Esophageal Speech Research Articles

Voice rehabilitation after total laryngectomy. The Göteborg experience

The main objective of laryngectomee rehabilitation is to restore the ability to communicate orally as well as possible. For a long time electrolarynx speech and oesophageal speech were the only available options for the laryngectomised patient. Since the introduction of surgical prosthetic voice restoration over a decade ago, several new alternatives have become available. The technique, which involves a voice prosthesis in a surgically created tracheo-oesophageal fistula, enables the patient to use pulmonary air for speech. This technique often means considerable improvement to the life quality of the laryngectomised patient.This paper presents a five-year-experience with surgical voice rehabilitation of laryngectomees in terms of patient selection, presurgical evaluation, and two types of low pressure voice prostheses (Blom-Singer, Provox). The importance of the rehabilitation team is stressed.

気管食道シャントによる発声機構

Tracheoesophageal (TE) shunt speech is a good method of vocal rehabilitation after total laryngectomy. The mechanism of TE shunt speech is described in this paper.Fluoroscopic and strobofiberscopic examinations showed two bulges in the pharyngoesophageal (PE) segment. The upper one was a posterior bulging at the orifice of the PE segment, located in C4-C6, and the lower one was a circular bulging, located in C5-C7. The upper one was the sound source, i.e., the neoglottis, of TE shunt speech. In most patients, anteroposterior and undulating movements were found in the neoglottis and complete neoglottis closure was achieved. Electromyographic and anatomical findings suggested that the neoglottis was formed by the thyropharyngeal muscle. Manometric examination showed that the lower bulge had an adverse effect on the vibrating status of the neoglottis.It was concluded that the neoglottis of TE shunt speech was formed by (1) the stenotic portion of the PE segment by muscle contraction and (2) mucosal vibration caused by expiratory airflow. This mechanism was like that of normal laryngeal phonation. The mechanism of vibration in esophageal speech was similar to that in TE shunt speech.The reasons for poor shunt phonation are: (1) phonation gap at the neoglottis, (2) random vibration of the neoglottis and (3) infraneoglottic stenosis. Surgical interventions were developed to improve (1) and (3) and good results were achieved clinically. Determination of the vibrating status of the neoglottis is the most important aspect in improving TE shunt speech.

Electromyography of cricopharyngeal muscles in patients with oesophageal speech.

Subject for the examination were 30 patients who during total laryngectomy had had two silver clips for haemostasis inserted into the cricopharyngeous muscle about 3 cm from the sewing place in the midline, facilitating the location of the muscle and the placing of a needle electrode. Twelve to 18 months after laryngectomy and phoniatric rehabilitation, electromyographic examinations were performed. Each EMG recording was evaluated as to amplitude, discharge frequency and time duration of muscle electric activity. EMG recordings made during deglutition and phonation proved dependences of cricopharyngeous muscle activity on quality of oesophageal voice production and higher activity of muscle during phonation than deglutition in patients who developed very good and good oesophageal speech.

喉頭摘出術２５症例の検討

A clinical study was conducted of 25 patients who underwent total laryngectomy in our hospital from 1987 to 1990.1) Of these 25 patients, 18 had laryngeal cancer, 3 had esophageal cancer, 3 had cancer of the hypopharynx and 1 had thyroid cancer.2) The primary diagnosis in 8 of the 18 patients with laryngeal cancer was T1 or T2, and these patients underwent total laryngectomy for surgical salvage because of initial radiation failure.3) Recurrence rates after initial radiation were 10.5% for T1 glottic cancer.4) Patterns of failure after total laryngectomy for laryngeal cancer were stomal recurrence in 3 patients, neck metastasis in 2 patients and distant metastasis in 1 patient.5) The patients with esophageal (IuIm) and thyroid cancer had total laryngectomy because of paratracheal invasion.6) A simple objective evaluation of esophageal voice is described in this paper.

The Psychosocial Impact of a Laryngectomy

Fifty-one laryngectomees completed a structured interview that yielded data on (1) demographics, (2) illness and surgery variables, (3) social networks and support, (4) preparation at the time of surgery, (5) rehabilitation of communication and related problems, (6) lifestyle changes, (7) identity changes, (8) quality of life, and (9) psychological adjustment, assessed on a series of standard scales. Gender, surgical variables, and the extent of the patient's social support predicted the use of esophageal speech. Preoperative visits by fellow laryngectomees predicted later quality of life. Poor psychological adjustment was related to the length of time spent in the hospital after surgery, dissatisfaction with social support, and changes in lifestyle after surgery. Changes in identity also were predictive of both psychological adjustment and quality of life. The authors discuss these results in the context of laryngectomees' rehabilitative and psychosocial needs.

