Finding Their Voices: Speech Rehabilitation after Total Laryngectomy
Michael Groves, M.D.
Jan. 29, 2009
Disclaimer: The information contained within the Grand Rounds Archive is intended for use by physicians and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No warranties, either express or implied, are made with respect to accuracy, completeness or timeliness of this material. This material does not necessarily reflect the current or past opinions of the faculty of Baylor College of Medicine and should not be used as a basis for diagnosis or treatment, and is not a substitute for professional consultation and/or peer-reviewed medical literature
Today, we are going to be talking about speech rehabilitation after total laryngectomy. We will start with a brief introduction about laryngeal cancer. It is the second most common site of cancer in the upper aerodigestive tract. The incidence has actually been declining since 1988, and is currently 3.6 per 100,000. Ninety-five percent of these tumors are squamous cell carcinomas.
The concept of the laryngectomy for treatment of laryngeal cancer has been around for over 100 years now. One of the early and most famous laryngologists of the 19th century, Sir Morell Mackenzie, was quoted in 1888 as saying “total laryngectomy affords little prospect of success and the conditions of existence after it is performed are so utterly miserable, the patient being almost cut off with intercourse with his fellow beings.” What this shows is that even in the very early days of laryngectomy, people recognized that destruction of the patient’s ability to speak was a major blow to their well-being and that some sort of rehabilitation of this faculty was necessary to make laryngectomy a truly successful procedure.
A normal voice production system consists of three different elements. The first is the power source. The lungs and muscles of respiration provide a large volume of air, which can be forced through the vibratory apparatus--the second element. In a normal person, that source of vibration is the larynx. With vocal fold adduction the pressure built underneath in the subglottic area gradually forces the vocal cords apart. Now, the air moving between the two cords must speed up because the area between the two cords is much smaller than the area in the subglottic area. As it speeds up, the Bernoulli principle says that the pressure in that area must also go down, according to the laws of conservation of energy. So, as that pressure falls, and as air escapes, the subglottic pressure goes down and the elasticity and tension of the vocal cords causes all three of these to work together to bring the cords back together starting from the bottom and working up towards the top. This process repeats itself, over and over and over again many hundreds of times a second. These traveling waves create a vibrating column of air, which is then transmitted to the resonating system. The voicing sound, and that is all that it is at that point, a humming noise with a certain pitch produced by the tension of the vocal folds, is articulated by the tongue, palate, and teeth to produce intelligible speech sounds. Laryngectomees retain two of the three components of speech production—a power source and a resonating system. So, alaryngeal speech hinges upon replacing the vibratory mechanism that has been lost with removal of the larynx.
The history of alaryngeal speech rehabilitation goes back to about 1859 when Dr. Johan Czermak produced the first prosthetic larynx. This was for a young girl who had a complete laryngeal stenosis and a previous tracheotomy. So, his prosthesis passed air from the tracheotomy through the nose and into the pharynx. It was set to vibrate by a reed that was in the device, and the patient was able to produce an audible, but very quiet and musical type of voice. Dr.Czermak should also be endeared to our community as he was one of the original inventors of the head mirror. Theodor Billroth performed the first laryngectomy in 1873. Because of previous experiments in dogs, where closing the pharynx had failed, he left the patient with a common tracheopharyngostome. One of his colleagues, Carl Gussenbauer, developed a two-limbed prosthesis to help control salivary drainage. One went up into the pharyngeal segment and one went down into the trachea. He had an attachment that could be inserted into the pharyngeal segment to block salivary flow through the tube and allow for swallowing. You could also put in an attachment with a reed device, and air from the lungs would vibrate the reed and produce also a sort of musical voice. Patients did fairly well with this, but there were high rates of aspiration pneumonia and mortality associated with the common tracheopharyngostome.
In 1888 Struebing described a laryngectomee who had the pharyngeal segment of the tracheopharyngostome actually stenosed off, but he was still able to produce a voice. Struebing actually described the source of that voice as the base of the tongue. He described it as a whisper voice. Others suggested that patients not be given any sort of prosthesis immediately after their laryngectomy in case they developed this “pseudo-voice.”
