Tracheoesophageal Voice Prosthesis Research Articles

Chest Tube Placement of Secondary Tracheoesophageal Voice Prosthesis: Overcoming Challenging Anatomy in the Laryngectomy Patient

Introduction: Total laryngectomy is used to cure advanced larynx cancer in many patients. The removal of the larynx requires the rehabilitation of the patient’s ability to communicate, and one common method is to place a tracheoesophageal voice prosthesis (TEP) as a secondary procedure after the patient has completed cancer treatment. The traditional technique utilizes a rigid esophagoscope for access, but this can prove difficult in many patients who have kyphosis, scarring of the neck, or trismus. We describe a technique to allow TEP placement in these challenging patients that does not utilize rigid esophagoscopy to access the tracheoesophageal puncture site. Methods: For more than 15 years, the senior authors of this study have used this technique in patients in whom traditional methods of TEP with rigid esophagoscope were unsuccessful or not attempted due to the anticipated high probability of failure. The ease of this technique has prompted its use for all patients undergoing secondary TEP placement in their practice. The technique is described in detail in the Methods section below. Results: The described method has been successfully utilized to place TEPs in many patients with challenging anatomy. There have been no failed placements, including a patient with severe trismus who was able to have a TEP placed by placing the chest tube and flexible endoscope transnasally. Further, because of precise visualization and ease of the technique, there have been no observed complications of injury to the pharyngoesophageal lumen or creation of a false passage. Conclusion: The use of a chest tube and flexible scope allows for the protection of the pharyngoesophageal lumen, precise visualization and placement of the puncture, and avoidance of a false tracheoesophageal passage, all while minimizing the need for extension of the patient’s neck. This has proven ideal for patients suffering the consequences of cancer treatment such as cervical scarring, fibrosis, kyphosis, and trismus.

Coronavirus disease 2019 status and related anxiety levels in cases undergoing total laryngectomy.

This study aimed to evaluate rate of the COVID-19 disease, its severity, mortality rate and anxiety levels in subjects who underwent total laryngectomy. The subjects who underwent total laryngectomy were included in the study. The data were first obtained retrospectively and then a telephone survey was applied. Anxiety levels was evaluated by the Coronavirus Anxiety Scale (CAS). A total of 54 subjects were included in the study. Nine (16.7%) males were reported to be infected with SARS-CoV-2. Five (55%) of them were hospitalized; 2 of them (22%) were taken to intensive care units, and one subject (11%) died. Although a tendency to increase risk of COVID-19 disease in the tracheoesophageal voice prosthesis users (23.1% vs 14.63%) was observed, statistically difference was not significant. The average total CAS score was significantly higher in those who had COVID-19. The data documented that people who underwent total laryngectomy developed more frequent and more severe COVID-19 disease and had a higher mortality rate. Although no obvious variable was found, our data suggest that using a tracheoesophageal voice prosthesis may be somewhat effective. Besides, our subjects presented very low anxiety about COVID-19.

Long-Term Complications of Tracheoesophageal Voice Prosthesis.

Background: The aim of our multicenter retrospective study was to evaluate the long-term complications associated with primary and secondary tracheoesophageal puncture (TEP) in patients who underwent total laryngectomy (TL) for laryngeal cancer and were subsequently rehabilitated to phonatory function with tracheoesophageal speech (TES). Materials and Methods: To evaluate the long-term outcomes and complications of TEP, the following data were collected: mean time of prosthesis replacement, mean time of onset of complications, type of complications, and type of failure. Results: Complications occurred in 18 out of 46 patients (39.2%) with primary TEP and in 10 out of 30 patients (33.4%) with secondary TEP, out of a total of 76 enrolled patients. Common complications included prosthesis leakage, fistula leakage, granulation, and prosthesis extrusion. Prosthesis replacement due to fistula leakage or prosthesis extrusion was observed exclusively in the group of patients with primary TEP. Among the 28 patients (35.7%) who experienced complications, rehabilitation with TEP failed in 10 cases, primarily due to abandonment and spontaneous fistula closure. Conclusions: TEP, both primary and secondary, represents a valid option for vocal rehabilitation in patients undergoing TL. However, identifying prognostic factors that could influence the success of TEP would be beneficial to allow a targeted rehabilitation process.

Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration

Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive. To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration. This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023. Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL. The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula. The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.

Endoscopic submucosal dissection for esophageal cancer behind a tracheoesophageal voice prosthesis.

Endoscopic submucosal dissection for esophageal cancer behind a tracheoesophageal voice prosthesis.

Hybrid primary puncture in stapler-assisted total laryngectomy.

