Changing trends of speech outcomes after total laryngectomy in the 21st century: a single-center study

Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy

BACKGROUND

Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown.

METHODS

Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022.

RESULTS

A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group.

CONCLUSIONS

Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

Protocolized awake secondary tracheoesophageal puncture with immediate voicing

Tracheoesophageal (TE) puncture with voice prosthesis placement is a common method for vocal rehabilitation in patients who have undergone total laryngectomy. Tracheoesophageal voice prosthesis (TEP) placement after laryngectomy, known as secondary TE puncture, is traditionally done in the operating room, using rigid esophagoscopy. Traditional secondary TEP placement carries a number of downsides including risks associated with general anesthesia, high cost, and technical challenges associated with anatomical variables. As a result, in-office secondary TE puncture has become an increasingly utilized procedure with many advantages but currently lacks standardization. Here, we describe a kit-based, awake, in-office secondary TE puncture with primary TEP placement technique. This technique calls for an endoscopic snare in the event there is difficulty passing the guidewire in the cranial trajectory. No surgical technique videos demonstrating in-office secondary TE puncture currently exist. Here, we present a video tutorial of our technique, breaking down the procedure into 10 steps from analgesia to voicing.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs

BACKGROUND

After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context.

AIMS

(1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy.

METHODS & PROCEDURES

A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis.

OUTCOMES & RESULTS

The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general.

CONCLUSIONS & IMPLICATIONS

The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require.

WHAT THIS PAPER ADDS

What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

Novel stapler-assisted technique for closure of persistent tracheoesophageal puncture fistula

Tracheoesophageal puncture (TEP) is a reliable method to restore voice and is an important part of voice rehabilitation following laryngectomy. However, complications following this procedure, including peri-prosthetic leakage and resulting aspiration pneumonia, may necessitate surgical closure. In this study, we present an effective and reliable method for TEP closure using a stapler-assisted technique. Case series study for patients who underwent stapler-assisted TEP closure reviewed from 2017 to 2021. All five patients had successful closure of their TEP tract without further leakage. No postoperative bleeding, wound infection, or esophageal stenosis occurred. One patient had postoperative stomal stenosis. The stapler-assisted technique for TEP closure is easy, quick, and effective. The reliability and quick return to oral intake post-operatively make it a preferable option over previous techniques.

Voice rehabilitation with voice prosthesis: Long term results, complications and risk factors

OBJECTIVES

Despite the advances in surgical and non-surgical organ preservation treatments, total laryngectomy (TL) remains the most effective treatment in advanced larynx cancer and as salvage procedure in chemoradiation failure. One of the most devastating sequel after TL is loss of voice. Voice prosthesis (VP) is currently the preferred choice for voice rehabilitation. The purpose of this study is to identify VP complications, its lifespan and factors that influence the longevity of the VP.

METHODS

We performed a retrospective study at a Tertiary University Hospital. Medical records of patients that underwent total laryngectomy, between January 1st of 2008 and 31st of December of 2017 were analyzed.

RESULTS

Of the 84 patients that underwent laryngectomy, 60 had VP. The average age at the time of surgery 60.2 years old and there was a male preponderance (57:3). The mean lifespan of the prosthesis was 7.53 months. Leakage through the prosthesis was the most common reason for replacement of the prosthesis, followed by leakage around the prosthesis. Follow up time and manual suture were associated with prosthesis replacement. There was no significant relationship between the staging, tumor location or adjuvant radiotherapy and number of prosthesis replacement or its lifespan.

CONCLUSIONS

Rehabilitation after TL is of major importance to improve quality of life after surgery. Tracheoesophageal puncture with voice prosthesis is a safe procedure for vocal rehabilitation and was performed in the majority of patients in our study. Follow-up time and type of suture were the main determinants of the lifespan of the prosthesis.

Quality of Life in Caregivers, Spouses, and Partners of Total Laryngectomees: A Scoping Review

PURPOSE

The purpose of this study was to (a) review methods used to assess quality of life (QOL) in caregivers, partners, and spouses of those who have undergone total laryngectomy (TL); (b) identify patterns in caregiver QOL changes postoperatively; and (c) review previously proposed interventions for caregivers.

METHOD

PubMed, EMBASE, and CINAHL Complete were searched using the Medical Subject Heading terms laryngectomy, spouse, caregiver, and partner. Two reviewers independently screened and identified records meeting inclusion criteria. This scoping review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Initial search returned 143 results and 12 met inclusion criteria. Eight studies assessed postoperative QOL changes in categories such as psychological health, physical health, sexuality, and interpersonal relationships. Four studies proposed interventions for caregivers perioperatively. There were no consistently used inventories, and only one intervention was formally tested.

