January 20, 2004 Features

Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration

Cancer of the larynx primarily affects older individuals in the sixth and seventh decades of life. Fewer than 1% of cases occur in individuals below the age of 30 years. Excluding new cases of carcinoma in situ, and basal and squamous cell cancers of the skin, cancer of the larynx is expected to account for approximately 0.7% of the 1.3 million cases of cancer in adults in 2003.

An estimated 9,500 new cases of laryngeal cancer will have been diagnosed in 2003. Although the male-to-female ratio for laryngeal cancer in the United States is approximately 3:1, recent data show that the incidence among women is increasing. Laryngeal cancer is one of the more curable cancers of the upper aerodigestive tract, with an estimated five-year survival rate of 68%; however, this rate has not changed significantly over the past 25 years. Thus, the focus of current research has been to evaluate and improve quality of life after therapy for head and neck cancer (see Jamal et al. and Sinard et al. in the references online).

Patients with head and neck cancer often face multiple and frequently severe psychological and functional problems associated with their disease and its treatment. Preservation of the larynx with functional conservation is a primary goal of treatment in patients with laryngeal cancer but is not always possible. Patients in whom treatment has failed or whose cancer is so advanced that partial laryngectomy, radiation therapy, and chemotherapy are no longer options for cure are best treated by total laryngectomy. Whereas conservation treatment approaches are associated with a significant risk of long-term complications such as aspiration, permanent tracheotomy, and aphonia, total laryngectomy is associated with a high potential for excellent postoperative speech and swallowing, few associated complications, and minimal morbidity. This is frequently the treatment of choice.

Total laryngectomy involves removal of the entire larynx, including the cricoid and thyroid cartilages, both arytenoids, the true and false vocal folds, and the hyoid bone. The surgery results in a complete separation between the pharynx and trachea, and thus between the alimentary and respiratory pathways (see Fig. 1 for the anatomic changes due to total laryngectomy).

Swallowing function is usually preserved after total laryngectomy. Therefore, the focus of rehabilitation after total laryngectomy is restoration of voice and speech with the goal of restoring the patient's speech production to a level as close as possible to the premorbid level. With the current state-of-the-art of rehabilitation practice and technology, no patient undergoing total laryngectomy should be without s ome method of functional speech production. However, no single approach is applicable to all individuals who have had a laryngectomy.

The method of alaryngeal speech production for a given patient should be selected on the basis of the individual's needs, personality, physical capabilities, level of independent functioning, family support, and motivation. For each patient, availability of and accessibility to services provided by a knowledgeable clinician also must be considered. The clinician's skill and expertise with the method of choice is often an important factor in the patient's communication success. These factors are particularly important for patients who have had a laryngectomy and are seeking tracheoesophageal (TE) voice restoration. Thus, the selection of alaryngeal communication is multifactorial and patient specific and should never be a unilateral choice of the physician, family, or speech-language pathologist.

Speech-Language Pathology Consultation

Despite scientific and technologic advances related to laryngectomy, and the current investigative focus on post-treatment functional outcomes and quality of life, many individuals who have had a laryngectomy report never having had a preoperative consultation with a speech-language pathologist. The necessity and benefits of such consultations are most clearly demonstrated in patients who are about to undergo total laryngectomy. Patients have little understanding of the role of the larynx and its relationship to normal swallowing and speech production and have even less understanding of how these functions will be changed after total laryngectomy. Some patients even reject surgery because of their fear and limited understanding of postoperative functioning.

Preoperative consultations with speech-language pathologists provide information about the rehabilitative process, facilitate understanding of how changes in postoperative anatomy affect function, allow demonstration of the various alternatives for speech production, and provide reassurance about functional restoration and quality of life after surgery. Most important, preoperative speech-language pathology consultation eliminates the misconceptions and stereotypes associated with total laryngectomy and frequently facilitates patient acceptance of and compliance with treatment.

Alaryngeal Speech Production

The three major approaches used to restore oral communication after total laryngectomy are the artificial larynx (electrolarynx), esophageal speech, and tracheoesophageal (TE) voice restoration. Although countless laryngectomy recipients speak using an electrolarynx and others communicate via esophageal speech, TE voice restoration has emerged as the state-of-the-art and preferred approach for alaryngeal voice rehabilitation worldwide.

