Surgical Voice Rehabilitation Research Articles

Autologous Fat Augmentation in Post Type III Cordectomy Patients.

Neocord formation after Type III cordectomy is insufficient for complete glottic closure due to scarring and soft tissue deficit. This study evaluates the role of autologous fat injection (AFI) in phonosurgical management of patients who have previously undergone Type III cordectomy for early glottic cancer. Data was collected from hospital records of patients who underwent AFI after previously undergoing Type III cordectomy. A minimum duration of 6months post-cordectomy was maintained before fat injection. Trans-oral injection was performed at a single site. Pre-operative voice evaluation was done using VHI, GRBAS scale and MDVP software. Post-operative evaluation was done at 6weeks. 21 out of 62 post-Type III cordectomy patients chose to undergo fat augmentation and were included in the study. A comparison of pre-operative and 6months post-operative AFI voice analysis showed a significant improvement in VHI, all parameters of GRBAS scale, and improvement in Jitter, Shimmer, SPI and NHR. There was a decrease in fundamental frequency but this was not statistically significant. AFI is an effective procedure for surgical voice rehabilitation of patients who have undergone Type III cordectomy for early laryngeal cancer.

Surgical voice rehabilitation performed by means of voice prosthesis post laryngectomy

Introduction. In 1972, in Poland, Professor Erwin Mozolewski presented a pioneering thesis concerning the creation of intubated voice fistula in a group of 24 patients. It was undoubtedly the prototype of today’s voice prosthesis. Materials and method. The study involved 33 men after total laryngectomy due to advanced squamous cell carcinoma, treated in the Otolaryngology Ward of the District Hospital in Skarżysko-Kamienna between the years 2012–2017, who were implanted with a voice prosthesis Provox II and Provox Vega. Results. During the analyzed period, 127 voice prosthesis were replaced in 33 patients. This paper focuses on complications connected with the implantation of voice prosthesis. The most common reason for replacement of a voice prosthesis was fluid leakage through the voice prosthesis channel – 95 cases. Spontaneous prolapse of the voice prosthesis occurred in 11 patients, and after re-insertion of the prosthesis, the correct fistula voice was obtained. The voice prosthesis was replaced due to difficulty in creating the prosthetic speech in 8 patients. A much more serious complication is the occurrence of leakage around the voice prosthesis. In the examined group, leakage around the prosthesis occurred in 5 patients. An inflammatory plaque was formed around the prosthesis, which was removed in case of significant prosthetic cover or at the request of an alarmed patient – in 4 patients. The prosthesis protruded and rotated in the trachea and hung on a fragment of mucous membrane of the trachea in 1 patient.

Using a tracheal stent for conservative management of speaking valve-associated tracheo-oesophageal fistula.

Surgical voice rehabilitation is an essential dimension of treatment following total laryngectomy. The gold standard is tracheo-oesophageal puncture and speaking valve placement. Whilst offering excellent phonation in many patients, there is a well-documented risk of valve associated fistula formation, the incidence of which varies from 1 to 21% 1. Risk factors for delayed valve associated tracheo-oesophageal fistula include post chemo-radiotherapy (salvage laryngectomy), oesophageal stricture, persistent fungal infection and poor patient compliance in managing their speaking valve2. This article is protected by copyright. All rights reserved.

Surgical vocal rehabilitation after total laryngectomy

SAYED S.I., DWIVEDI R.C. & KAZI R. (2011) European Journal of Cancer Care20, 286Surgical vocal rehabilitation after total laryngectomy This module will help health professionals understand the impact on speech for patients undergoing a total laryngectomy for laryngeal cancer and the issues around surgical voice rehabilitation techniques.

