Post-Laryngectomy Voice Rehabilitation

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Post-Laryngectomy Voice Rehabilitation

Head and Neck Surgery
Author Credentials 

Chase M. Heaton, MD
Assistant Professor, Head and Neck Oncologic and Reconstructive Surgery
Department of Otolaryngology – Head and Neck Surgery
University of California, San Francisco
San Francisco, CA

Sky T. Yang, MS, CCC-SLP
Speech Language Pathologist
Department of Otolaryngology – Head and Neck Surgery
University of California, San Francisco
San Francisco, CA

Frank R. Miller, MD
Assistant Professor
Director of Head and Neck Surgery
Department of Otolaryngology—Head & Neck Surgery
University of Texas Health Science Center San Antonio

Module Summary

The loss of voice is generally considered the most disabling consequence of total laryngectomy. Post-laryngectomy voice rehabilitation is a critical component of caring for patients who undergo total laryngectomy. The evaluation and education of patients should occur simultaneously with the cancer treatment plan. Optimal therapy includes a multidisciplinary approach with both the surgeon and the speech pathologist working together. While several options are available to patients (artificial larynx, esophageal speech), the use of a prosthetic device placed via a tracheoesophageal puncture is now the gold standard. Overall success rates of 80%-90% have been reported using the various prosthetic devices.

Module Learning Objectives 
  1. Describe post-laryngectomy anatomy.
  2. Review the role of the speech-language pathologist in post-laryngectomy rehabilitation.
  3. Explain the three major options for post-laryngectomy voice rehabilitation, including speech with an artificial larynx, esophageal speech, and tracheoesophageal speech.
  4. Describe the technique for formation of a tracheoesophageal puncture (TEP).
  5. Review the relative benefits of primary TEP versus secondary TEP.
  6. Recognize the reasons for TEP failure.

Anatomy

Learning Objectives 
  1. Understand the anatomic and physiologic changes produced by laryngectomy.
  2. Laryngectomy produces complete separation of the airway from the digestive tract.
  3. Trachea is exteriorized to the lower central neck to form a permanent tracheostoma. Patients no longer breathe through their mouth and nose. Patients can no longer be intubated “from above” (through the mouth/nose).
  4. Pharynx is usually reconstructed by primary closure, or a flap may be utilized in the case of a partial or total pharyngectomy, or in salvage situations (prior radiation and/or chemotherapy).
  5. Dysphagia is not uncommon secondary to pharyngeal muscle spasm, pharyngeal stenosis, stricture following circumferential flap reconstruction, or recurrent tumor.

Incidence

Learning Objectives 
  1. Know that the majority of laryngectomy procedures are performed secondary to laryngeal cancer. Less common indications would be trauma and chronic aspiration.
  2. Recognize that approximately ~13,300 cases of laryngeal cancer are diagnosed per year, and the vast majority [90%] are squamous cell carcinoma. 5-year survival rate for all patients is 60.7% (2007-2013 National Cancer Institute data). 
  3. Overall incidence is declining with the reduction in the tobacco smoking population.
    • 75% of all laryngeal cancer (USA) involve glottic larynx.
    • Historically, late stage tumors were treated with laryngectomy and postoperative radiation. Since the early 1990s, there has been a trend toward attempted laryngeal preservation using chemoradiotherapy protocols (approximately 60% laryngeal preservation). Currently it is well accepted that late stage (clinical T4) tumors are best managed with primary surgery.
    • Major risk factors for developing laryngeal cancer include tobacco (primary major risk factor), alcohol, gastroesophageal reflux disease (GERD), human papilloma virus, and altered molecular biology (i.e., damaged tumor suppressor oncogenes).
References 
  1. Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med.1991 Jun 13;324(24):1685-90.

Patient Evaluation

Learning Objectives 

Recognize the critical role of the speech-language pathologist in both the preoperative evaluation/counseling and postoperative rehabilitation.

