Laryngectomized Subjects Research Articles

Possibility of deglutition function after laryngectomy

Objective: Surgical procedures on the larynx lead to some swallowing disorders of that may occur at any time during the postoperative period and can be present in all phases of swallowing. The aim of the study was to explore the prevalence of dysphagia after laryngectomy, the correlation and difference in dysphagia symptoms depending on the extent of the surgery. Methods: The study included 40 laryngectomized subjects of both sexes, median age 63.50 years. Data were collected by a survey of respondents and questionnaire structured from three sets of closed-ended questions. The data were statistically processed in the statistical program SPSS (version 16.0, SPSS Inc., Chicago, IL, USA). Results: The incidence of dysphagia is more often after partial laryngectomy with statistically significant differences in certain symptoms. A positive and statistically significant correlation was found between swallowing disorders and the consequences of oncological treatments. A negative and statistically significant correlation was found between swallowing disorders and the type of complications. Conclusion: The results show that patients who had surgery have varying degrees of swallowing disorders. The ability to identify symptoms of dysphagia becomes increasingly important when developing appropriate interventions for this subgroup of laryngeal cancer patients.

Discrepancies of SARS-CoV-2 testing results among patients with total laryngectomy.

PurposePrevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is obtained with nasopharyngeal swabs. By the way, there is no consensus regarding sampling in totally laryngectomized subjects (who thus breathe directly by the tracheostomy and, theoretically, may be infected in the trachea). The aim of this study is to evaluate possible differences between swab results in the trachea and in the nasopharynx of this category of patients. MethodsA retrospective chart review was performed in April 2021 among patients who previously had been operated on for total laryngectomy and who underwent swabs for SARS-CoV-2 research in 3 health-care centers in Northern–Eastern Italy. Data regarding the site of swabbing (trachea or nasopharynx) were analyzed. A comprehensive review of the literature regarding the same topic was then performed.ResultsA total of 25 totally laryngectomized subjects underwent swabs. Among them, 5 tested positive in the trachea (1) and in the nasopharynx (4). According to the literature review, 4 more subjects tested positive in the trachea (1) and in the nasopharynx (3). Data were overall divergent and no statistically significant correlations emerged between results of the tests performed in the two sites.ConclusionDue to these discrepancies, both tracheal and nasopharyngeal swabs are recommended in these kinds of patients, to obtain a reliable test and to avoid false negatives.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00405-021-07203-8.

Influence of position and angulation of a voice prosthesis on the aerodynamics of the pseudo-glottis

The use of a tracheoesophageal valve, also known as voice prosthesis, is currently the most appealing solution for recovering the ability to speak in subjects who have undergone a total laryngectomy. The prosthesis allows the passage of air from the trachea to the esophagus, thereby promoting the flow-induced vibration of the subject’s pharyngoesophageal segment. In turn, the pharyngoesophageal segment modulates the air flow from the lungs into the subject’s vocal tract, acting as an alternative source of acoustic energy to generate voice. The vibration of the pharyngoesophageal segment will likely depend on the aerodynamic forces acting on its wall, which will be defined by the flow characteristics downstream from the valve’s outlet. Previous works have investigated the pressure drop across different prosthesis designs with both in-vitro and in-vivo experiments. Nevertheless, the aerodynamic aspects of the flow in the tracheoesophageal region have only been investigated experimentally in an idealized geometry. This work investigates the influence of the prosthesis position on the aerodynamic behavior of the pharyngoesophageal segment in terms of wall pressure distribution and characteristics of the velocity field. The investigations were carried out with a static model of the tracheoesophageal region based on the finite volume method and a Reynolds-averaged Navier–Stokes solver. The geometry of the system was based on computed tomography images obtained from laryngectomized subjects during phonation at different voice registers and included the geometry of a commercially available voice prosthesis. The results suggest that the position and angulation of the voice prosthesis have a minor influence on the pressure loss along the tracheoesophageal segment and on the pressure distribution on the pharyngoesophageal segment’s wall.