As I said before, mortality rates continued to be quite high from wound infection and aspiration pneumonia. A famous American laryngologist, Dr. Jacob Da Silva Solis-Cohen, was the first to separate the tracheostoma from the pharyngeal wound entirely, by sewing the trachea to the skin. Then two years later, Dr. Themistocles Gluck, a German surgeon, described the modern laryngectomy technique with primary closure of the pharyngotomy.
Two years later, after many patients developing a pseudo-voice or whisper voice had been reported, Stoerk in 1896 declared laryngeal prosthesis antiquated. Now this did not completely halt development of these prostheses. Over the next thirty years there were many reports in the literature of new devices that tried to overcome the musical quality of the voice and other problems associated with user comfort and wear. Then, in 1926, Seeman was able to describe the vibratory mucosa of pseudoglottis and explain esophageal speech. That was the more or less the last nail in the coffin, as far as any further development, or at least reports of development, of artificial laryngeal devices for many years. Then in the 1930s, Western Electric Company introduced the first electrolarynx. This was refined over many decades, but the default method of alaryngeal speech rehabilitation at this time remained the esophageal speech.
There were surgeons who attempted to produce some sort of voicing conduit from the trachea into the pharyngeal area using mucosalized tunnels. This is an example of one that was created by Dr. Conley. These techniques were very challenging surgically and still had problems with increased risk of aspiration. Additionally, these tracts would often close down and stenose and that made it difficult to maintain them.
Finally in 1980, Singer and Blom introduced the tracheoesophageal prosthesis. At the time, it wasn’t a new idea to have air being directed from the trachea into the esophagus to produce a voice. What was new was the simple technique that they described to create the fistula, as well as the in-dwelling prosthesis that they used to allow these patients to create a voice.
So, our modern speech rehabilitation options include esophageal speech, which has been around for a very long time; the artificial larynx, which has been around since the 1930s; and the tracheoesophageal puncture with the prosthesis that has been in existence since the 1980s.
Speech rehabilitation begins with counseling the patient about these options at the time of their diagnosis of advanced laryngeal cancer. There is a lot of research that has been done in terms of organ sparing treatment protocol that has been quite successful, but there are a good number of patients who will end up undergoing laryngectomy for particularly advanced disease or radiation failure. So, methods of speech rehabilitation after laryngectomy continue to be an important subject.
Esophageal speech is produced when air is injected into the esophagus by the patient and then expelled, causing the pharyngoesophageal (PE) segment to vibrate. This PE segment is made up of musculature and mucosa of the lower cervical area, around C5 to C7. Vibrating this area with the power that is generated from the air being ejected from the esophagus produces a belch-like sound, which is then articulated by the lips, tongue, teeth and palate. Insufflation of the esophagus depends on pressure in the oropharynx overcoming the pressure of the PE segment.
There are three different methods of insufflation of the esophagus. One is consonant injection when the patient uses pressure that has built up in the mouth and pharynx during production of closed consonants such as a P or a T. That air is then forced down into the esophagus to be regurgitated. The benefit of that is, when you get good at it, you can actually do this while you are talking. So, there are no pauses: you don’t have to stop to fill your esophagus to continue talking. So your fluency is going to go up significantly if you can manage consonant injection. It is difficult to learn, and so, this takes time before people can get to this point. The second method of insufflation is glossopharyngeal press. Basically the tongue is used as a piston to force air down into the esophagus. The third insufflation method is the inhalation method. The PE segment is relaxed and the patient rapidly but gently lowers his diaphragm and that can decrease intrathoracic pressure and draw some air into the esophagus to be expelled for speech production.
So, what are the advantages of esophageal speech? It is hands-free and inexpensive. There are no complications related to the device and no additional surgery required, so the patient does not have to undergo additional risks of the general anesthetic or wound healing complications, especially after radiation. The problem with esophageal speech is that it is extremely difficult to master. Reported success rates vary widely, but it is somewhere around 25%. So, three-quarters of your patients are going to be unable to achieve esophageal speech if you intend to use this as your only rehabilitation option. It also takes quite a while to learn, so they may be without speech for some time. Also, people, in general, don’t like the sound of esophageal speech.
