Head & Neck Surgery - Otolaryngology
4th Edition

123
Voice Rehabilitation after Laryngectomy
Mark I. Singer
Carla D. Gress
The operative procedure of total laryngectomy separates the airway from the digestive tract and establishes a permanent tracheostoma at the base of the neck. The pharynx is reconstituted by simply closing the mucosa or, in more complex cases, by interposing skin flaps to preserve an adequate lumen for swallowing. Although the process of swallowing is simplified without the larynx, sound production is lost. The threat of voicelessness has a profound and devastating effect on laryngeal cancer patients. Several voice-restoring methods have been proposed and are reviewed.
Anatomy of the Operative Defect
Total laryngectomy or wide-field laryngectomy includes removal of the supraglottic larynx and hyoid bone, intrinsic larynx, portions of the pharynx, the strap muscles, one or more rings of the trachea, and part or all of the thyroid gland. The resection may include neck dissection, upper mediastinal lymph node dissection, and portions of the tongue base. The actual resection of the larynx requires entrance into the pharynx, determined by the location of the primary disease. It is desirable to make an entry away from the tumor and yet have complete visualization of the disease. The resulting defect, a pharyngotomy, consists of varying amounts of pharyngeal and esophageal mucosa, constrictor muscle remnants, and tongue base. The usual closure of this defect is primary. The geometry of closure (“T,” “Y,” “I,” or horizontal suture line) is determined by the amount of residual tissue, resultant tension, and the surgeon’s experience.
The usual approach to laryngectomy separates the pharyngeal constrictor muscles at the oblique line of the thyroid cartilage (Fig. 123.1). Specifically this includes the inferior pharyngeal constrictor and cricopharyngeus muscles. The separated constrictors are used as the third or external layer in the conventional three-layer closure of the pharynx. The junction of the pharynx and esophagus has been studied by speech pathologists as the sound source for alaryngeal speech and is called the “PE” segment, the pseudoglottis, or the CP (cricopharyngeus). It is difficult to predict resultant voice or quality because of variations in anatomy, tumor extent, muscle bulk, and operative technique. Pharyngeal closure after laryngectomy is generally concerned with controlling secretions, swallowing, and prevention of fistula formation. Recently, attention has been directed to alaryngeal voice acquisition and the possibilities for maximizing the results by changing the reconstructive technique (1, 2).
Mechanics of Voice Restoration
When the patient is healed and able to swallow after the laryngectomy, three possibilities for speech rehabilitation exist: the artificial larynx (electrolarynx), esophageal speech, and tracheoesophageal speech.
Artificial Larynx
The artificial larynx is an instrument that serves as a voicing source. The most common types are placed against a supple point on the neck and introduce a mechanical sound into the tissues and air spaces of the vocal tract. This sound, emanating from the mouth, is articulated by the structures of the remaining vocal tract (the tongue, lips, and teeth) as understandable speech. The artificial larynx is rapidly learned and does not delay or interfere with the acquisition of other forms of alaryngeal speech.
Figure 123.1 Separation of the pharyngeal constrictors from the larynx. E, esophagus; Ic, inferior constrictor; Mc, middle pharyngeal constrictor.
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A second type of artificial larynx uses a tube adapter to direct the sound to the oral cavity, where it can be articulated with some reduction in intelligibility. This is useful for patients whose necks do not transmit the electrical sound or in the immediate postoperative period when the neck is healing. Most of the intraoral tube devices are electrically powered, although a few air-powered (pneumatic) instruments use the patient’s exhaled air to activate a sound source of vibrating elastic bands. A newer device consists of an electric sound source that is housed in a denture and is activated by a hand control or by the tongue (3).
The artificial larynx or electrolarynx has the advantages of low cost, availability, short learning time, and loudness. Its disadvantages are the dependence on batteries, mechanical sound, conspicuous appearance, loss of hands-free speech, and hygiene of the intraoral tubes or dental appliance. It also relies on the use of batteries and is often not covered by insurance policies. Nevertheless, many laryngectomized patients use the artificial devices as the primary method for speech communication.
Esophageal Speech
Esophageal speech is another recommended method for alaryngeal speech rehabilitation, and variations of the technique have been known for more than 100 years. The most successful users (5% to 30% of laryngectomy patients) have natural voice quality with fluency and intelligibility, free of extraneous noise from the stoma or facial–oral gestures. The characteristic esophageal voice is low in fundamental frequency (∼65 Hz), is of short duration, and requires some effort to produce. The patient learns to insufflate the esophagus, usually under the di-rection of a speech pathologist or another patient with a laryngectomy. The most common method involves trapping air in the mouth or pharynx and then injecting it into the esophagus by the propulsive action of the tongue. The air may be stored in the esophagus and the stomach. With diaphragmatic effort, the air refluxes through the esophagus and crosses the upper esophageal sphincter. The mucosa of this region is vibrated by the released air and produces a characteristic belch-like sound. This sound issues from the mouth, in similar fashion to that from the artificial larynx, and is articulated by the tongue, lips, and teeth. Rapid repetitive movements of injection and release produce fluent and understandable speech.
