A prospective, randomized comparative study of patient perceptions and preferences of two types of indwelling voice prostheses

BACKGROUND

Technical and device life issues are frequently the focus of post-laryngectomy rehabilitation studies examining indwelling voice prostheses. Patient perceptions and preferences are considered less often.

AIMS

To determine patient perceptions of two indwelling voice prostheses across parameters relating to device use and maintenance and to determine what factors contribute to patient preferences.

METHODS & PROCEDURES

In a randomized, cross-over study, 31 laryngectomy patients completed a 3-week trial of both the new indwelling Provox Vega and a comparator device, the Blom-Singer Classic Indwelling. Patient perceptions of the insertion process, cleaning and care, and voicing were explored after each trial. At the end, overall preference and factors influencing device preference were examined.

OUTCOME & RESULTS

At the conclusion of the crossover trial, a significantly higher proportion of patients felt voice effort, overall voicing, bloating, and ease and effectiveness of cleaning were superior for the Provox Vega. No preference was noted for insertion processes. Overall device preference was influenced by improved voicing followed by cleaning and care.

CONCLUSIONS & IMPLICATIONS

Patients do not perceive all indwelling devices as equal and should have the opportunity to trial different devices to find the best device for their needs.

Further experience with modification of an intraluminal button for hands-free tracheoesophageal speech after laryngectomy

Tracheoesophageal (TE) speech using a voice prosthesis and hands-free speaking valve with an intraluminal attachment is the gold standard for voice restoration after total laryngectomy. Modification of a standard self-retaining silicone cannula or laryngectomy button often aids in the attachment of a speaking valve within the tracheal lumen for hands-free TE speech production. An increased number of laryngectomized individuals are able to achieve hands-free TE speech when the standard length, flange, and diameter of a silicone button is customized to accommodate individual tracheostomal contours. A technique is presented for modification of a standard silicone laryngectomy button to facilitate hands-free TE speech after total laryngectomy.

Development and evaluation of a novel tracheostoma button and fixation system (Provox LaryButton and LaryClip adhesive) to facilitate hands-free tracheoesophageal speech

CONCLUSION

This newly developed tracheostoma button and fixation system was appreciated by the majority of the patients in this study and led to an increased use of automatic speaking valves (ASVs).

OBJECTIVE

Development and prospective clinical evaluation of a new tracheostoma button and fixation system to enhance hands-free speech in laryngectomized patients.

PATIENTS AND METHODS

The Provox LaryButton and LaryClip adhesive system were prospectively evaluated in 11 patients: 10 male, 1 female; mean age 60.5 years, range 46-80 years; median follow-up since laryngectomy 4.9 years, range 9 months to 21 years. A study-specific questionnaire was used and the observation period was 3 weeks.

RESULTS

Eight patients were compliant, three dropped out of the study. The LaryClip adhesive system was tried by seven of these compliant patients, and ultimately used by six. At the start of the study two patients used an ASV on a daily basis, three alternated between an ASV and regular, manually operated heat and moisture exchangers (HME), three only used a HME. At the end of the study, three used the ASV daily, five alternated between ASV and HME. Seven patients indicated that they would continue using the new system, six with clips and one with the button only.

Voice and speech after laryngectomy

The aim of the investigation is to compare voice and speech quality in alaryngeal patients using esophageal speech (ESOP, eight subjects), electroacoustical speech aid (EACA, six subjects) and tracheoesophageal voice prosthesis (TEVP, three subjects). The subjects reading a short story were recorded in the sound-proof booth and the speech samples were acoustically analysed. Speech sound production was judged by 15 students of phonetics. The following variables were considered: (1) voice quality: fo, jitter, shimmer and harmonic-to-noise ratio, (2) speech sound production: number of recognized VCV syllables, and (3) temporal organization of speech: duration of the phonetic block, number of syllables in the phonetic block, rate of speech, rate of articulation and number of syllables in the longest phonetic block. The results showed that nearly normal air-stream source (lungs) in speech production of speakers with tracheoesophageal prosthesis significantly contributed to the speech timing and speech intelligibility of the alaryngeal speakers.