In Video S1, a new surgical technique for hybrid primary tracheoesophageal (TE) puncture in stapler-assisted total laryngectomy is shown. The video describes the surgical steps of the procedure and illustrates some tips and tricks. The procedure incorporates an upper mini-pharyngotomy to enable retrograde placement of the voice prosthesis (VP), eliminating the need for rigid esophagoscopy. This has made it possible to exploit, without additional risks, the potential of the stapler combined with primary TE puncture and VP placement. In our experience, this hybrid procedure in stapler-assisted total laryngectomy is not related to adverse events such as pharyngocutaneous fistula (PCF), hypertonicity, and functional complications. Therefore, it can be considered a valid technique that allows for easy insertion of a primary voice prosthesis also in case of mechanical sutures.

Protocolized awake secondary tracheoesophageal puncture with immediate voicing.

Tracheoesophageal (TE) puncture with voice prosthesis placement is a common method for vocal rehabilitation in patients who have undergone total laryngectomy. Tracheoesophageal voice prosthesis (TEP) placement after laryngectomy, known as secondary TE puncture, is traditionally done in the operating room, using rigid esophagoscopy. Traditional secondary TEP placement carries a number of downsides including risks associated with general anesthesia, high cost, and technical challenges associated with anatomical variables. As a result, in-office secondary TE puncture has become an increasingly utilized procedure with many advantages but currently lacks standardization. Here, we describe a kit-based, awake, in-office secondary TE puncture with primary TEP placement technique. This technique calls for an endoscopic snare in the event there is difficulty passing the guidewire in the cranial trajectory. No surgical technique videos demonstrating in-office secondary TE puncture currently exist. Here, we present a video tutorial of our technique, breaking down the procedure into 10 steps from analgesia to voicing.

Endoscopic management of tracheoesophageal prosthesis-induced esophageal mucosal bridge.

Esophageal mucosal bridge (EMB) is a rare, often incidental finding encountered during esophagogastroduodenoscopy (EGD). It can be of congenital origin, or occur secondarily to local esophageal trauma, radiation therapy, and various inflammatory conditions involving the esophageal mucosa [1]. While mostly asymptomatic, EMB can often result in dysphagia by causing luminal obstruction. We present a case of symptomatic EMB secondary to long-standing tracheoesophageal voice prosthesis (TEVP) that was successfully treated with endoscopic resection using a scissor-type dissection knife.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs.

After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context. (1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy. A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis. The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general. The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require. What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

The management of advanced laryngeal and hypopharyngeal cancers between years 20202021 single-centre experience

Introduction: Laryngeal cancer is the most frequent neoplasm of the head and neck region. Despite advances in chemo-radiotherapy (CRT), surgery still remains an important role in the management of laryngeal cancer. Laryngeal preservation techniques, including endoscopic laser resection, are becoming more popular nowadays. However, total laryngectomy (TL) remains a reasonable option for advanced disease in selected patients. The main aim of this study was to perform general characteristics of patients with advanced laryngeal and hypopharyngeal cancer treated with TL as well as to perform a detailed analysis of the disease, treatment modalities and complications. Material and methods: This is a retrospective single-centre analysis. Baseline characteristics and preoperative clinical variables were collected. The study group consisted of 42 patients with advanced-stage carcinoma of the larynx and hypopharynx treated with TL between January 2020 and December 2021 at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, Poland. Preoperative and postoperative clinical variables were collected. Statistical analysis was performed using R software (R version 4.0.3). Results: The mean age of patients at diagnosis was 63.6 +/- 9.2 years, 32 (76.2%) patients were male. The most common symptoms at diagnosis were: hoarseness (78.6%) and dyspnea (47.6%). There was no statistically significant association between symptoms present at diagnosis and the stage of diagnosed laryngeal cancer according to the TNM classification (T3, T4a, T4b). Stage III was observed in 33 (78.6%) patients, IVa in 8 (19%) and IVb in 1 (2.4%) patient. Of the 42 included patients, total laryngectomy was performed in 39 (92.9%) patients and pharyngolaryngectomy in 3 (7.1%) patients. Tracheoesophageal voice prosthesis was implanted in all patients. Complications after surgery were observed in 5 (11.9%) patients. Squamous cell carcinoma was diagnosed in 100% of patients. Complementary therapy was performed in 36 (85.7%) patients. Conclusions: Our study population confirmed that patients suffering from advanced laryngeal and hypopharyngeal cancer are mostly men aged over 60 years with the most common variant of smoking history of over 20 cigarettes per day for a period over 5 years. Symptoms at diagnosis and TNM classification staging of laryngeal cancer are not related parameters.