In the second method for esophageal speech insufflation, the patient relaxes the upper esophageal sphincter and introduces air into the esophagus by inhaling during the increased negative intrathoracic pressure of inspiration. This is less common than the injection method and is characterized by breathy voice quality and less intensity. Successful esophageal speech is preferred to the artificial larynx because it is less conspicuous and does not require the use of hands, is more natural sounding, and the patient is independent of devices. The critical problem with esophageal speech is its low acquisition rate and the extended learning period.
Shunts and Valves
From the time of the first laryngectomies, it was known that tracheal air during exhalation can be shunted to the pharynx or esophagus through a planned fistula or tract, and this pulmonary-driven insufflation can produce effective speech (Figs. 123.2 and 123.3) (4, 5, 6). The same principles of speech production apply with articulation at the oral cavity and sound produced in the upper esophageal sphincter. The shunts, however, introduced a new series of problems that limited their wide application. Particularly after radiation, mucosal-lined tracts are difficult to maintain, and patency is compromised by stenosis at the level of the tracheal or pharyngeal meatus. Continued salivary flow through them often causes inflammation, breakdown, and sometimes necrosis. Patency of the shunt to tolerate airflow at resistances of 35 to 45 cm H2O/LPS for natural speech production also allows salivary reflux into the trachea. Chronic salivary soiling of the upper airway with tracheoesophageal shunts makes their use hazardous in patients with compromised pulmonary reserve.
For this reason, some investigators developed mechanical valves to divert the secretions from the trachea or attempted to devise biologic valves (sphincters) for airway protection (Fig. 123.4) (3). Most of these efforts failed because of valve incontinence or stenosis. Radiation therapy is a relative contraindication to techniques that rely on tissue valving.
Figure 123.2 Modified tracheostomy cannula for air diversion to the pharynx.
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Prosthetic replacements for the larynx had a brief lifespan in the early 1960s. Synthetic valves of Teflon or Dacron were sewn into canine tracheas, but these procedures failed because of the inability to place prosthetic material in a contaminated airway for long-term incorporation and the failure to clear the secretions effectively from the valves and trachea.
Duckbill Voice Prosthesis
The creation of a successful, surgical voice-restoration technique did not occur until the introduction of the tracheoesophageal puncture (TEP) by Singer and Blom in 1979. It was proposed as a secondary salvage technique for those who failed to produce esophageal speech or those who were displeased with the electrolarynx voice. A removable silicone tube was developed in 1978 that would maintain an endoscopically placed tracheoesophageal puncture and would serve as a one-way valve (Figs. 123.5 and 123.6) (7). The design called for a simple valve that was biologically compatible, removable, and inexpensive. The initial caliber was 3.3 mm (14 French), and the simplest valve concept was a slit through the long axis of the tube. The end opposite the stent/valve was open with a second window on the inferior (ventral) surface.
Figure 123.3 Mucosal shunt for voice restoration proposed by Conley.
This early voice prosthesis was called a “duckbill” valve to describe the action of the slit valve, and it became known as the “duckbill voice prosthesis.” The silicone tube was well tolerated by the trachea and esophagus, with a low incidence of foreign-body reaction. A retention collar was added to the valve end to maintain its position in the puncture tract.
The puncture can be placed primarily (at the time of laryngectomy) or secondarily (after laryngectomy) without contraindication of radiation therapy. The puncture permits a direct midline communication from the posterior trachea to the anterior esophagus at a location inferior to the cricopharyngeus muscle and pharyngeal constrictor muscles. The location at the tracheostoma permits direct visibility for the patient and clinician.
The prosthesis functions by allowing exhaled air to enter the esophagus. After the esophageal reservoir is filled, a continuous air stream flows superiorly toward the pharynx and vibrates the mucosa of the upper esophageal segment, producing sound. This is an intense sound and is continuous because of the efficiency of the respiratory system to maintain volume and pressure for voice. When phonation is finished and airflow stops, the valve slit closes and prevents pharyngeal secretions from entering the airway. Taking advantage of the mechanics of normal breathing, the patient can vary voicing efforts, and more natural phrasing is possible. Measurements of intensity, fundamental frequency, and speaking rate confirm that tracheoesophageal speech is more acoustically similar to normal laryngeal speech and is more intelligible and acceptable than standard esophageal speech (8, 9, 10). Initially, patients learn to cover the tracheostoma manually, and with varying pressure, they achieve a fluent voice with little air escape or masking noise.
