Hands-free speech after surgical voice rehabilitation with a Provox® voice prosthesis: experience with the Provox FreeHands HME tracheostoma valve® system

Automatic speaking valve in tracheo-esophageal speech: treatment proposal for a widespread usage

PURPOSE

Aim of this study was to calculate the percentage of the Automatic Speaking Valve (ASV) use in a large cohort of laryngectomized patients with voice prosthesis (VP) and to analyze the main reasons for non-use. Subsequently, a specific rehabilitation training was proposed.

METHODS

One hundred-ten laryngectomized patients with VP were enrolled in the first phase of the study (census). Among them, 57 patients were included in the second phase (intervention), in which a training based on moving phonatory exercises was proposed. Structured questionnaires were used before and after training in order to investigate ASV use rate (days/week and hours/day; reasons for impeding the ASV use), average adhesive life-time during ASV use; hands-free speech duration; skin irritation. Patients also expressed their degree of on a VAS scale from 0 to 100.

RESULTS

In the census phase the percentage of use of ASV (everyday, without problems) was equal to 17.27% (19/110 patients). The main causes of disuse concerned excessive fatigue and poor durability of the adhesives. The analysis of the results pre vs. post-training showed a statistically significant increase (p < 0.05) in all the investigated parameters. Patients reported a good level of treatment compliance (average frequency of performing exercises equal to 4.2 ± 2.5 days/week for 1.4 ± 1.01 h/day) and high degrees of satisfaction. After treatment, the percentage of use of AVS increased by 43% reaching a rate of 60% (66/110 patients).

CONCLUSION

A specific and targeted approach that simulate the phonatory and breathing difficulties of everyday life can increase the ASV usage rate.

Improving Hands-Free Speech Rehabilitation in Laryngectomized Patients with a Moldable Adhesive

OBJECTIVE

This study aims to assess the product performance of a new moldable peristomal adhesive with corresponding heating pad designed to facilitate and improve automatic speaking valve (ASV) fixation for hands-free speech in laryngectomized patients.

METHODS

Twenty laryngectomized patients, all regular adhesive users with prior ASV experience, were included. Study-specific questionnaires were used for data collection at baseline and after two weeks of moldable adhesive use. The primary outcome parameters were adhesive lifetime during hands-free speech, use and duration of hands-free speech, and patient preference. Additional outcome parameters were satisfaction, comfort, fit, and usability.

RESULTS

The moldable adhesive enabled ASV fixation adequate for hands-free speech in the majority of participants. Overall, the moldable adhesive significantly increased adhesive lifetime and duration of hands-free speech compared to participants' baseline adhesives (p < 0.05), regardless of stoma depth, skin irritation, or regular use of hands-free speech at baseline. The participants who preferred the moldable adhesive (55% of participants) experienced a significant increase in the adhesive lifetime (median of 24 h, range 8-144 h) and improved comfort, fit, and ease of speech.

CONCLUSION

The moldable adhesive's lifetime and functional aspects, including the ease of use and custom fit, are encouraging outcomes and enable more laryngectomized patients to use hands-free speech more regularly.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2965-2970, 2023.

Improving Hands-free Speech Rehabilitation in Patients With a Laryngectomy: Proof-of-Concept of an Intratracheal Fixation Device

Permanent hands-free speech with the use of an automatic speaking valve (ASV) is regarded as the optimal voice rehabilitation after total laryngectomy. Due to fixation problems, regular ASV use in patients with a laryngectomy is limited. We have developed an intratracheal fixation device (ITFD) composed of an intratracheal button augmented by hydrophilic foam around its shaft. This study evaluates the short-term effectiveness and experienced comfort of this ITFD during hands-free speech in 7 participants with a laryngectomy. We found that 4 of 7 participants had secure ASV fixation inside the tracheostoma during hands-free speech for at least 30 minutes with the ITFD. The ITFD's comfort was perceived positively overall. The insertion was perceived as being mildly uncomfortable but not painful. This proof-of-concept study demonstrates the feasibility of the ITFD that might improve stomal attachment of ASVs, and it provides the basis for further development toward a prototype suitable for long-term daily use.

