Tracheoesophageal Prosthesis Research Articles

Tracheoesophageal speech: A dedicated objective acoustic assessment

After total laryngectomy, the placement of a tracheoesophageal (TE) prosthesis offers the possibility to recover a new voice. However, the quality of the resulting TE speech is known to be degraded. To assess a patient's voice, current approaches rely either on quality-of-life questionnaires or on a perceptual evaluation carried out by speech therapists. These two methods exhibit the disadvantage of being both subjective and time-consuming. In this paper, we propose a dedicated scale, called A4S, for the objective Automatic Acoustic Assessment of Alaryngeal Speech. For this purpose, we first identify the artefacts existing in TE speech. These are linked to the periodicity, regularity, high-frequency noise and gargling noise/creakiness of the signal, as well as to the speaking rate. Specific acoustic features are proposed for the characterization of each artefact. A statistical study shows that TE speakers have a significantly worse voice compared to the control group, except for the speaking rate. Based on these advances, the A4S scale is proposed. This scale is made of five normalized dimensions, related to the five identified artefacts. A given patient's phonation can then be represented by a pentagon in a radar chart, which allows a fast and intuitive visualization of the strengths and flaws of the voice. A4S can then be seen as a useful tool for speech therapists to design tailored exercises specific to the patient's voice. In addition, we show the applicability of A4S for the follow-up of patients, as well as to study the impact of the type of surgery (open neck, robot and flap reconstruction) used for total laryngectomy and of a pre-surgical radiotherapy on various aspects of the TE voice.

Correlation of maximum phonation time and vocal intensity with intraluminal esophageal and pharyngoesophageal pressure in total laryngectomees.

This study aimed to correlate maximum phonation time, vocal intensity, and dynamic extension with intraluminal esophageal and pharyngoesophageal segment pressure during tracheoesophageal phonation. Prospective analysis. Tertiary academic hospital. The study was conducted on 20 total laryngectomees with alaryngeal speech and with secondary insertion of a tracheoesophageal prosthesis who were submitted to vocal recording of maximum phonation time and vocal intensity (minimum, habitual, and maximum). The participants were then submitted to manometry for the determination of the amplitude of intraluminal esophageal (proximal, middle, and distal) and pharyngoesophageal segment pressure during phonation. A significant positive correlation was detected between habitual vocal intensity and the middle (0.004) and distal (0.05) esophagus, in addition to a correlation of maximum intensity with the middle esophageal portion (0.03). Dynamic extension showed correlation with the amplitude of esophageal pressure. There was no significant correlation between the variables studied and pressure of the pharyngoesophageal segment or between maximum phonation time and esophageal pressure amplitude. The middle and distal regions of the esophagus were found to be compliant, permitting an adjustment of vocal intensity. There was no correlation between maximum phonation time and the amplitude of esophageal and pharyngoesophageal segment pressure.

Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap

Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes. Retrospective cohort study. We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted. Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications. These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results. 2b.

Laryngectomy rehabilitation

It is important on a periodic basis to evaluate and re-evaluate the standard of care in your area and to compare it to the care provided in other parts of the world. This can result in modifications and improvement in the patient's outcome. Over the last year, additional weight has been added to the medical literature regarding the value of moisture exchangers, chronic low-risk medications, the relationship between vocal rehabilitation and esophageal reflux disease, as well as the chronic concern regarding tracheo-esophageal puncture site enlargement. Multidisciplinary input remains critical for optimum success as measured not only by the vocal outcomes, but also by the quality-of-life metrics. Optimum outcomes for vocal rehabilitation following laryngectomy suggest the need for careful multidisciplinary perioperative planning and therapy. There have been improvements in tracheo-esophageal prosthesis design, moisturization, and ease of speech generation. Additional research is needed to explore the relationship between speech and chest wall kinematics, puncture site and location, prosthesis leakage, and the potential relationships to gastro-esophageal reflux disease. Future effort should be directed toward measurable improvements in the quality of life.

