Predictive value of objective esophageal insufflation testing for acquisition of tracheoesophageal speech

Has Esophageal Speech Returned as an Increasingly Viable Postlaryngectomy Voice and Speech Rehabilitation Option?

PURPOSE

The literature on postlaryngectomy voice and speech rehabilitation is long-standing. Although multiple rehabilitation options have existed over the years, the acquisition and use of esophageal speech (ES) has decreased significantly over the past 40 years. This reduction coincides with the increased application of tracheoesophageal puncture (TEP) voice restoration. The literature suggests that voice acquisition failures observed secondary to TEP may represent a similar phenomenon that led to ES acquisition failures.

METHOD

A comprehensive review of the literature on ES and TEP voice/speech was conducted. Specific attention was directed toward information on ES and TEP speech failures. Information on pharyngoesophageal segment (PES) spasm in the context of ES and TEP voicing failures was of specific importance.

RESULTS

Similarities between voicing failures with both ES and TEP were identified. In order to resolve spasm in TEP speech, proactive efforts to eliminate it were undertaken, and regardless of the method used, voicing improvements were observed. These data suggest that both ES and TEP speech acquisition failures may be related to the same control mechanisms influencing the PES.

CONCLUSIONS

The elimination of PES spasm provides evidence that justifies the reconsideration of ES. Consequently, ES may return as an increasingly viable postlaryngectomy voice and speech rehabilitation option.

Secondary tracheoesophageal puncture with a flexible transillumination device: a new technique and its outcomes

OBJECTIVES

This study aims to describe a new secondary tracheoesophageal puncture technique with voice prosthesis insertion under local anesthesia with a low-cost device and evaluate its outcome.

METHODS

With a transoral flexible transillumination device of aluminum of 2.3 mm with fiberoptic light, the esophagus's anterior wall is visualized through the tracheostomy. A tracheoesophageal fistula is made with a blade and passed through the fistula. Then a bent trocar is introduced into the lumen using the device as a guidewire. Once in the lumen, a thin guide wire is passed through up to the mouth. The voice prosthesis is positioned with retrograde insertion. Then, the patient is discharged without hospitalization.

RESULTS

15 patients submitted to this technique had a successful surgical outcome. There were no complications as pneumothorax, esophageal perforation, bleeding, or hospitalization.

CONCLUSION

The new device is feasible under local anesthesia.

Intraluminal Esophageal Pressures in Speaking Laryngectomees

Objectives

The objective of the present study was to evaluate intraluminal esophageal pressure during voice and speech emission in speaking laryngectomees with a tracheoesophageal prosthesis.

Methods

In our prospective analysis in a tertiary-care academic hospital, 25 laryngectomees were divided into 2 groups: 11 speaking individuals with a tracheoesophageal prosthesis and a control group of 14 nonspeaking laryngectomees. All patients were subjected to manometry during voice and speech emission tests. We determined the pressures achieved in the distal, middle, and proximal parts of the esophagus.

Results

Statistical analysis revealed that the amplitude of pressure in the distal esophagus during sound emission was higher in speaking laryngectomees; in the middle esophagus, intraluminal pressure during emission of the sentence was higher in speaking subjects, and in the proximal esophagus there was no difference between the groups.

Conclusions

During the manometric evaluation of the distal and middle esophagus in the presence of voice and speech emission, the intraluminal pressure revealed a significant difference for the speaking laryngectomees with a tracheoesophageal prosthesis. The proximal esophagus behaved similarly in the groups of speakers and nonspeakers. Speaking laryngectomees with a tracheoesophageal prosthesis depend on a differentiated performance of the middle and distal parts of the esophagus.

Detection of ideal reservoir level after laryngectomy using endoilluminator in voice rehabilitation

OBJECTIVE

To assess the diagnostic value of a novel device, the endoilluminator, in patients who can or cannot attain effective speech after application of voice prosthesis.

STUDY DESIGN

Prospective clinical study.

METHODS

Thirty-four patients who underwent total laryngectomy and whose insufflation test was positive were included. As a result of efforts to develop an insufflation test that includes a light apparatus, we attained a device that we call an endoilluminator. We found that the area it illuminated when a patient achieved effective speech was a predictive factor for the test result. That is, patients for whom the upper part of the tracheostomy (where the standard tracheoesophageal fistula will be opened) was illuminated were categorized as the positive test group, whereas those for whom the neck skin above this region was illuminated were categorized as the negative test group.

