Voice Restoration Research Articles

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

Effects of sound pressure levels on fundamental frequency in tracheoesophageal speakers

The quality of tracheoesophageal (TE) voice after laryngectomy is dependent on numerous factors. The relative contribution of specific variables is not well described. To evaluate the modulation of fundamental frequency (F0)—pitch—in TE speakers after total laryngectomy and voice restoration, we instructed 11 TE speakers to complete a series of vocal tasks under standardized conditions. All patients underwent standard laryngectomy with appropriate neck dissection and full-course radiation therapy. Each speaker produced 4 sustained phonations at distinct levels. Sound pressure level (SPL)—intensity—and F0 measurements were taken for each level. Statistical analysis to assess the relative effect of SPL on F0 demonstrated a statistically significant effect. However, the knowledge of SPL allowed only a 9% greater prediction of F0, indicating that factors other than SPL are integral to the modulation of F0 by TE speakers. These data lend further support to the theory that TE voice is an active process incorporating the myoelastic properties of the pharyngoesophageal segment as well as the properties of aerodynamic flow. (Otolaryngol Head Neck Surg 1999;121:23-6.)

Restoration of Voice after Laryngectomy

The importance of speech is not fully appreciated until the voice is lost. Speech is more than verbal communication; in addition, vocal intonation displays our emotional state. Cancer of the larynx is the most common head and neck malignancy in the western world1 and for a long time the only available treatment was major laryngeal surgery, (Billroth did the first total laryngectomy in 1873). Fortunately, since the advent of cobalt-60 in the 1950s and the improvement in endoscopic techniques, many patients with early disease can now be cured with radiotherapy alone or with minor surgical interventions that preserve the voice2-5. For some, however-those who do not respond and have residual disease or recurrence, and those who present with advanced diseasea major laryngeal resection provides the only hope of cure6'7. In a minority of cases partial laryngeal surgery, avoiding a permanent tracheostome, is feasible. However, the resulting voice is often poor and swallowing problems, especially aspiration, can be debilitating. In the UK, most patients who proceed to surgery still undergo a total laryngectomy. This involves the permanent separation of the respiratory tract from the upper digestive tract and the removal of the most important anatomical unit involved in voice production. It is a mutilating operation with lifelong functional and psychological consequences. Laryngectomized patients have a relatively favourable prognosis, with a 5-year survival rate of 65-75%8. Although this survival rate has changed little over the past 25 years, developments in post-laryngectomy speech rehabilitation have led to substantial improvements in quality of life. Here we offer a review of voice rehabilitation techniques.

咽喉食摘後の音声再建 遊離空腸移植によるエレファント型シャント法

A modified technique was devised for simultaneous esophageal reconstruction and voice restoration after laryngopharyngoesophagectomy. This technique minimizes the length of intestinal tract which is sacrificed and uses a free jejunal graft to create an elephant-type shunt aimed at improving the chances for successful voice restoration. The results of voice restoration with this free jejunal graft technique compared favorably with results in cases reexamined after application of Ehrenberger & Kawahara's reconstructive technique. This free jejunal graft technique is briefly described, together with endoscopic findings and barium contrast findings at the time of phonation. The endoscopic findings revealed that the grafted intestinal mucosa on the oral-cavity side constricted simultaneously with phonation. The shape of this constriction differed among patients, showing three basic patterns: uniform constriction, anteroposterior constriction and side-to-side constriction. At the time of phonation, barium fluoroscopy revealed, a dilation of the reconstructed esophagus in the vicinity of the junction with the shunt and constriction of the grafted intestinal tract. However, phonation was not always accompanied by images of constriction. Based on these findings, two possible sites for the neoglottis permitting phonation after this reconstruction technique were hypothesized: the mucosa of the shunt aperture opening mucosa and the constricting portion of the reconstructed esophagus. However, the actual site remains to be elucidated.Possible causes and solutions are also discussed for the potential problems involved with this modified reconstruction, including reflux, stenosis of the shunt opening, permanent stenosis of the tracheal opening etc.