Esophageal insufflation and videofluoroscopy for evaluation of esophageal speech in laryngectomy patients: clinical implications.

Esophageal speech proficiency in 75 laryngectomy patients was rated on a seven-point scale by a speech therapist. Radiologic evaluation of the reconstructed pharyngoesophageal (PE) region during swallowing, attempted phonation, and phonation, by means of esophageal insufflation and barium-enhanced videofluoroscopy and spot radiography revealed the PE segment to be normal in 13 patients and hypotonic in 21. Hypertonicity or spasm of the PE segment was detected in 28 patients. Three patients had a postoperative stricture. Speech in 24 patients was fluent at the time of assessment; the remainder had negligible speech. Correlation between esophageal speech fluency and response at insufflation was highly positive. Esophageal insufflation, when combined with radiologic assessment, provides a reproducible method for accurate evaluation of the PE transition zone. Videofluoroscopy allowed good visualization of tracheoesophageal dynamics. Results indicated anatomic factors in the reconstructed PE region to profoundly affect the acquisition of esophageal speech.

Oesophageal speech after laryngectomy: a study of possible influencing factors

52 patients with laryngeal carcinoma were studied before and after laryngectomy with regard to what factors might influence the development of oesophageal speech. The investigations consisted of oesophageal manometry, a follow-up interview and a review of surgical approaches and radiotherapy. 43% of the patients achieved socially acceptable oesophageal speech, 22% were able to speak single words, and 35% had no oesophageal speech at all. 61% had post-operative dysphagia. Age was the only factor which significantly correlated to intelligible speech. The intraoesophageal pressure during oesophageal phonation exceeded in all cases the low PO-HPZ pressure after operation. The extension of surgery and radiation field, severity of dysphagia, alcohol and smoking habits, and mental condition did not differ between the 3 groups of oesophageal speech. It was concluded that the rather complicated process of acquiring oesophageal speech is much more dependent on learning ability which decreases with age than on various kinds of motor dysfunction after laryngectomy.

Sprachverständlichkeit und psychosoziale Anpassung bei verschiedenen Stimmrehabilitationsmethoden nach Laryngektomie*

Intelligibility and psychosocial adjustment are measured by the PLTT (Post-Laryngectomy-Telephone-Test) and a newly developed questionnaire (FPAL). 110 male patients with total or partial laryngectomies are tested. Three different groups are compared with each other: laryngectomees with voice prostheses, laryngectomees with oesophageal voice or artificial larynx, and patients with partial laryngectomies. As was to be expected, intelligibility (single words and sentences) was best in patients with partial laryngectomies. The intelligibility of the laryngectomees with voice prostheses is significantly higher than the intelligibility of patients with oesophageal voice or artificial larynx. There was no difference between the groups with regard to the subjective assessment of intelligibility in relation to various communication partners. Partial laryngectomies have the lowest negative impact on the social and psychological situation of the patients. Laryngectomees, however, are more lonely, indicate more psychological stress in social interactions, and have a less positive evaluation of their life. Statistical analyses reveal no difference in psychosocial adjustment between laryngectomees with voice prostheses, oesophageal voice and artificial larynges.

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy was studied in 42 patients. A significant reduction was found in the mean daily frequency of sputum production, forced expectoration in order to clean the airway and stoma cleaning after use of the HME for 6 weeks. Symptoms of fatigue and malaise decreased significantly, while social contact improved. Patients using oesophageal speech or an electrolarynx benefited more than patients using a voice prosthesis. The findings indicate that respiratory problems after total laryngectomy can be reduced significantly with the use of a device with heat and moisture exchanging properties. In turn, reduction of respiratory symptoms results in an improved quality of life.