Multicenter randomized crossover trial evaluating the provox luna in laryngectomized subjects

ObjectivesThe aim of this study was to compare the relative compliance and the dermatological and pulmonary outcomes when the Provox Luna system (Atos Medical, Malmö, Sweden) is added during the night to the usual tracheastoma care of laryngectomized subjects.MethodsThis was a multicenter randomized crossover trial conducted in the Netherlands Cancer Institute, Erasmus Medical Center, and Maastricht University Medical Center in The Netherlands. The study included 46 laryngectomized subjects with prior heat and moisture exchanger (HME) and adhesive experience.ResultsA significant improvement in the number of compliant individuals was found: Luna: n = 43 of 45 (96%); usual care: n = 35 of 46 (76%), P = 0.02. The Luna period was associated with longer intervals of daily HME use (Luna 23.2 hours [range: 15.6–24.0 hours], usual care [UC]: 21.5 hours [range: 6.0–24.0 hours], P = 0.003) and an increased frequency of skin improvement overnight (Luna 3.9 days [standard deviation (SD)]: 7.0 days), Usual Care: 8.1 days ([SD: 10.8 days], P = 0.008). Fifty‐six percent (n = 26) of participants wanted to continue using the Provox Luna system at the conclusion of the study.ConclusionAn improvement in compliance and skin recovery overnight was observed when the Provox Luna was added to the usual adhesive and HME use. Therefore, there is utility in supplementing the usual post‐total laryngectomy care with the Provox Luna system at night, particularly in the setting of compliance concerns and in subjects who desire dermatological relief overnight.Level of Evidence1b Laryngoscope, 129:2354–2360, 2019

Reconstruction of Mandarin Electrolaryngeal Fricatives With Hybrid Noise Source

The Mandarin electrolaryngeal (EL) speech is suffering from severe fricative confusion due to improper EL source in EL speech production and abnormal physiological structure of vocal tract in the laryngectomized condition. To reduce the fricative confusions, this paper proposes a hybrid noise source by combining the typical natural fricative sources and compensation sources that consider the acoustic defects in the frequency domain caused by the truncated vocal tract and abnormal source location in EL speech production. All parameters of the model are fricative-specific and the parameters of the compensation sources are determined by analyzing the vocal tract transfer functions before and after the laryngectomy. All five Mandarin fricatives are produced by laryngectomized subjects with an experimental EL system loading the hybrid noise source and the wideband noise source. The acoustic and perceptual features of these reconstructed EL fricatives are analyzed and evaluated by comparing with the conventional EL fricatives and normal fricatives. The results indicate that the hybrid noise source successfully improves the acoustic properties of the EL fricatives by forming better spectral shapes, raising the frequencies of average energy concentration, and producing better spectral skewness and kurtosis. Finally, due to these improvements of acoustic properties, the hybrid noise sources achieve much larger intelligibility for EL fricatives than the wideband noise source and the conventional EL source. Thus, the hybrid noise source is an effective, feasible, and promising method of reducing the severe fricative confusions and improving the intelligibility of EL speech.

Expressões faciais emocionais em indivíduos laringectomizados totais

Objetivos: verificar se existem diferenças no grau de inteligibilidade de indivíduos laringectomizados totais, que utilizam diferentes formas de comunicação oral (fala murmurada, laringe eletrônica, voz esofágica e voz traqueoesofágica); verificar se existem diferenças na expressão facial (número e duração de movimentos faciais) de indivíduos laringectomizados totais, que utilizam diferentes formas de comunicação oral, durante tarefas de discurso espontâneo alegre e triste e, ainda, verificar se existem diferenças estatisticamente significantes na expressão facial (número e duração de movimentos faciais) de indivíduos com elevada e baixa inteligibilidade durante tarefas de discurso espontâneo alegre e triste. Métodos: tratou-se de um estudo exploratório, comparativo de base descritiva e de metodologia transversal, sendo que se constituiu um grupo de treze indivíduos laringectomizados totais. Os indivíduos foram filmados durante as duas tarefas de discurso espontâneo alegre e triste e avaliados quanto à inteligibilidade do discurso por pessoas sem patologia da comunicação, sendo que a análise da expressão facial foi realizada com recurso ao Sistema de Codificação de Ação Facial. A análise descritiva e inferencial foi efetuada com recurso ao SPSS19 por meio da aplicação dos testes Mann-Whitney e Kruskall-Wallis.Resultados: verificou-se que os diferentes tipos de comunicação apresentam diferentes graus de inteligibilidade no discurso e que descritivamente existem diferenças na expressão facial dos indivíduos laringectomizados totais durante o discurso espontâneo alegre e triste . Verifica-se ainda diferenças estatisticamente significantesna expressão facial nos grupos de baixa e elevada inteligibilidade, na duração média de cada unidade dos olhos no discurso espontâneo triste (p-valor=0,01).Conclusão: verificou-se que nos dois contextos emocionais, os laringectomizados, independentemente da sua forma comunicativa, são menos expressivos facialmente do que os normofalantes.