Anatomical and Functional Correlates of Voice Quality in Tracheoesophageal Speech

The purpose of the current study was to assess the anatomic and functional correlates of voice quality in tracheoesophageal speech, with dynamic imaging studies of the neoglottis. Videofluoroscopy (providing a lateral view), digital high-speed endoscopy (providing a "birds-eye" view), and their relationships with perceptual evaluations of voice quality were investigated. Several significant relationships were found. Imaging with videofluoroscopy revealed that the following anatomic and functional parameters (established during phonation) are related to voice quality: presence of a neoglottic bar, regurgitation of barium, tonicity of the neoglottis, and minimal neoglottic distance. Furthermore, the index of the increase of the maximal subneoglottic distance from rest to phonation also showed a significant relationship with voice quality. Imaging with digital high-speed endoscopy revealed features relevant to voice quality, including amount of saliva, visibility of the origin of the neoglottis, shape of the neoglottis, and regularity of the vibration. Knowledge of the anatomic and functional correlates of tracheoesophageal voice quality provides prerequisite information for future (phono-) surgical and/or clinical improvements to the voice quality of postlaryngectomy (prosthetic) voice production.

Effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox silicone tracheoesophageal voice prosthesis

CONCLUSION

Daily application of a buccal bioadhesive slow-release nystatin tablet (100,000 IU per tablet) significantly increased the voice prosthesis lifetime in laryngectomized patients compared to conventional local cleaning of the prosthesis with an antimicrobial agent on a brush.

OBJECTIVE

To investigate the effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox tracheoesophageal voice prosthesis in post-laryngectomy patients.

MATERIAL AND METHODS

A buccal bioadhesive tablet, based on a spray-dried Amioca/Carbopol 974P mixture containing 10% (w/w) Carbopol 974P, was loaded with 100,000 IU of nystatin. Patients were included in the study when replacement of their voice prosthesis was required and were divided into three groups. Conventional daily local cleaning of the voice prosthesis by means of an oral nystatin suspension on a brush (Group 1; n = 7) was compared with application of one nystatin buccal bioadhesive tablet per day, after breakfast, on the gingiva above the upper canine (Group 2; n = 7). The control group (n = 5) used no antimicrobial agents. The lifetime of the prosthesis was followed and expressed in days.

RESULTS

The lifetime of the voice prosthesis was significantly increased in Group 2 compared to Group 1 (p < 0.05; paired t-test), indicating that sustained release of nystatin in the oral cavity, by means of erosion of the tablet over a period of approximately = 8 h, is more effective at preventing microbial colonization of the prosthesis than local cleaning.

Speech and voice analysis after near-total laryngectomy and tracheoesophageal puncture with implantation of Provox 2 prosthesis

Vocal characteristics were compared in two groups of patients who were operated on due to laryngeal cancer. One group was composed of patients after near-total laryngectomy and the other after total laryngectomy followed by tracheoesophageal puncture with implantation of Provox 2 prosthesis. Acoustic analysis was carried out using the EZ Voice Plus program and included the following parameters: fundamental frequency, jitter, shimmer, harmonic to noise ratio, range of fundamental frequency, maximal phonation time and intensity.

The development of successful tracheoesophageal voice restoration

Effective treatment for laryngeal cancer concerns the preservation of voice. Progress has been made in treatment, rehabilitation,restoration of the airway, and nonsurgical treatments. With the introduction of tracheoesophageal speech and the voice prosthesis,many treated patients acquire socially acceptable speech after total laryngectomy and maintain satisfactory quality of life.