A second valve was later developed for closing the tracheostoma for phonation (11). The higher airflows for tracheoesophageal voice production close a curled valve diaphragm against a plastic housing. With normal res-piration, two-way flow through the valve is possible. This allows natural speech that is inconspicuous without the hands and is quieter. The tracheostoma valve can be attached by using an adhesive to the peritracheal skin or to a silicone tube (laryngectomy tube) that is inserted into the tracheostoma (12). Use of a tracheostoma valve
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requires varying intratracheal pressures. It cannot be used in patients who have impaired respiratory function, such as chronic obstructive pulmonary disease. The adhesive attachment of the tracheostoma housing requires a meticulous technique to ensure a long-lasting seal. Although desirable, the tracheostoma valve is effective for only 25% to 30% of the laryngectomized population (13).
Figure 123.4 Skin tube shunt from the trachea to the hypopharynx (Asai procedure).
The early experience and a growing population of tracheoesophageal speakers rapidly accrued a group of voice failures estimated at 25% to 40% (the numbers varied depending on the criteria for successful voice acquisition) (14). A proposed solution was the development of a low-pressure voice prosthesis (8) (Fig. 123.7). The design consideration was to reduce airflow resistance to that of the larynx itself (30 cm H2O/LPS), which requires less effort for voicing. A further refinement has been to increase the diameter of the prosthesis from the standard 16F to 20F, permitting increased airflow with a resultant increase in loudness. Numerous prosthetic devices are currently on the market, including in-dwelling prostheses, designed to meet individualized patient requirements for aerodynamic characteristics, length of wear, ease of insertion, and prevention of aspiration.
Figure 123.5 Duckbill (slit-valve) voice prosthesis.
Figure 123.6 Voice prosthesis in place in the tracheoesophageal puncture.
Figure 123.7 Low-pressure (trap-valve) voice prosthesis.
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Patient Evaluation for Secondary Tracheoesophageal Puncture Candidacy
In the general survey of the laryngectomized patient, the initial stage of disease, operative technique, use of radiation therapy, and reconstruction methods should be noted. The patient’s health, age, and physical status are assessed. Relative concerns that may reduce the success of voice restoration are pharyngeal stricture with symp-tomatic dysphagia, radiation therapy exceeding 6,500 cGy, malnutrition, diabetes, dementia, and severe chronic obstructive pulmonary disease.
The physical examination includes a careful head and neck examination with attention to stomal hygiene, patient’s dexterity, as well as overall motivation and interest in voice restoration. The patient’s inability to use and care for the prosthesis due to impaired mental status or decrease in manual dexterity due to age, arthritis, or neurologic insult/disease has been overcome with the introduction of the indwelling prosthesis. Bilateral severe sensorineural hearing loss and limited pulmonary function are also relative contraindications to TEP because the patient cannot hear the TE voice, and limited pulmonary air restricts the fluency and volume of speech, respectively (6).
The stoma should be free of a cannula if possible and at least 1.0 cm in one dimension. Microstomia makes it difficult to place the prosthesis and may compromise the airway because of the prosthesis size. If microstoma exists, the stoma should be dilated and stented with a laryngectomy tube or revised by Z-plasty. Patients who have undergone radiation therapy whose tissues appear to be at risk are better managed by the former method. However, the posterior wall of a laryngectomy tube can be fenestrated to allow the use of voice prosthesis and laryngectomy tube together.
A preoperative esophageal insufflation test is important in predicting the likelihood of successful secondary tracheoesophageal speech. It estimates the possibility of dysfluency from pharyngeal constrictor spasm (15, 16). The TEP crosses the upper tracheostoma and enters the esophagus inferior to the reconstituted cricopharyngeus muscle and upper esophageal sphincter. The distention of the esophagus that occurs with air ingestion results in a reflexive increase in tone in the pharyngeal constrictor muscles. This finding was described in early manometric studies of the region in normal, nonlaryngectomized patients (17). Insufflation of the esophagus in the clinical setting requires placement of a catheter through the nose into the upper esophagus. Air is introduced into the esophagus either by an external source or by adapting the tube to a special connector fixed to the tracheostoma. After air enters the esophagus and is released, voice production and connected speech are attempted, which may result in sound (i.e., ah, a low-pitched rumble, or eructation) or in a series of connected words, as in counting. The fluency of speech should be assessed carefully, observing any air trapping, which, if complete, will cause gastric filling, dis-tention, discomfort, and even vagal syncope. One of four responses is obtained after the insufflation test: fluent, sustained voice production with minimal effort indicating relaxed pharyngoesophageal muscles; a breathy, hypotonic voice indicating the absence of pharyngeal constrictor muscle tone; hypertonic voice characterized by intermittent production of effortful speech with gastric distention and posttrial burping; and spasm characterized by no production of voice even with substantial pulmonary air flow. Despite these possible responses to esophageal insufflation, no definitive guidelines exist for successful duration of speech, airflow, or desirable pressures (pharyngeal or intratracheal). Some patients may have increased pharyngeal constrictor tonicity during tracheoesophageal voicing, but no reliable data show the incidence of patients who will succeed despite equivocal catheter insufflation testing. Furthermore, dysfluency on insufflation testing may be due to causes unrelated to pharyngoesophageal spasm, including postradiation tissue edema or the presence of recurrent disease. Therefore esophageal insufflation testing may be considered a subjective evaluation of esophageal distention and should not be used as the sole method for determining the need for open-neck exploration and pharyngeal constrictor relaxation.