Molecular Characterization of Fungal Colonization on the Provox™ Tracheoesophageal Voice Prosthesis in Post Laryngec-tomy Patients

Background:Tracheoesophageal voice prostheses (TVPs) have been the gold standard in rehabilitation, after laryngectomy, producing faster and premier voicing towards esophageal speech. Fungal colonization shortens the device’s lifetime and leads to prosthesis dysfunction, leakage, and subsequent respiratory infection. Therefore, in the current study, we aimed to investigate the fungal colonization patterns and to propose prophylactic measures that shall increase the longevity of voice prosthesis.Methods:Failed TVPs were removed - due to leakage and/or aspiration - from 66 post laryngectomy patients and examined. They were referred to Amiralam and Rasoul Hospital, the main centers of Ear, Nose, and Throat in Tehran, Iran from April 2018 to January 2020. Fungal colonization patterns were assessed using DNA sequencing techniques. Furthermore, the susceptibility to fluconazole, amphotericin B, nystatin, and white vinegar was evaluated according to the Clinical and Laboratory Standards Institute (CLSI) guidelines.Results:Resident fungal species from the upper airways colonized all the 66 TVPs (100%). Diabetes (31%) and smoking (98%) were the predominant underlying disease and predisposing factors, respectively. Among the 79 fungal agents isolated from the 66 TVPs, Candida glabrata (n=25, 31.7%) was the most common. A significant reduction in minimum inhibitory concentration (MIC) values were observed for white vinegar when used alone (P<0.05).Conclusion:White vinegar at a very low concentration could decrease the amount of fungal colonization on TVPs without any adverse effects; its wide accessibility and affordability ensure a decrease in the overall health cost.

The end of tracheostomal stenosis? Introducing the fish mouth technique.

Post-laryngectomy tracheostomal stenosis is common and often results in an inadequate airway. Several techniques have been described to minimise tracheostomal stenosis. The star technique involves an 'X' incision with four flaps sutured into the trachea. The petal technique involves two inferior flaps on either side being sutured into the trachea. The authors combined the star and petal techniques, resulting in an innovative fish mouth technique. This innovation involves two lateral skin flaps being sutured into an incision on either side of the lateral wall of the trachea. This results in an elongated, broadened and elliptical tracheostoma, mimicking that of a fish mouth. Benefits of the fish mouth technique include adequate stoma size for respiration, easier clearing of secretions, self-sufficiency without a stent, easier cleaning of a tracheoesophageal voice prosthesis, and stoma occlusion for voice production. The fish mouth technique is easily reproducible and suitable for those with a voice prosthesis.

Total Laryngectomy: A Review of Surgical Techniques.

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures. To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP. This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019. Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed. Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type. This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Complications associated with tracheoesophageal voice prostheses from 2010 to 2020: A MAUDE study.

Tracheoesophageal puncture with voice prosthesis placement remains the gold standard for voice restoration following total laryngectomy, but may cause various complications. This study aims to summarize patient-related and device-related adverse events associated with tracheoesophageal puncture and voice prosthesis placement. The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to tracheoesophageal puncture with voice prosthesis placement from January 1, 2010, to April 30, 2020. Data were extracted from reports pertaining to tracheoesophageal prostheses. Seventy-seven reports involving tracheoesophageal voice prostheses were identified, from which 111 adverse events were extracted. Of these, 58 (52.3%) were patient-related, while 53 (47.7%) were device-related. The most frequently reported patient-related adverse events were aspirated prosthesis (24 [41.4%]), foreign body during placement (11 [19.0%]), aspiration pneumonia (9 [15.5%]), and aspirated brush tip (8 [13.8%]). The most common device-related adverse events were detached brush tip (15 [28.3%]), leak (14 [26.4%]), and torn esophageal flange (11 [20.8%]). While tracheoesophageal puncture with voice prosthesis placement has revolutionized voice rehabilitation following total laryngectomy, the procedure may be associated with adverse events both at the time of placement and later. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further research is needed to clarify optimal approaches to education.

Tracheoesophageal voice prosthesis management in laryngectomy patients during the COVID-19 pandemic

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncology patients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers is deferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent procedures may be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses, such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center’s approach to managing this unique patient population.