[Clinical and acoustic characteristics of tracheoesophageal bypass with prosthesis]

The authors analyse different aspects of tracheoesophageal bypass with prosthesis, how to prolong operation of voice prostheses. It is shown that replacement of the prostheses is frequently necessary not because of wear but rather due to fungal or microfloral affection. Radiotherapy had no adverse effects on prosthesis. Complications of tracheoesophageal bypass with prosthesis, acoustic characteristics of the repaired voice are described.

Total laryngectomy with tracheoesophageal conduit

Tracheoesophageal puncture has made high-quality voice restoration readily available to most individuals who must undergo TL. Although none of these patients would voluntarily choose to undergo TL if not faced with a life-threatening condition, at least some achieve a better quality of life, including better vocal function, after treatment and rehabilitation. The methods involved in placement and maintenance of a tracheoesophageal prosthesis are straightforward and permit successful, long-term voice restoration for most patients. Although far from perfect, TL with TEP affords both quality and quantity of life to a group of individuals who currently have no alternative but to undergo debilitating surgery in an effort to extend their lives.

Modification of the Barton button for tracheoesophageal speech: an innovative maxillofacial prosthetic technique

Laryngectomized, tracheoesophageal speakers who achieve hands-free speech wear a special breathing valve to automatically shunt air into the pharyngoesophagus for speech production. The standard method of attachment is adherence to the peristomal skin with glues and adhesives. The Barton button is a simpler, more efficient alternative that provides intraluminal attachment within the trachea. Although the device is appealing, constraints in standard design and dimensions have limited its success. This article presents a technique for modification of the Barton button to increase its successful use by tracheoesophageal speakers.

Aero-acoustics of silicone rubber lip reeds for alternative voice production in laryngectomees

To improve voice quality after laryngectomy, a small pneumatic sound source to be incorporated in a regular tracheoesophageal shunt valve was designed. This artificial voice source consists of a single floppy lip reed, which performs self-sustaining flutter-type oscillations driven by the expired pulmonary air that flows through the tracheoesophageal shunt valve along the outward-striking lip reed. In this in vitro study, aero-acoustic data and detailed high-speed digital image sequences of lip reed behavior are obtained for 10 lip configurations. The high-speed visualizations provide a more explicit understanding and reveal details of lip reed behavior, such as the onset of vibration, beating of the lip against the walls of its housing, and chaotic behavior at high volume flow. We discuss several aspects of lip reed behavior in general and implications for its application as an artificial voice source. For pressures above the sounding threshold, volume flow, fundamental frequency and sound pressure level generated by the floppy lip reed are almost linear functions of the driving force, static pressure difference across the lip. Observed irregularities in these relations are mainly caused by transitions from one type of beating behavior of the lip against the walls of its housing to another. This beating explains the wide range and the driving force dependence of fundamental frequency, and seems to have a strong effect on the spectral content. The thickness of the lip base is linearly related to the fundamental frequency of lip reed oscillation.

Experience with Barton button and peristomal breathing valve attachments for hands-free tracheoesophageal speech

BACKGROUND

Tracheostoma breathing valves permit hands-free tracheoesophageal (TE) speech production; however, few laryngectomees routinely use them because of problems with attachment.

METHODS

We retrospectively reviewed the charts of 45 TE speakers to determine the success rate and factors associated with successful breathing valve use based on attachment. All patients attempted to use a tracheostoma breathing valve with either a standard or customized peristomal housing, or a standard or customized Barton button. Device selection was based on inspection of the patient's neck and peristomal contour. Six to eight consecutive hours of attachment defined success.

RESULTS

Overall, 9% of subjects succeeded with any peristomal attachment as compared to 68% with either a standard (57%) or customized (85%) Barton button. Smooth stomal contour, a contiguous stomal lip, and correct button length were important for successful Barton button use.

CONCLUSIONS

Standard or customized Barton buttons offer excellent alternatives to peristomal housing attachments for hands-free TE speech in select patients.