CONCLUSIONS

The literature available on TL caregiver QOL contains inconsistent inventories and study design. There are few interventions available, and it would be beneficial to develop a standardized QOL inventory for this population to better target caregiver needs.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19287887.

Tracheo Esophageal Prosthesis Insertion Under Endoscopic Guidance and Local Anaesthesia- Feasibility and Outcome

OBJECTIVES

Voice rehabilitation after laryngectomy is by tracheo esophageal puncture (TEP) and prosthesis insertion. Secondary TEP is very difficult due to neck fibrosis. Puncture under local anaesthesia with endoscopy guidance is a feasible option.

METHODS

Retrospective review of all laryngectomy patients from March 2009 till March 2019 was done and the methods of voice rehabilitation were assessed. The patients undergoing the procedure were classified according to the timing of insertion and type as primary insertion under general anaesthesia (Group P), secondary insertion under local anaesthesia (Group L), secondary insertion under general anaesthesia (Group G). The speech outcome and the procedure outcome were compared.

RESULTS

There were 148 patients who underwent laryngectomy, of which groups P, G, L were 12, 12 and 11. The rate of successful insertion was 100% in primary, 91.6% in secondary in general anaesthesia and 91% in secondary under local anaesthesia. All secondary TEP were done after surgery and radiotherapy. Complications related to the insertion techniques were minimal. Speech outcome were similar on intelligibility rating scale and longevity was not affected by the method.

CONCLUSION

TEP in local anaesthesia is feasible and has comparable outcome with TEP in general anaesthesia. Financial burden was very much less in group L compared to the other two groups.

Prosthetic voice rehabilitation after laryngoesophagectomy: surgical and functional outcomes

PURPOSE

Quality of Life (QoL) after extensive head and neck resections is of paramount importance, especially after pharyngolaryngectomy or pharyngolaryngoesophagectomy where complex digestive tract reconstruction is required (with gastric pull-up or colon transposition). Tracheodigestive puncture (TDP) is the only vocal restoration option in this group of patients. The aim of this study is to evaluate postoperative complications, vocal outcomes, voice-related and swallowing-related QoL after secondary TDP in this cohort of patients.

METHODS

A retrospective study was conducted in the tertiary referral center of Verona Hospital between June 2014 and June 2020. Patient demographics, clinical and surgical data were assessed. Speech objective and subjective evaluation was performed. QoL was assessed with Voice Handicap Index-10 (VHI-10) and M.D. Anderson Dysphagia Inventory (MDADI) questionnaires.

RESULTS

Seven patients met the inclusion criteria, but two had died before questionnaires were administered. No intraoperative complications were noted after TDP surgery. There were delayed complications in four cases (57.1%) and all were treated with restoration. Intelligible voice was restored in all patients. Maximum phonation time and maximal voice intensity recorded were 5.42 ± 3.27 s and 65.20 ± 5.45 dB, respectively. Acceptable average VHI-10 and MDADI scores were obtained in all patients.

CONCLUSIONS

Secondary TDP performed after gastric pull-up or colon transposition reconstructions are feasible and effective procedures. An intelligible voice was restored in all patients, with satisfactory patient-perceived voice-related and dysphagia-related quality-of-life outcomes.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Importance

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures.

Objective

To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP.

Design, Setting, and Participants

This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019.

Main Outcomes and Measures

Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed.

Results

Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type.

Conclusions and Relevance

This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Endoscopic visualization for tracheoesophageal puncture tract sizing

BACKGROUND

Accurate tracheoesophageal prosthesis (TEP) size is essential for optimal functioning. Current sizing techniques do not afford direct visualization. The clinical utility of direct visualization with unsedated transnasal esophagoscopy (TNE) to improve TEP sizing accuracy has not been established.

AIMS/OBJECTIVES

The purpose of this investigation was to determine if endoscopic visualization with TNE during TEP fitting improves sizing accuracy.

MATERIAL AND METHODS

Participants undergoing secondary TEP placement had their TEP sized without visualization and with visualization during TNE. The effect of endoscopic visualization on TEP sizing was assessed.

RESULTS

The mean age (SD) of the cohort (N = 15) was 61.20 (±10.19) years. The percent disagreement between non-visualized and endoscopic-visualized puncture tract measurement was 60%. The mean difference in puncture tract length with visualization compared to without visualization was 1.75 mm (±1.91). Discordance between non-visualized and endoscopic-visualized puncture tract length was worse for persons with a history of radiation (66.7%) than without radiation (33.3%) (p < .05). The overall test agreement between endoscopic and non-endoscopic sizing techniques was moderate (Cohen's kappa coefficient = 0.254; (p < .05).

