Tracheoesophageal Shunt Research Articles

The Localisation of a Tracheoesophageal Shunt during Laryn(-gopharyn)gectomy Determines the Risk of Shunt Insufficiency.

Tracheoesophageal shunt insufficiency (TESI) is a common and potentially life-threatening complication after laryn(-gopharyn)gectomy (L(P)E). We investigated whether TESI could be the result of a specific shunt location. A monocentric, retrospective cohort analysis of 171 consecutively treated L(P)E patients was performed. Patients with a secondary prosthesis instillation and patients with insufficient postoperative imaging were excluded. Disease related data as well as location of primary voice prosthesis were assessed. The cohort was divided into 62 TESI-positive and 109 TESI-negative individuals. The mean time from surgery to TESI was 32 months. No differences were observed in gender, age, tumor localization, T/R/M-status. Surgery without adjuvant therapy was more often performed in TESI-negative individuals when compared with their positive counterparts. However, Cox regression including T/N status, therapy and categorized distance of the tracheoesophageal shunt to the manubrium (≤1.5 cm vs. >1.5 cm) revealed that a distance of ≤1.5 cm was associated with a 2.1-fold increased risk of TESI, while all other parameters did not influence the event-free survival. Primary shunt positioning ≤1.5 cm to the ridge of the manubrium is associated with an increased risk of TESI. In these individuals secondary shunt operation resulting in a position >1.5 cm distant to the manubrium should be recommended.

Treatment of an Enlarged Periprosthetic Leakage Using Filler Injection in Patients With Provox Prosthesis: A Case Report

Recently, the most commonly used method for voice rehabilitation in total laryngectomy patients is to maintain tracheoesophageal shunt speech after inserting a voice prosthesis. One of the most common side effects, besides valve deterioration, is periprosthetic leakage due to dilatation of the tracheoesophageal shunt. Tissue implantation may be considered as one of the conservative treatments before attempting surgical treatment. When tissue implantation is attempted more than once, the treatment success rate is close to 90%. The authors experienced a case in which an 86-year-old patient developed aspiration pneumonia due to periprosthetic leakage. The patient refused surgical treatment. He was treated successfully for injecting hyaluronic acid filler 3 times and has been without a leakage for 9 months. This procedure can be considered as an alternative method to treat periprosthetic leakage.

A New Substitute Voice Using a Smartphone Application

Although widely used by patients who have undergone laryngectomy, vocalization using an electronic artificial larynx, tracheoesophageal shunt vocalization, and esophageal speech cannot reproduce a patient’s original voice, and this negatively affects their quality of life. In 2020, our department introduced a smartphone app called “coestation®,” an AI-based software that can reproduce voices with great similarity to the patient’s original voice by synthesizing 200 voice-recorded sentences.Our user survey revealed a high level of satisfaction with the similarity between the synthesized voices and the patients’ original voices. However, patients also showed dissatisfaction with the time lag and complexity of the app. In fact, only four of the six patients who agreed to participate in the survey were able to use the app properly. Consequently, the average voice-related quality of life among the app users was 61.9%, which is slightly lower than that among patients who used traditional substitute voices. Despite the remarkable quality of the voices reproduced by this innovative app, it should be constantly improved based on the patient feedback in order to meet their expectations.

Current Status of Voice Restoration after Total Laryngectomy – Tracheoesophageal Shunt Voice –

In the treatment of advanced laryngeal or pharyngeal cancer, while progress has been made in larynx-sparing therapies such as chemoradiotherapy, induction chemotherapy, and partial laryngectomy, total laryngectomy still plays an important role in terms of local control and salvage surgery. The importance of rehabilitation after total laryngectomy has been recognized. Regarding voice substitution, it is important to select the most appropriate means in accordance with the patient’s social background and wishes, and we believe it is important that all facilities offer patients equal opportunities to choose. Although guidance on esophageal speech is often mainly provided by patient groups, it is becoming increasingly important to build partnerships not only with physicians but also with speech-language pathologists, nurses, physicians in charge of community medicine, caregivers, social workers, etc., in order to perform shunt speech. We believe that by successfully coordinating with multiple professions and reducing the burden on physicians, it will be possible to provide voice restoration in accordance with the patient’s wishes. We introduce the current status of voice restoration and explain the multidisciplinary efforts to select voice restoration in our department. We also discuss our attempts to provide voice therapy for patients with shunt dysphonia.