Effects of direct cedrol inhalation into the lower airway on brain hemodynamics in totally laryngectomized subjects

A previous study reported that when cedrol (odorant) is inhaled directly through the lower airway of the trachea, it decreases the sympathetic nervous activity and blood pressure in totally laryngectomized subjects (Umeno et al., 2008). In the present study, totally laryngectomized subjects were asked to inhale cedrol into the lower airway in the same manner and its effects on regional cerebral blood flow (rCBF) were analyzed. Our results indicated that hippocampal rCBF was bilaterally increased during cedrol inhalation as compared to the inhalation of blank air. These results provide the first evidence that an odorant in the lower airway modulates autonomic activity via the central nervous system.

Endotracheal temperature and humidity measurements in laryngectomized patients: intra- and inter-patient variability

This study assesses intra- and inter-patient variability in endotracheal climate (temperature and humidity) and effects of heat and moister exchangers (HME) in 16 laryngectomized individuals, measured repeatedly (N = 47). Inhalation Breath Length (IBL) was 1.35 s without HME and 1.05 s with HME (P < 0.0001). With HME, end-inspiratory (minimum) humidity values increased 5.8 mg H2O/L (P < 0.0001) and minimum temperature values decreased 1.6°C (P < 0.0001). For the temperature and humidity minimums, the inter-patient variability was much smaller than the short- and long-term intra-patient variability. For exhalation breath length and full breath length, the opposite was the case. Conclusions: (1) Because inter-patient variability is smaller than intra-patient variability, investigating endotracheal climate in a limited number of laryngectomized subjects is justified, provided repeated measurements per patient are accomplished; (2) main contributor to intra-patient variability is the positioning of the catheter tip in the trachea; (3) an HME leads to a shortened IBL which enhances the HME effect.

Measuring the neck frequency response function of laryngectomy patients: implications for the design of electrolarynx devices.

Measurements of the neck frequency response function (NFRF), defined as the ratio of the spectrum of the estimated volume velocity that excites the vocal tract to the spectrum of the acceleration delivered to the neck wall, were made at three different positions on the necks of nine laryngectomized subjects (five males and four females) and four normal laryngeal speakers (two males and two females). A minishaker driven by broadband noise provided excitation to the necks of subjects as they configured their vocal tracts to mimic the production of the vowels /a/, /ae/, and /I/. The sound pressure at the lips was measured with a microphone and an impedance head mounted on the shaker measured the acceleration. The neck wall passed low-frequency sound energy better than high-frequency sound energy, and thus the NFRF was accurately modeled as a low-pass filter. The NFRFs of the different subject groups (female laryngeal, male laryngeal speakers, laryngectomized males, and laryngectomized females) differed from each other in terms of corner frequency and gain, with both types of male subjects presenting NFRFs with larger overall gains. In addition, there was a notable amount of intersubject variability within groups. Because the NFRF is an estimate of how sound energy passes through the neck wall, these results should aid in the design of improved neck-type electrolarynx devices.

Acoustical analysis of Spanish vowels produced by laryngectomized subjects.

The purpose of this study was to describe the acoustic characteristics of Spanish vowels in subjects who had undergone a total laryngectomy and to compare the results with those obtained in a control group of subjects who spoke normally. Our results are discussed in relation to those obtained in previous studies with English-speaking laryngectomized patients. The comparison between English and Spanish, which diFfer widely in the size of their vowel inventories, will help us to determine specific or universal vowel production characteristics in these patients. Our second objective was to relate the acoustic properties of these vowels to the perceptual data obtained in our previous work (J. L. Miralles & T. Cervera, 1995). In that study, results indicated that vowels produced by alaryngeal speakers were well perceived in word context. Vowels were produced in CVCV word context by two groups of patients who had undergone laryngectomy: tracheoesophageal speakers (TES) and esophageal speakers. In addition a control group of normal talkers was included. Audio recordings of 24 Spanish words produced by each speaker were analyzed using CSL (Kay Elemetrics). Results showed that F1, F2, and vowel duration of alaryngeal speakers differ significantly from normal values. In general, laryngectomized patients produce vowels with higher formant frequencies and longer durations than the group of laryngeal subjects. Thus, the data indicate modifications either in the frequency or temporal domain, following the same tendency found in previous studies with English-speaking laryngectomized speakers.