Carotid Blow-Out Masquerading as Gastrointestinal Hemorrhage: A Case Report

Tracheo-esophageal prostheses (TEP) are commonly used for speech restoration following laryngectomy for laryngeal cancer. The device is placed through the tracheoesophageal wall into the esophagus superior to the tracheal stoma. We report a case of a ruptured carotid artery presenting as a gastrointestinal bleed. The diagnosis was elusive for a while as initial extensive workup for a source of gastrointestinal bleeding was unsuccessful. To the best of our knowledge, this is the first reported case of a TEP device causing a carotid blow out. This case highlights the importance of looking for atypical sources of bleeding when routine investigations do not provide an etiology. doi: http://dx.doi.org/10.4021/jmc1163w

Carotid Blow-Out Masquerading as Gastrointestinal Hemorrhage: A Case Report

Tracheo-esophageal prostheses (TEP) are commonly used for speech restoration following laryngectomy for laryngeal cancer. The device is placed through the tracheoesophageal wall into the esophagus superior to the tracheal stoma. We report a case of a ruptured carotid artery presenting as a gastrointestinal bleed. The diagnosis was elusive for a while as initial extensive workup for a source of gastrointestinal bleeding was unsuccessful. To the best of our knowledge, this is the first reported case of a TEP device causing a carotid blow out. This case highlights the importance of looking for atypical sources of bleeding when routine investigations do not provide an etiology. J Med Cases. 2013;4(5):277-279 doi: https://doi.org/10.4021/jmc1163w

Aspiration of tracheoesophageal prosthesis in a laryngectomized patient

Background: The voice prosthesis inserted into a tracheoesophageal fistula has become the most widely used device for voice rehabilitation in patients with total laryngectomy. Case presentation: We describe a case of tracheoesophageal prosthesis’ (TEP) aspiration in a laryngectomized patient, with permanent tracheal stoma, that appeared during standard cleaning procedure, despite a programme of training for the safe management of patients with voice prosthesis. Conclusions: The definitive diagnosis and treatment were performed by flexible bronchoscopy, that may be considered the procedure of choice in these cases, also on the basis of the literature.

Aspiration of tracheoesophageal prosthesis in a laryngectomized patient

BackgroundThe voice prosthesis inserted into a tracheoesophageal fistula has become the most widely used device for voice rehabilitation in patients with total laryngectomy.Case presentationWe describe a case of tracheoesophageal prosthesis’ (TEP) aspiration in a laryngectomized patient, with permanent tracheal stoma, that appeared during standard cleaning procedure, despite a programme of training for the safe management of patients with voice prosthesis.ConclusionsThe definitive diagnosis and treatment were performed by flexible bronchoscopy, that may be considered the procedure of choice in these cases, also on the basis of the literature.

Improved Outcomes in Primary Prosthesis Placement during Tracheoesophageal Puncture

Objective: Tracheoesophageal prosthesis facilitates esophageal speech in postlaryngectomy patients. The vocal prosthesis can be placed either during tracheoesophageal puncture (TEP) or, more commonly, in a delayed fashion. Our objectives were to: 1) analyze the voice outcomes and 2) compare the pain and emergency care, following primary versus delayed prosthesis placement. Method: A 2011 cohort study. A tracheoesophageal puncture occurred in conjunction with, or within 3 months of, total laryngectomy. Nine patients underwent primary and 11 patients underwent delayed prosthesis placement. The primary outcome was voice production at the first postoperative appointment. Secondary outcomes included pain and perioperative emergency room visits. Results: All patients (100%) with prostheses placed at the time of the TEP had voice production at the first postoperative clinic visit, in comparison to only 45% (5/11) of patients with prostheses placed in delayed fashion. Significant pain with vocalization occurred in zero primary placement prosthesis patients, but in 55% (6/11) of delayed placement prosthesis patients. Only one primary placement prosthesis patient (11%) sought emergency medical care related to their stoma or voice prosthesis versus 7 (64%) delayed placement prosthesis patients. Conclusion: Primary prosthesis placement during TEP has significantly improved voice and quality of life outcomes with earlier voice production, reduced postoperative pain and the virtual elimination of perioperative emergency room visits. This significant modification of the standard technique represents a highly successful and cost-effective approach to vocal rehabilitation in post-laryngectomy patients.