The electrolarynx is probably the most common form of post-laryngectomy speech because it is easy to learn. It is an electric motor that vibrates an electrolarynx membrane. When that is placed to the neck, those vibrations are transmitted through the soft tissues and sets the column of air in the pharynx to vibrate as well and again, that noise sound is articulated by the tongue, lips, teeth and palate in order to produce understandable speech sounds.
There is also a modification where you can place an oral tube and hold it in front of the mouth and the tube goes in there and directs these vibrations into the esophagus and the laryngopharynx and then they are able to articulate sound. The oral tube configuration is actually nice in the immediate post-operative period because otherwise the patients are having to press the electrolarynx against their neck when they are tender from their surgery and do have to apply a fair amount of pressure in order for those vibrations to be effectively transmitted. Immediately post-operatively there is some edema and some other factors that may make the transmission of those vibrations less effective, so the oral tube is beneficial in that setting.
What are our advantages of the electrolarynx? Well, it is easy to learn, and allows a rapid return to speech. Patients can be speaking on post-operative day one, two, and three. When they get good at it, it is fairly clear to the listener. Among the disadvantages are the fact that it is costly. It requires batteries, which can run out. When it is lost, it must be replaced. Also, the electrolarynx requires the use of the patient’s hands. It produces a mechanical sound that some people find unpleasant. It is highly stigmatized in popular culture. You have probably seen representations of people in comics or cartoons and movies that aren’t portrayed very positively. People tend to blame the victim when they are using an electrolarynx, because people assume that the person smoked so much that they developed throat cancer.
So what about the tracheoesophageal puncture? As I said, this was first described by Singer and Blom in 1979. They originally proposed the secondary PET as a way to rehabilitate the 75% of patients who fail to achieve esophageal speech, as esophageal speech was still considered the primary method of speech rehabilitation. At this point, TEP has become the preferred method of speech rehabilitation for many patients, as well as doctors and speech pathologists.
There are two different configurations. One is a temporary prosthesis, shown here, which requires that the patient occlude the stoma in some way. The air is directed from the trachea through the prosthesis into the pharynx to allow the PE segment to vibrate in order to produce noise, which, again is articulated by the teeth, lips, tongue and palate. Maintenance of these prostheses requires a fair degree of manual dexterity on the part of the patient, as well as both reasonable vision and cognitive ability.
In order to overcome some of those limitations for patients who could not manage these temporary prostheses, they developed the indwelling prosthesis, which has a larger esophageal cuff that holds it in place better and must be replaced by a speech pathologist or a physician. These tend to stay in place for a little bit longer between replacements. They don’t require as much cleaning.
What are the advantages of the tracheoesophageal speech produced by this tracheoesophageal puncture and prosthesis? It has a high success rate: over 75% to 97% success rates has been reported. It allows a rapid return to speech. With secondary TEP, it can be placed within a couple of days of the original surgery. It gets excellent listener ratings, especially compared to esophageal or the electrolaryngeal speech. It uses the pulmonary air supply, allowing a larger volume of air that can be passed through the vibratory segment and fluency and understandability will therefore be better. As far as disadvantages, if the prosthesis must be changed frequently, it can be expensive. Also it often still requires the use of the hands.
There are also complications related to the device and from the surgery. A few of these complications include leakage through the prosthesis or the valve. That can be caused just by a simple prosthetic defect as well as candida infection of the prosthesis, which can warp the plastic and cause it to not function properly. There is leakage around the prosthesis, which is often related to one that has not been properly fitted. That requires some manipulation where you remove the prosthesis and put a smaller tube in to keep the track open but allow it to close down slightly. It is important to resist the urge to put a bigger prosthesis in the hole. A wider prosthesis will just make the problem worse. These can become dislodged or dropped while they are being manipulated by the patient during cleaning. That can lead to aspiration. The device usually does not go down very far and can often just be coughed up. Granuloma and irritation, increased mucous production, hypersensitive gag and cough are all inconveniences associated with the use of the tracheoesophageal prosthesis.