RESULTS

In 27 of the 34 patients, appropriate localization was determined using the endoilluminator, and these patients achieved effective speech. In the remaining seven patients, localization was inappropriate and they did not achieve effective speech during the first week, first month, or third month postpuncture. In further investigations of these seven patients, a pharyngoesophageal spasm was detected in five, and a pharyngoesophageal stricture was detected in two.

CONCLUSION

Endoilluminator increases the success rate of the insufflation test by accurately predicting a patient's ability to achieve effective speech after application of voice prosthesis.

Ultrasound-guided botulinum toxin injection: A simple in-office technique to improve tracheoesophageal speech in postlaryngectomy patients

BACKGROUND

Pharyngoesophageal spasm is a known entity to cause hypertonic/failed tracheoesophageal speech and is successfully treated by botulinum toxin A injection. However, success of botulinum toxin treatment is based on the accurate localization of the pharyngoesophageal segment.

METHODS

A 65-year-old man who had a laryngectomy using voice prosthesis with hypertonic speech underwent ultrasonographic localization of the hypertonic pharyngoesophageal segment. The ultrasound findings were confirmed using videofluoroscopy. Under ultrasound guidance, botulinum toxin was injected into the hypertonic pharyngoesophageal segment and subsequently voice outcomes were evaluated by a speech language pathologist and the pharyngoesophageal segment was assessed by using an ultrasound scan.

RESULTS

The patient had improvement in his postinjection tracheoesophageal puncture speech. Ultrasound scan assessment of the pharyngoesophageal segment showed adequate dilation as compared to the pre-botulinum toxin injection treatment.

CONCLUSION

Ultrasonographic localization of the hypertonic pharyngoesophageal segment and ultrasound-guided botulinum toxin injection is a simple, quick, and relatively cheap method to be used in routine practice.

Computerized manometry use to evaluate spasm in pharyngoesophageal segment in patients with poor tracheoesophageal speech before and after treatment with botulinum toxin

Tracheoesophageal voice (TEV) with voice prosthesis (VP) is an efficient and reproducible method used in vocal rehabilitation after total laryngectomy (TL), prevented by spasms in the pharyngoesophageal segment (PES). Computerized Manometry (CM) is a new, direct and objective method used to assess the PES.

Aim

to carry out an objective analysis of the PES, with CM, before and after the injection of botulinum toxin (BT).

Study design

clinical-prospective.

Materials and Methods

analysis of eight patients consecutively submitted to TL with TEV and VP, without vocal emission, with PES spasms seen through videofluoroscopy, considered the gold standard for spasm detection. All had their spasms treated with the injection of 100 units of BT in the PES. The assessment was based on PES videofluoroscopy and CM, before and after BT injection.

Results

There was a PES pressure reduction according to the CM after BT injection in all patients. The average pressure in the PES seen through the CM in eight patients before BT injection was 25.36 mmHg, and afterwards it dropped to 14.31 mmHg (p=0.004). There was vocal emission without stress and PES spasm improvement seen through the videolaryngoscopy after BT injection.

Conclusion

We observed a reduction in PES pressure after BT injection, seen through CM in all the patients, with spasms improvement seen through videofluoroscopy.

Use of computerized manometry for the detection of pharyngoesophageal spasm in tracheoesophageal speech

Objective

To evaluate the utility of computerized manometry (CM) to identify pharyngoesophageal segment (PES) spasm during tracheoesophageal speech.

Study Design

Prospective clinical, controlled study.

Subjects and Methods

Intraluminal pressures of the PES were collected in 12 tracheoesophageal speakers without spasm and 8 tracheoesophageal speakers with PES spasm before and after localized injection of botulinum toxin to the PES. All subjects underwent voice analysis and videofluoroscopy in addition to CM before and after treatment.

Results

All tracheoesphageal speakers with PES spasm presented with mean intraluminal pressures greater than 16 mmHg (mean, 25.36 mmHg). In contrast, mean intraluminal pressures of subjects without spasm was 11.76 mmHg ( P < 0.05). The negative predictive value associated with the use of 16 mmHg as a threshold value for spasm was 100%.

Conclusion

CM is a clinically useful tool to aid in speech rehabilitation for tracheoesophageal speakers. Intraluminal pressures of greater than 16 mmHg was highly predictive for PES spasm. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Botulinum toxin in speech rehabilitation with voice prosthesis after total laryngectomy

In tracheo esophageal puncture (TEP), we carry out a myotomy of the pharynx constrictor muscle; however, about 9 to 79% of patients need such procedure. The consequence of such procedure is an increase in salivary fistula rates in the postoperative. Botulin toxin is used in an outpatient basis.