Simultaneous reconstruction of pharyngoesophagus and phonetic shunt following laryngopharyngoesophagectomy

Because of its many advantages, free jejunal transfer has gained wide acceptance for pharyngoesophageal reconstruction after ablative surgery. Because the jejunum is well vascularized, it facilitates good wound healing, and has a low incidence of anastomotic insufficiency, fistula formation and stricture. However, voice rehabilitation in this group of patients can be difficult. Therefore, we performed primary tracheojejunal shunt operations for voice restoration with jejunum siphons using Nozaki's method (type 3). In this procedure, after dividing a section of the jejunum into two segments, the reconstructed neopharyngoesophagus is anastomosed in a side-to-end fashion to the fabricated shunt using the other segment of the jejunum, as an "elephant nose shunt" so called because of its appearance. Voice restoration can be achieved in patients who undergo laryngopharyngoesophagectomy through these reconstructive procedures. We performed this surgery for nine hypopharyngeal cancer patients after total pharyngo-laryngo-esophagectomy. Following placement of the shunt, no special care was required. Only one patient developed a severe aspiration. No leakage was seen and the swallowing function was preserved in all patients. Four of nine patients could speak well following these procedures. A vibratory source is created in the neoesophagus, above the elephant shunt. During speech production, narrowing of the inside and vibration of the jejunal mucosa can be observed using a laryngeal fiber scope. In order to study the acoustical characteristics of shunt speech, voice analysis was performed in patients with restored phonatory function using Computerized Speech Lab Model 4300 (KAY). Irregularities of pitch periods in the voice sample were measured using Jita (the pitch period) and Jitt (relative evaluation of the pitch) for the very short term (cycle-to-cycle), and PPQ (pitch period pertubation quotient) for the short term (cycle-to-cycle with a smoothing factor of 5 periods). Irregularities of the peak-to-peak amplitude were measured using ShdB (evaluation in dB of the peak-to-peak amplitude) and Shim (relative evaluation of the peak-to-peak amplitude) for the very short term (cycle-to-cycle), and APQ (amplitude perturbation quotient) for the short term (cycle-to-cycle with a smoothing factor of 11 periods). The pertubation parameters of shunt speech are larger than normal ones not only in terms of the period but also in terms of the amplitude. These results are similar to those of laryngeal polyps, recurrent nerve palsy and esophageal speech. Recovery of phonation using Nozaki's type 3 method with the elephant nose shunt appears promising for pharyngo-laryngo-esophagectomized patients.

遊離回盲部移植法による音声再建手術

遊離回盲部移植法による音声再建手術

Voice restoration after laryngectomy.

Speech therapists have traditionally played a major part in voice restoration after laryngectomy. Nurses have a potentially complementary role to play, which is explored in this article. The three main methods of voice restoration are outlined and the nurse's role in the management of laryngectomy patients is discussed.

The VoiceMaster voice prosthesis for the laryngectomized patient.

Since the introduction and performance of total laryngectomy, voice restoration has become an important issue. Voice prostheses are widely used for this purpose. Based on experience with previous and current prostheses, the important characteristics for any voice prosthesis can be defined. These characteristics are: indwelling fixation, low resistance to airflow, less bothersome and easier insertion into the tracheoesophageal (TE) fistula. Also, predictable long device life span (resistance to Candida deterioration) and easy removal of the prosthesis to allow inspection or cleaning and consequent re-insertion are desirable. The VoiceMaster voice prosthesis was developed with these characteristics in mind. The VoiceMaster prosthesis is described in this paper. The first results from the preliminary study in which the currently available VoiceMaster was tested are very encouraging.

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.)