  1. Preoperative assessment:
    1. Recognize patient’s anxiety about loss of “voicebox.” Understand the significant quality of life impact laryngectomy has on patients and their families/friends.
    2. Assess patient’s cognitive ability and manual dexterity in order to assure that they can adequately care for themselves following surgery.
    3. Assess patient’s oral-motor range of motion, strength and coordination including lingual, mandibular and labial movements
    4. Assess patient’s speech articulation, intelligibility, as well as any accent or dialect variations in speech.
    5. Discuss anatomic changes as well as potential therapeutic options to rehabilitate patient, especially as influenced by extent of necessary surgical resection and previous radiation therapy.
    6. Provide available resources and supplies for voice restoration and pulmonary rehabilitation.
    7. Facilitate an opportunity to meet a patient who has previously undergone a laryngectomy, and/or connect patient and family members to peer support groups.
    8. Help set patient’s expectations for communication during hospitalization and identify a preferred method of communication immediately post op (e.g. boogie board, iPad, sign language etc). This can empower patients during the most acute stages of recovery.
    9. Explain all options available for alaryngeal voice rehabilitation, including electrolaryngeal speech, esophageal speech, and tracheoesophageal speech following placement of tracheoesophageal prosthesis (TEP).
  2. Postoperative rehabilitation.
    1. Establish early use of electrolarynx. Train patient on optimal placement of device, coordination of device with articulation, and adjustment of pitch, volume and tone of device.
    2. If primary TEP is placed, establish early use of TEP voice prosthesis.
    3. If secondary TEP is planned, assess voice outcomes with air-insufflation test, and educate patient on the benefits and burdens of TEP placement.
    4. Educate patient on stomal care issues, lifestyle alterations (i.e., swimming, small boat fishing).
    5. Educate patient on pulmonary health and rehabilitation, including the purpose of peri-stomal device and heat moister exchange (HME) filter.  
      • Changes in air temperature, air quality, and relative humidity may result in impaired ciliary activity, increased hypersecretory state, and decreased airway resistance.
    6. Common miscellaneous issues to manage:
      • loss of sense of smell.
      • tracheostomal secretions.
      • Lymphedema.
      • dysphagia.
      • difficulties with alaryngeal speech.
      • TEP assessments including sizing and fittings.
      • psychosocial adjustment to loss of “voicebox.”
References 
  1. Casper JK, Colton RH. Clinical manual for laryngectomy and head/neck cancer rehabilitation. San Diego, CA: Singular Publishing; 1993.
  2. Hilgers FJ, Ackerstaff AH, Aaronson NK, Schouwenburg PF, Van Zandwijk N. Physical and psychosocial consequences of total laryngectomy. Clinical otolaryngology & allied sciences. 1990;15;421-25.
  3. Zuur JK, Muller SH, de Jongh FH, van Zandwijk N, Hilger FJ. The physiological rationale of heat and moisture exchangers in post-laryngectomy pulmonary rehabilitation: a review. Eur Arch Otorhinolaryngol. 2006 Jan;263(1);1-8.

Imaging

Learning Objectives 
  1. Know that preoperative computed tomography (CT) scanning can indicate the extent of surgical resection necessary, and thus the prognosis for different types of post-laryngectomy speech rehabilitation.
  2. Understand that a modified barium swallow (MBS) is useful in the postoperative period to evaluate patients with dysphagia or failed/strained TEP speech. The MBS can guide the physician and speech pathologist as to the underlying cause of failure, such as stricture, tumor recurrence, or cricopharyngeal spasm. Fluoroscopic visualization with the MBS may help to identify any pharyngoesophageal segment spasm and strictures, and guide therapeutic intervention, such as botulinum toxin injection and esophageal dilations.
References 
  1. Zormeier MM, Meleca RJ, Simpson ML, et al. Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy. Otolaryngol Head Neck Surg. 1999;120:314-19.

Treatment

Learning Objectives 

Know the options available for post-laryngectomy speech rehabilitation and list the advantages and disadvantages of each option.

