Voice Rehabilitation after Total Laryngectomy
August 25, 2005
Christina L. Corey, M.D.

Today we will discuss voice rehabilitation after total laryngectomy. Total laryngectomy is a surgical procedure that has been employed for more than a century. The human voice is often sacrificed in the surgical treatment of laryngeal cancer. Although significant advances have been made in the conservative treatment of laryngeal cancer, total laryngectomy continues to play an important role.

Case Report:

DT is 60 year old former smoker who presented to clinic with 7 month history of worsening hoarseness. He also reports dyspnea, odynophagia, as well as a 20-pound weight loss over the past few months. He denies any dysphagia or hemoptysis. His social history was notable for a 10-pack/year history of smoking and drinking six beers per day for the last 20 years. His physical exam was significant for a paralyzed left true vocal cord, which was replaced entirely by tumor, which extended over to involve the entire right true vocal cord. There was also some left subglottic extension. CT of the neck revealed a mass involving the left true vocal cord with obliteration of the left periglottic space and mucosal irregularity extending from the glottis to approximately the level of the cricoid cartilage. There was also notable invasion of the thyroid cartilage and several level II-IV lymph nodes. He then underwent tracheotomy, direct laryngoscopy, and esophagoscopy. Biopsies were obtained and pathology returned as moderately to poorly differentiated squamous cell carcinoma. He was staged as a T4 N2b MO squamous cell carcinoma of the glottis and then underwent: total laryngectomy, left selective neck dissection of levels II-IV, and primary TEP. He tolerated the procedure well, and on postop day seven, began the use of an electrolarynx with an oral adapter. He was able to produce intelligible speech and although his articulation was not always precise due to his right facial and neck edema, he was able to communicate. On postop day 23, an indwelling TEP prosthesis was placed. He developed good speech with self-occlusion of the stoma since then.

Prior to our discussion of voice rehabilitation, we will first discuss normal voice production. The normal voice is produced by the interaction of three physiologic mechanisms. First, the lungs act as bellows to move a large air column through the larynx. Next, the mucosal waveform on the true vocal cords meeting together then causes the air column to vibrate, thus producing sound. The vocal cord vibration cycle occurs 85-255 times a second during phonation. The rapid opening and closing of the vocal cords occur in a vibratory pattern and are responsible for sound production. Immediately prior to phonation, the true vocal cords approximate so that the glottic airway is reduced to a thin linear space.

Air pressure develops below vocal cords from expired air from the lungs during exhalation. Sound is produced by the passage of air under pressure through the adducted cords in their phonatory position about 3mm apart. The cords reapproximate with each other by three primary forces: the Bernoulli effect, which causes apposition of the cords as air travels through the glottis; the inherent tension of the cords; and by the decreasing subglottic air pressure. When the cords approximate, subglottic air pressure quickly rises and forces them apart again for the cycle to repeat itself. This now vibrating air column then reaches the third mechanism, the voice resonator, which is composed of the pharynx, soft palate, cheek, lips, and especially the tongue. This forms the vibrating sound into meaningful words.

The larynx is the second most common site for cancer in the upper aerodigestive tract. Laryngeal cancers account for approximately 1.2% of all new cancer diagnoses in the United States. According to the National Cancer Institute’s SEER data, the age-adjusted rate for larynx cancer was 4 cases per 100,000 in 1973-2000. Squamous cell carcinoma (SCC) is the most common histopathologic diagnosis, accounting for more than 95% of all laryngeal malignancies. Surgery, radiation, or both are the primary treatments for these cancers. Although organ preservation protocols and conservation laryngeal surgeries are in use today, patients with advanced or recurrent SCC of the larynx continue to undergo total laryngectomy in the course of their treatment.

Following a total laryngectomy, the surgical defect is illustrated at right. The pharyngeal wall is composed of 5 layers. From internal to external, they are as follows: mucous membrane; submucosal; pharyngobasilar fascia, a fibrous layer that is attached to the skull; muscular layer, composed of inner longitudinal and outer circular muscles; and buccopharyngeal fascia, a loose connective tissue layer. This fascia is continuous with the fascia covering the buccinator and pharyngeal muscle. It contains the pharyngeal plexus of nerves and veins.

A watertight mucosal closure of the pharyngeal wall is accomplished by performing a Connell stitch. A cricopharyngeal myotomy is then performed. This will be important later on for TEP voice phonation which will be discussed later in this talk.

