Tracheoesophageal Voice Restoration Research Articles

Tracheoesophageal Prosthesis Use Is Associated With Improved Overall Quality of Life in Veterans With Laryngeal Cancer.

Veterans have an increased risk of laryngeal cancer, yet their oncologic and functional outcomes remain understudied. We sought to determine the longitudinal impact of tracheoesophageal puncture and voice prosthesis on quality-of-life measures in veterans following total laryngectomy (TL). We performed a cross-sectional analysis of TL patients (n = 68) treated at the Michael E. DeBakey Veterans Affairs Medical Center using the Voice Handicap Index (VHI), MD Anderson Dysphagia Index (MDADI), and University of Washington Quality of Life Index (UW-QOL). Using tracheoesophageal (TE) speech was associated with significantly better VHI, MDADI, and UW-QOL scores compared to other forms of communication. The association between TE speech use on VHI, MDADI, and UQ-QOL persisted even when the analysis was limited to patients with >5-year follow-up and was maintained on multivariate analysis that accounted for a history of radiation and laryngectomy for recurrent laryngeal cancer. Using tracheoesophageal speech after total laryngectomy is associated with durable improvements in quality of life and functional outcomes in veterans. Tracheoesophageal voice restoration should be attempted whenever technically feasible in patients that meet the complex psychosocial and physical requirements to appropriately utilize TE speech.

Device Life of the Tracheoesophageal Voice Prosthesis Revisited

ImportanceVoice prosthesis (VP) device life is a limiting factor of tracheoesophageal (TE) voice restoration that drives patient satisfaction, health care costs, and overall burden. Historic data suggest that TE VPs have an average device life of generally 3 to 6 months, but these data are typically derived from small samples using only 1 or 2 devices.ObjectiveTo reexamine current device life in a large, contemporary cancer hospital in the United States that uses a wide assortment of VPs.Design, Setting, and ParticipantsThis retrospective observational study included 390 laryngectomized patients with a tracheoesophageal puncture (TEP) who had VP management at MD Anderson Cancer Center between July 1, 2003, and December 31, 2013.Main Outcomes and MeasuresTracheoesophageal voice–related outcomes were: (1) device life duration to VP removal, and (2) treatment-related and prosthetic-related factors influencing device failure. Primary independent variables included treatment history (extent of surgery and radiation history), VP type (indwelling vs nonindwelling, size, specialty features), and reason for removal (leakage, complication, other). Duration was examined using Kaplan-Meier analysis. Disease, treatment, and patient-specific factors were analyzed as predictors of duration.ResultsOverall, 3648 VPs were placed in the 390 patients (median [range] age, 62 [34-92] years). Indwelling prostheses accounted for more than half (56%) of the devices placed (55%, 20-Fr diameter; 33%, 8-mm length). More than two-thirds (69%) of prostheses were removed because of leakage, while the rest were removed for other reasons. Median device life was 61 days for all prostheses. Indwelling and nonindwelling VPs had median device lives of 70 and 38 days, respectively. There was no significant difference between specialty prostheses compared with standard devices (median duration, 61 vs 70 days, respectively). The Provox ActiValve (Atos Medical) had the longest life. Neither radiation therapy nor extent of surgery had a meaningful impact on device life.Conclusions and RelevanceOur data suggest that VP duration demonstrates a lower durability than historically reported. This may reflect the intensification of treatment regimens that complicate TEP management in an era of organ preservation; however, further investigation is needed.

The Effect of Initial Tracheoesophageal Voice Prosthesis Size on Postoperative Complications and Voice Outcomes.