An Exploratory Investigation of a New Substitute Voice Using a Smartphone Application

Patients with head and neck cancer who undergo total laryngectomy often suffer from significant communication disorders due to permanent aphonia. While various substitutes for voice loss, including an electronic artificial larynx, tracheoesophageal shunt, esophageal speech, and written communication, have been currently employed to communicate against aphonia, few methods have used the voice of a preoperative patient. “Coestation®” is a smartphone application that synthesizes patients’ voice and is now clinically applied to patients with amyotrophic lateral sclerosis (ALS). To verify whether this application has the potential to become a new substitute voice, we launched a clinical investigation for patients with head and neck cancer who were scheduled to undergo total laryngectomy. We preoperatively performed a voice synthesis using the smartphone application in two patients and postoperatively requested them to use an electronic artificial larynx and the synthesized voice. The patients stated that the synthesized voice was more similar to their original voice than the artificial larynx and were very satisfied about its voice quality. Based on these preliminary results, we plan to enroll more patients to assess the general usefulness of the synthesized voice as a new substitute voice.

Support for Patients with Tracheoesophageal (TE) Shunt Speech: Evaluation of Three Cases of Shunt Closure

Support for Patients with Tracheoesophageal (TE) Shunt Speech: Evaluation of Three Cases of Shunt Closure

Speech intelligibility and aspiration of Amatsu tracheoesophageal shunt

Speech intelligibility and aspiration of Amatsu tracheoesophageal shunt

Long-term results of Amatsu tracheoesophageal shunt: Follow-up of more than 5 years.

The Amatsu tracheoesophageal shunt (ATES) represents a nonprosthesis surgical option for voice restoration in laryngectomized patients. However, data regarding the long-term efficacy of ATES are lacking. Retrospective, single-institution study. Between 2001 and 2010, 16 patients with laryngeal cancer underwent total laryngectomy with ATES at the Hyogo Cancer Center (Akashi, Hyogo, Japan). Of these, 11 achieved long-term tracheoesophageal speech that was maintained for a follow-up exceeding 5 years (range 75-161 months; median 95 months). All patients were male and ranged from 46 to 74 years of age at the time of ATES surgery. Of 11 eligible patients, eight were able to speak intelligibly with ATES at last follow-up. Regarding aspiration, three patients experienced no leakage, and six experienced mild leakage of saliva without medical intervention at last follow-up. Almost all patients maintained an unchanged degree of voice quality (9 of 11) and leakage (8 of 11). The favorable voice restoration and low aspiration rates achieved in this study appear to support the long-term efficacy of ATES. 4. Laryngoscope, 128:1395-1397, 2018.

Our experience with Russian voice prostheses long used in patents after laryngectomy with tracheoesophageal shunting and endoprosthesis replacement