Italian Experience of Voice Restoration after Laryngectomy with Tracheoesophageal Puncture

This report concerns 102 cases of tracheoesophageal puncture performed as a means of secondary voice restoration after total laryngectomy, in 70 patients proving unable to learn esophageal speech and as a treatment of choice in a further 32 cases. Complications arose in 21 cases but were generally minor and could be overcome. Results were favorable in 45 of 70 and 29 of 32 cases, respectively. The method was considered effective, particularly when supported by the patient's determination to learn a verbal communication method.

喉摘後の音声再建-TEシャントの新しい展開-

During the past 14 years the tracheoesophageal (TE) shunt capability has been performed on 207 patients for primary voice restoration following total laryngectomy, and 172 patients (83%) retained fluent and intelligible speech with TE shunt. On the basis of successful results of postlaryngectomy speech with the TE shunt operation, the acquirement of both TE and esophageal speech, the primary tracheojejunal (TJ) shunt operation following pharyngolaryngoesophagectomy and the TE puncture operation for primary or secondary voice restoration reported by Singer and Blom were performed.Out of 172 patients who had TE speech, 8 obtained voice capability with esophageal speech and the vibratory source during phonation with esophageal voice was located at the hypopharynx as well as with TE speech. These indicated that the TE speakers could acquire the esophageal voice.The primary TJ shunt operation was performed on 6 patients for voice restoration following pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. A fistula was created between the membraneous tracheal flap and the lower part of the transplanted jejunum. The membraneous part of the trachea was tubed to construct the TJ shunt. Out of 6 patients, 5 retained phonatory function. No leakage was seen at all during deglutition and a swallowing function was obtained in all 6 patients.A total of 29 patients underwent the TE puncture operation. Seventeen and twelve were performed for primary and secondary voice restoration after total laryngectomy, respectively. Out of 29 patients, 24 acquired fluent speech with voice prosthesis.

空腸遊離移植による下咽頭頚部食道再建術の評価

Forty-four patients with cancer in the hypopharynx and cervical esophagus underwent pharyngoesophageal reconstruction with a free jejunal graft after total removal of a tumor combined with resection of the circumferential tissues. The graft survival rate was 93.2% (41 of 44). Postoperative complications occurred in 16 patients (36.4%), which included postoperative death in one (2.3%), graft necrosis in 3 (6.8%), fistula formation in 4 (9.1%) and graft stricture in 3 (6.8%). All 3 cases of graft necrosis underwent successfully reimplantation. The mean interval time was 20.9 days until oral intake was possible. Thirty-two of 42 patients (76.2%) were able to take usual food. Esophageal speech was limited in the selected cases by this procedure. A cumulative survival rate of 5 years was 40.6% in this series. This method of reconstruction should be advocated as one of relatively safe and reliable procedures for patients with hypopharyngeal and cervical esophageal cancer.

Tongue dynamics during speech and swallowing in laryngectomees—an ultrasound demonstration

Diagnostic ultrasound was employed to visualize the activity of the tongue, the floor of the mouth, and the hyoid in normal and laryngectomized individuals. Differences in articulatory and masticatory dynamics were noted between groups and among alaryngeal speech modes. Swallowing was seen to be less efficient in some of the laryngectomees. Abnormal activity in the floor of the mouth and the hyoid was observed in all laryngectomized talkers, especially during conventional esophageal speech.

下咽頭癌に対する一期的頚部食道および音声再建術

Total laryngopharyngectomy is common in the treatment for most of hypopharyngeal cancer. Reconstructive surgery was performed byusing of a pedicled pectoralis major myocutaneous flap to the two male patients in our hospital. Additional operation of making a tracheoesophageal shunt was performed at the same time for the purpose of voice restora tion. Both of the two patients speak well in comparatively short period after the operation. It is well known that acquirement of esophageal voice after total laryngopharyngectomy is very difficult. Therefore, it is very significant to perform laryngopharyngectomy and reconstructive surgery for voice restoration at the same time.

Back to the Beginning: Nursing Case Management of the Older Client with Alaryngeal Speech Needs

A laryngectomy is a devastating event with many responses, the most dramatic of which is the loss of normal voice production. The three most common methods of alaryngeal speech are esophageal speech, artificial larynx, and tracheoesophageal puncture. A nurse case manager who functions as coordinator of formal and informal support systems will help ensure the outcome of satisfactory alaryngeal speech for older laryngectomees.