The optimal initial size of tracheoesophageal voice prosthesis (TEVP) for tracheoesophageal voice restoration (TEVR) remains unclear. As purported advantages exist favoring the placement of both 16F and 20F prostheses, this study compares complications and voicing outcomes after placement of 16 and 20 French (F) prostheses. All cases of TEVR at an academic medical center were retrospectively reviewed (2007-2013). Complications including dislodgement, leakage, infection, and granulation tissue were compared. Outcomes including frequency of prosthesis change, acquisition of speech, and time to fluent speech were compared. Of 47 patients, 25 received 20F prostheses, and 22 received 16F. Postoperative complications were similar between groups, including leakage around the prosthesis (P = .373) and aspiration pneumonia (P = .670). There were no significant differences in timing of voicing or ability to achieve fluency. Although the 20F group appeared to undergo fewer prostheses changes per year (3.0 vs 5.3) and had a longer duration of use before first prosthesis change (76 vs 43 days), neither difference was found to be statistically significant. Voice restoration was successfully achieved using either 16F or 20F prostheses. Prosthesis diameter did not significantly affect complications or voicing. Both prostheses may be placed with safety and efficacy, allowing the practitioner to choose based on the potential individual benefits of either device.

Placement of a 16-French voice prosthesis at the time of secondary tracheoesophageal voice restoration

PurposeTracheoesophageal voice restoration (TEVR) has traditionally been described with fistula tract creation, catheter placement, and prosthesis placement. Prosthesis placement at the time of tracheoesophageal puncture (TEP) utilizing 20-French prostheses has been previously described. Smaller initial prostheses may allow fluent speech with reduced long-term complications, such as widening of the fistula and peri-prosthesis leakage. This study evaluates the safety and efficacy of the 16-French prostheses placement at the time of secondary TEP. MethodsAll cases of 16-French tracheoesophageal voice prosthesis (TEVP) placement at the time of secondary TEP were reviewed from 1/2011 through 12/2013 at a large academic medical center. Perioperative complications attributable to device placement were recorded, including inability to place prosthesis, intraoperative complications, post-operative infection, prosthesis dislodgement, prosthesis leakage, and inability to obtain voice. ResultsTwenty-one patients received placement of a 16-French TEVP at the time of secondary TEP. All prostheses were placed without intraoperative complications. The proportion of patients who had minor complications within the first postoperative month was 23.8%, including leakage through the prosthesis (3 of 21), granulation tissue near the prosthesis (1 of 21), retained sheath (1 of 21) and prosthesis displacement (1 of 21). Leakage and displacement were addressed with change and replacement, respectively. Fluent voicing was achieved in 85.7% patients, with a median time to voicing of 18.5days. ConclusionsPlacement of 16-French TEVPs is effective and safe, with an acceptable rate of minor complications attributable to the prosthesis. Therefore, a smaller prosthesis may be primarily placed at the time of secondary TEP and is our preference.

Primary Placement of a 16 French Voice Prosthesis at the Time of Tracheoesophageal Voice Restoration

Objectives: Tracheoesophageal voice restoration (TEVR) has traditionally been described with fistula tract creation, catheter placement, and secondary prosthesis placement. Successful primary prosthesis placement at the time of primary or secondary puncture using a 20 French prosthesis has been previously described. We now wish to evaluate whether 16 French prostheses can be used safely and effectively. Methods: All cases of primary 16 French tracheoesophageal voice prosthesis (TEVP) placements at a large academic medical center were retrospectively reviewed from January 2011 through December 2013. Perioperative complications attributable to device placement were recorded. These included inability to place prosthesis during procedure, intraoperative issues with primary placement, postoperative infection, prosthesis dislodgement, leakage around/through the prosthesis, or inability to obtain voice. Results: Twenty-two patients received primary placement of a 16 French TEVP. All prostheses were successfully placed, and there were no intraoperative complications. Approximately 18% of patients had a postoperative complication, including leakage through the prosthesis (3 of 22) and prosthesis displacement (1 of 22). These were addressed with prosthesis change and replacement, respectively. Conclusions: Placement of 16 French TEVPs is effective and safe, with a low rate of complication directly attributable to the prosthesis itself. Therefore, a smaller prosthesis may be primarily placed at the time of TEVR and is preferred over the previously described 20 French prosthesis.