Pharyngoesophageal spasm, suspected with a dysfluent speech pattern on insufflation testing, may be confirmed by anesthetic block of the pharyngeal plexus. The most effective method for analysis combines radiographic assessment with a plexus block. The patient is evaluated by videofluoroscopy with a barium-coated pharynx and
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esophagus; the lateral view is preferred. An at-rest view is first obtained to review the morphology of the neo-pharynx and to rule out stricture, fistula tract, or per-sistent neoplasm. Several views during voicing are taken. The pharynx is examined for the mass of constrictors, seen in the retropharyngeal radiographic plane as a bar (Fig. 123.8) (18). Note the axial length with reference to the proximity to the tongue base and its overall breadth.
Figure 123.8 Lateral radiograph demonstrating the constrictor mass during esophageal distention. (Reprinted from Singer MI, Blom ED. A selective myotomy for voice restoration after total laryngectomy. Arch Otolaryngol 1981;107:670–673; with permission.)
The study is followed by the pharyngeal plexus block with local anesthesia (150 to 200 mg of 2% lidocaine without epinephrine). The anesthetic is injected with a 23-gauge, 1.5-inch needle placed at the level of the pre-vertebral fascia and then extracted 1 to 2 mm before injection. The neck skin is entered at the level of C2–C3 immediately parapharyngeal and medial to the carotid sheath. After 3 to 5 minutes, the patient is instructed to attempt voicing, which is nearly always effective, effortless, and fluent. The voicing dynamics are now analyzed by fluoroscopy. The typical appearance shows a reduction in the mass of the constrictor muscles, including the axial length. In effect, the pinchcock effect of the constrictors during esophageal distention is temporarily blocked by the anesthetic and is readily documented by the radiographic examination. This indicates that the use of botulinum toxin A, pharyngeal constrictor myotomy, or pharyngeal plexus neurectomy will most likely be successful in treating pharyngoesophageal spasm.
Secondary voice restoration should be delayed until 6 weeks after laryngectomy, 6 to 8 weeks after postoperative radiation therapy, or until the peristomal skin has recovered from radiation toxicity, and at least 1 month after recovery from reconstruction of a total laryngopharyngectomy or total laryngopharyngoesophagectomy defect and adjunctive therapies. Patients after reconstruction should also undergo barium swallow to evaluate the reconstructive changes and the presence of a stricture.
Differential Diagnosis
The diagnostic problem is to evaluate voice failures after TEP (Table 123.1). The largest percentage of patients is the group who reflexively elevate the upper esophageal sphincter pressure during esophageal distention above the threshold for voice fluency. The patients may be capable of only a few syllables, a fluent “ah” or counting up to only 5 or 6, but also may exhibit considerable effort to voice, with the characteristic appearance and results of the Valsalva maneuver. Some patients initially demonstrate the Valsalva pattern. By using breath control and internal feedback, they can reduce esophageal distention and the resultant upper esophageal sphincter tonicity.
This dysfluent speech pattern may change over a 4- to 6-week period, but if it has not improved (and ≥15% to 25% will not change), further investigation and possible intervention are required. Voice is reassessed by the open-tract test, in which the voice prosthesis is removed and the patient tries to speak. This is successful in only a few patients, which demonstrates that the failure is the result of the unfavorable mechanics of the voice prosthesis. The device may be too long or too short. Confirmation of correct fitting length can be assessed by flexible endoscopic evaluation of the esophagus while the patient is asked to prolong phonation. If the voice retains a strained quality after assuring a proper fit, switching to a prosthesis with low-resistance characteristics and larger diameter (20F) helps reduce the resistance to airflow and results in less effort for most patients.