Wpływ wybranych czynników na rehabilitację logopedyczną chorych po całkowitym usunięciu krtani

The operation of total laryngectomy deprives patients of the ability of voiced communication, causes isolation and loneliness. The loss of voice and speech leads to a predominant cripplehood, disturbs verbal communication in the social and family circle. The best ways of voiced communication of the patients after laryngectomy are an esophageal speech and the speech using voice prosthesis. The aim of the study is to estimate the voice and speech rehabilitation of the patients after total laryngectomy. The study comprised 30 patients who in the years 2007-2009 underwent an operation of laryngectomy at the Department of the Surgery of the Head and Neck and the Laryngological Oncology in the Greater Poland Cancer Center in Poznań. In this group 9 patients used voiced speech after grafting the voice prosthesis, 15 patients (12 men and 3 women) underwent a classical rehabilitation of the esophageal speech, 6 patients (4 men and 2 women) used an electronic voice prothesis. The most important factors which influenced on mastering an esophageal speech were: pressure inside the esophagus, appearing a reverberation, time of training at home, length of time of logopedic rehabilitation, age and education. Necessary time to master a speech in the group of 9 patients with voice prothesis was 4-5 days. Length of time of the classical speech rehabilitation lasted from 3 to 8 months. 3 persons (20%) mastered a very good degree of esophageal speech, 7 patients a good degree (46.67%) and 2 patients (13.33%) - a sufficient degree of esophageal speech despite of low pressure inside the esophagus and appearing a reverberation quickly. 3 patients (20%) used an oral and guttural pseudo-whisper, a voiced reverberation was not obtained during the whole time of logopedic rehabilitation. The surgical voice rehabilitation, in spite of the possibility of complications, enjoys a great popularity among patients. The classical rehabilitation of the esophageal speech was more difficult for the tasted group of patients but mastering a speech to a very good and good degree lets communicate naturally.

Surgical voice rehabilitation in unilateral vocal fold paralysis

Unilateral recurrent nerve paralysis leads to glottic insufficiency, significantly reducing vocal ability. Due to its unusually long course, the recurrent laryngeal nerve is prone to iatrogenic lesions involves many medical fields generally with little expertise in voice disorders. Whenever the etiology is uncertain, a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover in many cases laryngeal electromyography yields a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in cases of unilateral recurrent nerve palsy. Patients with persistent glottal gap may express the wish for surgical voice rehabilitation. Nowadays a broad spectrum of endoscopic and open approaches are available for this purpose. This review describes advanced techniques of voice-improving surgery available in specialized centers today.

Current status and future prospects in prosthetic voice rehabilitation following laryngectomy

Total laryngectomy or laryngopharyngectomy remains the procedure of choice for advanced-stage (UICC T3 and T4) laryngeal carcinoma around the world despite advances in conservative laryngeal surgery and radiotherapy. However, it has profound effects on respiration and deglutition, in addition to the most disabling effect-the loss of verbal communication. Successful voice restoration can be attained with any of three speech options, namely esophageal speech, electrolarynx, and tracheoesophageal (TO) speech using an artificial valve. Although, no single method is considered the best for every patient, the tracheoesophageal puncture has become the preferred method in the past decade. Several types of voice prostheses have been produced since the first prosthesis was introduced in 1980 by Blom and Singer. However, eventually all prostheses are confronted by the same problem, i.e., the development of a biofilm, leading to deterioration and ultimately to dysfunction of the prostheses, necessitating replacement. This article attempts to sum up the historical background as well as the current state of surgical voice rehabilitation following laryngectomy; we review the recent major advances as well as the future prospects. Data was collected by conducting a computer-aided search of the MEDLINE and PubMed databases, supplemented by hand searches of key journals. Over 50 articles published in the last three decades on the topic have been reviewed, out of which about 20 were found to be of relevance for this article.

Hands-free speech after surgical voice rehabilitation with a Provox® voice prosthesis: experience with the Provox FreeHands HME tracheostoma valve® system