Novel therapeutic approach to relieve pharyngoesophageal spasm after total laryngectomy

Total laryngectomy results in a variety of functional changes including the loss of normal laryngeal voice and alterations in swallowing physiology.1 The current literature recognizes tracheoesophageal (TE) voice restoration as the preferred alaryngeal speech alternative in most patients with total laryngectomy. The method depends on the use of a unidirectional valved prosthesis that maintains the TE puncture and also allows pulmonary air flow into the esophagus for phonation while preventing aspiration during swallowing.

A Contemporary View of Tracheoesophageal Voice Restoration

Voice restoration following total a laryngectomy has evolved over the past several decades. The patient who undergoes a total laryngectomy with tracheoesophageal (TE) puncture moves through several phases of treatment during their postoperative recovery and vocal restoration. The method of TE puncture is relatively simple; however, TE voice restoration is often complicated by the challenges associated with more intensive cancer treatment regimens, the geographical distance that impedes access to rehabilitative services, and myriad available products that require specialized knowledge and experience. In this article, we will provide a contemporary view of TE voice restoration, including its challenges for patients and clinicians. In addition, we will discuss the speech-language pathologist's role in the patient's rehabilitation, from providing evaluation and instruction regarding voice restoration and care of the stoma to ensuring the patient's transition back into their normal daily routine.

Outcomes of Elective Total Laryngectomy for Laryngopharyngeal Dysfunction in Disease‐Free Head and Neck Cancer Survivors

Total laryngectomy (TL) can be offered for management of chronic aspiration, radionecrosis, and/or airway compromise after head and neck cancer (HNC) treatment. The objective of this study was to evaluate functional outcomes after TL in disease-free HNC survivors. Retrospective case series with chart review. The University of Texas MD Anderson Cancer Center. Twenty-three disease-free HNC survivors who underwent TL for laryngopharyngeal dysfunction. TL ± pharyngectomy. Post-TL swallowing-related (diet, gastrostomy dependence, and pneumonia rates) and communication outcomes. All patients who underwent TL for dysfunction were previously treated with radiotherapy (12/23, 52%) or chemoradiotherapy (11/23, 48%). Preoperative complications included aspiration (22/23, 96%), pneumonia (16/23, 70%), tracheostomy (9/23, 39%), and stricture (7/23, 30%); 17 patients (74%) required enteral/parenteral nutrition, and 13 of 23 (57%) were nothing per oral (NPO). Rates of pneumonia, NPO status, and feeding tube dependence significantly decreased after TL (P < .001). At last follow-up after TL, all patients tolerated oral intake, but 4 (17%) required supplemental enteral nutrition. Continued smoking after radiotherapy and a preoperative history of recurrent pneumonia were significantly (P < .05) associated with final tube dependence and/or diet level. Sixteen patients (70%) underwent tracheoesophageal (TE) puncture, and 57% (13 of 23) communicated using TE voice after TL. Salvage TL may improve health status by significantly decreasing the rate of pneumonia and improve quality of life by restoring oral intake in patients with refractory laryngopharyngeal dysfunction after HNC treatment. TE voice restoration may enhance functional outcomes in select patients treated with elective TL for dysfunction.

A brief review of voice restoration following total laryngectomy

Despite advances in conservative laryngeal surgery and radiotherapy, total laryngectomy still remains the procedure of choice for advanced-stage (UICC T3 and T4) laryngeal carcinoma, around the world. The functional rehabilitation of the laryngectomized patients has been a concern of head and neck surgeons and speech therapists. Significant developments in speech rehabilitation over the past three decades have led to substantial improvements in the quality of life of these patients. The tracheoesophageal (TE) voice prosthesis has become the gold standard in various centers for voice rehabilitation since its introduction in 1980. Successful tracheoesophageal voice restoration in laryngectomy patients can be very rewarding and patients no longer have to live in silence while they await the results of their cancer treatments. They can face the challenges of life with the knowledge that a near normal quality of life is very much possible.In this article, we present a brief review of voice restoration following laryngectomy.