Relation between the dimensions and intraluminal pressure of the pharyngoesophageal segment and tracheoesophageal voice and speech proficiency

The objective of the present study was to relate the dimensions and the intraluminal pressure of the pharyngoesophageal segment (PES) to the voice and speech proficiency of total laryngectomees with a tracheoesophageal prosthesis (TEP). Twenty total laryngectomees with secondary TEP insertion underwent evaluation of voice and speech, manometry, and videofluoroscopy. Most laryngectomees (65%) were moderate speakers. The poorer speakers presented a lower intraluminal pressure in the PES at rest (4.44 mmHg) and a higher value (40.46 mmHg) during phonation. Good speakers presented a significant difference in the anteroposterior distance between prominence of the PES and the posterior pharyngeal wall (PPES-PPW) in the rest (6.09 mm) to phonation (3.24 mm). The poorer speakers presented a lower intraluminal pressure in the PES at rest and a higher value during phonation compared with moderate speakers. Good speakers showed a significant difference in the PPES-PPW dimension.

Characteristics of tracheoesophageal voice and speech in laryngectomized patients after primary and secondary application of vocal prosthesis

Total laryngectomy is a radical procedure that leads to permanent loss of the voice generator and a part of the voice resonator, the larynx, where the basic laryngeal tone is created. One method of voice and speech rehabilitation is implantation of tracheoesophageal prosthesis. The aim of this study was to determine the characteristics of tracheoesophageal speech in patients with primary and secondary vocal prosthesis, to analyze the influence of gender and age on characteristics of the tracheoesophageal speech and self-assessment by patients themselves. This paper presents the results of voice and speech rehabilitation in 48 laryngectomized patients aged 44 to 77 years, with implanted vocal prosthesis during the period from 2008 to 2010 at the Clinic for Ear, Nose and Throat of the Clinical Centre of Vojvodina. The assessment of voice and speech characteristics included: maximum phonation time for the sound /a/, the length of phrases, reading of phonetically balanced word lists, intelligibility of words, reading phonetically balanced text and self-assessment of speech quality of patients referred to their communicative needs. Characteristics of voice and speech in patients who underwent primary vocal prosthesis in relation to secondary placement show no statistically significant difference. In patients under the age of 60, statistically significant better result in terms of speech intelligibility was found. There were no statistically significant differences depending on the patients' gender. Only one patient (1/48) assessed his speech as unsatisfactory. As developing countries cannot provide adequate number of prostheses and their continuous supply for all laryngectomy patients, the installation of a secondary vocal prosthesis could be an adequate method of rehabilitation. A large percentage of success in education of tracheoesophageal speech recommends the placement of vocal prosthesis.

Objective and Subjective Assessment of Tracheoesophageal Prosthesis Voice Outcome

To investigate the relationships between objective measures and the results of subjective assessment of voice quality and speech intelligibility in patients submitted to total laryngectomy and tracheoesophageal (TE) puncture. Retrospective. Twenty patients implanted with voice prosthesis were studied. After surgery, the entire sample performed speech rehabilitation. The assessment protocol included maximum phonation time (MPT), number of syllables per deep breath, acoustic analysis of the sustained vowel /a/ and of a bisyllabic word, perceptual evaluation (pleasantness and intelligibility%), and self-assessment. The correlation between pleasantness and intelligibility% was statistically significant. Both the latter were significantly correlated with the acoustic signal type, the number of formant peaks, and the F2-F1 difference. The intelligibility% and number of formant peaks were significantly correlated with the MPT and number of syllables per deep breath. Moreover, significant correlations were found between the number of formant peaks and both intelligibility% and pleasantness. The higher the number of syllables per deep breath and the longer the MPT, significantly higher was the number of formant peaks and the intelligibility%. The study failed to show significant correlation between patient's self-assessment of voice quality and both pleasantness and communication effectiveness. The multidimensional assessment seems to be a reliable tool to evaluate the TE functional outcome. Particularly, the results showed that both pleasantness and intelligibility of TE speech are correlated to the availability of expired air and the function of the vocal tract.