There is some debate as to whether it is better to perform a primary (done at the time of laryngectomy) or secondary (done as a second procedure some time after laryngectomy) TEP. Brown et al. in 2003 played recordings of patients that had received primary or secondary TEP to blinded trained and untrained listeners, as well as having the patients themselves and one of their relatives listen to their voice and rate their voice quality subjectively. Then they performed some tests in terms of the intensity of speech, the fundamental frequency and the maximum phonation time. They found no difference in these subjective measures or these objective measures between the primary and the secondary TEP. Functionally, they seem to act very similar. There is also no difference in terms of complications in his report.
What are the general benefits of the two? Well, with primary you have a very early return to voicing, whereas with the secondary it may be slightly delayed. They are trying to learn how to use their electrolarynx or tablet writing while waiting for their secondary TEP. The catheter, which enters below the level of the pharyngotomy in the primary TEP, can be used as a source of feeding. It will take pressure off that wound as it heals. Also, with the primary, you can avoid a second anesthetic, which can be a major risk factor in some of these patients who have coronary artery disease or other medical morbidities. Also, it is an open procedure. You don’t have the problem of a patient who has had a lot of radiation to their neck and difficulty extending the neck, which could make it difficult to get the esophagoscope to the appropriate level to in order to perform the secondary TEP. It is a little bit, maybe simpler technically to perform it. Both are reversible, but the primary TEP is reversible right away if the patient does not want to continue with their primary TEP. Some argue that a major benefit of a secondary TEP, is that it avoids complications associated with external beam radiation therapy. However, there are many case series in the literature that note no significant increase in complications associated with XRT in primary versus secondary TEP.
If you take those at face value, then you might say that it seems like the primary is the most viable option. I would argue that these case studies are not strong evidence when looking at the rates of complication associated with the radiation.
The only absolute contraindication to doing a primary TEP is the separation of the common party wall, either inadvertently during the surgery or if you have to fully separate because you have esophageal extension and you are performing some sort of gastric pull up or jejunal free flap, where the trachea and the esophagus are not in direct connection. If you do try to perform a primary TEP in these patients, you put them at risk for abscess formation and mediastinitis.
A relative contraindication is a complex reconstruction, such as when you are using a pec flap or something of that sort. Most people will probably just delay for a secondary TEP.
When you look at the acoustic features of the two of the three methods of speech rehabilitation after laryngectomy and compare them to natural laryngeal speech, a few different patterns arise. One is that there is a significant difference in the terms of fundamental frequency of esophageal speech. So, it is much lower frequency than laryngeal or PE speech. This may not be a big deal for your male patients, but for a female to have a vocal range that is that low, it may be unpleasant for them and they may not wish to do esophageal speech for that reason alone.
It is interesting that the median intensity of TE speech is actually higher than either laryngeal or esophageal, what is described in the paper as a comfortable conversational level. That is probably because the patient is having to use higher pulmonary pressures to overcome the valves, which is then transmitted to it, creating a higher intensity of speech production.
Maximum phonation time is extremely different between the three. These are all significant differences between each of these groups compared to the laryngeal speech. Despite having the full pulmonary reserve in order to produce speech with the TE puncture, you still cannot match a normal larynx in terms of its ability to produce phonation for a long period of time. So, your fluency is pretty good with a tracheoesophageal puncture, but it won’t be totally normal compared to a laryngeal speaker.
Despite the fact that esophageal speech seems to be the lowest rated and the least liked laryngeal speech, there are reports in literature, such as this one from Quer et al. in 1992, of patients, despite having a TEP, continuing to receive training in esophageal speech. A large portion of these patients actually went to only esophageal speech when they were able to achieve it. The author is positive that this is because of some of those general benefits which I discussed earlier. It is easy, you don’t have to worry about cleaning your prosthesis, and you don’t have to buy any new prostheses, and, if you are understandable, than that is probably sufficient for most of these patients. They want to be able to communicate and if they can do it without the bother of all of these other devices, then they may switch to just esophageal speech.
Three to fifteen percent of patients fail to achieve useful speech after a tracheoesophageal puncture and there are many reasons for this, including lack of motivation, lack of vision or manual dexterity, alcoholism, and living far away.