The patient with persistent voice failure with the open-tract test should be evaluated systematically by using video fluoroscopic examination and pharyngeal constrictor local anesthetic block. It is unusual for voice failure to occur from a morphologic abnormality of the pharynx or stricture or
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the angle of the prosthesis. If the air is directed to the distal esophagus, it will regurgitate superiorly to the pharynx as the esophagus distends. If the pharynx is tubular and rigid (common with skin-flap pharyngeal reconstruction), the voice may be breathy or whisper-like. Myocutaneous flap reconstructions are characterized by decreased pitch, judged as “wet,” and can be slow to initiate because of the inertia introduced by the bulk of the flap (19, 20).
TABLE 123.1 EVALUATION OF TRACHEOESOPHAGEAL SPEECH FAILURE
Prosthesis failure: position, size, type, patency
Reflex pharyngeal constricture spasm
Nonvibrating pharyngoesophageal segment: radiation-induced, edema, reconstructed segment
Puncture closure
Inadequate air supply: decreased respiratory support, improper stoma occlusion
The free microvascular transfer of a segment of jejunum represents another problem. The segment of intestine is often redundant and traps air and secretions. This also is complicated by the intrinsic tonicity of the intestine, which impedes free egress of air across the grafted segment. Although a myotomy of the jejunal wall has been suggested, evidence of its efficacy remains to be documented. Although gastric transposition introduces mechanical complexity at the level of the tracheostoma, no increased risks have been described by puncture at this level into the stomach. The resultant airflow is unimpeded, and the pitch is low, with a characteristic hollow voice (21).
Surgical Technique
The TEP is readily established secondarily by using an endoscopic technique (4). A rigid esophagoscope is introduced with the patient under general anesthesia through the laryngectomized pharynx and into the upper thoracic esophagus (Fig. 123.9). Mucosal irregularity, stricture, or ulceration at the level of the cervical esophagus should be noted. At the tracheostoma, the esophagoscope is rotated 180 degrees from introduction, with the longer side of the bevel now opposed to the posterior trachea. A window on this surface facilitates the puncture.
The membranous trachea is palpated through the stoma, ensuring that the esophagoscope is against the posterior trachea. Transillumination of the trachea is not usually helpful for the precise placement of the puncture. A puncture location is identified 5 mm from the superior trachea, and the window on the esophagoscope is aligned with this point. A 14-gauge needle is curved and introduced through the wall of the trachea, corresponding with the endoscope window. Direct vision through the esophagoscope allows direction of the needle into the lumen of the endoscope. Puncture of the posterior esophageal wall and its possible sequelae are prevented by the posterior wall of the esophagoscope.
With the needle in place, a 16-gauge intravenous catheter is threaded through the needle until the catheter is retrieved at the mouth. The needle is withdrawn, and with the catheter in place as a guide, the puncture is dilated carefully with a small hemostat. The catheter is attached to a urethral catheter (14F), filiform, or other gradually tapered device. With continuous traction at the mouth, the intravenous catheter/dilating catheter is pulled retrograde through the esophagus and hypopharynx, “trailing” the esophagoscope into the oral cavity. At this point, the intravenous catheter is released, and it must be ensured that no significant bleeding is present; then the esophagoscope is reinserted. The integrity of the anterior esophageal wall at the site of the puncture is examined, and, with the tip of the endoscope, the dilating catheter is directed into the distal esophagus. A suture is placed at the lateral tracheostoma to tie the dilating catheter in place.
The patient may be released on an ambulatory basis and permitted to resume a normal diet. Neither analgesics nor antibiotics are used. The patient can use an electrolarynx or limited esophageal voice. The stoma requires increased hygiene, and increased tracheal secretions are expected. In some cases, a temporary laryngectomy may be inserted for better stoma maintenance. The prosthesis is usually fitted in 2 days.
Fitting and placement of the voice prosthesis is simple. The first step in fitting is to remove the dilating catheter from the puncture that was placed in the operating room, and serially dilate the puncture by using catheters to 18F to ease placement of the measuring device, and measure the distance across the puncture (Fig. 123.10). The vocal tract
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is tested before placing the prosthesis by covering the tracheostoma and introducing air with exhalation. Patients will voice easily, and most will be capable of connected speech. The second step is the actual insertion of the voice prosthesis. The prosthesis is fixed to an inserter and introduced into the puncture at an angle corresponding to the presentation of the retention collar, end on. The collar will pass with slight resistance into the esophageal lumen; when fully entered, it will unfold, and a locking sensation is detectable.
Figure 123.9 Endoscopic voice restoration (tracheoesophageal puncture).
Figure 123.10 Fitting distance from the posterior trachea to the anterior esophagus.
The voice prosthesis is oriented by vertical placement of the silicone strap above the tracheostoma. It is fixed to the skin with paper adhesive tape. Efforts to produce and sustain voice may now begin with the prosthesis in position. The next steps vary from patient to patient and include instruction in careful stoma occlusion for efficient airflow, proper hygiene practices and management of secretions, varying breath control and diaphragmatic pressure, diminishing injection behavior from esophageal voice, experience with prosthesis cleaning and replacement, and guidelines for emergency situations. Long-term success in voice restoration requires that the patient fully comprehend the importance of maintaining the puncture at all times and diligently observing the prosthesis for signs of failure.