Despite broad current diagnostic capabilities, most (60–70 %) patients with larynx cancer seek medical advice only when they have stages III and IV. Until the present time, laryngectomy has remained the most common treatment option for cancer of the larynx and laryngopharynx. Tracheoesophageal shunting with endoprosthesis replacement is one of the most important surgical vocal rehabilitation techniques after laryngectomy. According to different authors» data, the mean lifetime of voice prostheses is 6–12 months. The long-term use of voice prostheses in patients after laryngectomy with tracheoesophageal shunting with endoprosthesis replacement was the object of our investigation. Patient G., aged 34 years was admitted to the Department of Head and Neck Tumors, Oncology Clinical Dispensary (OCD) One, Moscow Healthcare Department, with a diagnosis of larynx cancer spreading to lymph nodes (LN) (T3N1M0) in the left neck on September 16, 2010. Surgery involving laryngectomy with tracheoesophageal shunting and implantation of a Russian voice prosthesis, as well as radical fascial excision of LN and fat in the neck on the left side were performed on September 21, 2010. During the 4-year use of the voice prosthesis, his voice was sonorous and good. The voice prosthesis was removed in November 2014. Antifungal therapy was used; a new voice prosthesis was implanted. His speech was fluent and his voice was sonorous and good. Patient M., aged 54 years was admitted to the Department of Head and Neck Tumors, OCD One, Moscow Healthcare Department, with a clinical diagnosis of laryngopharynx cancer (T4N1M0) and an aftereffect of gamma-therapy with a summary focal dose of 42 Gy on November 18, 2003. Surgery involving laryngectomy with laryngopharyngeal resection, tracheoesophageal shunting, and endoprosthesis replacement with implantation of a Russian voice prosthesis, as well as radical fascial excision of LN and fat in the neck on the right side were performed on November 25, 2003. The voce prosthesis was removed in December 2014. Antifungal therapy was performed. A new Russian prosthesis was implanted in the tracheoesophageal shunt. His voice was sonorous and good.

当科における気管食道シャント閉鎖術症例の検討

当科における気管食道シャント閉鎖術症例の検討

ボイスプロテーゼによる音声再建例の合併症とカンジダ感染の検討

Between December 2004 and December 2011, we have used the indwelling voice prosthesis for voice rehabilitation in 28 patients after total laryngectomy in our department. To clarify both the complications and safety of voice reconstruction using a voice prosthesis, and the occurrence of candida colonization, we conducted a retrospective study with a review of the Japanese literature. Twenty-six patients who were observed over a period of more than six months at our hospital were enrolled in this study. We examined the interval of prosthesis replacement, types and frequency of complications, candida colonization, and clinical outcomes. The median follow-up time postoperatively was 28.8 months (range 8.1-95.7). The average interval of prosthesis replacement was 147 days (4.9 months). Complications occurred in 14 patients (54%), and 6 patients (23%) of whom were hospitalized. The main complications were periprosthetic leakage, increased granulation around the tracheoesophageal shunt and stenosis of the trachea stoma. There were no significant differences in the frequency of complications in the background factor of the patients as far as age (p = 0.495), radiation therapy (p = 0.686) or reconstruction time (p = 0.257) were concerned. Candida species was detected in 81% of the specimens which we submitted to a culture test and confirmed the pseudohyphae which comfirmed the pathogenicity from the histopathological examination. Moreover, radiation therapy was significantly associated with the detection of candida (p = 0.004). Permanent closure of the tracheoesophageal shunt for periprosthetic leakage was required in one patient, but we were able to deal with the other complications. No patient experienced any life-threatening complications and all are safely using the prostheses. It has been reported that complications will occur over the long-term, thus careful follow-up is necessary.

Voice prosthesisを用いた気管食道シャント手術による術後音声機能獲得に関する検討

voice prosthesisを用いた気管食道シャント手術による術後音声機能獲得に関する検討

Near-total Laryngectomy: An Oncologically Safe Alternative

ABSTRACT Traditional treatment for advanced transglottic laryngeal and hypopharyngeal cancers is wide field laryngectomy. Patients who undergo wide field laryngectomy must also undergo voice rehabilitation with a prosthesis, electrolarynx or esophageal speech. These are associated with complications, such as bloating of the stomach, stenosis, aspiration and difficulty with hygiene of the TEP prosthesis. Near-total laryngectomy is a surgical treatment modality, where speech is maintained by way of a dynamic myomucosal shunt. It was specially designed to overcome the serious complications of adynamic tracheoesophageal shunt methods. How to cite this article Dass A, Singhal SK, Gupta N, Verma H. Near-total Laryngectomy: An Oncologically Safe Alternative. Int J Phonosurg Laryngol 2014;4(1):30-32.