Replacement of a malpositioned tracheoesophageal catheter in the radiology department

This article describes a safe and easy method to position a tracheoesophageal catheter correctly. The procedure is carried out under fluoroscopic guidance and requires neither general nor local anesthesia. The only modification necessary was removal of the tip of the hollow rubber catheter, to create an opening through which the guide wire could be passed.

The tracheostomal washer: a simple aid for tracheo-oesophageal speakers with a large tracheostome

A simple device is described which enables the patient with a tracheo–oesphageal valve and a large tracheostome to easily occlude the stoma, avoiding the need for stomaplasty.

Improved LAboratory Prototype ELectrolarynx (LAPEL): using inverse filtering of the frequency response function of the human throat

The electrolarynx (EL) provides a valued means of verbal communication for people who have lost their larynx. Existing ELs have some drawbacks such as harsh, raucous, and unpleasant sound and the presence of background noise. This study presents an experimental analysis of two commercial ELs and describes the development and testing of an improved LAboratory Prototype ELectrolarynx (LAPEL) which more accurately simulates the sound of a natural larynx and has lower background noise. This natural sound is obtained by determining the frequency response function (FRF) of the tissue of the human neck and using this information to tailor the input signal to the EL by inverse filtering such that its output spectrum resembles that of the natural larynx. The result was subjectively judged to have a superior and more natural sound than existing electrolarynxes.

Characteristics of Groningen tracheo-oesophageal speaking valves prior to insertion and after removal for failure

The Groningen valve was first used in Sheffield in 1986 in a patient who underwent laryngectomy for malignant disease. Since then it has been the main tracheo-oesophageal prosthesis used on our Unit for speech rehabilitation post-laryngectomy. This biflanged device inserted primarily or as a secondary procedure remains in situ until failure occurs either because of leakage or because increased effort is required to produce satisfactory phonation. This in vitro study we examined the differences between new valves prior to insertion and those removed for failure. The mean forward opening pressures were shown to be similar in the two populations but the mean forward resistances were increased in those valves which were defective (P less than 0.001). In addition the mean reverse opening pressure was found to be significantly lower in the defective valves when compared with their new counterparts (P less than 0.05).

Use of a portable manometer as a screening procedure in voice rehabilitation

Abnormal tone in the pharyngo-oesophageal (PO) segment may lead to failure in developing oesophageal speech. Videofluoroscopy may give a qualitative assessment of the PO segment but is expensive, time consuming and lacks quantification. A custom built PO segment manometer was therefore assessed as a means of predicting eventual oesophageal speech outcome. Two groups of patients were studied. In group 1 (18 patients) the PO segment pressures were compared to their videofluoroscopy findings. Videofluoroscopy categorized the patients into four groups. The PO pressures corresponded to this grouping, pressures above 20 mmHg being associated with voice failure. In group 2 (12 patients) the PO pressures in the early post-operative period were compared to their eventual speech outcome. In all cases the pressures predicted the eventual speech outcome. The pressure manometer is a simple, cheap and portable device which is a reliable screening test to predict the potential for oesophageal speech.

Tracheo-oesophageal puncture: a review of problems and complications

Tracheo-oesophageal puncture now has a well established role and in several units is now the principal means of speech rehabilitation following laryngectomy. Although not a difficult procedure, there are a number of problems and complications that may be encountered. With proper management these can usually be overcome and a useful voice achieved. This study looks at those problems in a series of 119 patients and discusses their management.

Aerodynamic properties of the low-resistance Groningen button

Shunt tracheoesophageal speech is currently the most successful form of voice and speech rehabilitation in laryngectomees. Insertion of valve prostheses into the tracheoesophageal shunts has overcome drawbacks caused by stenosis of the shunt and aspiration. In 10 years of satisfactory results with the standard Groningen button valve prosthesis, the overall concept of this device has proved its value. The airflow resistance, however, is relatively high, so that a low-resistance device has been developed without changing the favorable characteristics of the standard device. The design of this low-resistance Groningen button is described. The airflow resistances of the standard and low-resistance Groningen buttons have been measured and compared. The airflow resistance of the low-resistance Groningen button is also compared with the reported airflow resistances of various other valve prostheses.