The initial prosthesis design required that it be removed and cleaned daily. However, this placed a great responsibility on the patient, possibly contributing to failure and complications, particularly in those with limited dexterity. Several indwelling devices with improved retention capabilities have been introduced more recently. The physician or speech pathologist must perform placement, because the insertion and removal techniques can be traumatizing to the tissues, and special instruments are sometimes required. The prosthesis remains in place and is cleaned externally until a new prosthesis is needed. Candidiasis results in premature failure of the prosthesis (usually valve degradation with aspiration of liquids through the prosthesis) but can be managed effectively with nystatin oral suspension (22).
TABLE 123.2 MANAGEMENT OF DYSFLUENT SPEECH
Use correct-size prosthesis with optimal airflow characteristics
Perform pharyngeal constrictor myotomy, neurectomy, or Botox injection
Allow edema to subside, provide external pressure
Dilate the puncture or repuncture
Speech therapy
Patients with persistent pharyngoesophageal spasm after a successful primary or secondary TEP can be secondarily treated with a pharyngeal constrictor myotomy (Table 123.2) (14), a pharyngeal constrictor neurectomy, or botulinum toxin A injection to reduce the tonicity of the upper esophageal sphincter. The myotomy is undertaken with a dilator (36F) in place in a manner analogous to a cricopharyngeal myotomy for dysphagia in patients with an intact larynx. Complications of this procedure are few but include salivary leakage and fistula formation, hypotonic voice, and esophageal reflux.
A secondary pharyngeal constrictor neurectomy (23) is approached in a fashion similar to the pharyngeal constrictor myotomy. The pharynx is distended with a mercury-filled dilator. Surgery is performed on the opposite side of the neck if a previous radical neck dissection has occurred. The parapharyngeal tissues are dissected to the level of the prevertebral fascia. The pharynx is rotated away from the carotid sheath, exposing the posterolateral wall of the pharyngoesophagus.
A careful dissection of the fascia overlying the con-strictor muscles is done, directing the dissection superiorly to the base of the tongue, where a key landmark is en-countered, the middle pharyngeal constrictor muscle. The main branches of the pharyngeal plexus are found at the junction of the middle and inferior pharyngeal constrictor muscles, where they course before dividing and innervating the underlying constrictor muscle fibers. When the branches of the pharyngeal plexus are stimulated, a fine contraction in the constrictor muscles is produced that moves from superior to inferior. After the pharyngeal plexus is identified, which represents one to three nerve branches at this level, the fibers are electrocoagulated and divided. The procedure is performed unilaterally. The wound is then drained away from the stoma and closed. The patient may resume a normal postoperative diet, and speech rehabilitation may begin the following day.
Botulinum toxin A may be injected under electromyographic guidance or fluoroscopy into the pharyngeal constrictor muscles to correct spasm (24). Its effect usually occurs within 72 hours after injection and may require repeated injections approximately every 6 months. This method is the preferred method of choice for most patients, particularly for poor surgical candidates and for those who do not wish additional surgery.
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Voice Restoration During Laryngectomy
Maves and Lingeman (25) and Hamaker et al. (26) were the first to introduce TEP as a primary technique at the time of laryngectomy. Patient-selection criteria are essentially the same as those for secondary TEP. If a patient is indecisive regarding primary TEP, a puncture can be performed and then allowed to close if the patient does not wish TE speech. Placing a TEP primarily requires the careful construction of the tracheostoma and a pharyngeal constrictor relaxation procedure. The surgical steps include incision (laryngectomy), followed by tracheostoma construction, TEP, unilateral pharyngeal constrictor myotomy or pharyngeal plexus neurectomy, and buttressing the tracheoesophageal party wall (26).
After laryngectomy, the stoma is constructed. The optimal tracheal diameter is ≥3 cm to prevent stenosis. The midline inferior skin flap is sewn to the midline anterior tracheal ring by using half vertical mattress sutures, which allow coverage of the cartilage. Interrupted sutures are placed at 5-mm intervals on either side of the midline, pulling the trachea laterally. This creates a straight, horizontal membranous trachea, which is sewn to the superior skin flap. If the trachea is smaller than 3.0 cm, a stomaplasty is performed (27).