Vocal Handicap and Quality of Life After Treatment of Advanced Squamous Carcinoma of the Larynx and/or Hypopharynx

To evaluate and correlate voice-specific quality of life (QOL) and health-related QOL (HR-QOL) after treatment for advanced cancer of the larynx and/or hypopharynx. Cross-sectional study. Patients submitted to partial laryngectomy (PL), salvage PL (sPL), concomitant radiotherapy and chemotherapy (RT+Chemo), total laryngectomy (TL), salvage TL (sTL), total pharyngolaryngectomy (TP) and salvage total pharyngolaryngectomy (sTP). The following questionnaires were used: (1) Voice Handicap Index (VHI) and (2) University of Washington Quality of Life Questionnaire (UW-QOL; version 4). Eighty-four patients participated in the study. All the patients PL (10), sPL (1), and RT+Chemo (24) communicated by laryngeal voice. Of the 49 patients submitted to total removal of the larynx, 30 communicated with alaryngeal phonation, the major part being tracheoesophageal prosthesis (17). The worst subscale of VHI for the total patient group was functional (mean=13.15), and the value of the total score was 31. Patients submitted to PL, RT+Chemo, and TL presented slight handicap (medians of 27, 14, and 21.5, respectively). Patients treated with sTL, TP, and sTP presented moderate handicap (medians of 45, 37.5, and 31.5, respectively). HR-QOL was considered between good and excellent for 78.6% of the patients, and poor for 21.4%. The correlation between voice-specific QOL and HR-QOL was significant (P=0.0001). Patients treated for advanced cancer of the larynx/hypopharynx present slight to moderate voice handicap and good/excellent HR-QOL. Stricter analysis of both the VHI and UW-QOL data suggests that more attention be given to the vocal handicap of the individual patient.

Simplified technique of tracheoesophageal prosthesis placement at the time of secondary tracheoesophageal puncture (TEP)

Secondary tracheoesophageal (TE) puncture standardly involves placement of a catheter at time of TE fistula creation. We explore the feasibility of placement of the prosthesis at the time of TE puncture (TEP) obviating the need for a subsequent procedure to place the prosthesis. We describe the technique and evaluate the success and potential advantages. Retrospective chart review of consecutive patients who underwent TE prosthesis placement at the time of secondary TEP from 3/2009 to 1/2011. Fourteen patients underwent the primary TE prosthesis placement at the time of secondary puncture and were evaluated. Assessed outcomes included patient demographics, success of prosthesis placement, need for repeat procedure, early or late prosthesis dislodgement, complications, and specific voice outcomes. Patient cohort included nine males, five females, with average age of 64 years. All TE prosthesis placements were successful. The 12-mm 20 F Blom-Singer Indwelling prosthesis was used in all cases. No complications occurred during prosthesis placement. Two perioperative complications occurred: one case of transient pulmonary edema from general anesthesia, one case of posterior tracheal wall swelling. The second was addressed with placement of a larger prosthesis. All patients successfully achieved good voice at an average of 4 days after the procedure (range: 1-9 days). This initial series of 14 consecutive patients demonstrates successful TE prosthesis placement at the time of secondary TE puncture. Functional voice was achieved in all patients with no significant immediate complications. No dislodgements occurred and no repeat procedures were required. Voice acquisition was achieved at an earlier time (4 days on average) than with traditional techniques and without the necessity of a subsequent procedure. Primary prosthesis placement at the time of secondary TE puncture is a successful option for surgical voice restoration with distinct advantages and minimal complications.

Determining the efficacy and cost‐effectiveness of the activalve: Results of a long‐term prospective trial

To investigate 1) whether the Provox ActiValve results in increased device-life in individuals with below average device-life, 2) whether it is cost-effective, and 3) whether it has any impact on voice-related quality of life. Prospective study. Individuals who experienced below-average tracheoesophageal prosthesis (TEP) life were studied. Individuals with persistent below-average TEP life were enrolled in the study and underwent periodic re-evaluation. The majority (73%) experienced significant improvement as a result of use of the device. Those who continued to wear the device were followed for an average of 30.45 months (range, 14.70-43.49 months) and wore a total of 31 devices over this time. They demonstrated an average increase in device-life of more than 500%, going from an average of 1.93 months with a traditional indwelling device to 10.30 months with the ActiValve. The majority of individuals found that voicing with the ActiValve was either the same or better than with their previous indwelling TEP. Voice-related quality of life was not significantly different from that of a group of controls. Overall satisfaction with the device was high, and the majority would have chosen the ActiValve in the future. Overall, there were estimated to be cost savings to third-party payers through use of the ActiValve in this population. The ActiValve is effective in increasing device-life in selected patients who have failed conservative measures. Our protocol for use of the device requires individuals to meet several usage criteria before initial placement and to return for periodic monitoring.