  1. Artificial larynx (electrolaryngeal speech): use of an electrical (battery-powered) device to create sound and allow for communication. Generally, two types of devices: one placed against the skin of the neck and the second type with an oral piece placed into the oral cavity.
    1. Advantages:
      • simple concept, immediately available postoperatively.
      • inexpensive.
      • always available as backup communication system.
      • no aspiration risks
    2. Disadvantages:
      • mechanical, robotlike voice.
      • must carry device so hands are working when speaking.
      • can be difficult to understand, particularly on telephone.
      • can be influenced by neck and/or facial swelling.
  2. Esophageal speech: the traditional technique for laryngectomy voice rehabilitation. Prior to 1980 it was the best option available. Esophageal speech essentially consists of various techniques (injection, swallow, inhalation) to produce air into the esophagus with subsequent vibration of the air column to produce speech.
    1. Advantages:
      • no surgical procedures necessary.
      • no mechanical device (hands-free phonation).
      • more organic sounding voice when compared with electrolarynx.
      • no aspiration risks
    2. Disadvantages:
      • difficult to learn, with success rates of only 30%-50%.
      • inadequate injected air volume (80-100 cc) limits ability for sustained speech.
      • limited voice with respect to duration, intensity, and pitch.
      • maximum phonation time averages 2 seconds (as compared with 12-15 seconds for TEP speech and 25 seconds in normal subjects).
      • voice may sound more “wet”
  3. Tracheoesophageal speech: Blom and Singer published their initial experience with the endoscopic creation of a tracheoesophageal fistula for post-laryngectomy speech rehabilitation in 1980. The tracheoesophageal fistula is maintained with a one-way silicone valve that allows air to be directed from the lungs into the upper esophagus. The air is then vibrated along the pharyngoesophageal tract to produce a voice. At this point in time the technique of tracheoesophageal speech is the gold standard for post-laryngectomy voice rehabilitation.
    1. Advantages:
      • lung-powered speech allows for longer duration of speech.
      • more closely approximates normal speech (in terms of fundamental frequency) than esophageal speech.
      • variety of prostheses with select cases using hands-free phonation.
    2. Disadvantages:
      • requires surgical procedure for placement of a secondary tracheoesophageal fistula.
      • need adequate stoma size.
      • need adequate patient manual dexterity to care for prosthesis and stoma.
      • prosthetic failure secondary to fungal colonization, and/or reflux
      • requires maintenance of prosthesis, risks for aspiration are present if prosthesis is not well maintained.
    3. Types of tracheoesophageal speech prosthetic devices.
      • Non-indwelling prosthesis (e.g low pressure/duck bill prosthesis):
        • classic type based on original design 
        • changed by patient every 2-3 days.
        • typically less problems with fungal colonization.
        • generally less expensive compared to in-dwelling prosthesis
      • In-dwelling (long-term) prosthesis:
        • changed by physician/speech pathologist on average ~2-3 months (Lewin, 2016)
        • changed more or less frequently as indicated
        • less daily maintenance.
        • requires larger puncture site.
        • higher incidence of fungal buildup and secondary prosthesis malfunction. Can be alleviated with selection of optimal TEP voice prosthesis (e.g.device with silver oxide which may reduce anti-fungal agents).
        • Prices are variable

Surgical Therapies

Learning Objectives 

Describe the techniques of TEP.