Artificial Larynx (Electrolarynx)

Despite significant improvements in speech production using other methods and despite the mechanical sound produced by artificial larynges, this method remains the prevailing speech alternative for most patients after total laryngectomy. Although there are numerous varieties and manufacturers of artificial larynges, they all work similarly. The electronic sound produced by these battery-powered devices is transmitted through the tissues of the neck or cheek or delivered intra-orally via a plastic tube into the oral cavity for speech production, as shown in Fig. 2.

The electrolarynx provides a simple and effective means of immediate oral communication. Although these devices offer rapid acquisition of speech ability and ease of use, many patients prefer other alternatives that offer more natural vocal quality and a capacity for hands-free communication. It is likely that the prevalence of these devices owes partly to the limited experience of speech-language pathologists with the rehabilitation of patients with laryngectomies outside of large cancer centers.

Esophageal Speech

The traditional choice for alaryngeal speech production, esophageal speech is produced when oral air is compressed into the esophagus and then expelled past the pharyngoesophageal segment, producing vibration of the pharyngoesophageal mucosa for sound production. The sound is then shaped by the articulators of the oral cavity into words and speech. Fig. 3 demonstrates this process.

Currently, few individuals who undergo laryngectomy choose to learn to produce esophageal speech or go on to become conversational esophageal speakers. Limited familiarity with the method, the time required to learn esophageal speech, and the disappointing incidence of patients who acquire the skill needed to use this technique have reduced its popularity.

TE Voice Restoration

With the potential for spontaneous, effortless speech production, TE voice restoration has often been cited as the alaryngeal speech alternative most comparable to normal laryngeal speech in quality, fluency, and ease of production. Compared with artificial larynges and esophageal speech, TE speech production is characterized by better speech quality, longer phonatory duration, and louder voice. Individuals with layngectomies who are TE speakers are generally more satisfied with their speech than are those who use an artificial larynx or esophageal speech. In addition, TE speakers are generally less frustrated than other alaryngeal speakers and report fewer limitations in their communication interactions.

Technique

TE voice restoration depends on the creation of a small surgically created fistula or puncture through the party wall between the trachea and the esophagus. The opening is maintained by a prosthesis with a unidirectional valve that opens to divert pulmonary airflow into the esophagus for sound production when the tracheostoma is occluded but prevents saliva and food from entering the trachea during swallowing. The sound egresses superiorly into the mouth, where the structures of the oral cavity then shape the sound into words for speech production. Fig. 4 illustrates the method of TE speech production.

The TE puncture can be performed at the time of total laryngectomy, thus eliminating the need for a second surgery and enabling patients to speak immediately after surgery. However, there are some patients-for example, those who have been heavily irradiated-for whom the risk of complications associated with the procedure is great. In these cases, TE puncture is more advisable after the patient has fully healed from surgery. In general, however, complications resulting from TE puncture are rare, and patients usually leave the office speaking after they have been fitted with an appropriate TE voice prosthesis.

Evaluation

Successful TE speech outcomes depend on careful evaluation of many factors and selection of the best prosthesis for the particular patient. When the method of TE voice restoration was first introduced and its use reported by Singer and Blom in 1980 (see references online), only one type of voice prosthesis was available, the duckbill, so named because its distal end opened and closed like the bill of a duck. Later, the tracheostoma breathing valve with peristomal attachment was introduced to allow TE speech without use of a finger or thumb to occlude the stoma, thus enabling hands-free communication. As the popularity of the method increased and scientific investigation grew, new prostheses and devices were developed and later marketed to enhance the overall quality of life of people with laryngectomies. 

Prostheses

A variety of prostheses are available for TE voice restoration. The standard TE prostheses, which are managed by the patient, a family member, or both, include duckbill prostheses, low-pressure prostheses with or without increased resistance to airflow, and ultra-low-pressure prostheses. All are available in 16- or 20-Fr diameters (see Figs. 5-8 for illustrations of these and the following prostheses).

Indwelling type prostheses are designed primarily for patients who cannot manage their prosthesis independently. These prostheses must be removed and inserted by a speech-language pathologist, physician, or trained medical professional.