CONCLUSION AND SIGNIFICANCE

The percent disagreement between non-visualized and endoscopic-visualized TEP sizing is high (60%). The data suggest that endoscopic visualization with TNE improves sizing accuracy during TEP placement.

Tracheoesophageal puncture closure with annular mucosal flap

BACKGROUND

To present an effective and easily applicable method for tracheoesophageal puncture (TEP) closure by using a localized annular flap instead of bulky and distant flaps.

METHODS

The medical records of patients who underwent TEP closure surgery with the annular mucosal flap technique between July 2012 and August 2018 were retrospectively reviewed. Fistula size, indication for closure, duration of surgery, radiotherapy status, and surgery results were analyzed.

RESULTS

We have used our technique in nine patients. No postoperative bleeding, wound infection, esophageal stenosis, and tracheostoma stenosis occurred. In all these patients except one, successful closure was achieved. None of the patients had a recurrence of the TEP.

CONCLUSION

The annular mucosal flap technique for TEP closure is easy and quick to apply. The patient's oral feeding at the sixth hour after procedure without using a nasogastric tube makes the technique preferable as a priority.

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

OBJECTIVE

To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature.

METHODS

Retrospective review.

RESULTS

Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09).

CONCLUSION

Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E875-E881, 2021.

Current opinions in otolaryngology and head and neck surgery: functional considerations in reconstruction after laryngectomy

PURPOSE OF REVIEW

To review reconstruction techniques following total laryngectomy, partial laryngopharyngectomy, and total laryngopharyngectomy with an emphasis on long-term swallow and speech outcomes.

RECENT FINDINGS

Recent literature has shown that the use of fasciocutaneous free flaps in the reconstruction of laryngectomy defects may lead to improved speech and swallow outcomes as compared with regional or free musculocutaneous flaps. Radial forearm and anterolateral thigh are the most often used fasciocutaneous free flaps, with similar speech and swallow outcomes. Primary closure with myofascial flap onlay yields similar speech and swallow results to fasciocutaneous flaps following laryngectomy that spares sufficient pharyngeal mucosa.

SUMMARY

Whenever reconstructing a salvage laryngectomy defect or a primary laryngectomy defect with mucosal deficiency, current evidence suggests that a fasciocutaneous free flap used to augment pharyngeal volume both improves fistula rates as well as long-term speech and swallow outcomes. When sufficient pharyngeal mucosa is present, myofascial onlay can be considered as well.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Interdisciplinary interventions in the perioperative rehabilitation of total laryngectomy: an integrative review

The aim of this study was to use the scientific literature to identify interdisciplinary interventions for rehabilitation during the perioperative period for cancer patients who underwent total laryngectomy. We systematically researched controlled descriptors: laryngectomy, patient care team/education, patient care team/manpower, patient care team/methods, patient care team/utilization and rehabilitation. We performed a qualitative narrative synthesis and identified 549 articles. Of these, 113 were duplicates, 398 were excluded during the analysis of the title and abstract, 1 was excluded for unfeasibility of access, and 4 were excluded after reading the article in full, resulting in 33 included articles. The articles addressed different types of interdisciplinary actions, such as vocal, olfactory, pulmonary and alimentary rehabilitation; comparisons of prosthetic devices; and descriptions of practices for total laryngectomized patient rehabilitation. Although the interventions found in the literature were effective in the rehabilitation of the total laryngectomized patient, their interdisciplinarity was not evidenced but was highlighted in these studies as a factor for improvement in terms of practical assistance and quality of life.

Rehabilitation of the laryngectomised patient. Recommendations of the Spanish Society of Otolaryngology and Head and Neck Surgery

Total laryngectomy remains essential treatment for locally advanced laryngeal carcinoma, related to better survival rates. However, it involves changes for the patient, such as the inability to communicate verbally, breathing or aesthetic changes, which affect their quality of life and require comprehensive rehabilitation. This paper was written by the total laryngectomy rehabilitation workgroup of the National Head and Neck and Skull Base working committee of the Spanish Society of Otolaryngology and Head and Neck Surgery. The purpose of the article is to combine materials, surgical procedures and means towards the comprehensive rehabilitation of total laryngectomy patients, so that they can achieve a good quality of life. This paper is aimed at all health care professionals caring for total laryngectomy patients. It is also aimed at the patients themselves, as well as ENT surgeons. We have considered staffing and material needs, all procedures before, during and after surgery and after hospital discharge. There are also detailed recommendations about types of rehabilitation and follow-up, and the need for recording these events. The comprehensive rehabilitation total laryngectomy patients is very important if we want to improve their quality of life. The recommendations we mention aim to help the healthcare professionals involved in the treatment of total laryngectomy patients to help them achieve a good quality of life, as similar as possible to the life they led before surgery.