Tracheoesophageal speech: vocal rehabilitation after total laryngectomy

Treatment of laryngeal cancer has evolved over nearly 100 years and includes many methods to conserve the function of speech. It was understood from the inception of total laryngectomy that diversion of exhaled pulmonary air into the pharynx or esophagus would produce satisfactory speech. The effect on safe deglutition of the phonatory fistulae limited the wide applicability of these techniques. The introduction of a silicone bivalve device for use in a tracheoesophageal tunnel permits large numbers of laryngectomees to use tracheoesophageal speech. Acoustic, intelligibility, and aerodynamic studies are described for four laryngectomees and reveal that this method more nearly approximates normal laryngeal speech than conventional esophageal speech. The criteria for contemporary treatment of laryngeal carcinoma are not altered by this rehabilitative method, and expected survival rates are not likely to be affected. The findings and analysis of this method of alaryngeal speech rehabilitation may have important implications for future therapy of laryngeal carcinoma.

Evaluations of Blom-Singer tracheoesophageal puncture prostheses performance

Empirical and theoretical approaches to the assessment of Blom-Singer tracheoesophageal puncture prosthesis performance are described in this paper. The results of empirical studies provide new insights about the behavior of Blom-Singer devices. Namely, the overall average resistance (about 126 cm H2O/LPS) of these devices stems from two major factors: air entrance and air exit effects. The magnitudes of airway resistance for each of these factors and the relative contribution each factor makes to the total airway resistance of these prostheses are delineated. The performance of these devices and modifications thereof are shown to be characterized and predicted quite well using a one-dimensional, spring-constant mathematical model.

Trial production of the handy amplifier for oesophagus speech

Oesophagus speakers cannot raise their voices. This seems to be the biggest trouble in daily life for them. Therefore, a handy amplifier has been produced by way of trial experiment to alleviate their trouble. This instrument is made up of a microphone, amplifier and speaker. The amplifier and speaker is put in a compact box 10.0 x 6.7 x 2.8 cm. The microphone is put in a cigarette holder and connected to the amplifier by a thin cord 30 cm long. When the sound is uttered whilst touching the holder with the lips it is heard through the speaker via the amplifier in the chest pocket of the coat. This instrument is recommended by many oesophagus speakers.

[Functional results following laryngectomy (author's transl)]

Vocal rehabilitation and deglutition post laryngectomy were evaluated. 71% of 62 patients had an intelligeable voice, 31% in this group using an electronic device (Servox). Minor problems in deglutition occurred in 35.5%. The functional results suggest definite role for classic laryngectomy even from the aspect of rehabilitation.

Rehabilitation after total laryngectomy

The process of speech acquisition after laryngectomy is described with emphasis on the three principal types of alaryngeal voice (oesophageal, artificial larynx and surgically facilitated voice). Current views on the use of the artificial larynx and factors that may interfere with alaryngeal speech development are discussed. The availability of laryngectomy rehabilitative services in some major centres is surveyed.

Voice rehabilitation after laryngectomy. Results with the use of a hypopharyngeal prosthesis

The Northwestern voice prosthesis for laryngectomees is described. The prosthesis contains no vibrator but activates vibration of the patient's pharyngeal or upper esophageal tissue by transporting air from the tracheostoma to a fistula in the upper neck, well away from major blood vessels. The prosthesis fits directly onto the laryngectomy tube and allows the patient to breathe, speak, and cough without any manual adjustments. The important advantage of this prosthesis is the fistula location. It can be placed at the time of original surgery and is also workable in patients who have had radiation and extensive radical surgery with total reconstruction of their gullet. The prosthesis can be used by primary total laryngectomees while learning esophageal speech or installed in those who are unable to use the electronic larynx or to learn esophageal speech. Four case studies are presented.