The Amatsu's Tracheoesophageal Shunt: Analysis of 84 Cases

Amatsu's tracheoesophageal shunt can be indicated for vocal rehabilitation in candidates to total laryngectomy. It is performed in the period of the procedure of total laryngectomy and has been indicated due to its technical facility, exemption from the use of voice prosthesis, and lack of additional costs for its maintenance. To evaluate the results obtained with the Amatsu's tracheoesophageal shunt, along 14 years of experience, in two Brazilian hospitals. Clinical retrospective. From 1991 to 2005, eighty-four patients were submitted to the Amatsu's tracheoesophageal shunt. Seventy-seven (91.7%) were male and seven (8.3%) female, aged between 30 and 82 years, mean age of 57.5 years, and an average age of 52 years. All patients had squamous cell carcinoma of larynx and/or hypopharynx. Sixty-eight (81.0%) were stage III or IV. They were submitted to total laryngectomy and the Amatsu's tracheoesophageal shunt was performed during the tumor removal surgery. The following variables were analyzed: acquisition of intelligible speech, vocal recovery time after surgery, and the occurrence of specific surgical complications of the shunt (pulmonary aspiration). Seventy-six patients were evaluated with respect to the effectiveness of the technique. Fifty-three patients (70.0%) presented vocalization by the shunt; in 46 patients (60.5%), the speech was fully intelligible. The time required for restoration of speech was 12-87 postoperative days. Of the 83 patients evaluated in relation to the development of complications, 25 (30.1%) presented aspiration by the shunt during oral ingestion. In 23 patients (27.7%), the aspiration was managed conservatively without complications. Two patients (2.4%) required surgical closure of the shunt due to intractable aspiration. Vocal rehabilitation with the Amatsu's tracheoesophageal shunt is effective in most patients who underwent total laryngectomy. It can be evidenced by the acquisition of intelligible speech in most patients. The aspiration, although often, is not shown to be a limiting complication.

TEシャント発声でのQOL

TEシャント発声でのQOL

A prospective randomized multicenter clinical trial of the Provox2 and Groningen Ultra Low Resistance voice prostheses in the rehabilitation of post-laryngectomy patients: A lifetime and preference study

To prospectively study patients' preference for and the lifetime of the Groningen Ultra Low Resistance (GULR) and Provox2 tracheo-esophageal shunt prosthesis (TESP, plural TESPs) in post-laryngectomy patients. Eighty post-laryngectomy patients were included in 4 oncological centers in the Netherlands. We used a repeated measures design study with 4 randomized groups in a partial cross-over design using 3 consecutive TESPs (3 intervals) in different orders. (Group 1: GULR-GULR-GULR; Group 2: GULR-GULR-Provox2; Group 3: Provox2-Provox2-GULR; and Group 4: Provox2- Provox2-Provox2). Replacement dates and reasons for replacement were monitored with questionnaires as were patients' preferences for GULR or Provox2. A great variability of lifetime within and between groups was seen. Mean lifetimes found (all groups and intervals added) were 106.2 and 102.7 days, and median lifetimes were 76 and 65 days for GULR and Provox2, respectively. Lifetime showed no significant differences between groups, intervals, and TESP types. Many patients dropped out due to reasons having to do with GULR-characteristics (n=21). The main dropout reason was "high phonating resistance (HPR)" (57.1%). Only 10 patients preferred GULR. A significantly larger number of patients (n=39, 79.6%) preferred Provox2 either by choice or by dropping out due to GULR-characteristics (P<0.001). The main replacement reasons were "leakage though TESP" (GULR 59.1%, Provox2 52.1%) and HPR (GULR 15.9%, Provox2 12.7%). No significant differences in lifetime between GULR and Provox2 were found. The patients' preference for Provox2 was significant (P<0.001). Patients' preference was a more important outcome measurement in TESP effectiveness than device lifetime.