Some standard and indwelling prostheses have a small hood that projects from the distal end to cover the internal valve; others do not. After a complicated reconstruction of the pharynx or esophagus, the esophageal lumen may be small or the TE tract unusually positioned. The ability to select and place an appropriate TE voice prosthesis often requires considerable familiarity with the various types of postoperative anatomy and with characteristics of the individual patient. Just as a single optical prescription will not fit everyone who wears glasses, not every TE speaker should wear the same type of TE voice prosthesis. Each prosthesis has advantages and disadvantages, and the selected device should accommodate the patient's physical and vocal needs and remedy the presenting complication.

One advantage of TE voice restoration is that it offers the possibility of hands-free communication using a tracheostoma breathing valve (TSBV) to automatically shunt air into the esophagus for voice production, effectively eliminating the need for manual occlusion of the stoma utilizing a digit or thumb. Again, the devices vary and should be selected on the basis of the patient's individual needs. Some TSBVs are spring loaded, and some have a small diaphragm that closes in response to an increased build-up of pulmonary "back-pressure" against the valve to close it, thereby shunting air into the esophagus without the need for manual occlusion of the stoma. Adherence of hands-free valves may be achieved peristomally with adhesives and tapes or intraluminally using specially designed devices.
Separation of the upper and lower airways due to total laryngectomy results in respiratory changes. A variety of heat and moisture exchange systems are available to restore preoperative respiratory functions that are lost as a result of the separation of the airway from the nasopharynx after total laryngectomy, such as warming and filtering the air, and regulation of the resistance to airflow. Restoration of these functions should be attempted in all patients who have undergone a laryngectomy because they are essential to maintaining healthy respiration, thereby reducing and preventing postoperative respiratory complications such as excessive mucus production, crusting, and bleeding.

Problems

Most problems experienced by TE speakers are related to the management and use of the TE prosthesis. They include problems experienced during sizing, fitting, removal, and replacement of the TE voice prosthesis. Over the past 10-15 years, improved design, an increased variety of devices, and better training have significantly reduced the incidence and severity of these types of complications.

Additionally, problems may occur that are directly related to the laryngectomy itself, including pharyngeal constrictor tightening or "spasm" (see Fig. 9), hypopharyngeal narrowing or stricture, flaccidity of the neoglottic segment, and stomal stenosis and irregularity. Some of these problems may be exacerbated by gastroesophageal reflux and yeast colonization within the oropharynx, which are common in individuals who have undergone laryngectomy.

The problems associated with TE voice restoration may limit speech production and cause frustration to TE speakers but usually can be corrected when accurately identified. The use of botulinum toxin (Botox) injection as a noninvasive treatment for the relief of muscle spasm has been very successful in facilitating fluent TE voice production and is preferred over surgical alternatives.

In addition to pharmacologic alternatives, improved surgical techniques, advances in the design of intraluminal devices for breathing valve attachment, and better prosthetic construction have reduced the magnitude of complications and, in many cases, virtually eliminated them.

Clearly, TE speech restoration is not simply a matter of "popping in" a prosthesis. Although the method of TE voice restoration is simple in theory, its success ultimately requires a speech-language pathologist with substantial knowledge and experience. Access to a strong multidisciplinary team including specialists in head and neck surgery, maxillofacial prosthodontics, plastic surgery, and other disciplines will help clinicians to provide optimal postoperative rehabilitation

Speech Treatment

In many instances, speech treatment for TE speakers is offered as a technical formula for prosthetic mastery. The goals of selecting and fitting the appropriate voice prosthesis, attaching a tracheostoma breathing valve, and troubleshooting problems often define treatment. Once the goals have been met, speech treatment is frequently terminated. The patient is discharged with instructions for caring for the prosthesis and obtaining supplies.
Superior TE speech, however, is not synonymous with the ability to place and maintain a prosthesis. Because of the near-normal quality of TE speech, individuals with laryngectomies often select TE voice restoration because of the desire to fit in again and to draw little attention to themselves. Yet, while TE speech has been compared with normal laryngeal speech, execution of this method of alaryngeal communication remains quite different. Because of the need to use a digit-to-stoma application or a tracheostoma breathing valve, many patients develop extraneous movements or behaviors to shunt the air, unaware that these behaviors are often distracting, unnatural, and unhygienic. Neither do the variations in inflection and intonation, patterns of stress, intensity, prosody, and fluency-hallmarks of laryngeal speech-follow naturally after placement of a prosthesis.