The history of voice prostheses begins in 1859. The first artificial larynx was devised by Czech physiologist Johann Czermak. It was given to an 18-year-old girl who had been tracheotomized because of complete laryngeal stenosis. The device consisted of a tracheal cannula and a tube with a metal reed. The patient produced sound by placing the tube in the mouth and breathing out to vibrate the reed. This device was modified numerous times over the next 60 years but these early laryngeal prostheses were limited by their irritative effect on surrounding tissues, increased respiratory complications, and pain and difficulty using the prostheses.

In 1874 the first successful laryngectomy was reported to the German Surgical Society by Carl Gussenbauer . It was performed on a 36-year-old religious instructor by Theodore Billroth. The patient went home four months after the surgery and learned to speak with an artificial larynx designed by Gussenbauer . The artificial larynx shunted air from the trachea, past a reed, and into the pharynx.

In 1922, Seeman first recognized that the cervical esophagus could act as a neoglottis, and the stomach and distal esophagus as an air reservoir. This was the beginning of the technique of esophageal speech.

In 1927, Beck described the first tracheoesophageal puncture, when a patient purposely passed a red-hot ice pick through the trachea into the esophagus three times to obtain a permanent fistula and, as a result, voice.

In 1929, Bell Laboratories produced a new artificial larynx, designated type 2A, which consisted of a metallic reed that vibrated inside a tube that was connected by the speaker between the mouth and the stoma. Air forced up the trachea, through the tube and across the reed, was then manipulated in the speaker's mouth to create artificial speech. This model, with minor changes, was manufactured by Western Electric Company for many years.

In 1942, the first electronic larynx known as Sonovox was developed by Wright. Sound was introduced to the throat by transmission through the soft tissue of the neck. This device inspired the design of many electrolarynges and also let the train “talk” in the Walt Disney movie Dumbo.

In 1957, Dr Herbert Cooper and the engineers of the Rand Development Corporation manufactured the Cooper-Rand oral-type electrolarynx which also incorporated independent controls for levels of loudness and pitch. This feature was incorporated into subsequent neck-type devices.

In 1960, Asai introduced voice restoration via tracheo-esophageal shunt. This initially needed three separate operative procedures, although in a subsequently modified version, only one procedure was required. However, this technique was plagued with problems including disruption of the shunt, stenosis, and aspiration. A number of other surgical techniques of lesser or greater complexity, with or without the use of distant flaps, have been described, although their use has not been widespread.

In 1979, Singer and Blom introduced the tracheoesophageal puncture (TEP) and silicone prosthesis. Since their introduction, variations on the procedure and of the prosthesis have been proposed but the general principles remain the same today.

Plans for restoring communication begin after making the diagnosis and establishing the need for total laryngectomy. Communication options available include writing, gestures, pneumatic and electrical larynges, esophageal speech, and TE speech with prosthesis.

The three main options for voice restoration after total laryngectomy are: (1) esophageal speech, (2) electrolarynx speech, and (3) tracheoesophageal speech.

Esophageal speech was the mainstay of alaryngeal communication until the early 1980s and had been used as a method of voice restoration for over 100 years. It entails trapping air in the mouth or pharynx and propelling it into the esophagus. The patient can then reflux the air up through the esophagus, vibrating the pharyngoesophageal segment. This produces a belch-like sound that can be articulated by the tongue, lips, and teeth. The vibratory segment is located in the lower cervical region, corresponding to C5 through C7. The cricopharyngeus and the inferior and middle constrictor muscles contribute to the formation of the vibratory segment.

The three basic approaches to esophageal insufflation are consonant injection, glossopharyngeal press, and inhalation. All techniques are based on the pressure differential principle that air flows from areas of higher pressure to areas of lower pressure. Consonant injection involves using consonants/articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. The glossopharyngeal press method can only be used during rest or during interphase intervals. With this method, the tongue acts as a piston, forcing air downward into the esophagus. And finally, the inhalation method involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax and relaxing the PE sphincter so air insufflates the esophagus.

The advantages of esophageal speech are that it is less conspicuous than the artificial larynx, it requires no batteries and no apparatus must be purchased or maintained, it does not sound mechanical, and it does not require additional surgery, and provides hands-free speech.

The major disadvantage of it is that very few laryngectomees are successful users. Proficiency in esophageal speech typically requires several months of speech therapy. Speech acquisition is delayed because of the learning curve, and difficulties with pitch, rate, duration, phrasing and loudness are possible. Forty to 75% of laryngectomees fail to acquire functional esophageal speech. Given these disadvantages, esophageal speech has largely been relegated to a second tier means of postlaryngectomy voice rehabilitation.

