling

Prosthesis Extrusion
Partial extrusion can result in a false passage
Can result from pressure necrosis from short prosthesis
Longer prosthesis can bridge the passage and allow for
spontaneous healing

Complete extrusion
Inability to locate the prosthesis should prompt CXR
Endoscopic removal in airway
Allow for passage if in GI

TEP Emergencies

Emedicine: laryngectomy rehabilitation

TEP emergencies
Inability to insert the esophageal flange fully
Results in increased voice resistance
Tract will close from the esophagus within 24 hours
May re-dilate and stent with a catheter

Aspiration
Commonly when patients attempt to replace TEP
Most common location is right upper mainstem
Dyspnea
Aspiration of secretions

Detailed instructions should be given in case of aspiration

Avoidance of deep inhalation

Retrieval with topical anesthesia and flexible bronch

References
Hotz, MA. Success and Predictability of Provox
Prosthesis Voice Rehabilitation. Arch Otolaryngol Head
and Neck Surg 2002; 128:687-691
Baileys Head and Neck Surgery. Chapter 123.
Cummings Otolaryngology. Chapter 113.
Lombard LE. Emedicine: Laryngectomy Rehabilitation.