Voice restoration and clinical outcome in patients undergoing laryngectomy with voice prostheses

Since the introduction of the tracheoesophageal fistula (TEF) technique for restoration of voice in 1983, we performed voice restoration using primary tracheoesophageal fistula in 83 patients undergoing laryngectomy. The success rate for voice restoration with TEF was 80.6% (good voice; 69.8%, fair voice; 10.8%). Thirty-one patients out of 51 patients who have been followed for over 3 years had 34 problems with TEF (15 granulations of TEF, 7 difficulties in insertion of voice prostheses, 4 stenoses of the tracheal stoma, 5 other reasons). However, most patients could use TEF by following appropriate procedures. Our results suggest that the Blom Singer TEF procedure is a safe, simple and effective means of alaryngeal communication.

Voice restoration after laryngectomy: Experience with the Blom–Singer extended‐wear indwelling tracheoesophageal voice prosthesis

Voice restoration after laryngectomy: Experience with the Blom–Singer extended‐wear indwelling tracheoesophageal voice prosthesis

Voice restoration after laryngectomy: experience with the Blom-Singer extended-wear indwelling tracheoesophageal voice prosthesis.

The Blom-Singer tracheoesophageal voice prosthesis has undergone continuous design modifications during the last 18 years to make it more effective, anatomically compatible, and easier to use. This evolution continues with the recent introduction of an indwelling-style voice prosthesis intended for use by individuals who are unable or disinclined to use a self-removable-style voice prosthesis. The a priori self-lifespan goal of the indwelling prosthesis was 180 days. The present investigation describes the experience of 81 consecutive participants who used a total of 206 indwelling voice prosthesis. Selection criteria included total laryngectomy and either primary (n = 35) or secondary (n = 46) tracheoesophageal puncture. All participants had external-beam radiotherapy either pre- or postlaryngectomy. Specifically, lifespan of the prosthesis, the effects and clinical management of fungal colonization, and participant satisfaction with this style prosthesis were studied. A prosthesis use rate of 90% was observed. Group 1 prostheses (without fungal colonization and without Nystatin therapy) exhibited a lifespan significantly longer than did group 2 prostheses (with fungal colonization and prior to Nystatin therapy) (sample mean [mean] = 185.6 days versus 80.6 days; p < .05). Group 3 prostheses (following Nystatin therapy) also exhibited a lifespan significantly longer than that of group 2 prostheses (mean = 156.1 days versus 80.6 days; p < .05). Lifespans of group 1 and group 3 prostheses were not significantly different (p < .05). The extended-wear, indwelling voice prosthesis achieved its a priori lifespan goal of 180 days (6 months) with almost uniform patient preference and without risk of increased complications. When fungal colonization was present. Nystatin therapy significantly prolonged prosthesis lifespan.

Surgical closure of persisting failed tracheoesophageal voice fistula.

Tracheoesophageal puncture (TEP) is a highly successful procedure for voice restoration. Occasionally, however, patients fail to achieve satisfactory voice or develop salivary leakage through the fistula into the trachea. Closure of the TEP is then necessary. In most cases, spontaneous closure occurs once the prosthesis has been removed. When the fistula does not close spontaneously, surgical closure is indicated to prevent aspiration and pulmonary complications. We describe a three-layer technique that employs interposition of dermal graft. The technique was used on 14 patients over a 7-year period. Most patients received irradiation to the neck. Complete closure was achieved in 13 of 14 cases; 1 patient developed partial breakdown of the closure. Our technique is relatively easy to perform and has a high success rate (92%). Irradiation did not adversely affect the closure rate.

Tracheal advancement flap for postlaryngectomy stomal stenosis.

Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. "Success" was defined as producing a stable, trouble-free stoma requiring no stenting; "partial success" as an improved stoma requiring some stenting; and "failure" as no improvement and continuous stenting. Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration.

Tracheoesophageal puncture using a flexible gastroscope and a percutaneous endoscopic gastrostomy set.

Tracheoesophageal puncture is an established procedure for voice restoration following laryngectomy. A method using a flexible gastroscope and a percutaneous endoscopic gastrostomy (PEG) set is described. This overcomes a number of problems and complications which may be encountered when using a rigid endoscope.