Improving alaryngeal speech intelligibility

Laryngectomized patients using esophageal speech or an electronic artificial larynx have difficulty producing correct voicing contrasts between homorganic consonants. Voicing of a voiceless consonant is the most frequent listener misidentification. A therapy technique is described that emphasizes “pushing harder” on voiceless consonants to improve the intelligibility of alaryngeal speakers. Laryngectomy speech therapy programs should focus first on the production of voiceless consonants before attempting to effect voicing.

Surgical voice restoration in alaryngeal patients

Blom Singer’s technique of surgical voice restoration in laryngectomized patient is a highly successful method of speech rehabilitation. This technique has been further simplified and adopted in 20 of our cases with 90% success in acquiring speech. Though primary tracheo-oesophageal puncture (TEP) is a good attempt of rehabilitation, we feel that post-operative healing and fibrosis will displace the puncture site causing difficulty to insert the prosthesis by the patient. The high success rate with secondary TEP makes us believe that it is a better technique to be adopted. Further, plan for secondary TEP will give enough time to the patients to develop oesophageal speech, if they are capable of.

Stimmrehabilitation nach totaler Laryngektomie: Mikrovaskuläre Larynxersatzplastik (Laryngoplastik) statt Stimmprothese

Since the introduction of the so-called voice prostheses tracheoesophageal puncture is currently the most widely used surgical procedure for vocal rehabilitation after total laryngectomy. The voice prosthesis renders possible a reliably reproducible voice, which is superior (period of uninterrupted sound production, basal frequency, voice intensity) to the other techniques (esophageal speech, external vibrators, other surgical reconstructive measures), but has the following disadvantages: high initial phonation pressure, formation of granulation tissue around the voice shunt, blockage or leakage of the prosthesis or the voice shunt, displacement of the prosthesis, spontaneous occlusion when the prosthesis is accidentally removed, overtaxing the patients who have difficulties in replacing and cleaning the prosthesis. As an alternative new surgical technique a substitute larynx tube (laryngoplasty) was formed by a microvascular anastomotic forearm flap and connected to the trachea and pharynx in ten patients with extensive (T3-T4) laryngohypopharyngeal carcinoma. All ten patients developed a voice comparable with those of patients who have a voice prosthesis (frequency, voice intensity, period of uninterrupted sound production). An advantage of this graft over the voice prosthesis is that the phonation pressure required is low. While they were still in hospital eight patients learned to speak without using their hands by means of a tracheostomal valve. So far (six months postoperative) this surgical procedure has proved to be a practicable surgical alternative to a voice prosthesis.

振動部からみた喉摘後の代用音声 文献的考察

We reviewed the present status of our understanding of the various methods of vocal rehabilitation after total laryngectomy with respect to the vibrating portion.In a pneumolarynx with a rubber membrane, the vocal intensity and the phonating duration can be controlled easily, but it is difficult, although not impossible, to control the vocal pitch. An electrolarynx produces monotonous and noisy sound during phonation, and its vocal control ability is poor at present.In tracheoesophageal shunt speech and injected esophageal speech, the mucosal membrane vibrates to produce sound at the so called “neoglottis” level. Many authors have stressed the importance of a proper tonicity of the pharyngo-esophageal segment for good voice production. However, there is no conclusive evidence that the vibrating status correlates with speech skill. Voice quality in both speaking methods is a little poorer than in tracheopharyngeal speech, and injected esophageal speech has the added disadvantage of the short duration of phonation.From the viewpoints of voice quality, vocal control and articulation, tracheopharyngeal shunt speech is considered to be the best method at present, even though it is difficult to control the vocal pitch.We suppose that the ability to control the vocal pitch would provide one of the most important improvements for vocal rehabilitation following total laryngectomy.

食道音声の客観的評価法 母音の音質を対象として

A method of objectively evaluating the voice quality of esophageal speech is described in this paper. We used the vowel/a/ of 27 esophageal speakers as a voice sample.As judged from perceptual impressions, the voice samples were ranked by the paired comparison method. Acoustic parameters such as maximum phonation time, fluctuation of intensity and periodicity of vibration were examined. We compared the perceptual ranking and those three parameters by non-parametric statistical methods. There was a significant correlation between the last two parameters and the perceptual ranking. Low fluctuation (less than 10dB in 500msec from the voice on set) and periodic vibration were assumed to be a standard for the good voice quality of esophageal speech.