Aim

analyzing the efficacy of botulin toxin (BT) use in the rehabilitation of totally laryngectomized patients with tracheoesophageal voice (TEV) with spasms (S) of the pharyngoesophageal segment (PES) without myotomy.

Materials and Methods

We analyzed eight patients submitted to total laryngectomy (TL), rehabilitated with TEV, with speech prosthesis (SP) and struggle to utter voice because of PES spasms. They were all submitted to treatment of such motor alteration with the injection of 100 units of BT in the PES. The evaluation was based on perceptive voice analysis, video fluoroscopy (VF) of the PES, acoustic voice analysis and computerized manometry (CM) of the PES, all before and after BT injection.

Study design

prospective

Results

There was a reduction in PES CM pressure after BT injection. Acoustic analysis showed an improvement in harmonics quality after treatment. There was smoother voice utterance and spasm improvement after BT.

Conclusion

all patients with PES spasms presented vocal improvement after BT injection in the PES.

Reabilitação vocal pós-laringectomia total: resultados em longo prazo com prótese fonatória Blom-Singer® de longa permanência

Avaliar o uso em longo prazo de próteses fonatórias (PF) para reabilitação fonatória de pacientes submetidos à laringectomia total (LT). Foram estudados a influência do tempo de realização da punção tráqueo-esofágica (PTE), o uso de radioterapia pós-operatória (RTXpos-op), idade e seguimento do paciente, sobre a taxa de sucesso de uso da PF. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODOS: Setenta e um pacientes submetidos à LT e reabilitados com PF de longa permanência. Todos foram avaliados por otorrinolaringologista e fonoaudióloga, quanto aos aspectos funcionais vocais, durante o seguimento. Os dados relativos a tempo de colocação da PF, tempo de utilização da PF, uso de RTXpos-op, idade do paciente, tempo de seguimento e tempo de duração de cada PF foram anotados. RESULTADOS: Houve 87% de pacientes com PTE primária e 13% com secundária. O tempo de seguimento variou de 12 a 87 meses, com média de 38 meses para a PTE primária e 51 meses para a secundária. Houve 59% de pacientes submetidos a RTXpos-op. A taxa de sucesso geral foi de 94%. Na PTE primária foi de 97% e na secundária 78% (p=0,07) e, após dois anos, foi de 96% na PTE primária e 75% na secundária (p=0,07). Utilização de RTXpos-op e idade do paciente não influenciaram no sucesso de utilização de PF, independentemente do tempo de seguimento. CONCLUSÕES: Houve tendência de maior sucesso na reabilitação vocal de pacientes submetidos à LT com a PTE primária. O uso de RTXpos-op e idade não influenciou nesta taxa de sucesso.

Speech rehabilitation after total laryngectomy: long-term results with indwelling voice prosthesis Blom-Singer®

To evaluate long-term use of indwelling Blom-Singer voice prosthesis (VP) for vocal rehabilitation of patients submitted to total laryngectomy (TL). We studied the influence of time of performance of tracheo-esophageal puncture (TEP), use of radiotherapy (XRT), patients' age and length of follow-up, on the rate of success of use of VP.

STUDY DESIGN

Clinical prospective.

MATERIAL AND METHOD

Seventy-one patients were submitted to TL and rehabilitated with indwelling VP. Both otolaryngologist and speech pathologist evaluated all patients for the vocal functional issues during the follow-up. The relative data on time of placement of VP, time of use of PF, use of XRT, age, length of follow-up and interval of duration of each VP were recorded during the follow-up.

RESULTS

There was 87% of patients with primary TEP and 13% with secondary. The follow-up varied from 12 to 87 months, with average of 38 months for primary and 51 months for secondary TEP. There were 59% of patients submitted to XRT. The general rate of success was of 94%. In primary TEP it was of 97% and in the secondary, it was 78% (p=0.07) and after two years, the success rate was of 96% in primary TEP and 75% in secondary TEP (p=0.07). The use of XRT and patient age did not influence the success of use of VP among primary and secondary TEP, independently of length of follow-up.

CONCLUSION

Tendency to greater success rate in voice rehabilitation after TL with primary TEP was observed. Postoperative XRT and age did not influence success rate.

Comparison of pharyngoesophageal segment pressure in total laryngectomy patients with and without pharyngeal neurectomy

BACKGROUND

To compare pharyngoesophageal segment (PES) pressure values in total laryngectomy patients with and without pharyngeal neurectomy (PN) in the early postoperative period.