There are site risk specific factors: recurrent residual tumor, excessive granulation tissue or prosthesis malfunction, which I already talked a little bit about. There can also be problems with the PE segment. Sometimes it is hypotonic and you get this crackly, sort of loose or wet, character of the voice. Sometimes there is PE spasm, which was the case with our patient. So, when air is insufflated into the esophagus, the pressure goes up. There is in normal patients, as well as laryngectomy patients, a reflex, spasm of the PE segment when air passes through it. In some patients, it is loose enough that air can still escape and produce voice. In other patients, it is such a tight spasm that prevents speech, or makes it weak, choppy or strangulated. As I have stated, they estimated that is accounts up to 79% of all TE speech failures. The other group of patients would probably have a permanent stricture, which would interfere with their swallowing as well.
Ways of dealing with this. Most people prevent it, or try to prevent it at the time of the original laryngectomy by performing one of these procedures to decrease the ability of those muscles to perform a complete arch around the esophagus and to close it off entirely. Using one of these, some say you would be able to decrease your rate of PE spasm limiting speech to about 6%.
If you are dealing with a secondary TEP, there is sort of a protocol that you go through in terms of determining if that patient has spasm and how you might deal with it before you perform the TEP. It is a simple esophageal insufflation test. Blom and Singer have produced this nice test kit, where you put this device over the trachea, which when occluded, will then direct air through this catheter that goes into the nose and esophagus. You can see it there. If the patient fails that, you can do the same test, after having the patient swallow some barium that outlines the esophagus and pharynx. During another video fluoroscopy, you can visualize the PE segment that is spasming during speech production. If you are able to visualize that, you may try marking it, with some nipple markers on the skin level, then performing a pharyngeal plexus block on one side, where you inject 2% Lidocaine into the area and presumably inhibit the muscles from being able to contract. Then have the patient again try to voice. If that works, then you have a good chance of success with your TEP.
When you already have your TEP and the prostheis in place and are still not getting a voice, and you have not done some of these pre-operative things to identify the spasm before you did your procedure, or if you did the primary procedure, then, first, rule out a prosthesis issue. You examine the prosthesis, you try replacing it, after you make sure that is not malfunctioning itself. If they still cannot voice, then you take it out once more and have them try to voice through an open track. If they cannot voice through an open track, then you know it is probably a PE spasm or some sort of stenosis. If they do voice, with an open track, then again, you just replace the prosthesis, because it is most likely malfunctioning.
In order to treat PE spasm, there are several options. One is open procedure, such as a selective pharyngeal myotomy or pharyngeal plexus neurectomy, but these are both second procedures performed under anesthesia, which can be risky for some patients. You have a significant complication rate, especially in patients who have had radiation in the past. The most viable option now is probably Botox injections. This is a chemical denervation of those pharyngeal constrictors by preventing acetylcholine release at the neuromuscular junction which prevents contraction of the muscle. Many case reports have been put out, some with not very much information, but in general, they report positive results with good success rate, even with the first injection.
Lewin et al. over at M.D. Anderson had a report, which had the most information. They actually said that their mean duration was a full twenty months, when usually Botox wears off after about six months. Their longest success rate was thirty-seven months.
Really briefly I want to talk about quality of life in these patients. A lot of attention is focused on voice rehabilitation in laryngectomy patients. Early on, when the quality of life issues became important in the research, there were some reports that perhaps quality of life was not that greatly affected by having the larynx removed. One report was by Deleyiannis et al., who didn’t actually find any difference in the quality of life between pre-op laryngectomees and post-op laryngectomees. In terms of speech, they found it wasn’t even the most important thing to those patients. More important were activity level, recreation and swallowing function. The problem with the study was that it was an invalidated questionnaire, and only looked at ten patients.
What was revealing from this study, was from the patient who scored the worst in terms of his quality of life. He is quoted as saying: “They told me I would lose my voice. They forgot I cannot clear my throat, sniff or blow my nose, hum a tune or whistle a note, gargle or scratch my neck, or feel my nose when it burns…I laugh without a sound and suffer the mental pain of stress and the physical pain of anxiety. I cannot even sigh or swim. People turn and look. Kids point and make fun. I cannot blow on soup to cool it or sip my cocoa.” This makes us conscious that this is a significant blow to the patient’s quality of life, even if their speech can be rehabilitated effectively.