  1. Primary TEP: creation of tracheoesophageal fistula at the time of laryngectomy. Usually done in combination with cricopharyngeal myotomy or pharyngeal plexus neurectomy.
    1. Advantages:
      • simple procedure done at completion of laryngectomy.
      • provides alternate feeding route in early postoperative period via catheter placed into TEP. Alternatively the prosthesis can be placed at the time the puncture is made.
      • avoids need for second operative procedure.
    2. Disadvantages:
      • risk of oral-cutaneous fistula and impaired healing, especially in post-radiation setting.
      • immature stoma may contract, requiring secondary revision of TEP site.
      • puncture site may migrate to unfavorable position if flap reconstruction is used (rotational or free tissue) as flap healing takes place.
  2. Secondary TEP: creation of tracheoesophageal fistula some period of time after laryngectomy has healed and the patient has completed adjuvant therapy. Generally done under general anesthetic with the puncture of the posterior tracheostoma wall into the cervical esophagus and the placement of a standard sized prosthesis. The tracheoesophageal prosthesis may be sized and changed by a physician/speech pathologist post-operatively in clinic. Classically done via rigid esophagoscopy but several technical variations have been described, including use of the transnasal or transoral esophagoscope. Select cases can be done under local anesthesia.
    1. Advantages:
      • mature tracheostoma makes it easier to pick the optimal puncture site.
      • simple procedure done as an outpatient.
      • patient has adapted to care of tracheostoma.
    2. Disadvantages:
      • second operative procedure.
      • difficult to place in selected patients with kyphosis, limited neck mobility from radiation and prior surgery, bulky neopharyngeal flap reconstructions, etc.
  3. TEP speech after flap reconstruction.
    1. Many patients undergoing laryngectomy often require partial to total pharyngectomy for complete tumor extirpation. Partial to total pharyngectomy often necessitates reconstruction with a regional pedicled flap (pectoralis major) or a microvascular free flap (most commonly radial forearm flap or anterolateral thigh flap, less so often jejunal flap). Patients undergoing flap reconstruction can attain success with TEP speech albeit with a decreased subjective quality. 
    2. Most patients with jejunal free flap reconstruction tend to have a wet quality to the voice secondary to increased mucous production in the reconstructed segment.
    3. TEP voice outcomes with anterolateral thigh and radial forearm free flap reconstruction are superior to that of jejunal and rotational pectoralis flap reconstruction.
    4. There is no difference in voice outcome measurements (maximum sustained phonation time, fluency, intelligibility, syllable count) following reconstruction with anterolateral thigh and radial forearm free flaps
References 
  1. Blom ED, Singer MI, Hamaker RC. A prospective study of tracheoesophageal speech. Arch Otolaryngol Head Neck Surg. 1986;112:440-47.
  2. Brown DH, Evans PH. A simplified method of tracheoesophageal puncture for speech restoration. Laryngoscope. 1992;102:579-80.
  3. Cannon CR. Using an endotracheal tube in difficult secondary tracheoesophageal puncture: a novel technique. Otolaryngol Head Neck Surg. 2001;125:117-19.
  4. Deschler DG, Doherty ET, Reed CG, Singer MI. Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx. Otolaryngol Head Neck Surg. 1998;118:771-76.
  5. Diedrich WM. Anatomy and physiology of esophageal speech. In: Salom SJ, Mount KH, editors. Alaryngeal speech rehabilitation: for clinicians by clinicians. Austin, Texas: Pro-Ed Publishers; 1991.
  6. Fagan JJ, Lentin R, Oyarzabal MF, et al. Tracheoesophageal speech in a developing world community. Arch Otolaryngol Head Neck Surg. 2002;128:50-53.
  7. Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol. 1985;111:182-86.
  8. Haughey BH, Frederickson JM, Sessions DG, et al. Vibratory segment function after free flap reconstruction of the pharyngoesophagus. Laryngoscope. 1995;105:487-90.
  9. Heatley DG, Anderson AG. Tracheoesophageal puncture for speech rehabilitation after laryngectomy. Laryngoscope. 1992;102:581-82.
  10. Lewin JS, Baumgart LM, Barrow MP, Hutcheson KA. Device life of the trachealesophageal voice prosthesis revisited. JAMA Otolaryngology-Head and Neck Surgery. 2016;143(1);65-71.
  11. McAuliffe MJ, Ward EC, Bassett L, Perkins K. Functional speech outcomes after laryngectomy and pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg. 2000;126:705-709.
  12. Meeker SS, Lavertu P, Hicks DM. Successful tracheoesophageal puncture voice restoration in a patient with total glossectomy. Otolaryngol Head Neck Surg. 1997;116:113-15.
  13. Mendelsohn M, Morris M, Gallagher R. A comparative study of speech after total laryngectomy and total laryngopharngectomy. Arch Otolaryngol Head Neck Surg. 1993;116:508-10.
  14. Simpson CB, Postma GN, Stone RE, Ossoff RH. Speech outcomes after laryngeal cancer management. Otolaryngol Clin North Am. 1997;30:189-205.
  15. Singer MI, Blom ED, Hamaker RC. Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope. 1986;96:50-54.
  16. Jacobi I, Timmermans AJ, Hilgers FJ, et al. Voice quality and surgical detail in post-laryngectomy tracheoesophageal speakers. Eur Arch Otorhinolaryngol. 2016 Sep;273(9):2669-79.
  17. Revenaugh PC, Knott PD, Alam DS, et al. Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap. Laryngoscope. 2014 Feb;124(2):397-400.

Complications

Learning Objectives 

Recite the possible failures of tracheoesophageal prosthesis speech.