There are two types of electrolarynges, an external type that is placed against the neck (the most common) and an oral type (intraoral placement device). The neck placement type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. The sound vibration is transmitted through a metal or plastic head on the device and transmitted through the tissues in the pharynx, hypopharynx, and the oral cavity and then articulated normally. Most neck placement devices can also be converted into an intraoral device by using an adapter. A small tube is placed towards the posterior oral cavity, and the generated sound is then articulated. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. The intraoral feature can be useful in the postoperative period when tenderness can prevent the adequate placement of an electrolarynx on the neck. In addition, sound transmission can be attenuated by edema and postradiation tissue changes.

Both types are electrically driven. They use a battery powered electronic circuit to cause an electromagnetic plunger to strike a hard membrane or drum, thereby generating a vibrating tone. The tone is designed to have a frequency range close to that of the average human speaking voice. This tone is then articulated by the tongue, lips, and teeth as understandable speech.

The main advantages of the electrolarynx are its relatively short learning time, ability to use immediately postop, relative availability, its relative low cost and its minimal maintenance. The main disadvantages include the mechanical sound quality, necessity to use a hand to operate the controls; dependence on batteries; maintenance of the intraoral tubes, which can be blocked by saliva, which thereby impedes sound transmission; and finally, interference of the articulation process secondary to the need for the tube to be in the oral cavity.

Tracheoesophageal puncture with prosthesis is currently the surgical method of choice for vocal restoration after total laryngectomy. Tracheoesophageal speech has revolutionized the rehabilitation of the laryngectomized patient over the past ten to fifteen years.

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, or secondarily, weeks or years following the total laryngectomy. Several days after surgery, a speech pathologist measures the length of the puncture tract and selects a size and style of a one-way–valved prosthesis that is placed in the puncture tract. Once in place, the patient digitally occludes the tracheostoma to phonate.

The basis of tracheoesophageal speech is that tracheal air during exhalation is shunted into the pharynx through a small, silicone valved prosthesis in a fistulous tract. The prosthesis serves as a one-way valve to prevent salivary soiling of the airway, and opens to divert pulmonary air across PE segment. Sound is then produced by vibrating the mucosa of the pharyngoesophageal segment. Speech is then produced by articulation of this sound in the oral cavity.

The tracheostoma breathing valve device consists of two parts: 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. There are two types of housing: the first is the standard peristomal housing devised by Blom, Singer, and Hamaker, which is attached to the peristomal skin with an adhesive disc and a layer of liquid adhesive. The second type of housing is the Barton button, developed by Barton and associates in 1988, which uses intraluminal rather than peristomal attachment. It is composed of soft, silicone rubber which conforms to the patient’s stoma.

The advantages of tracheoesophageal voice are many. The procedure is possible in patients who have had a laryngectomy, neck dissection, and/or radiotherapy. Moreover, the fistula is a convenient route for esophagogastric feeding in the immediate postoperative period. The procedure is also easily reversible if desired by the patient. In addition, tracheoesophageal speech is more quickly attained than esophageal speech. Since its air supply is pulmonary, tracheoesophageal speech is more intelligible, natural sounding, and has improved intensity and duration of speech, achieving more words with one breath (25-30) when compared to esophageal speakers.

One of the main disadvantages of tracheoesophageal speech is its need to manually cover the stoma when voicing, although in many this has been relieved by the creation of hands-free valves. The patient must also have adequate pulmonary reserve to be able to perform tracheoesophageal speech. Other disadvantages unique to secondary tracheoesophageal puncture include: additional surgery for secondary punctures, violation of the posterior esophageal wall, passage of the catheter through a false passage, and esophageal perforation. O ther complications associated with tracheoesophageal prostheses will be discussed later in this talk

In 1979, Singer and Blom introduced the tracheoesophageal puncture, proposed as a secondary salvage technique for those who failed esophageal speech or were displeased with the electrolarynx voice. Secondary tracheoesophageal puncture is delayed 6 weeks following total laryngectomy, 6-8 weeks following postoperative radiation therapy, or until the peristomal skin has recovered from radiation therapy. Primary tracheoesophageal puncture developed from concepts of secondary tracheoesophageal puncture. The only absolute contraindication to primary tracheoesophageal puncture is separation of the party wall at the puncture site. If puncture is performed following separation of the party wall, abscess formation, sloughing of the posterior tracheal wall, and possibly mediastinitis can occur.