Inspiratory coactivation of the genioglossus enlarges retroglossal space in laryngectomized humans

To investigate the relationship between the electrical activity of the genioglossus (GG-EMG) and associated tongue movement, seven laryngectomized subjects breathing through a tracheal stoma (without pressure or flow change in the upper airway) were studied in the supine position. Tongue movement, with the use of lateral fluoroscopy, and GG-EMG expressed as a percentage of maximum voluntary genioglossal activation were monitored simultaneously during 1) spontaneous inspiration (SI), 2) resistive loaded inspiration (LI), and 3) rapid inspiration (RI). Tongue position during each maneuver was compared with its position during spontaneous expiration. Peak GG-EMG during the three maneuvers was significantly different from each other (SI: 5.4 +/- 1.6, LI: 11.9 +/- 1.8, and RI: 51.6 +/- 9.4 (SE) %, respectively). Associated forward movement of the posterior aspect of the tongue was minimum during SI; however, significant movement was observed during LI, and this was increased during RI. Significant covariance existed between peak GG-EMG and this movement. Genioglossal coactivation with inspiration enlarges the glossopharyngeal airway, particularly in its caudal part. In subjects with intact upper airways, this activation may protect or enhance upper airway patency in an effort-dependent manner.

Effect on breathing of raising end-expiratory lung volume in sleeping laryngectomized man

In animals, tonic vagal activity from lung receptors provides a means by which changes in end-expiratory lung volume can influence respiratory timing. We wished to examine whether increasing the end-expiratory lung volume within the tidal volume range had a similar effect in man. In order to minimize behavioral influences on breathing, the study was performed in subjects during deep non-rapid eye movement sleep. Five laryngectomized subjects were chosen for the study since their permanent tracheal stomata allow simple, airtight connection to respiratory apparatus and avoided problems with glottic closure. During EEG-documented sleep, end-expiratory volume was increased by up to 350 ml with the addition of expiratory threshold loads of 1 to 10 cm H 2O. End-expiratory volume increased linearly with expiratory pressure. Inspiratory and expiratory times (T I and T E) were not affected by increases in end-expiratory volume. Tidal volume (V T) was decreased such that end-inspiratory volume remained unchanged. The decrease in V T may result from a reduction in inspiratory muscle efficiency at a higher lung volume. The results of the study provide no evidence that tonic vagal afferent information from the lungs is important in controlling respiratory rhythm within the tidal volume range in man when behavioral control of breathing is minimized.

Respiration during exercise in conscious laryngectomized humans

We compared respiratory patterning at rest and during steady cycle exercise at work rates of 30, 60, and 90 W in 7 male chronically laryngectomized subjects and 13 normal controls. Breathing was measured with a pneumotachograph and end-tidal PCO2 by mass spectrometer. Inspired air was humidified and enriched to 35% O2. Peak flow, volume, and times for the inspiratory and expiratory half cycles, time for expiratory flow, minute ventilation, and mean inspiratory flow were computer averaged over at least 40 breaths at rest and during the last 2 min of 5-min periods at each work rate. During the transition from rest to exercise and with increasing work rate in both groups, there was an increase in respiratory rate and depth with selective and progressive shortening of expiratory time; these responses were not significantly different between the two groups, but there was a suggestion that respiratory "drive" as quantitated by mean inspiratory flow may limit in the laryngectomized subjects at high work rates. Time for expiratory flow increased on transition from rest to exercise and then decreased in both groups as the work rate increased; it was shorter in the laryngectomy than control group at all levels. In the laryngectomized subjects there was significantly more breath-by-breath scatter in some variables at rest, but there was no difference during exercise. It is concluded that chronic removal of the larynx and upper airways in mildly hyperoxic conscious humans has only subtle and, therefore, functionally insignificant effects on breathing during moderate exercise. Evidence is provided that the upper airways can modulate expiratory flow but not expiratory time during exercise.

The effect of lung inflation on breathing in man during wakefulness and sleep

To determine whether the Hering-Breuer inflation reflex could be demonstrated in the presence and absence of behavioral influences on breathing, lung inflation was performed via the tracheal stoma in eleven laryngectomized subjects: seen seated at rest with their eyes closed and six recumbent during their deepest non-rapid eye movement sleep. Laryngectomized subjects were chosen for study since their permanent tracheal stoma and absence of a glottis abolisehd the sensation of inflation in the upper airways, avoided problems with glottic closure and allowed simple, airtight connection to respiratory apparatus. At rest, awake, inflation volumes of 500–3050 ml caused no reproducible apnea. During EEG-documented sleep, the inflation reflex was tested on 75 occasions using inflation volumes of 540–2100 ml. On the 66 occasions not associated with subject arousal inflation exceeding approximately 1 L produced apnea terminated by inspiration; greater volumes gave longer apneas. At the end of the study the subjects were woken and retested; no reproducible apnea was found. We conclude that the Hering-Breuer inflation reflex can be demonstrated above the resting tidal volume range in adult man in the absence of the behavioral control breathing.