METHODS

Forty-five previously untreated laryngeal carcinoma patients were enrolled into this prospective randomized study. Twenty of them underwent total laryngectomy with PN, and 25 underwent total laryngectomy without PN. PES pressures were measured on the tenth postoperative day with a four-channel catheter.

RESULTS

Average PES pressures in patients with and without pharyngeal neurectomy were 12.82 +/- 6.11 mmHg and 17.40 +/-.72 mmHg respectively (p <.05). When compared with the critical point of 20 mmHg that is closely related to voice attainment in the group without pharyngeal neurectomy, 10 (40%) patients had pressure levels greater than 20 mmHg and in the other group only 1 (5%) patient had a pressure level greater than 20 mmHg. The difference between the groups with pressure levels greater than 20 mmHg was found to be statistically significant (p <.05).

CONCLUSIONS

Pharyngeal neurectomy results in a statistically significant decrease of PES pressures in total laryngectomy patients.

Cineradiography of the pharyngoesophageal segment in postlaryngectomy patients

The use of tracheoesophageal voice prostheses has gained wide acceptance in the field of vocal rehabilitation after total laryngectomy. In a randomized study with 3 arms, alaryngeal speech proficiency was assessed in 60 postlaryngectomy patients: 20 patients underwent primary unilateral pharyngeal myotomy, 21 patients underwent neurectomy of the pharyngeal plexus in addition to pharyngeal myotomy, and 19 patients did not undergo an additional surgical procedure. Pharyngoesophageal (PE) dynamics were examined during esophageal and tracheoesophageal speech. A single vibrating PE segment was seen in good alaryngeal speakers. Hypertonicity, spasm, strictures, and hypotonicity of the PE segment were correlated significantly with poor or moderate alaryngeal speech. Unilateral myotomy with or without unilateral neurectomy prevented hypertonicity or spasm of the PE segment. The acquisition of alaryngeal speech did not differ significantly between the 2 groups who had undergone an additional surgical procedure. Evaluation of anatomic and physiological factors may be helpful in subsequent clinical management to achieve effective alaryngeal speech.

Tracheoesophageal speech following transmucosal pharyngeal myotomy with the potassium-titanyl-phosphate laser

Successful communication following laryngectomy usually involves an electrolarynx or oesophageal speech. Only within the past decade has tracheoesophageal puncture been advocated for alaryngeal speech and evolved into the procedure of choice. Successful production of speech after total laryngectomy using tracheoesophageal speech may be impaired secondary to anatomical and functional difficulties. The primary limitation of tracheoesophageal speech is pharyngoesophageal spasm occurring in the upper oesophageal sphincter impeding airflow through this segment. Our report presents four patients who underwent a pharyngeal myotomy with the potassium-titanyl-phosphate (KTP) laser. Post-operatively, each patient was able to communicate with functional alaryngeal speech. A transmucosal pharyngeal myotomy may represent an alternative for patients with speech failure after tracheoesophageal puncture.

Secondary tracheoesophageal puncture: factors predictive of voice quality and prosthesis use

OBJECTIVE

To identify factors predicting prosthesis use and final speech quality in patients undergoing secondary tracheoesophageal puncture (TEP) for voice restoration alter laryngectomy.

METHODS

We undertook a retrospective study of 168 patients who underwent secondary TEP at the Cleveland Clinic between June 1980 and October 1993. Factors examined were: patient demographics, extent of initial surgery, method of pharyngeal preparation, history of irradiation, insufflation test results, pharyngeal stricture, and concurrent medical conditions. Univariate and multivariate statistical analyses were performed to identify predictive factors.

RESULTS

At last evaluation, 73.8% (124) of the patients were still using the prosthesis. Quality of speech was the only predictor of prosthesis use (p < .001). Phonation on the first day was achieved in 90% (151) of patients. Speech result improved significantly over the first 6 months (p < .001). Univariate analysis found that the need for reconstruction at laryngectomy (p = .04), the presence of pharyngeal stricture (p = .001), and continued prosthetic use (p < .001) were associated with the speech result. There was no significant advantage to the lack of approximation of the pharyngeal constrictors (p = .31). Stepwise logistic regression showed that only the absence of pharyngeal stricture was associated with a better-quality voice (p = .001).

CONCLUSION

Tracheoesophageal puncture is a reliable method for restoring voice after laryngectomy. Prosthesis use decreases with time, and good voice quality is the only predictor of continued prosthesis use. In this series the absence of pharyngeal stricture was the only significant predictor of good to excellent speech.