The TEP is placed after the stoma is constructed and before the pharynx is closed (26). The upper tracheal rings are fixed anteriorly and inferiorly to the skin flap rather than through a concentric skin defect. After stabilizing the tracheostoma, a right-angled hemostat is placed against the membranous trachea 1 cm from the tracheal edge by way of the open pharynx (Fig. 123.11). The membranous trachea is incised transversely for 3 to 4 mm to permit the tips of the hemostat to protrude into the tracheostoma. The tracheoesophageal common wall should not be separated; if this occurs, it should be closed to prevent saliva from dissecting into this space. The tip of the hemostat is used to direct a 16F silicone Foley catheter into the esophagus to serve as a stent for the TEP and as a convenient feeding tube.
Management of the pharyngeal constrictor muscles to prevent pharyngeal spasm is the key to successful TE speech. A very reliable method for preventing spasm, if done properly, is a pharyngeal constrictor myotomy. The pharynx is rolled over a tubular structure, most often a finger or dilator, and the muscles are incised vertically in the posterior midline of the pharynx from the level of the puncture to the tongue base. The muscles are cut to the level of the submucosa. If bleeding occurs, careful use of bipolar cautery is recommended. If an inadvertent pharyngotomy is made, the mucosa is repaired at this time. If flap reconstruction of the pharynx is performed, the segment of muscle from the puncture site to the inferior flap is myotomized (26, 27).
An alternative method that can be performed to prevent pharyngeal spasm is a unilateral pharyngeal plexus neurectomy (10). The neurectomy is less traumatic to the pharyngeal wall, effectively reduces the increase in wall tension (sphincter spasm) during esophageal distention, and preserves the elasticity and vascularity of the constrictor muscles. This is performed after neck dissection while the larynx is in place (Fig. 123.12). The cornu of the thyroid cartilage and the greater cornu of the hyoid bone form a space that includes the middle pharyngeal constrictor muscle and the muscular hiatus through which the plexus fibers travel. The nerves are electrically stimulated for identification, coagulated, and divided as previously mentioned. This method also is useful when the pharynx is already closed and a myotomy was inadvertently not performed.
Figure 123.11 Primary placement of the tracheoesophageal puncture via the pharyngotomy.
The party wall usually separates ∼3 to 5 mm above the site of the puncture. The party wall is buttressed by using interrupted sutures of 3-0 chromic or 4-0 vicryl, which obliterates this space. This prevents the collection of saliva in this area if a fistula develops and helps to maintain the integrity of the posterior stoma. If separation of the party wall extends below the area of the planned puncture, then the puncture is delayed, as this can lead to pocket formation with abscess and loss of the posterior tracheal wall (26, 27).
Results
Many variables have been studied by various clinicians to predict those patients who will achieve successful TE speech with primary or secondary puncture. However, no consensus has been reached among these studies. We reviewed 128 patients over a 9-year period who had under-gone primary
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voice restoration during laryngectomy (20). Two 4-year periods were analyzed. In the earlier group of 48 patients, 29% experienced voice failure, which was reduced to 13% by revision procedures. The more current group failed 15% of the time, with revision reducing it to 9%. This finding represents an improving trend for voice rehabilitation, with the development of improved voice prostheses, more effective patient training, and refinement of the operative techniques. Speech after laryngectomy was successful 10 to 35 days postoperatively (average, 22 days). Tracheostoma stenosis occurred in 4%, and closure of the TEP occurred in 10% of cases because of extrusion of the prosthesis, radiation therapy, or inadequate stoma hygiene (Table 123.3).
Figure 123.12 Surgical anatomy of the pharyngeal plexus during laryngectomy.
The shape of the low-pressure voice prosthesis (trapdoor valve) has introduced a problem that has affected the acceptability of this device. The tapered or obturator tip of the duckbill prosthesis gave way in the new design to a short bevel and retention collar, which complicated insertion of the prosthesis into the lumen of the esophagus. In many cases, the retention collar resides within the lumen of the puncture tract itself, producing a scarred ridge anterior to the meatus of the esophageal puncture. Stenosis of the esophageal meatus, difficult voicing, and eventual extrusion of the prosthesis may occur with closure of the fistula. Insertion can be eased by placing the prosthesis tip and the folded retention collar into half of a gelatin capsule, thus creating a rounded tip for introduction into the puncture tract. Some prostheses bypass these insertion problems by using retrograde introduction of the prosthesis via a special guidewire or catheter.
TABLE 123.3 COMPLICATIONS
Epidural abscess or vertebral osteomyelitis secondary to violation of posterior esophageal wall during secondary tracheoe-sophageal puncture (TEP)
Mediastinitis secondary to dissection of party wall
Loss of the puncture site by dislodgment of the catheter placed at the time of puncture
Partial or complete extrusion of the prosthesis
Migration of the puncture site
Formation of granulation tissue
Stomal or pharyngoesophageal stenosis
TEP dilation
Aspiration of saliva and foods through puncture site
Esophageal prolapse
Tracheostoma prolapse
Other puncture problems include tracheal granulation tissue (treated with cautery or laser), prolapse of eso-phageal mucosa through the TEP, or leakage at the TEP and aspiration. Aspiration of the prosthesis itself has occurred in 3% to 5% of users and is prevented by careful instruction and modification of the method for patient insertion or by using the indwelling devices. The significant problem and hazard of aspiration through the TEP is usually managed by reconstructing the tracheoesophageal common wall by interposing a sternocleidomastoid muscle flap (Fig. 123.13) or, in heavily irradiated patients, placing a pectoralis major myofascial flap (20).