A simple closure technique for reversal of tracheoesophageal puncture

Speech restoration after total laryngectomy has been revolutionized by the technique of tracheoesophageal puncture (TEP) and speech valve prosthesis placement. Unfortunately, complications may arise from this procedure, sometimes necessitating reversal and surgical closure of the TEP. We present a simple yet effective method of closing a TEP and review previously described techniques.

Simplified Technique of Tracheoesophageal Prosthesis Placement at the Time of Secondary Tracheoesophageal Puncture

Simplified Technique of Tracheoesophageal Prosthesis Placement at the Time of Secondary Tracheoesophageal Puncture

Intraluminal Esophageal Pressures in Speaking Laryngectomees

The objective of the present study was to evaluate intraluminal esophageal pressure during voice and speech emission in speaking laryngectomees with a tracheoesophageal prosthesis. In our prospective analysis in a tertiary-care academic hospital, 25 laryngectomees were divided into 2 groups: 11 speaking individuals with a tracheoesophageal prosthesis and a control group of 14 nonspeaking laryngectomees. All patients were subjected to manometry during voice and speech emission tests. We determined the pressures achieved in the distal, middle, and proximal parts of the esophagus. Statistical analysis revealed that the amplitude of pressure in the distal esophagus during sound emission was higher in speaking laryngectomees; in the middle esophagus, intraluminal pressure during emission of the sentence was higher in speaking subjects, and in the proximal esophagus there was no difference between the groups. During the manometric evaluation of the distal and middle esophagus in the presence of voice and speech emission, the intraluminal pressure revealed a significant difference for the speaking laryngectomees with a tracheoesophageal prosthesis. The proximal esophagus behaved similarly in the groups of speakers and nonspeakers. Speaking laryngectomees with a tracheoesophageal prosthesis depend on a differentiated performance of the middle and distal parts of the esophagus.

Prosthetic voice rehabilitation after total laryngectomy

Loss of voice is a major concern after total laryngectomy. Tracheo-esophageal prosthesis was described in 1980 by Blom and Singer as a method of postlaryngectomy voice rehabilitation. Since then it has seen many phases of developments. Now it has evolved into highly effective method with success rates more than 90% and better quality of voice than other modalities. It also gives good quality of life and voice related quality of life. Though it is associated with some complications, they are easy to manage. All these have made tracheo-esophageal prosthesis the 'Gold Standard' of post-laryngectomy voice rehabilitation.

Improved Tracheoesophageal Prosthesis Sizing in Office-Based Tracheoesophageal Puncture

Tracheoesophageal puncture (TEP) for postlaryngectomy speech is increasingly being performed as an office-based procedure. We review our experience with office-based TEP and compare outcomes with those of operating room-based TEP. Our hypothesis was that office-based TEP results in improved prosthesis sizing, reducing the number of visits dedicated to prosthesis resizing. A retrospective chart review was performed of all patients who underwent secondary TEP at our institution from 2001 to 2008. The primary dependent measure was the change in the length of the voice prosthesis. We also evaluated the number of visits made to the speech-language pathologist for resizing before a stable prosthesis length was achieved, and the number of days between voice prosthesis placement and the date a stable prosthesis length was observed. Thirty-one patients were included in this study. There was a significant difference in prosthesis length change between patients who had office-based TEP and patients who had operating room-based TEP (p < 0.001). In addition, the office-based cohort required fewer visits to the speech-language pathologist for TEP adjustments before a stable TEP length was achieved (p < 0.001). Voice prosthesis sizing was better in patients who had office-based TEP than in patients who had operating room-based TEP. This outcome is likely due to the lesser degree of swelling of the tracheoesophageal party wall in the office-based procedure.