Primary and secondary tracheoesophageal puncture patients show no significant differences in complication rates or speech quality. Wenig et al compared 20 primary and 18 secondary tracheoesophageal punctures. Their speech quality was equivalent as assessed by two speech language professionals and an untrained listener. Kao et al demonstrated similar results.

Brown et al compared a group of patients who had undergone primary tracheoesophageal puncture with a group of patients who had secondary tracheoesophageal puncture. The perceptual rating of quality of the tracheoesophageal puncture voice by the patient, the patient’s relative, and blind ratings by trained and untrained observers showed no difference in any of the groups and no difference between patients undergoing primary vs. secondary tracheoesophageal puncture.

The acoustic analysis showed no difference in voice intensity or average frequency; the average, maximum, and minimum frequency of conversational speech; or maximum phonation time between patients undergoing primary vs secondary tracheoesophageal puncture.

The goal of voice restoration is to provide fluent, effortless, and intelligible speech. In a retrospective study by Lavertu et al of 168 patients who underwent secondary tracheoesophageal puncture at Cleveland Clinic between 1980 and 1993, 74% (124) of patients were still using the prosthesis. Phonation on the first day was achieved in 90% of patients (151). Speech result improved significantly over the first 6 months (p < .001). Quality of speech was the only predictor of prosthesis use (p < .001).

Acoustic analysis of tracheoesophageal speech has been compared with laryngeal, esophageal and electrolarynx speech by many studies. In a study by Robbins et al, 45 laryngeal, tracheoesophageal, and esophageal speakers were analyzed for intensity, frequency, rate of speech production, and duration. Tracheoesophageal speech had a higher fundamental frequency more closely approximating normal speech and was found to be more similar to laryngeal speech than esophageal speech. When compared with esophageal speech, tracheoesophageal speech gave superior voice quality in reference to volume and speech duration. Tracheoesophageal puncture speech duration in this study was 12 seconds compared with 2 seconds in esophageal speakers; this was in contrast to laryngeal speech duration of approximately 22 seconds. Moreover, the rate of speech was faster and the intelligibility superior to that acquired using the artificial larynx or esophageal speech.

In another study by Mendelsohn et al, patients who had undergone total laryngectomy with primary tracheoesophageal puncture underwent comprehensive testing of speaking proficiency. During conversational speech, the amplitude and fundamental frequency of tracheoesophageal puncture speakers compared with laryngeal speakers was not statistically significant. When significant changes were produced by stressing the speech mechanism, significant differences were observed. The tracheoesophageal puncture group was unable to shout as loud (p = 0.001) or sing as high (p < 0.001) as laryngeal speakers.

Regarding radiotherapy, the need for postoperative radiation therapy is not a contraindication for primary tracheoesophageal puncture. Numerous studies have shown that postoperative radiotherapy does not appear to have any deleterious long-term effects on tracheoesophageal speech or to cause an increase in frequency of complications related to TEP. Rates of pharyngocutaneous fistula, wound breakdown, stomal stenosis, and esophageal stenosis were similar.

A patient satisfaction survey performed by Clements et al shows that tracheoesophageal voice speakers were significantly more satisfied with their speech, perceived their speech to be of better quality, perceived improved ability to communicate over the telephone, and had less limitation of interaction with others compared with groups of tablet writers, esophageal speakers, and users of electrolarynxes. They also rated their overall quality of life higher.

Silverman and Black performed a study with 71 consecutive total laryngectomy patients over a 5 year period. Generally, patients rated themselves as less talkative after surgery. Ninety percent acknowledged the irretrievable loss of the larynx but rated themselves as coping. Eighty-nine percent of patients evaluated overall satisfaction with tracheoesophageal speech as highly favorable. Sixty-eight percent were not concerned with digital occlusion for voicing via tracheoesophageal puncture. In this study, all patients favored tracheoesophageal speech in comparison to the use of an electrolarynx. Eighty-three percent preferred tracheoesophageal speech in comparison to esophageal speech. Of five environmental settings, 95% reported to be comfortable talking to friends and family. Patients were equally comfortable talking to strangers as they were talking on the phone

One of the most common problems following tracheoesophageal puncture is voice restoration failure. Studies have shown that failure rates range from 3% to 15%. Some of the common causes of voice restoration failure following tracheoesophageal puncture include: patient motivation and learning capabilities; poor vision; neurological disabilities or arthritis, although use of a Barton button may significantly aid patients with arthritis. Other causes of failure are persistent tumor, scarring, stomal stenosis, and pharyngoesophageal incoordination or spasm.