If the aim of TE voice restoration is to facilitate verbal communication similar to premorbid functioning, then treatment must go beyond the single goal of speech production. Superior TE speakers master the fundamentals of the method but also refine and maximize it to reach their ultimate potential to communicate in a socially acceptable way. The speech-language pathologist should be careful not to prematurely discontinue treatment for a patient who might benefit from further intervention.

Present and Future

The state of alaryngeal communication has advanced considerably since its inception, when only one artificial larynx was available, esophageal speech training required several months, and only one prosthesis was available for tracheoesophageal speech.

Advances in technology continue to parallel the proliferation of advances in medicine, surgery, and reconstruction. Patients are now sophisticated and informed. There is a clear expectation of success with little tolerance for failure. Speech-language pathologists treating individuals with laryngectomies must be highly skilled and knowledgeable in the area of alaryngeal voice rehabilitation.

Practicing clinicians must continue to receive training in state-of-the-art alaryngeal rehabilitation. Graduate training programs must partner with institutions to train students, and experienced clinicians must provide mentorships for clinicians. Thus we will ensure excellent service and maximal patient success and quality of life after total laryngectomy. 

Jan S. Lewin, is associate professor of speech pathology and audiology at the University of Texas M.D. Anderson Cancer Center. Contact her by e-mail at jlewin@mdanderson.org.

cite as: Lewin, J. S. (2004, January 20). Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration. The ASHA Leader.

References

Jemal, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E., & Thun, M. J. (2003). Cancer statistics 2003. Cancer Journal for Clinicians2003, 53(1), pp. 5-26.

Sinard, R. J., Netterville, J. L., Garrett, C. G., & Ossoff, R. H. (1996). Cancer of the larynx. In E. N. Myers & J. Y. Suen, eds. Cancer of the head and neck, (pp. 381-421). Philadelphia: W. B. Sauders Company.

Singer, M. I., & Blom, E. D. (1980). An endoscopic technique for restoration of voice after total laryngectomy. Annals of Otology, Rhinology and Laryngology, 89, pp. 529-533.



Figures

Click on figure to see details.

 

Fig. 1a

Figure 1: Normal anatomy (L) and anatomic changes after total laryngectomy.

Fig. 2a

Figure 2: Artificial larynx (Electrolarynx), neck placement (L) and intraoral placement.

Fig. 3a

Figure 3: Esophageal speech.

Fig. 4a

Figure 4: Tracheoesophageal (TE) speech.

Fig. 5a

Figure 5: Prostheses for tracheoesophageal voice restoration (16- and 20-Fr), InHealth low pressure (L) and Bivona duckbill;

Fig. 6a

Figure 6: Indwelling prostheses for tracheoesophageal voice restoration, ATOS Provox 2 (L) and InHealth InDwelling.

Fig. 7a

Figure 7: Tracheostoma breathing valves (TSBV) and types of neck attachments (L-R) Bivona springloaded TSBV with intraluminal attachment, ATOS Provox Larytube with ring and TSBV, Peristomal attachment of a single valve housing (note TE voice prosthesis at superior portion of stoma), InHealth TruSeal adhesive housing for peristomal attachment and adjustable TSBV, Barton Mayo Button (L), button placed within the stoma (middle), and button with TSBV attached (note the lack of peristomal adhesives and tapes).

Fig. 8a

Figure 8: Heat and moisture exchange systems (L-R) Kapitex Trachi-Naze Plus Stoma Stud and filters and system worn by patient, ATOS Provox adhesive base plates with HME cassettes, InHealth Blom-Singer Adjustable Tracheostoma Valve II (ATSV II) kit with Humidifier Cap, ATOS Provox Larytube with HME cassette;

Fig. 9a

Figure 9: Problems with tracheoesophageal (TE)voice restoration, Lateral radiograph demonstrating pharyngeal constrictor spasm.

 


  

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