In vitro Experiments with the Triangular Flap Cutter Applied to Functional Tracheoesophageal Shunt for Voice Rehabilitation after Total Laryngectomy

Backgrounds: Since the introduction and practice of functional tracheoesophageal shunt (FTES) for voice rehabilitation after total laryngectomy, patients have often suffered from fistula-related complications such as aspiration, tract stenosis and infection partly as a result of nonstandardized or incorrectly made flap operation. In striving to solve these problems as far as possible, a triangular flap cutter (TFC) was developed to perform the flap operation. Methods: Flap operations were performed using a TFC on 10 tracheoesophageal models (pigs) and 10 fresh esophageal models (esophageal cancer patients, with their informed consent) and incision parameters and incision effects were detected. Results: Perfect triangular flaps were achieved in 18 out of 20 cases using the TFC with minimal peripheral tissue injury (average time, 2–3 min). Of the 2 unsuccessful cases, 1 case exhibited insertion failure and the other experienced flap creation failure due to clinical contraindication for TFC use and insufficient operational skills, respectively. Conclusions: The TFC is a new device, which offers the unique advantage of precise incision for the creation of a flap, with the potential to resolve fistula-related problems and improve operation efficiency.

Playing a brass instrument after total laryngectomy: A case report

A brass instrument is a musical instrument in which the tone is produced by vibration of the lips as the player blows into a tubular resonator. The case of a professional brass player who continued his activity after total laryngectomy, with insertion of a voice prosthesis in a tracheoesophageal shunt, is reported. A videoendoscopic and videofluoroscopic study of the patient during brass playing was conducted. A nonvibrating, open neoglottis during brass playing was found on videoendoscopy. Videofluorography revealed an enlarged hypopharynx, a thick neoglottis while playing at lower tone; at higher pitch the tongue base was retracted, the neoglottis was thin and stretched, and the subneoglottic area was extremely enlarged. The case reported shows that the insertion of a voice prosthesis in a tracheoesophageal shunt seems to create a regulating airflow system sufficiently advanced to play a brass instrument, further reducing the disability of laryngeal speakers.

Clinical evaluation of a membrane-based voice-producing element for laryngectomized women

A newly developed artificial voice source was clinically evaluated in laryngectomized women for voice quality improvements. The prosthesis was placed in a commercially available, tracheoesophageal shunt valve. In 17 subjects, voice-producing element (VPE) prototypes were compared with the subject's regular tracheo-esophageal shunt voice in a randomized cross-over trial. The evaluation was based on aeroacoustic measurements and perceptual analysis. Considerably higher fundamental frequencies were attained with the use of the VPE. The sound pressure level also increased for most subjects. The required driving pressures of the lung and air flow rates were altered, allowing significantly longer phonation times in 1 breath. Accumulation of mucus did not interfere with the proper functioning of the device during these tests. A VPE with sound-generating membranes is suitable for providing a substitute voice source for laryngectomized patients, especially patients suggestive of a severely hypotonic or atonic pharyngoesophageal segment who can benefit from a more melodious and louder voice.

Preoperative concurrent chemoradiotherapy versus pre- and postoperative radiotherapy for advanced hypopharyngeal carcinoma: A single-center study

Objective The purpose of this study was to improve the survival and phonatory rates in patients with advanced hypopharyngeal carcinoma. Methods Seventy-two consecutive patients with advanced hypopharyngeal carcinoma were treated with pre- and postoperative radiotherapy (RTS), or preoperative concomitant chemoradiotherapy (CCRTS). Surgical procedures, including total laryngectomy plus partial pharyngectomy (TLPP) to preserve the posterior pharyngeal wall offering a functional neoglottis for esophageal or tracheoesophageal shunt phonation postoperatively, were conducted for patients who did not achieve CR. Results A significantly higher survival rate at 5 years (93.3%) was observed for N0-2b stage patients in the CCRTS group ( n = 16) than the RTS group ( n = 34; 41.5%) ( p < .005). The distant metastasis-free rate was 92.9% (CCRTS group) versus 55.4% (RTS group) ( p < .05) in these patients. In the CCRTS group, the 5-year survival rate with laryngeal or esophageal and/or tracheoesophageal shunt phonation was 22.2%. Conclusion It is suggested that the CCRTS protocol and TLPP procedure may improve the survival rates without deterioration of phonatory rates in patients with N0-2b advanced hypopharyngeal carcinoma.