Excellent results have been reported with the use of voice prostheses for the rehabilitation of laryngectomees. Patients, however, consider it a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gesture or to work with both hands. An automatic tracheostoma valve helps patients overcome this problem. We describe a prospective clinical trial evaluating our experience with the Provox FreeHands HME Automatic Tracheostoma Valve system. Twenty-four laryngectomees were randomly selected from the patients who had undergone laryngectomy at the ENT Department. Immediately, after 4 weeks and 6 months later having been fitted with a Provox FreeHands HME, the patients were asked to complete a questionnaire in order to assess their satisfaction, voice quality, wearing comfort, fixation, potential problems, and the effectiveness of the HME cassette. In addition, we investigated relevant voice quality parameters including dynamics range, frequency range of the speaking voice, and maximum phonation time. Seven patients discontinued the study due to problems of securing the valve to the skin (four patients) or recurrent cancer (three patients). Ten of the remaining 17 patients wore the valve daily for an average of 8.4 h. A total of 88% of the patients considered it a great advantage to be able to speak without having to use their hands. With the Provox FreeHands HME, maximum phonation time was 8.7 (+/-6.2) s and the dynamic range was 21.9 (+/-5.8) decibels. The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent compliance and good voice rehabilitation.

Assessment of irregular voices after total and laser surgical partial laryngectomy.

To assess the merits of computer-aided voice analysis procedures for very irregular voices of patients after total and laser surgical partial laryngectomy, and to characterize qualitative differences in speech and voice function between these 2 groups of patients. Cross-sectional study. University hospital in Göttingen, Germany Twenty-nine patients with advanced laryngeal carcinomas (T3-T4; according to the Union Internationale Contre le Cancer, TNM staging system, stages III-IVa) were examined: 18 patients with tracheoesophageal speech (voice prosthesis) after total laryngectomy and 11 patients who underwent partial transoral resection of the larynx (by means of laser microsurgery without surgical voice rehabilitation). Speech intelligibility was measured by a standardized and validated telephone test, and voice quality was determined by 2 computerized voice analysis systems (multidimensional voice program and Göttingen hoarseness diagram). The telephone test demonstrated a significantly better speech performance of the patients who had undergone organ-preserving surgery. The voices of both patient groups were too irregular for a qualitative differentiation with the multidimensional voice program. The multidimensional voice program results also failed to show significant correlations to speech intelligibility. The Göttingen hoarseness diagram showed significantly more regular voices in patients with partial laryngectomy than total laryngectomy. These results were correlated with speech intelligibility. The Göttingen hoarseness diagram is suitable for a qualitative assessment even of irregular voices. Voice prosthesis offers a voice quality that at best approaches that of patients with partial laryngectomy.

Quality of life for patients after laryngectomy and surgical voice rehabilitation. Experience with the Provox prosthesis

Our study included 52 patients who received follow-up care after laryngectomy; a Provox I prosthesis was used for voice rehabilitation. The EORTC Quality of Life Questionnaire was used to assess the postoperative quality of life of these patients with voice prostheses. Of the patients, 36.1% complained of a lack of energy, and 22% experienced sadness suggesting a reactive depression. Of the 55.6% of patients who expressed satisfaction with managing their disease, more than two-thirds were afraid of a potential deterioration of their health. More than 90% of the patients received extensive support from family and friends. As many as 52.8% expressed themselves satisfied with their current life, which is perhaps attributable to the successful rehabilitation of their voice. Eating problems, i.e., varying degrees of dysphagia as a result of treatment, were experienced by 47.3% of the patients. After the laryngectomy, 11% continue to smoke and 46% regularly consume alcohol. For this reason, rehabilitation measures should place more emphasis on patient education and on programs designed to help patients stop smoking and drinking alcohol.

Surgical voice rehabilitation after laser surgery for glottic carcinoma.