Pharyngolaryngectomy with free jejunal autograft reconstruction and tracheoesophageal voice restoration: Indications for replacements, microbial colonization, and indwelling times of the Provox 2 voice prostheses

The purpose of this prospective study was to investigate shunt-related and device-related complications and microbial colonization of voice prostheses in patients after pharyngolaryngectomy with jejunal autograft reconstruction in comparison to patients after standard laryngectomy. Nine patients after pharyngolaryngectomy with jejunal autograft reconstruction (group 1) and 14 patients after standard laryngectomy (group 2) equipped with the Provox(®) 2 voice prostheses were followed up over 2 years. Anamnestic data, documentation of shunt-related or device-related complications, the Provox(®) 2 indwelling time, and standard microbiological procedures of voice prostheses were used for analyses. A total of 157 prostheses were replaced. No significant difference in mean prosthesis indwelling time (p = .45) was observed between group 1 (116 ± 114 days) and group 2 (129 ± 99 days). Patients with jejunal autograft reconstruction needed prosthesis replacements more frequently within the first 60 days after prosthesis insertion in comparison to patients after standard laryngectomy (p = .007). The main indication for replacement in both groups was the device leakage (group 1: 93.1%, group 2: 92.1%). Prostheses of group 1 were more often colonized with Staphylococcus aureus (p = .027) and Enterobacteriaceae (p = .015). This study demonstrated that, in comparison with patients after standard laryngectomy, patients after jejunal autograft reconstruction have similar shunt-related and device-related complications and prosthesis indwelling times. Therefore, tracheoesophageal voice rehabilitation could be strongly recommended in these patients.

Surgical voice restoration after total laryngectomy: An overview

Total laryngectomy is potentially a debilitative surgery resulting in compromise of some of the most basic functions of life including speech and swallowing. This may have a profound adverse effect on the patient's physical, functional, and emotional health, and may result in a decreased quality of life (QOL). Until the 1980s, total laryngectomy was regarded as a dreadful, but often, life-saving procedure for which there was little alternative, and was used as a last resort. At that time survival at any cost in terms of QOL was paramount and many laryngectomies were forced into an isolated life as a mute and dysphasic recluse. Most attempts at voice restoration produced inconsistent results and often techniques were laborious, expensive, and ineffective, particularly when carried out as a salvage procedure after failed radiotherapy. Progress in voice rehabilitation, following total laryngectomy, over the last 30 years, has made an enormous difference in the whole concept of the management of laryngeal cancers. Currently there are several options available for these patients, namely, esophageal speech, artificial larynx, and tracheoesophageal speech. The choice of speech rehabilitation varies from patient to patient, but tracheoesophageal voice has become the preferred method. This article provides a brief account of surgical voice restoration after total laryngectomy. Special emphasis has been given to the surgical technique, special considerations, complications, and the prevention / treatment of tracheoesophageal voice restoration.

A Short Perspective on the Surgical Restoration of Alaryngeal Speech

Despite advances in conservative laryngeal surgery and radiotherapy, total laryngectomy still remains the procedure of choice for advanced-stage laryngeal carcinoma around the world. The loss of natural voice is very often traumatic for the total laryngectomy patient, presenting lifelong challenges for communication in a world that relies heavily on verbal communication. Functional rehabilitation of these patients has long been one of the major challenges facing clinicians, but it is only in the last three decades that the emphasis on restoration of function and quality of life has become almost as important as cure and survival. Although voice restoration for alaryngeal speakers can be attained with any of 3 speech options - esophageal speech, electrolarynx and surgical voice restoration (SVR) using a valve the SVR technique has today become the preferred method and 'gold standard.' Successful tracheo-esophageal voice restoration in laryngectomy patients can be very rewarding, and patients are no longer condemned to silence while they await the results of their cancer treatments. They can face the challenges of life with the knowledge that a near-normal quality of life is very much possible.

