Laryngectomy: Phonation Alternatives and Their Impact on the Quality of Life

Background The decision to consent to surgery is a life-changing moment. This study addresses the impact of total laryngectomy (TL) on phonation and its effect on the quality of life (QoL) of patients. The primary objective of this cohort study is to compare the alternatives in phonation rehabilitation, and the secondary objective is to identify concurrent predictors of vocal outcomes. Methodology To perform a comprehensive analysis, we reviewed data from patients who underwent TL with bilateral radical neck dissection in the Department of Otolaryngology, Head and Neck Surgery at Centro Hospitalar Universitário de Santo António between January 2010 and October 2022. Adult patients who consented to participate in the study and underwent subjective evaluation were included in this study. Data regarding clinical history was primarily collected. Statistical analysis was performed using SPSS version 26 (IBM Corp., Armonk, NY, USA). Different types of vocal rehabilitation formed the subgroups to be compared. An additional analysis was performed for baseline variables collected in the clinical records, and vocal outcomes were measured using the Self-Evaluation of Communication Experiences After Laryngectomy (SECEL) questionnaire. Furthermore, linear models taking SECEL scores as the outcome were developed. Results The first search identified a total of 124 patients operated during the study period. In total, 63 patients were alive at the time of the current follow-up, with 61 deaths (49%). Overall, 26 of the 63 alive patients completed the SECEL questionnaire. All patients were male. The mean age at diagnosis was 62.2 ± 10.6 years. The mean age at the time of subjective vocal assessment with the SECEL questionnaire was 66.3 ± 10.4 years. The mean time of follow-up after the initial diagnosis was 4 ± 3.8 years. A statistically significant difference was observed in esophageal speech (ES), which was inferior to other modalities (mean SECEL total score for ES: 46.6 ± 12.2 vs. mean SECEL total score for all other modalities: 33 ± 15.1; p = 0.03). The follow-up time correlated significantly with vocal function, as measured by the SECEL questionnaire (p = 0.013). Conclusions The SECEL questionnaire can be a valuable tool to evaluate QoL in laryngectomy patients, given its usefulness in assessing the psychological impact derived from vocal functionality in this group. ES appears inferior to other modalities regarding voice-related QoL.

Esophageal Speech for a Patient with Amyotrophic Lateral Sclerosis Who Underwent a Central-part Laryngectomy to Prevent Aspiration: A Case Report

Background

To prevent aspiration, patients with irreversible dysphagia may undergo surgeries that separate the esophagus and trachea. Such interventions result in loss of vocal function and require alternative communication methods. We report a patient with amyotrophic lateral sclerosis (ALS) who used esophageal speech after receiving a central-part laryngectomy (CPL) to prevent aspiration.

Case

A 64-year-old woman with ALS was admitted to our hospital. The patient maintained good cognitive and oral function and presented with mild dysarthria and dysphagia. Faced with rapidly worsening respiratory distress, saliva aspiration, and excessive sputum, she underwent a tracheostomy on the premise of invasive ventilation. Subsequently, the patient began using a voice-generating application for communication. Given the patient's sincere hope to prevent aspiration and aspiration pneumonia, achieve safe oral intake, and decrease caregiver burden for frequent suctioning, the patient underwent a CPL. Following surgery, belching was observed during meals, and the patient could phonate when she belched. This finding led to four speech therapy sessions to practice esophageal speech, allowing the patient to use the pseudo-speech technique for short conversations. Removal of the entire cricoid cartilage in the CPL decreases the upper esophageal sphincter (UES) pressure, thereby allowing air to easily pass through the UES. Therefore, the patient could use the air as a sound source for esophageal speech without extensive training.

Discussion

Esophageal speech may be an alternative to oral communication in patients undergoing CPL. Further research is warranted to generalize these findings to patients undergoing CPL.

Influence of Collective Esophageal Speech Training on Self-efficacy in Chinese Laryngectomees: A Pretest-posttest Group Study

Total laryngectomy affects the speaking functions of many patients. Speech deprivation has great impacts on the quality of life of patients, especially on self-efficacy. Learning esophageal speech represents a way to help laryngectomees speak again. The purpose of this study was to determine the influence of collective esophageal speech training on self-efficacy of laryngectomees. In this study, 28 patients and 30 family members were included. The participants received information about training via telephone or a WeChat group. Collective esophageal speech training was used to educate laryngectomees on esophageal speech. Before and after collective esophageal speech training, all participants completed the General Self-Efficacy Scale (GSES) to assess their perceptions on self-efficacy. Through the training, laryngectomees recovered their speech. After the training, the self-efficacy scores of laryngectomees were higher than those before the training, with significant differences noted (T<0.05). However, family members' scores did not change significantly. In conclusion, collective esophageal speech training is not only convenient and economical, but also improves self-efficacy and confidence of laryngectomees. Greater self-efficacy is helpful for laryngectomees to master esophageal speech and improve their quality of life. In addition, more attention should be focused on improving the self-efficacy of family members and making them give full play to their talent and potential on laryngectomees' voice rehabilitation.