This spasm appears to be caused by reflex contraction of cricopharyngeal and constrictor muscles when the mid-esophagus is distended with air. It seems to be a cause of tracheoesophageal puncture speech failure in 10% to 12% of patients. Therapeutic options for pharyngoesophageal spasm include pharyngeal constrictor myotomy, unilateral pharyngeal plexus neurectomy, and more recently, chemical denervation of the pharyngoesophageal segment through the use of Clostridium botulinum toxin. Botulinum toxin is a potent neurotoxin, producing neuromuscular blockade by restricting the release of acetylcholine. Originally, type A botulinum toxin was used as an agent for the treatment of strabismus. Its use has been extended to treatment of focal dystonias, including blepharospasm, torticollis, and spasmodic dysphonia.

Several studies have demonstrated good results with Botox injection in tracheoesophageal speech failure associated with pharyngeal constrictor muscle spasm. Hamaker and Blom, in 2003, in their 12-year study involving 62 patients, reported a success rate of 79% after the first injection. Fifty-five percent of these patients responded for more than 6 months. With a second or third injection, 66% were able to maintain relaxation of the pharyngeal constrictors and no further intervention was required.

Lewin et al reported similar results in their study of 23 patients. Success rate after the first injection was 65%, which increased to 87% with one or two more injections. The average duration of response was 20.4 months. Although the effect of Botox is temporary when used in other conditions requiring muscle relaxation, Botox seems to be able to produce a sustained response in restoration of tracheoesophageal speech. This sustained effect is postulated to be related to the degree of tissue damage after surgery or radiation treatment, impairing the ability of the neuromuscular junction to regenerate. Lewin et al hypothesize that the effect of Botox in relieving PE spasm facilitates the initiation of tracheoesophageal speech in some patients, and once the technique of voluntarily relaxing this segment is mastered, repeat injections may not be required.

As far as our case, DT continues to phonate well using his tracheoesophageal puncture. He is currently receiving radiotherapy.

In summary, following total laryngectomy, the inability to speak is considered to be the most profound impairment. Rapid, effective restoration of voice and speech is critical to enabling the patient to return to normal functioning in their life.

Traditionally, esophageal speech and the electrolarynx have provided effective alaryngeal speech, although a large number of patients have been unsuccessful or dissatisfied with these options. The introduction of tracheoesophageal speech has revolutionized and significantly improved voice rehabilitation following total laryngectomy. In many countries, tracheoesophageal speech has become the method of choice for postlaryngectomy voice restoration.

Case Presentation :

DH is 60 year-old former smoker who presented to the Otolaryngology clinic with a seven-­month history of worsening hoarseness. He also reports dyspnea, odynophagia, as well as a 20 lb. weight loss over the past few months. He denies any dysphagia or hemoptysis.

Past medical history includes hypertension and depression. His past surgery history consisted of an appendectomy and a hemorrhoidectomy. His current meds include hydrochlorothiazide, lisinopril, trazodone and fluoxetine. He is a 10-pack year smoker; drinks six beers a day for 20 years and smokes marijuana.

Physical Exam revealed his no masses of the nose or ears. TMS clear; OC/OP: BOT/FOM soft, no lesions; HP/L: Left TVC paralysis, left TVC replaced by tumor which extends over to involve entire right TVC; right TVC mobile; some subglottic extension; valleculae/piriform sinuses clear Neck: No palapable LAD.

A CT Neck revealed a mass involving the L TVC with obliteration of the left periglottic space and mucosal irregularity extending from glottis to approximately the level of the cricoid cartilage. There was also notable invasion of the thyroid cartilage and several level II-IV lymph nodes.

He then underwent tracheotomy, direct laryngoscopy, and esophagoscopy. Biopsies were obtained; final pathology returned as squamous cell carcinoma. Patient was staged as T4 N2b MO SCC of glottis and then underwent total laryngectomy, Left selective neck dissection levels II-­IV, Primary TER. He tolerated the procedure well, and on POD7, he began use of an electrolarynx with an oral adaptor. On POD 23 his indwelling TE prosthesis was placed and he developed good speech with self-occlusion of his stoma.

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