Voice Change Following Total Laryngectomy Reconstruction

Introduction: Tracheo-esophageal voice prostheses are widely used following total laryngectomy. A number of authors have explored safe and effective surgical methods. However, changes in the tracheo-esophageal voice have received little attention. We studied the tracheoesophageal voice trends over time. Materials and Methods: The patients were 7 men and 1 women an average of 64.6±7.2 years old who had undergone total laryngectomy reconstruction. The survey items were CSL 4500（KayPENTAX）and PS-77E（Nagashima Medical Instruments）for the analysis, using the maximum phonation time （MPT）, fundamental frequency, maximum sound pressure, mean air flow rate（MFR）, and range of voice. We statistically analyzed the time course of each item at 1/, 3/, 6/, and 12 months postoperatively（analysis of variance, p<0.05）. In addition, the vowels at each point were analyzed by a sound spectrum, and changes in the formant information were confirmed. Result: the MPT significantly lengthened over time postoperatively（p<0.01）. Regarding the range of voice, although there was no significant difference over time, the frequency band tended to increase. In addition, the sound spectrum gram tended to become clearer as the formant structure progressed. The fundamental frequency, maximum sound pressure, and MFR did not differ markedly over time. Conclusion: In the rehabilitation of the tracheo-esophageal voice, it is important to acquire a stable expiratory volume, teach efficient speech methods, and give consulting to help at each periods.

Tracheoesophageal Puncture Site Closure With Butterfly Cartilage Graft.

A tracheoesophageal voice prosthesis is very effective for improving speech after total laryngectomy. Although it is generally a safe method, it may be necessary to close the tracheoesophageal fistula due to complications such as prosthesis-related cellulitis, granulation tissue formation, tracheoesophageal fistula necrosis, or salivary leakage around the prosthesis. Surgical and non-surgical methods for closure have been described. In this article, a method for closing the tracheoesophageal fistula with a butterfly cartilage graft is described. The butterfly cartilage technique is safe and efficient in terms of anatomical closure of the fistula. This study shows that the method can be easily applied, with low morbidity, using an auto-graft material with local anesthesia in an outpatient setting.

A Novel Device for Placement of a Secondary Tracheoesophageal Voice Prosthesis: A Preliminary Feasibility Study

Background: Tracheoesophageal puncture (TEP) for post-laryngectomy speech rehabilitation can be performed at the time of laryngectomy (primary) or at a subsequent time (secondary). Traditionally, the secondary procedure is performed using a rigid esophagoscope. Diseases like esophageal stricture, limited neck extension, and soft-tissue fibrosis can make this procedure technically challenging or impossible. We developed a novel device to perform a secondary tracheoesophageal puncture using a flexible esophagoscope. Objective: To test the feasibility of a novel device used to create a secondary TEP in post-laryngectomy cadavers. Methods: In this study, we performed a total laryngectomy on 3 fresh cadavers to establish the feasibility of our prototype. In each cadaver, a flexible esophagoscope was passed into the pharynx with the prototype. The prototype was passed through a working port and deployed to distend the esophagus. The puncture was visualized and a wire was passed via the newly established fistula. The device was activated, securing the wire, and then the esophagoscope and device were removed. Results: There was 100% successful deployment of the prototype device, allowing rapid creation of the puncture and security of the guide wire in each cadaver. There was no evidence of collateral mucosal injury or esophageal perforation. Conclusions: The prototype device offers an alternative method to safely and efficiently perform a secondary TEP without the requirement of rigid esophagoscopy which can sometimes be technically impossible in this patient population.

A pneumatic Bionic Voice prosthesis-Pre-clinical trials of controlling the voice onset and offset.

Despite emergent progress in many fields of bionics, a functional Bionic Voice prosthesis for laryngectomy patients (larynx amputees) has not yet been achieved, leading to a lifetime of vocal disability for these patients. This study introduces a novel framework of Pneumatic Bionic Voice Prostheses as an electronic adaptation of the Pneumatic Artificial Larynx (PAL) device. The PAL is a non-invasive mechanical voice source, driven exclusively by respiration with an exceptionally high voice quality, comparable to the existing gold standard of Tracheoesophageal (TE) voice prosthesis. Following PAL design closely as the reference, Pneumatic Bionic Voice Prostheses seem to have a strong potential to substitute the existing gold standard by generating a similar voice quality while remaining non-invasive and non-surgical. This paper designs the first Pneumatic Bionic Voice prosthesis and evaluates its onset and offset control against the PAL device through pre-clinical trials on one laryngectomy patient. The evaluation on a database of more than five hours of continuous/isolated speech recordings shows a close match between the onset/offset control of the Pneumatic Bionic Voice and the PAL with an accuracy of 98.45 ±0.54%. When implemented in real-time, the Pneumatic Bionic Voice prosthesis controller has an average onset/offset delay of 10 milliseconds compared to the PAL. Hence it addresses a major disadvantage of previous electronic voice prostheses, including myoelectric Bionic Voice, in meeting the short time-frames of controlling the onset/offset of the voice in continuous speech.