Transoral laser surgery today is the mainstay of treatment for T1 and T2 glottic carcinoma. The vocal ability remains sufficient in the majority of patients. However, in some cases, a significant glottic gap may persist, leading to poor voice quality. We report a special technique of medialization thyroplasty using autologous cartilage specifically adapted for vocal rehabilitation after laser resection. Six patients with a significant glottic gap following laser surgery were treated. For vocal rehabilitation, a special medialization technique was performed. The superior rim of the thyroid cartilage of the resected side was exposed. A 1 x 2-cm piece of cartilage was harvested and reimplanted into a subperichondrial pouch created on the inner side of the thyroid cartilage. When phonation was optimal, this cartilaginous strut was sutured and/or glued in place. In all 6 cases, the vocal function improved significantly. The dysphonia index (0 = normal, 3 = aphonia), which includes objective parameters as well as expert voice ratings and the patient's perception, increased by 1.1 on average (range, 0.4 to 1.6). The results have been lasting. The established medialization techniques are of limited value in a larynx scarred by laser surgery. Injection augmentation is often futile because the tight scar tissue does not lend itself to augmentation. Implantation of nonorganic material may cause problems if revision surgery for tumor recurrence should become necessary or if the implant protrudes into the scarred endolarynx. The technique reported avoids these pitfalls and leads to voice quality improvement comparable to that of established medialization procedures.

Advances and refinements in surgical voice rehabilitation after laryngectomy.

After Blom and Singer reported the construction of the so-called "duck bill" prosthesis in 1980, there have been quite a few newer voice prostheses constructed by other workers and new methods developed to predict the results, such as the insufflation and lidocaine test. Implanting the voice prosthesis with the Blom-Singer method has presented some problems and complications related to the puncture technique, therefore the following simplified esophagotracheal puncture technique is presented. The pharynx is opened with the laryngoscope which is then led up to the entrance of the esophagus. Through the laryngoscope, the distal end of the endo-extralaryngeal needle carrier, developed by the author and modified for mass production by R. Wolf Ltd., Germany, is led into the esophagus. The instrument is pushed forward as long as its distal bent, blunt end is palpable in the upper third of the tracheostoma. The needle with the thread (2/0 prolene) is pushed through from the inside, out in the upper third of the tracheostoma. A double wire forming a loop is led through the pointed metal cone (containing a built-in needle) and the catheter and tied behind a counterfixing pierced ball. The 2/0 prolene leading thread is then knotted with the wire. By pulling the thread and the wire, the pointed end of the metal cone with the needle built-in, perforates the soft parts and pulls the catheter with it (the same procedure will be used for primary puncture as well). After this procedure the voice prosthesis can easily be placed in the fistula in a conventional manner. Using this technique, 59 patients could be implanted without puncture-related complications or problems. Problems, not related to the puncture technique, such as Candida albicans infection etc., were solved using the well-known treatment modalities. To stop leakage around the prosthesis, injection of Bioplastique into the soft tissue surrounding the fistula was used with success.

Early indications for surgical vocal cord medial relocation in unilateral recurrent nerve paralysis in advanced age

Unilateral vocal cord paralysis is usually treated conservatively. Phonosurgery is not indicated before 1 year after the onset of the palsy as during this period spontaneous recovery can be expected. In the elderly patient conservative voice rehabilitation is often limited by a restricted general condition. In these cases a severe communication disorder may result unless vocal cord function recovers spontaneously. In 4 patients aged 68 to 79 years who had suffered from latrogenic unilateral vocal cord paralysis for 6 to 9 months, surgical medialisation of the paralysed vocal cord was carried out in local anaesthesia as an Isshiki-Type-I-operation after unsuccessful conservative treatment prior to surgery. In all cases a definite amelioration of voice function could be reached. There were no local or general complications. No spontaneous recovery of nerve function could be detected by electromyography between 6 to 9 months after the operation. Voice function remained stable during this period. We conclude that in elderly patients with unilateral vocal cord paralysis with no signs of spontaneous recovery and unsuccessful conservative treatment, surgical voice rehabilitation may be indicated before 1 year after the onset of the palsy.

Autotransplanted jejunum in head and neck cancer.

Today, the free transplantation of jejunum is a reliable and attractive method for a single stage reconstruction of huge defects in the upper aerodigestive tract following the resection of advanced carcinomas, even in preoperatively irradiated patients. While being accepted for pharyngo-esophageal reconstruction, there is still controversy about its application in the reconstruction of the oral cavity and/or naso-/oropharynx, due to the possibility of using the other flaps, especially the radial forearm flap. As a consequence to the development of microvascular surgical technique and to the decrease of complications (mortality, graft necrosis, fistulas, strictures and abdominal complications) the free jejunal autograft provides now the shortest hospitalisation time and the most rapid interval leading to successful oral alimentation, when compared with other techniques. In order to estimate the usefulness of jejunal grafts either for surgical voice rehabilitation or the possible influence of these transplants in prolongation of survival, further investigations are necessary. In addition, jejunal autografts tolerate postoperative radiotherapy, necessary to reduce the incidence of local and neck recurrences. Therefore jejunal autografts increase the likelihood of returning the patient to a functional state in a time period commensurate with the natural history of the disease.