Design and Preliminary Evaluation of Electrolarynx With F0 Control Based on Capacitive Touch Technology

An electrolarynx (EL) is one of the most popular voice rehabilitation technologies used after laryngectomy. However, most ELs generate monotonic EL speech, which has been shown to create a particular deficit in speech intelligibility, especially for Chinese Mandarin (Mandarin). Mandarin is a tonal language that makes lexical distinctions using variations in tone. Our purpose is to design an EL that can produce the four Mandarin tones, and to evaluate its performance. We designed a fundamental frequency (F0) control method for Mandarin EL speech and manufactured a touch-controlled electrolarynx (T-EL) prototype. Using monosyllables, disyllabic words, and frequently used phrases, we evaluated speech produced with a T-EL, as well as with monotone (M-EL) and variable-frequency modes (P-EL) of a commercially available TruTone EL. A male native Mandarin speaker with laryngectomy volunteered to be the speaker. Results show that the normal speech pitch contours of the four Mandarin tones were most closely matched by the characteristics produced with T-EL. The statistical accuracy of the T-EL's tone and word perception was significantly higher than that of the other EL types. Moreover, the confusion matrix indicates that the listeners could correctly identify the tones of monosyllables and disyllabic words in T-EL speech. Accurate tone judgment can improve the intelligibility of EL speech in Mandarin. The mean opinion score was used to evaluate the listeners' acceptability of EL speech. The scores of the T-EL and M-EL were very close, and the score of the P-EL was significantly lower than that of the other two ELs. However, the results from a single speaker cannot provide sufficient data to conclude which EL has a higher acceptability. The evaluation of multiple EL speakers with different EL types at difference levels of proficiency should be studied in future research.

Primary versus secondary tracheoesophageal puncture: systematic review and meta-analysis

Background:

Tracheoesophageal puncture represents the ‘gold standard’ for voice restoration following laryngectomy. Tracheoesophageal puncture can be undertaken primarily during laryngectomy or in a separate secondary procedure. There is no current consensus on which approach is superior. The current evidence comparing primary and secondary tracheoesophageal puncture was assessed.

Methods:

A systematic review and meta-analysis of articles comparing outcomes for primary and secondary tracheoesophageal puncture after laryngectomy were conducted. Outcome measures were: voice success, overall complication rate and pharyngocutaneous fistula rate.

Results:

Eleven case series met the inclusion criteria, two prospective and nine retrospective. Meta-analysis did not demonstrate statistically significant differences in overall complication rate or voice outcomes, though it suggested a significantly increased risk of pharyngocutaneous fistula in primary compared to secondary tracheoesophageal puncture.

Conclusion:

Primary tracheoesophageal puncture is a safe and efficient approach for voice rehabilitation. However, secondary tracheoesophageal puncture should be preferred where there is a higher risk of pharyngocutaneous fistula.

Objective and subjective voice outcomes after total laryngectomy: a systematic review

Background

Esophageal speech (ES), tracheoesophageal speech (TES) and/or electrolarynx speech (ELS) are three speech rehabilitation methods which are commonly provided after total laryngectomy (TL).

Methods

A systematic review of the literature was conducted to evaluate comparative acoustic, perceptual, and patient-reported outcomes for ES, TES, ELS and healthy speakers.

Results

Twenty-six articles could be included. In most studies, methodological quality was low. It is likely that an inclusion bias exists, many studies only included exceptional speakers. Significant better outcomes are reported for TES compared to ES for the acoustic parameters, fundamental frequency, maximum phonation time and intensity. Perceptually, TES is rated with a significant better voice quality and intelligibility than ES and ELS. None of the speech rehabilitation groups reported clearly better outcomes in patient-reported outcomes.

Conclusions

Studies on speech outcomes after TL are flawed in design and represent weak levels of evidence. There is an urge for standardized measurement tools for evaluations of substitute voice speakers. TES is the favorable speech rehabilitation method according to acoustic and perceptual outcomes. All speaker groups after TL report a degree of voice handicap. Knowledge of caretakers and differences in health care and insurance systems play a role in the speech rehabilitation options that can be offered.

Electronic supplementary material

The online version of this article (doi:10.1007/s00405-017-4790-6) contains supplementary material, which is available to authorized users.