  1. The overall success rate of acquisition of TEP speech is approximately 80%-95%. Although factors related to radiation treatment and extend of surgery can influence the success of TE voice restoration, they have not shown to be statistically predictive of TEP device life (2016, Lewin). The majority of failures of TEP speech are caused by:
    1. pharyngoesophageal segment spasm: estimated in one study to cause ~ 80% of all TEP failures. An air insufflation test over 20 mm Hg predicts a high likelihood of TEP failure secondary to spasm. Treatment options include dilation, pharyngeal myotomy, and botulinum toxin injection. Pharyngeal plexus neurectomy and/or pharyngeal myotomy at the time of laryngectomy may prevent these sequelae. More recently botox has been utilized to successfully manage these patients. Therapy consists of the injection of botox (50 to 75 units) into two to three along the pharyngoesophageal segment.
    2. hypopharyngeal and esophageal stricture: this is particularly likely if the neopharynx was closed tightly after a partial laryngectomy. This represents an anatomic limitation and may respond to dilation. In many cases the patient will have moderate to severe dysphagia. Definitive treatment may include pharyngeal reconstruction with a regional or microvascular free flap.
    3. tracheostomal stenosis.
    4. recurrent tumor.
    5. Gastroesophageal reflux disease.
    6. Negative pressure in neopharynx/esophagus during swallowing or inhalation.
      • May be alleviated with change in TE prosthesis type (E.g. Provox ActiValve with magnets to prevent inadvertent valve opening when the user breathes or swallows)
  2. Other complications related to TEP speech.
    1. Surgical:
      • esophageal perforation.
      • false tract.
      • hemorrhage.
      • mucosal laceration.
    2. Early postsurgical (0-4 weeks):
      • cellulitis.
      • mediastinitis.
      • salivary leakage.
      • fistula closure.
      • sternoclavicular arthritis.
    3. Late postsurgical (> 4 weeks):
      • unplanned closure.
      • aspiration of prosthesis.
      • peristomal necrosis.
      • salivary leakage.
      • prosthesis failure (premature often secondary to fungal colonization).
      • tracheostomal stenosis.
      • esophageal stenosis.
      • peristomal granulation.
      • papilloma at stomal site.
References 
  1. Bastian RW, Muzaffar K. Endoscopic laser cricopharyngeal myotomy to salvage tracheoesophageal voice after total laryngectomy. Arch Otolaryngol Head Neck Surg. 2001;127:691-93.
  2. Cocuzza S, Bonfiglio M, Chiaramonte R, Serra A. Relationship between radiotherapy and gastroesophageal reflux disease in causing tracheoesophageal voice rehabilitation failure. Journal of Voice. 2014;28(2);245-249.
  3. Henley J, Souliere C. Tracheoesophageal speech failure in the laryngectomee: the role of the constrictor myotomy. Laryngoscope. 1986;96:1016-20.
  4. Izdebski K, Reed CG, Ross JC, Hilsinger RL. Problems with tracheoesophageal fistula voice restoration in totally laryngectomized patients. Arch Otolaryngol Head Neck Surg. 1994;120:840-45.
  5. Lewin JS, Baumgart LM, Barrow MP, Hutcheson KA. Device life of the trachealesophageal voice prosthesis revisited. JAMA Otolaryngology-Head and Neck Surgery. 2016;143(1);65-71.
  6. Lewin JS, Bishop-Leone JK, Forman AD, Diaz EM. Further experience with botox injection for tracheoesophageal speech failure. Head Neck Surg. 2001;23:456-60.
  7. Mehle ME, Lavertu P, Meeker SS, et al. Complications of secondary tracheoesophageal puncture: the Cleveland Clinic Foundation experience. Otolaryngol Head Neck Surg. 1992;106:189-92.
  8. Meleca RJ, Dworkin JP, Zormeier MM, et al. Videostroboscopy of the pharyngoesophageal segment in laryngectomy patients treated with botulinum toxin. Otolaryngol Head Neck Surg. 2000;123: 38-43.
  9. Verschuur HP, Gregor RT, Hilgers FJM, et al. The tracheostoma in relation to prosthetic voice rehabilitation. Laryngoscope. 1996;106:111-15. 
  10. Zormeier MM, Meleca RJ, Simpson ML, et al. Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy. Otolaryngol Head Neck Surg. 1999;120:314-19.

Review

Review Questions 
  1. Discuss the role of the speech language pathologist in the preoperative assessment and postoperative management of laryngectomy patients.
  2. List the advantages and disadvantages of the three most common techniques for post-laryngectomy speech rehabilitation.
  3. What is the difference between a primary TEP and a secondary TEP? What are the advantages and disadvantages of each?
  4. Can a TEP be performed in patients who have undergone flap reconstruction of the pharynx?
  5. What is the most common reason for failure to obtain tracheoesophageal prosthesis speech? What are the options to treat this failure?