Voice rehabilitation after laryngectomy with voice prostheses. Results of a prospective follow-up study

Although the results of surgical rehabilitation by means of voice prostheses are on the average better than rehabilitation via oesophageal speech, the tracheoesophageal puncture (TEP)-technique has so far not been widely used in Germany. The majority of hospitals still prefer the "traditional" method of voice rehabilitation using oesophageal speech. The present prospective study was undertaken to compare the results of postlaryngectomy vocal rehabilitation, if patients were offered the surgical voice rehabilitation via voice prosthesis as an alternative to oesophageal speech. Taking into account all the patients who underwent laryngectomy from 1989 until 1990 in Tübingen, primary surgical voice rehabilitation was performed in 44 out of 54 patients (81.5%). Interestingly enough, 34 patients who underwent laryngectomy were able to perform communication via the telephone on the day of their discharge. Moreover, one-third of the laryngectomised patients showed a significant increase in speech intelligibility within the first six months after laryngectomy. 36 patients with laryngectomy were able to attain proficiency 6 months after surgery. In 12 patients the prosthesis had to be removed, since either phonation was impossible or patients successfully learned and preferred oesophageal speech. In conclusion, independent of the method of voice rehabilitation (prosthesis, electrolarynx, oesophageal speech), our results support the hypothesis that a voice rehabilitation regimen will yield a higher rehabilitation rate of patients if rehabilitation via surgical voice is offered as an alternative to learning the oesophageal voice. Therefore, it seems to be advisable that patients are allowed to have the choice between surgical rehabilitation and oesophageal speech restoration.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical voice rehabilitation after laryngopharyngectomy. Functional results of tracheo-hypopharyngeal shunts by jejunal transplantation.

For surgical voice rehabilitation after pharyngolaryngectomy we use the technique of placing a siphonlike jejunal interposition in order to create a tracheohypopharyngeal shunt. In this paper we present the functional benefits of this method of voice rehabilitation. The best results achieved are compared with a normal voice using the following test parameters: electroacoustic sound analyses and voice status. The findings show that the siphon voice is adequate for everyday purposes and can achieve useful social verbal communication.

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.

Acoustic and aerodynamic parameters of speech after laryngectomy and the Staffieri procedure.

The voice obtained with the Staffieri method of surgical voice rehabilitation after total laryngectomy was studied in 20 subjects and objectively described in terms of selected acoustic and aerodynamic parameters. Intensity and frequency, pressure and airflow were studied during sustained phonation of the vowel 'a'. Simultaneous recordings showed a relationship between intensity and between fundamental frequency, pressure and airflow in most of the subjects. As the subjects in the present study were not able to produce a vowel at target intensities and frequencies, the data were interpolated to 65 dB (A) intensity level for comparison purposes. We found no indication that from an acoustical and aerodynamical point of view, the Staffieri procedure should be preferred over other alaryngeal voice production methods.

Tracheal resection with laryngeal preservation

Summary A sixty year old patient with primary carcinoma of the cervical and upper thoracic trachea was submitted to surgical resection of the trachea with preservation of the larynx. A mediastinal tracheostomy was performed after resection of the manubrium and medial portions of the clavicles using the technic described by Grillo [4]. A distal laryngeal stoma was created in the neck at the level of the cricoid cartilage. After recovery from this surgical procedure voice rehabilitation has been accomplished by training the patient in the use of an acrylic connecting tube that allows him to use his own larynx for phonation on an intermittent basis. This atypical problem in speech rehabilitation was demonstrated by sound motion picture.