Verbal performance of total laryngectomized patients rehabilitated with esophageal speech and tracheoesophageal speech: impacts on patient quality of life

Introduction

Total laryngectomy has important psychophysical and social consequences for patients’ quality of life because of the functional changes resulting from the removal of the larynx. Voice deprivation is perhaps the most relevant limiting factor in social relationships, increasing feelings of solitude and tending to drive individuals into social isolation. Multiple voice rehabilitation methods after total laryngectomy are available. This study aimed to determine the acoustic quality of the rehabilitated voice achieved with esophageal speech (ES) and tracheoesophageal speech (TES), and acoustic quality impacts on patients’ perceptions of their quality of life.

Materials and methods

The patient inclusion criterion was the completion of a speech rehabilitation course with ES or TES at least 6 months after total laryngectomy. The voice acoustic analysis was carried out automatically by using the Multidimensional Voice Program. The following parameters were extracted: fundamental frequency (F0), Jitter% (Jitt), Shimmer% (Shim), and noise-to-harmonic ratio (NHR). Subjective voice evaluation was performed by using the following questionnaires: Voice Handicap Index (VHI), Voice-related Quality of Life (V-RQOL), and Voice Performance Questionnaire (VPQ).

Results

The acoustic analysis showed a difference between ES and TES patients on all acoustic parameters; this difference was significant for F0 (133.09±2.4 and 119±3.3, respectively; p<0.001), NHR (0.43±0.21 and 0.31±0.14, respectively; p=0.02), and maximum phonation time (2.02±038 s and 10.64±0.28 s, respectively; p=0.01. Regarding patient-related outcomes, TES correlated with better total scores compared with ES; however, the differences in the total scores on the VHI (p=0.09), V-RQOL (p=0.39), and VPQ (p=0.52) were not statistically significant.

Conclusion

The rehabilitation of laryngectomized patients must be addressed by a multidisciplinary team that considers the personalities, personal needs, and relational conditions of individual patients in order to determine and apply the phonatory rehabilitation method most suitable for achieving a better quality of life.

[The progress of voice restoration after total laryngectomy]

Total laryngectomy or laryngopharyngectomy is the main treatment strategy of choice for advanced laryngeal/hypopharyngeal carcinoma.However,the operation is associated with important consequences over and above the loss of normal voice.Therefore,it is necessary toachieve voice in the absence of a functional larynx.The objective of this article is to provide an over view of current methods and a summary of the present progress about voice rehabilitation after total laryngectomy.

Rehabilitation after Total Laryngectomy-A Tribute to the Pioneers of Voice Restoration in the Last Two Centuries

BACKGROUND

The most severe consequence of laryngectomy for patients is the loss of their voice. For this reason, voice rehabilitation has been an integral aspect of treatment after total laryngectomy from the very beginning. A wide variety of different technical and surgical approaches are available and reflect the problems associated with the rehabilitation of communication and swallowing after the removal of the larynx.

METHODS

We used Internet search engines and libraries to conduct a search of the current medical literature and historical sources of medical information in order to identify and summarize landmark work on this subject.

DISCUSSION

Four types of methods have been used to restore the voices of patients, i.e., external devices, esophageal speech, internal voice prostheses, and surgically created tracheo-esophageal fistulas that do not involve the use of a prosthetic device.

The electrolarynx: voice restoration after total laryngectomy

The ability to speak and communicate with one’s voice is a unique human characteristic and is fundamental to many activities of daily living, such as talking on the phone and speaking to loved ones. When the larynx is removed during a total laryngectomy (TL), loss of voice can lead to a devastating decrease in a patient’s quality of life, and precipitate significant frustration over their inability to communicate with others effectively. Over the past 50 years there have been many advances in techniques of voice restoration after TL. Currently, there are three main methods of voice restoration: the electrolarynx, esophageal speech, and tracheoesophageal speech through a tracheoesophageal puncture (TEP) with voice prosthesis. Although TEP voice is the current gold standard for vocal rehabilitation, a significant minority of patients cannot use or obtain TEP speech for various reasons. As such, the electrolarynx is a viable and useful alternative for these patients. This article will focus on voice restoration using an electrolarynx with the following objectives: 1) To provide an understanding of the importance of voice restoration after total laryngectomy. 2) To discuss how the electrolarynx may be used to restore voice following total laryngectomy. 3) To outline some of the current electrolarynx devices available, including their mechanism of action and limitations. 4) To compare pros and cons of electrolaryngeal speech to TEP and esophageal speech.