Effect of tracheoesophageal “puncture” on postlaryngectomy speech rehabilitation

This article examines the problems in assessing the proliferation of devices that have emerged internationally in the field of post-laryngectomy voice restoration. Success or failure of the procedure will certainly depend on the subjects chosen and the device(s) used. The selection of potential subjects may be greatly improved by using the classification we have evolved from analyzing videofluoroscopic studies of over 200 laryngectomees. This classification is currently being validated by undertaking pressure and acoustic measures in existing laryngectomized subjects. These results are discussed in the text.

Influence of upper airway sensory receptors on respiratory muscle activation in humans.

We reasoned that neural information from upper airway (UA) sensory receptors could influence the relationship between UA and diaphragmatic neuromuscular responses to hypercapnia. In this study, the electromyographic (EMG) activities of the alae nasi (AN), genioglossus (GG), and chest wall (CW) or diaphragm (Di) to ventilatory loading were assessed in six laryngectomized, tracheostomized human subjects and in six subjects breathing with an intact UA before and after topical UA anesthesia. The EMG activities of the UA and thoracic muscles increased at similar rates with increasing hypercapnia in normal subjects, in subjects whose upper airways were anesthetized, and in laryngectomized subjects breathing with a cervical tracheostomy. Furthermore, in the laryngectomized subjects, respiratory muscle EMG activation increased with resistive inspiratory loading (15 cmH2O X l-1 X s) applied at the level of a cervical tracheostomy. At an average expired CO2 fraction of 7.0%, resistive loading resulted in a 93 +/- 26.3% (SE) increase in peak AN EMG activity, a 39 +/- 2.0% increase in peak GG EMG activity, and a 43.2 +/- 16.5% increase in peak CW (Di) EMG activity compared with control values. We conclude that the ventilatory responses of the UA and thoracic muscles to ventilatory loading are not substantially influenced by laryngectomy or UA anesthesia.

Electrolaryngeal Speech Produced by Laryngectomized Subjects

The purpose of this study was to investigate the perceptual confusions individuals experience while listening to the speech of laryngectomized persons who used electrolarynges. Six talkers generated speech samples using two different models of electrolarynges. Intelligibility was evaluated from phonetic transcriptions of the speech samples. Confusion matrices were generated from the transcriptions. Talkers varied considerably in their intelligibility, but there was little difference in intelligibility for a given talker using either model of electrolarynx. The perceptual confusions revealed that most errors occurred on the voicing feature.

Perception of Intonational Contrasts in Alaryngeal Speech

The achievement of intonational contrasts by 4 normal and 16 laryngectomized speakers was assessed in this project. The laryngectomized subjects represented four clinical subgroups of alaryngeal speech: esophageal, tracheoesophageal, Western Electric #5 electrolarynx, and Servox electrolarynx. High-quality tape recordings of each subject's productions of two pairs of sentences (Bev loves Bob) spoken in statement and question from were presented to 40 listeners for evaluation using a two-interval-alternative-forced-choice procedure. Intonational contrasts were achieved in a highly effective manner by the normal, esophageal, and tracheoesophageal speakers. In contrast, users of electronic artificial larynges were generally unable to achieve these intonational distinctions except for one user of the Western Electric #5 electrolarynx.

Electroglottographic studies of Staffieri neoglottis.

Among several methods of surgical restoration of voice which were introduced in the last two decades, the one of Staffieri has so far been most successful, though perfection with this technique still remains to be achieved. Question has always been raised as to the nature of function of the neoglottis in the production of voice in these patients. An attempt has been made to study this function with the aid of electroglottography. Results show that the neoglottis functions in some ways similar to the normal human glottis, and as the source of vibrations in these laryngectomized subjects.

Tongue strength: Part II: In artificial alaryngeal speech

Tongue strength does not appear to be reduced in proficient esophageal speakers. However, no data exist on tongue strength for laryngectomized subjects who have not developed esophageal speech. Anterior and lateral tongue strength measures were obtained from 13 laryngectomized subjects who used an artificial larynx and 15 normal subjects by means of a pressure transducer and recording device. The results indicated that laryngectomized subjects had significantly weaker tongues in two of three directions measured. It was concluded that laryngectomy may affect tongue strength, but that the method of alaryngeal speech utilized postoperatively influences the return to normal.