Voice Restoration With the Advantage Tracheoesophageal Voice Prosthesis

To determine whether the Blom-Singer indwelling Advantage tracheoesophageal voice prosthesis (TEP) extends prosthesis life span significantly in patients with documented premature device failure due to fungal colonization. Data were collected in a prospective manner on a total of 42 standard indwelling TEP users who exhibited early device failure, that is, between 2 weeks and 6 months, due to fungal colonization of the flap valve despite appropriate use of oral antifungal agents. There were 29 men and 13 women, whose ages ranged from 36 years 10 months to 86 years 8 months. Baseline data were derived from the average number of days 3 previous standard indwelling prostheses functioned before leaking. An Advantage indwelling TEP was placed after the third change, oral antifungal agents stopped, and routine care implemented, that is, flush and brush the device in situ twice each day. Each participant was assigned to 1 of 3 groups. Group 1 had device failure equal to or less than 2 months (n = 12). Group 2 had device failure between 2 and 4 months (n = 19). Group 3 had device failure between 4 and 6 months (n = 11). Groups 1 and 2 exhibited significantly longer device life span, that is, 77 and 82 days, respectively (P < 0.01), and group 3 exhibited device life span that was longer but not significantly so, that is, 12 days (P > 0.05), after the change from standard to Advantage TEP. Individual data indicated that the majority of participants, that is, 32 of 42 (76.2%), experienced longer device life span after changing to the Advantage prosthesis. Specifically, 9 of 12 (75.0%) users in group 1, 17 of 19 (89.5%) users in group 2, and 6 of 11 (54.5%) users in group 3 exhibited longer device life span. The combination of using an Advantage TEP, discontinuing oral antifungal agents, and reducing the number of both TEP changes and clinic visits resulted in overall cost benefits for both the user and the health care system. The cost benefit for group 1 was dollar 520.00; group 2, dollar 393.00; and group 3, dollar 204.25. The Advantage TEP extended device life span significantly for standard indwelling device users with documented premature device failure due to fungal colonization, reduced costs associated with tracheoesophageal voice restoration rehabilitation, and enhanced user satisfaction by eliminating use of oral antifungal agents and reducing clinic visits. Use of an Advantage indwelling voice prosthesis is warranted from both cost and user satisfaction perspectives when early and repeated device failure occurs as a result of fungal colonization. B-3.

Tracheoesophageal Voice Restoration following Laryngotracheal Separation Procedure

Laryngeal dysfunction leading to incompetence and intractable aspiration can be a life-threatening problem. Laryngotracheal separation (LTS) can be used to prevent aspiration, but results in aphonia. The options for laryngeal speech following LTS are limited. We performed tracheoesophageal puncture (TEP) and insertion of a Blom-Singer valve in 3 patients in an attempt to restore their voice after LTS for chronic aspiration. Two patients had intractable aspiration (5 and 14 years) after full-course radiotherapy for laryngeal cancer, and 1 patient had aspiration after a stroke. In the first patient TEP was done as a secondary procedure, and in the other 2 patients it was done at the time of the LTS. The TEP was successful in providing these patients with phonation ability after their LTS procedure. There was no morbidity from these procedures. Creation of a TEP after an LTS procedure is relatively simple and relatively safe, and allows for the control of aspiration while maintaining vocal function.

Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration

Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration

Where are we in the use of tracheoesophageal puncture voice restoration: some possible complications on the horizon

Where are we in the use of tracheoesophageal puncture voice restoration: some possible complications on the horizon

Tracheoesophageal Voice Restoration: Origin – Evolution – State-of-the-Art

Tracheoesophageal voice has gradually evolved worldwide as a viable option for voice restoration following total laryngectomy. This article presents a brief overview of the principal surgical and prosthetic aspects of this technique.

Tracheoesophageal voice restoration following a total laryngectomy

Tracheoesophageal voice restoration following a total laryngectomy

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls ( p > 0.05). No significant differences ( p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences. (Otolaryngol Head Neck Surg 1998;118:771-6.)

TE Voice Restoration Following Total Laryngectomy

Educational objectives: To perform primary and secondary tracheoesophageal voice restoration procedures and measure, fit, and trouble-shoot tracheoesophageal voice prostheses.