Indwelling voice prosthesis insertion after total pharyngolaryngectomy with free jejunal reconstruction

Objectives

Total pharyngolaryngectomy with free jejunal reconstruction is often performed in patients with hypopharyngeal carcinoma. However, postoperative speechlessness significantly decreases patient quality of life. We investigated whether Provox® insertion could preserve speech after total pharyngolaryngectomy with free jejunal reconstruction.

Study Design

Retrospective chart review.

Methods

A total of 130 cases of secondary Provox® insertions after total pharyngolaryngectomy with free jejunal reconstruction were analyzed. Communication outcomes were compared using the Head and Neck Cancer Understandability of Speech Subscale. Outcomes and complications associated with insertion site (jejunal insertion vs. esophageal insertion) and adjuvant irradiation therapy were also evaluated.

Results

Provox® insertion had favorable communication outcomes in 102 cases (78.4%). Neither the insertion site nor irradiation affected the communication outcome. Complications were observed in 20 cases (15.4%). Local infection was the most common complication. Free jejunal insertion, in which the resection range was enlarged, had a lower complication rate than did esophageal insertion, and its complication rate was unaffected by previous irradiation. For all patients, the hospitalization duration and duration of speechlessness were 13.4 days and 14.6 months, respectively. Patients receiving jejunal insertions had a significantly shorter hospitalization duration than did those receiving esophageal insertions. Unlike Provox®2, Provox®Vega significantly reduced the complication rate to zero.

Conclusion

For jejunal inserson of a Provox® prosthetic, a sufficient margin can be maintained during total pharyngolaryngectomy and irradiation can be performed, and satisfactory communication outcomes were observed. Provox® insertion after total pharyngolaryngectomy with free jejunal reconstruction should be considered the standard therapy for voice restoration.

Level of Evidence

4.

Impact of Primary Tracheoesophageal Puncture on Outcomes after Total Laryngectomy

Objectives

To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP.

Study Design

Retrospective review of large national data set.

Setting

Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program.

Subjects and Methods

The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups.

Results

The incidence of “superficial” and “deep or organ space” surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12).

Conclusions

Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for “superficial” or “deep or organ space” surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Influence of timing, radiation, and reconstruction on complications and speech outcomes with tracheoesophageal puncture

BACKGROUND

We evaluated the impact of radiation, reconstruction, and timing of tracheoesophageal puncture (TEP) on complications and speech outcomes.

METHODS

Retrospective review identified 145 patients who underwent TEP between 2003 and 2007.

RESULTS

Ninety-nine patients (68%) had primary and 46 (32%) had secondary TEP, with complications occurring in 65% and 61%, respectively (p = .96). Twenty-nine patients (20%) had major complications (18 primary and 11 secondary; p = .42). Ninety-four patients (65%) had pre-TEP radiation, 39 (27%) post-TEP radiation, and 12 (8%) no radiation. With patients grouped by TEP timing and radiation history, there was no difference in complications, fluency, or TEP use. With mean 4.7-year follow-up, 82% primary and 85% secondary used TEP for primary communication (p = .66). Free-flap patients used TEP more commonly for primary communication after secondary versus primary TEP (90% vs 50%; p = .02).

CONCLUSION

Primary and secondary tracheoesophageal speakers experience similar high rates of complications. Extent of pharyngeal reconstruction, rather than radiation, may be more important in selection of TEP timing. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1765-1771, 2016.

Post-laryngectomy voice rehabilitation with a voice prosthesis in a young girl with advanced thyroid cancer

The aim of this report is to evaluate the effects of voice rehabilitation with a voice prosthesis in a young patient with thyroid cancer. A 17-year-old girl underwent voice restoration with a voice prosthesis after laryngectomy to treat thyroid cancer. She completed voice-related questionnaires (the Voice Handicap Index-10 and Voice-Related Quality Of Life Survey) at ages 17 and 21 and underwent phonetic functional evaluation. The sound spectrograms of her phonation using the voice prosthesis showed low frequency sounds without an obvious basic frequency. She was ashamed of her hoarse voice and did not use her voice prosthesis during high school. However, after beginning to work at age 20, she used her voice to communicate in the workplace. At age 21, her questionnaire scores, especially those related to the physical and functional domains, improved compared with those at age 17. Voice restoration with a voice prosthesis is recommended for young patients who undergo laryngectomy for advanced thyroid cancer. The advantages of voice restoration with a voice prosthesis may increase when the patient reaches working age, and it may improve post-laryngectomy quality of life considerably.