Novel esophageal speech therapy method in total laryngectomized patients: biofeedback by intraesophageal impedance

The loss of the best communication port after total laryngectomy surgery makes speech rehabilitation an important goal. Our aim was to improve the quality of esophageal speech (ES) using online esophageal multichannel intra-luminal impedance (MII) as a new biofeedback method. Twenty-six total laryngectomized patients were included. Before ES therapy, an esophageal motility test was carried out. MII catheters were placed in all subjects who were then randomized into two groups. Group 1 included 13 cases, who were retrained according to the classical method. Group 2 included 13 cases, who were retrained according to the simplified animation of air movements within the esophagus and upper stomach resulting from the modifications of intra-esophageal air kinetics gained by MII. The level of speech proficiency was evaluated relative to pretraining levels using perceptual scales in the third and sixth months. Acoustic voice was analyzed. The number of syllables read per minute and the intelligibility of monosyllabic and dissyllabic words were calculated. In this study, MII was used for the first time in alaryngeal speech rehabilitation as a biofeedback method; an overall sufficient speech level was achieved by 68.4% at the end of therapy, whereas attendance was 90%. A statistically significant improvement was found in both groups in terms of ES level compared with the pretraining period although there was no significant difference between groups. Although we did not observe the expected difference between groups suggested by our hypothesis, MII may be used as an objective tool to show patients how to swallow and regurgitate air during training, and may thus expedite ES therapy both for the speech therapist and the patient in the future.

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

OBJECTIVES/HYPOTHESIS

To describe the speech rehabilitation outcomes of patients undergoing total laryngectomy (TL) in the 21st century.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic center

SUBJECTS AND METHODS

Retrospective review of 167 patients who underwent TL from June 2000 to February 2012. Demographics, disease variables, and surgical factors were reviewed. Primary alaryngeal speech modality, speech outcome, and tracheoesophageal puncture (TEP) complication rates were assessed.

RESULTS

Overall TEP speech success rate (primary or secondary) was 72%. Overall TEP speech success rate was 76% for those with primary TEP and was 68% for those with secondary TEP. TEP speech success rates at first, second, and beyond second year were 75%, 72%, and 70%, respectively. Success rates for primary TL, salvage TL, primary TL with pharyngeal reconstruction, or salvage TL with pharyngeal reconstruction groups were 71%, 72%, 73%, and 71%, respectively. TEP-related complications occurred in 43% of patients, with no difference in complication rates between primary versus salvage TL or primary versus secondary TEP. For those with complications, TEP success rate was 65%.

CONCLUSION

This study showed TEP speech-outcome success rates lower than what has been historically reported. There was no significant difference in TEP speech outcome between primary versus salvage TL or primary versus secondary TEP. Patients with TEP-related complications had TEP speech-outcome success rates comparable to those without any complication. TEP may continue to be a superior option as a mode of speech in patients with TL, including those undergoing salvage TL.

LEVEL OF EVIDENCE

4.

Predictive value of esophageal motility test in the proficiency of esophageal speech

One method of speech rehabilitation following total laryngectomy surgery is esophageal speech therapy (EST). In this method, which has witnessed relatively low success rates at the end of therapy, identification of patients who can benefit from EST beforehand will be important for determining the appropriate method for alaryngeal speech rehabilitation and might be cost-effective, saving time and labor. To this end, this study conducted research on the feasibility of manometric data measured prior to therapy using an esophageal motility test (EMT) in order to determine the candidates most suitable for esophageal speech (ES) beforehand. A total of 51 total laryngectomy male patients who had never been subject to any kind of speech rehabilitation and had always been articulate were included in the study. Data were collected from 44 patients who completed EST, lasting for 6 months in total and consisting of 11 sessions. Manometric measures were obtained through EMT using a water-perfusion system with a Dent sleeve catheter on the patients prior to the therapy. Wepman's scale was used in order to evaluate ES proficiency. Following the therapy, in accordance with this scale, while patients whose scores was 1, 2, or 3 were considered as adequate, those whose scores were 4, 5, 6, or 7 were considered inadequate and were divided into two groups. Manometric correlations were analyzed between 17 patients (group I) who were able to perform ES at an adequate level and 27 patients (group II) who could not. No statistically significant difference between the groups could be observed in terms of average pressure generated within the upper and lower esophageal sphincters obtained through EMT, peak amplitude of esophageal body contraction pressure, contraction duration time, onset velocity, or peak velocity values. EMT conducted prior to application of EST to total laryngectomized patients did not have any value in determining the level of ES that a patient could reach. Our results also suggest that sphincter pressures or esophageal motility patterns do not have any predictive value and should not be performed.

Methods of voice reconstruction

This article reviews methods of voice reconstruction. Nonsurgical methods of voice reconstruction include electrolarynx, pneumatic artificial larynx, and esophageal speech. Surgical methods of voice reconstruction include neoglottis, tracheoesophageal puncture, and prosthesis. Tracheoesophageal puncture can be performed in patients with pedicled flaps such as colon interposition, jejunum, or gastric pull-up or in free flaps such as perforator flaps, jejunum, and colon flaps. Other flaps for voice reconstruction include the ileocolon flap and jejunum. Laryngeal transplantation is also reviewed.