Clinical feasibility study of protrach dualcare a new speaking valve with heat and moisture exchanger for tracheotomized patients

Objective

The aim of this study was to evaluate the clinical feasibility of the ProTrach DualCare (Atos Medical, Hörby, Sweden), a device combining a hands‐free speaking valve and a Heat and Moisture Exchanger (HME) for tracheotomized patients.

Study Design

A non‐randomized, prospective single center feasibility study.

Methods

Sixteen adult tracheotomized patients were included. Participants were asked to test the DualCare for two weeks while continuing their normal activities. After these two weeks, participants could choose whether or not to take part in the long‐term evaluation. The EuroQOL‐5D, Borg scale and questionnaires on speaking, pulmonary function and patient preference were used. During the long‐term evaluation, a minor redesign was implemented and all participants were asked to test the new device again for one week, with a potential long‐term evaluation. Eleven decided to participate.

Results

The device was well‐tolerated. Speaking noise was reduced (p = 0.020) and speech was considered to sound more natural compared to previously used devices according to the users (p = 0.020). Overall 11 participants preferred the DualCare to their standard device. No serious adverse events were reported.

Conclusion

Overall, 11 of 16 participants preferred the DualCare to their standard speaking valve or HME. Users of the DualCare were able to use hands free speech with the benefits of an HME and the device was considered clinically feasible and has the potential to improve quality of life of tracheotomized patients.

Level of Evidence

2b

Analysis of tracheostoma morphology

OBJECTIVES

Existing fixation methods of automatic speaking valves (ASVs) suffer from shortcomings which partly are the result of insufficient conformity of the intratracheal fixation method's shape to the tracheostoma anatomy. However, quantitative data are lacking and will be helpful to analyse solutions for airtight fixation. This article provides such data.

PATIENTS AND METHODS

The tracheostoma morphology was measured in computerized tomography scans of 20 laryngectomized patients. Measured were transverse and sagittal diameters, transition angle between skin level and tracheostoma lumen and between the tracheostoma lumen to the trachea, TE valve placement and stoma depth.

RESULTS

The mean transverse and sagittal diameters of the stoma at the peristomal lip are 19.2 mm [standard deviation (SD 5.2 mm)] and 17.6 mm (SD 5.3 mm), respectively. The mean transition angles are 84.5° (SD 15.6°) at skin level and 153.6° (SD 11.7°) into the trachea. The mean distance between TE valve and peristomal lip is 13.5 mm (SD 7.0 mm). The mean stoma depth is 14.0 mm (SD 6.4 mm).

CONCLUSIONS

Due to the large variation, no 'average tracheostoma morphology', suitable for shaping a generic intratracheal fixation device, can be defined. Therefore, providing an airtight fixation in each patient would require a large range of different sizes, customization or a new approach.

Correlation of intraluminal esophageal pressure with the dynamic extension of tracheoesophageal voice in total laryngectomees

PURPOSE

To evaluate and correlate the amplitude of esophageal contractions triggered by swallowing water with dynamic extension and habitual, strong and weak sound intensity in total laryngectomees wearing a tracheoesophageal prosthesis.

METHODS

Thirty total laryngectomees using tracheoesophageal voice with a phonatory prosthesis were evaluated by measuring the amplitude of contractions in the proximal, middle and distal esophagus and the pressure of the pharyngoesophageal transition by manometry. In order to measure vocal intensity the subject was asked to emit phonation of the vowel /a/ at habitual, strong and weak intensity which was captured with a sound pressure meter. Dynamic extension was calculated by subtracting strong intensity from weak intensity.

RESULTS

A positive correlation was observed between contraction amplitude and dynamic extension in the proximal (rho: 0.45; p=0.01) and distal (rho: 0.41; p=0.02) esophagus There was no correlation with other parameters.. Total laryngectomees wearing a phonatory prosthesis with a dynamic extension above 21 dBNPS had greater contraction amplitude than laryngectomees with a dynamic extension below this value.