That is backed up by a study from Terrell et al. that used the Veterans Affairs trial of randomizing patients to surgery and radiation therapy versus chemotherapy and radiation therapy. They found that there were no significant difference in speech scores on a validated head and neck quality of life measure between the patients who were randomized to surgery and those that are randomized to chemotherapy. That effect was durable even when you took the patients who failed chemo, radiation and then required a salvage laryngectomy and added them to the laryngectomy group versus no laryngectomy. The speech results were still the same. So, our rehabilitation of speech seems to be sufficient to produce no difference between someone who saves their larynx after laryngeal cancer and someone who doesn’t. The authors suggest that patients may have been accustomed to poor voice. Or, the head and neck quality of life speech domain was not sensitive enough to pick up a small difference between these groups. But, it has been validated in other studies to pick up very small differences. So, this is probably a valid finding here, that there is no significant difference. There is a significant difference in the SF-36 mental health domain and the head and neck quality of life pain domain, when you compare these patients randomized to chemo and XRT and those randomized to surgery and post-operative radiation. This difference becomes even more obvious when you take those patients who had salvage laryngectomy and put them in the group of patients who had a randomized laryngectomy and compared them to those who were able to save their larynx. Then you start to see significant differences in not only the mental health domain, but also the bodily obtained domain and you add patients had a significantly poor perception of their response to treatment and a significantly poor emotional well being scores on the head and neck quality of life.
This confirms findings from a survey that was done at Michael E. DeBakey, VA Medical Center on laryngectomees related to voice handicap and quality of life by Dr. Stewart back in 1998. That study showed voice handicap is not the only, or even the most important, dimension affecting the quality of life of patients following treatment for laryngeal cancer. We spend a lot of time focusing on rehabilitating patient’s speech, we do an excellent job of that, but to stop there and think that these patients are all doing great, because they can talk, is probably selling them a little bit short.
So, in conclusion, speech rehabilitation has long been recognized as an important part of treating laryngeal cancer patients. There are several existing options, but, at this point,tracheoesophageal speech after a tracheoesophageal puncture is generally the favored form.
The use of TE speech requires follow-up by the treating surgeon and speech pathologist to help patients deal with a lot of the device related complications that they may run into. The benefit of having all of these follow-up visits is that you can continue to focus on the patient’s other quality-of-life issues that may be even more important than the speech problem in determining their overall well being.
F7204 is a 64 y.o. Caucasian male who underwent a total laryngectomy with right modified radical neck dissection (levels II-V) on 11/20/07 for a T3N2aM0 squamous cell carcinoma of the larynx with subglottic extension. He subsequently underwent concomitant chemotherapy and external beam radiation for extracapsular spread, which was completed 3/18/08. He was successful in using a Servox electrolarynx with mouth-tube post-operatively, but desired a less cumbersome speech method, especially after losing his original device during Hurricane Ike and having to borrow a friend’s for several weeks.
He was referred to the MEDVAMC Speech Pathology clinic where they performed an esophageal insufflation test as an initial assessment for secondary tracheo-esophageal puncture (TEP) candidacy. Unfortunately, he was unsuccessful in producing esophageal speech. A follow-up examination with modified barium swallow and video-fluoroscopy of the pharyngo-esophageal (PE) segment during esophageal insufflation ruled out a static stricture and demonstrated a spastic PE segment. This was marked on the skin with nipple markers and the patient was taken to ENT clinic. There 2% lidocaine was used to perform a unilateral pharyngeal plexus block. Within 1 minute, the patient was able to produce an audible, yet strained esophageal voice. He was informed that he would be a suitable secondary TEP candidate, but that he may require post-operative Botox injections to manage his PE spasm.
He underwent an uncomplicated secondary TEP procedure on 1/9/09. As predicted, he has had significant difficulty producing a tracheo-esophageal voice. This difficulty is persistent even with open tract voicing and is therefore presumed to be due to his previously identified PE spasm. He is scheduled to undergo Botox injections to the pharyngeal constrictor musculature on 1/29/09.
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