Voice Quality
It is important for potential TE speech users to have realistic expectations. The goal of voice restoration is to provide fluent, effortless, and intelligible speech. The quality of voice cannot be controlled. Patients should realize that a learning curve is associated with TE speech, and it generally improves over time (28).
Figure 123.13 Sternocleidomastoid muscle flap augmentation of the tracheoesophageal common wall.
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Acoustic analysis of TE speech has been compared with laryngeal, esophageal, and electrolarynx speech by many. The fundamental frequency, intensity, and rate of TE speech approximate those of normal speech. In a study by Robbins et al. (29), esophageal and TE speakers were analyzed for intensity, frequency, and rate of speech production. TE speech was found to be more similar to laryngeal speech than to esophageal speech. When compared with esophageal speech, it gives superior voice quality in reference to volume and phrase length and is much easier to learn. The rate of speech is faster, and the intelligibility is superior to that acquired by using the artificial larynx or esophageal speech (30). However, in the presence of noise, a lower rate of listener intelligibility of TE speech is found compared with laryngeal speech.
The prevention of pharyngeal spasm is paramount to the production of successful TE speech. Acoustic analysis of TE speech was studied after three different surgical methods used to address the pharynx: pharyngeal plexus neurectomy, pharyngeal constrictor myotomy, and unilateral pharyngeal plexus neurectomy with a drainage myotomy limited to the cricopharyngeus. Patients undergoing pharyngeal plexus neurectomy had the highest fundamental frequency, which may be the result of the residual resting tone in the pharyngoesophageal segment. Management of the pharynx with neurectomy may be desirable in women undergoing laryngectomy with voice restoration.
Tracheoesophageal speech has been rated the most desirable form of alaryngeal speech by both speech pathologists and patients (31) and is the preferred method of alaryngeal speech by naïve listeners.
Emergencies
Two urgent conditions may result for prosthesis users and should be attended to without delay (Table 123.4). For patients who routinely change their prostheses, the inability to insert the tip of the prosthesis and collar into the lumen of the esophagus may occur, which results initially in increased voice resistance and, in some cases, complete loss of voice. The TEP tract will close from the esophagus externally, and it will be impossible after 24 to 48 hours to reenter the lumen. If this occurs, the TEP can be serially dilated with plastic catheters ranging from 10F to 18F and then stented with a flexible catheter for several hours before the voice prosthesis is replaced. If available, urethral dilators are an effective instrument for TEP dilatation. Dilatation must be performed with as little resistance as possible because it is possible to dissect into the tracheoesophageal common wall and enter the anterior mediastinum.
The second urgent condition is aspiration of the voice prosthesis. This condition usually occurs when patients attempt to replace the device in the TEP, and a cough is stimulated. The most common location for device
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impaction is at the level of the upper right mainstem bronchus and carina. This usually is well tolerated, but an uncomfortable dyspnea is present. Furthermore, in the resultant anxiety, the TEP is not stented, and tracheal aspiration of saliva may occur. This complication can be prevented in most cases by providing detailed instruction in emergency techniques at the time of initial prosthesis fitting. Should aspiration of the prosthesis occur, the patient should first securely stent the puncture and then attempt to bend over as far as possible and cough out the prosthesis. Deep inhalations should be avoided because the result may be deeper penetration of the prosthesis into the airway. In the event of failure, the patient should go to an emergency medical facility as soon as possible. The size of the prosthesis prevents it from occluding the airway; patients will experience only moderate dyspnea with aspiration of the prosthesis.
TABLE 123.4 EMERGENCIES
Aspiration of prosthesis
Airway obstruction
Tracheoesophageal necrosis
Voice prosthesis incompetence
The most efficient method for prosthesis retrieval is to use topical anesthesia and a rigid open or flexible bronchoscope with grasping forceps. After removing the foreign body, the TEP is stented with an 18F catheter for 24 hours before reinserting the prosthesis. The patient should avoid the changing process and should be introduced to the appropriate clinician follow-up team.
The Future
Laryngeal transplantation is currently under investigation. Animal studies have shown that canine laryngeal allografts can be physiologically reinnervated, which suggests that human larynges can be successfully innervated. However, additional research regarding the immunogenicity and function of transplanted larynges must be performed (32).
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