CONCLUSIONS

There was a positive correlation between pressure amplitude in the proximal and distal esophagus and increased dynamic extension. The individuals with normal dynamic extension had greater contraction amplitude in the proximal esophagus than individuals with dynamic extension lower than the expected values for age.

Post laryngectomy speech rehabilitation outcome in elderly patients

The aim of our work has been to evaluate the different options of tracheoesophageal voice rehabilitation in over 70-year-old patients, who had undergone laryngectomy, assessing advantages and drawbacks of this method of vocal recovery. A retrospective study has been carried out. This has included 40 subjects, all aged more than 70 years old, who have been referred to tracheoesophageal voice rehabilitation. It has been realized a phonatory fistula between trachea and esophagus with prosthesis positioning by means of a primary puncture in 18 cases and it has been realized a secondary puncture in 22 cases. The results gathered in these patients were compared with data obtained from a group made of 39 patients, less than 70 years of age that therefore represented our control group. In primary tracheoesophageal puncture (TEP), the short-term success was 67 %, while in the 22 cases who underwent secondary TEP, the short-term success was 64 %. After 2 years from TEP, the long-term success was 82.5 %. In the control group, the short-term success was 65 % in primary TEP and 73 % in secondary TEP. After 2 years from TEP, the long-term success was 77 %. The evaluation of the results has shown the absence of a statistically significant difference both as regards complications incidence, during and after surgery (p > 0.9) and as regards overall success ratio of prosthesis implants between the two groups (p > 0.7). The possibilities of tracheoesophageal recovery of elderly patients do not show dissimilarities in comparison with the results in younger subjects.

In Vitro Evaluation of the iValve: A Novel Hands-Free Speech Valve

Objectives:

We performed in vitro evaluation of a novel, disposable, automatic hands-free tracheostoma speech valve for laryngectomy patients based upon the principle of inhalation. The commercially available automatic speech valves close upon strong exhalation and open again when the pressure drops. This method makes long sentences or pauses difficult. The novel iValve is designed to allow almost natural speech, with mid-sentence pausing and whispering.

Methods:

The inhalation closing flows and exhalation opening pressures of 6 iValve prototype versions at different settings were compared with physiological values. The airflow resistance at inhalation was compared to physiological values and to commercial valve values.

Results:

The iValve prototypes showed flow and pressure ranges in concordance with the physiological values in the literature. The airflow resistance in the breathing mode was within the physiological airflow resistance range, yet above the values from the two commercial valves. The resistance in the speaking mode was above the physiological airflow resistance range.

Conclusions:

In vitro tests show that the iValve versions can be selected and adjusted to operate within the physiological range. The airflow resistance in the breathing mode is good. In speaking mode, inhalation should, and can, be decreased. The iValve should offer the patient a more intuitively useable alternative with more dynamic speech. Its low cost allows disposability and wider use.

Aerodynamic characteristics of the slit-like trachea-esophagus puncture for voice rehabilitation following total laryngectomy

CONCLUSIONS

The slit-like trachea-esophagus puncture is a reliable procedure to restore the voice in the patient who has undergone a total laryngectomy. The new voice quality could be similar to normal and could meet the patient's daily needs.

OBJECTIVES

We report a new method of tracheoneoesophageal (TE) voice rehabilitation. A slit-like trachea-esophagus puncture was made in the tracheoesophageal wall after the total laryngectomy. No voice prosthesis was used. The purpose of this study was to observe its aerodynamic characteristics.

METHODS

All 60 patients received voice rehabilitation with the slit-like fistula after total laryngectomy. All patients' voices were evaluated as excellent. The aerodynamic characteristics of trachea-esophagus voices were observed.

RESULTS

When a patient attempted to phonate, the upper esophagus was closed. Then, the hypopharyngeal cavity expanded. Just before phonating, the upper esophagus was full of air as a ball. The air flow escaped through the segment of the trachea-esophagus slit and entered the pharyngoesophageal segment (PES). The esophageal meatus opened. It was vibrated together with nearby mucus and mucosa to form the voice. The maximum phonation time of the slit-like fistula voice was not significantly different from the Blom-Singer prosthesis voice. Its sound intensity was similar to the normal voice.