Tracheal advancement flap for postlaryngectomy stomal stenosis

Background Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). Methods A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. “Success” was defined as producing a stable, trouble-free stoma requiring no stenting; “partial success” as an improved stoma requiring some stenting; and “failure” as no improvement and continuous stenting. Results Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. Conclusion The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration. © 1997 John Wiley & Sons, Inc. Head Neck 19: 211–215, 1997.

Long-term results of voice rehabilitation after total laryngectomy using primary tracheoesophageal puncture in Chinese patients

Purpose: Prosthetic voice restoration is an increasingly popular method of postlaryngectomy voice rehabilitation. Despite its success in non-tonal languages, the efficacy of tracheoesophageal speech in tonal languages was largely unknown. The aim of the present study was to evaluate the long-term results of voice rehabilitation using a Blom-Singer valve (BSV) in the tonal language of Cantonese. Patients and Methods: The records of 159 patients who underwent total laryngectomy and primary tracheoesophageal puncture (TEP) between May 1985 and December 1994 were retrospectively reviewed. Tracheoesophageal speech was regarded as functional if effective communication could be made during face-to-face conversation and telephone conversation. Any TEP-related complications were noted. Perioperative factors that might contribute to nonfunctional speech were subjected to statistical analysis. Results: Six hospital mortalities were excluded from speech analysis. Of the remaining 153 patients, the median follow-up was 25 months, ranging from 3 to 113 months. Seventy-three patients had closure of tracheoesophageal fistulae (TEF), and the main causes were ineffective voice production, dislodgment, and tracheostomal stenosis. Only 15 of them acquired functional speech before closure. The other 80 patients used a BSV as the chief modality of voice rehabilitation, with functional results achieved in 64 patients. None of the perioperative factors were found to be statistically significant in relation to nonfunctional speech. Conclusion: Primary TEP is an established method of voice rehabilitation after total laryngectomy. In our series, 52% patients achieved functional tracheoesophageal speech using a BSV.

Successful Tracheoesophageal Puncture Voice Restoration in a Patient with Total Glossectomy

Successful Tracheoesophageal Puncture Voice Restoration in a Patient with Total Glossectomy

Development and Clinical Evaluation of a Second-generation Voice Prosthesis (Provox®2), Designed for Anterograde and Retrograde Insertion

Prosthetic voice restoration has considerably improved the results of vocal rehabilitation after total laryngectomy, and is presently the method of choice for many health-care providers treating laryngectomized patients. The Provox® voice prosthesis, developed in the Netherlands Cancer Institute, is an indwelling device that has been applied in recent years with regular success. Its retrograde replacement method, using a disposable guide wire, assures reliable, atraumatic positioning of the prosthesis in the tracheoesophageal fistula. However, the method sometimes may be uncomfortable for the patient; therefore an adapted prosthesis and new replacement equipment were developed, which enable bidirectional insertion, i.e. not only in the traditional retrograde manner through the pharynx, but especially in an anterograde manner through the stoma. This second-generation voice prosthesis (Provox®2) was studied in a prospective clinical trial in 44 patients (33 experienced patients, seven first-time replacements and four primary insertions). The study demonstrated that the anterograde insertion with the Provox®2 system was applicable in all patients, making the voice prosthesis even easier to handle than with the traditional retrograde method. A stenosis of the pharyngoesophageal segment no longer interfered with the replacement. In addition, the patients judged the new method as being favourable, reporting significantly less discomfort during the replacement procedure (paired Student's r-test: P -< 0.0001). Furthermore, the adapted voice prosthesis could be removed from the tracheoesophageal fistula without excessive force (mean 7.9 N, range 6.0-14.0 N), more easily than the original Provox® (mean 20.9 N, range 5.5-25.0 N). It can be concluded that this second-generation indwelling voice prosthesis (Provox®2) seems to be a further improvement in the application of this voice rehabilitation system, not only simplifying the replacement procedure, but also diminishing the discomfort for the patient.