Tracheostomy cannulas and voice prosthesis

Cannulas and voice prostheses are mechanical aids for patients who had to undergo tracheotomy or laryngectomy for different reasons. For better understanding of the function of those artificial devices, first the indications and particularities of the previous surgical intervention are described in the context of this review. Despite the established procedure of percutaneous dilatation tracheotomy e.g. in intensive care units, the application of epithelised tracheostomas has its own position, especially when airway obstruction is persistent (e.g. caused by traumata, inflammations, or tumors) and a longer artificial ventilation or special care of the patient are required. In order to keep the airways open after tracheotomy, tracheostomy cannulas of different materials with different functions are available. For each patient the most appropriate type of cannula must be found. Voice prostheses are meanwhile the device of choice for rapid and efficient voice rehabilitation after laryngectomy. Individual sizes and materials allow adaptation of the voice prostheses to the individual anatomical situation of the patients. The combined application of voice prostheses with HME (Head and Moisture Exchanger) allows a good vocal as well as pulmonary rehabilitation. Precondition for efficient voice prosthesis is the observation of certain surgical principles during laryngectomy. The duration of the prosthesis mainly depends on material properties and biofilms, mostly consisting of funguses and bacteries. The quality of voice with valve prosthesis is clearly superior to esophagus prosthesis or electro-laryngeal voice. Whenever possible, tracheostoma valves for free-hand speech should be applied. Physicians taking care of patients with speech prostheses after laryngectomy should know exactly what to do in case the device fails or gets lost.

Graphical modeling can be used to illustrate associations between variables describing functioning in head and neck cancer patients

OBJECTIVE

To examine the associations between variables of functioning measured by the International Classification of Functioning, Disability and Health (ICF) in head and neck cancer (HNC) patients by means of graphical modeling.

STUDY DESIGN AND SETTING

Graphical modeling was used on a data set of a cross-sectional multicentric study of 145 patients with HNC. Functioning was qualified using the extended ICF checklist. Multiple imputation was used to handle missing data. The least absolute shrinkage and selection operator for generalized linear models was used to identify conditional associations between the ICF categories. Bootstrap aggregating was used to enhance the accuracy and validity of model selection.

RESULTS

The resulting graph shows largely meaningful associations between the ICF categories. One central point could be visualized consisting of a circular path of d330 Speaking, d350 Conversation, b510 Ingestion functions, s320 Structure of mouth, and b310 Voice functions. Another important structure in the graph were the bow-shaped associations beginning with d335 Producing nonverbal messages to b130 Energy and drive functions.

CONCLUSION

Graphical modeling can be used to describe associations between different areas of functioning in HNC patients. They found associations can be the basis for improved rehabilitation and gives a deeper understanding of functioning in HNC patients.

[Finger-free speech with the Provox FreeHands HME Automatic Tracheostoma Valve system. Clinical long-term experience]

INTRODUCTION

The use of voice prostheses allows excellent rehabilitation of laryngectomized patients but it is considered a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gestures or to work with both hands. An automatic tracheostoma valve helps patients to overcome this problem.

PATIENTS, MATERIAL AND METHODS

A total of 17 laryngectomized patients were asked to join a long-term study 18 months after having been fitted with a Provox FreeHands HME Automatic Tracheostoma Valve system. The patients completed a questionnaire in order to assess satisfaction, voice quality, wearing comfort, fixation, potential problems and the effectiveness of the HME cassette.

RESULTS

Of the 17 patients 4 discontinued the study due to problems of securing the valve to the skin (n=2) or fistula leakage (n=2). Of the remaining patients 7 wore the valve daily for an average of 6 h. Of the patients 76% considered it a great advantage to be able to speak without using their hands. With the Provox FreeHands HME Automatic Tracheostoma Valve system, maximum phonation time was 8.5 s (+/-6.8) and the dynamic range was 21.7 decibels (+/-5.6).

CONCLUSION

The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent long-term compliance and good voice rehabilitation.