2011 Alaryngeal Speech



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Dr. Supreet Singh Nayyar, AFMC

2011


Alaryngeal Speech

Role of larynx in Voice Production

  • Generator

    • Diaphragm , chest muscles, ribs, abdominal muscles and lungs

    • Provides and regulates air pressure to cause vocal folds to vibrate

  • Phonator

    • Larynx , vocal folds

    • Vibrate changing air pressure to sound waves producing voiced sound/buzzy sound

    • Varies pitch of the sound

  • Resonator

    • Pharynx, oral cavity, nasal passages.

    • Changes the buzzy sound into recognizable voice




  • Voice restoration options:

    • Esophageal

    • External vibratory voice

    • Fistula (or shunt) based




  • Oesophageal speech

  • Trapping air in the mouth or pharynx and propelling it into the esophagus

    • Closure of lips

    • Relaxation of PE segment

    • Retropulsion of tongue

  • Approximately 80ml of air can be stored in the esophagus or stomach (Bellow)

  • Using gentle contraction of abdominal & chest muscles, Controlled regurgitation of air past the mucosa of PE segment (Neoglottis / pseudoglottis)

  • Mucosa of ant & post walls approx. because of a bulge in the post pharyngeal wall bteween 4th & 7th vertebra

  • Neoglottis can be tuned to some degree by thyropharyngeus or middle constrictor muscle

  • Produces a belch-like sound

  • Articulated by the tongue, lips, and teeth

  • Patient learns how to rapidly insufflate and eject air through his or her esophagus to produce understandable speech

  • Advantages

    • Vs Electrolarynx

      • Less conspicuous than artificial larynx

      • Requires no batteries

      • Does not sound mechanical

      • Hands free

    • Vs TEP

      • No additional surgery

      • In motivated patients with contraindications for TEP

      • Freedom from prosthesis maintenance

      • Lower Cost

      • Comparable speech quality

  • Disadvantage

    • Low success rates (upto 50%)(Stell Maran)

    • Only 4-6 words per breath, ↓Duration of phonation

    • Choppy, low amplitude

    • Pitch modulation difficult

    • Delay in acquiring speech

  • External vibratory voice

  • Two types

    • External

      • Pneumatic

      • Electric

    • Transoral type

  • Both types are electrically driven and produce a mechanical sound

  • Sound is articulated by the tongue, lips, and teeth as understandable speech

  • Most common type is external type

  • Intraoral type  indicated for patients whose cervical tissues cannot transmit the sound such as those that have received radiation to the neck

  • Advantages

    • Short learning time

    • Ability to use immediately postop

    • No interference with post op healing

    • Relative availability

    • Low cost

  • Disadvantages

    • Mechanical sound  monotone , single pitch

    • Dependence on batteries

    • Maintenance of the intraoral tubes

Fistula based voice

  • Principle

    • Restoration of lungs as primary energy source

    • Uses lungs as bellow for pumping air

    • Fistula between trachea and oesophagus with one way valve

    • Entire inspiratory capacity (3000 ml) at disposal of the patient

    • Placement of fistula determines region of PE segment vibration

    • Modern methods direct prosthesis into cervical esophagus immediately posterior to tracheostoma

    • Greater air pressure occurs & PE segment generates voice with a higher frequency

  • Pre-Surgical Counselling

    • Anatomical Changes

    • Options available

    • Informed expectations

    • Answer questions; create rapport

    • Group consultation with laryngectomee with TEP patients

  • Contraindication for TE Speech

    • Inability to care for stoma

    • Stenotic stoma

    • Poor eyesight

    • Oesophageal stenosis

    • Poor motivation

    • Poor manual dexterity

  • Advantages

    • Rapid speech restoration

    • Natural sound

    • “Normal” utterance length

    • Indwelling = minimal maintenance; Hands-free is possible

    • Tonal language is intelligible

  • Disadvantages

    • Surgery required

    • Puncture stenosis

    • Aspiration of dislodged prosthesis

    • Aspiration of liquids leaking through and/or around prosthesis

    • Candida growth

  • Timing

    • Secondary TE Puncture

      • In case not performed at time of surgery, it is delayed until 2-4 wks to allow healing of tracheostoma

      • Some choose to delay therapy until after radiation therapy or in case of significant premorbid condition

      • Singer’s procedure

        • Rigid esophagoscopy into neopharynx

        • TEP site selection

          • Should allow easy access to prosthesis

          • Must allow unobstructed closure of stoma by patient’s finger

          • Usually 5-15 mm from mucocutaneous junction

        • Needle passed under vision into hole of oesophagoscope

        • Serial dilatation of the puncture site

        • 14 Fr rubber catheter passed

    • Primary TE puncture

      • Advantages

        • No second procedure

        • Myotomy & nurectomy at the time of puncture

        • Early voice development

        • No need for NG tube/gastrostomy

        • Psychological benefit

        • Cost saving

      • Disadvantages

        • Lost opportunity for esophageal speech

        • Post op RT - access problem

        • Mucositis induced inhibition of voice production

        • More complications

      • Procedure

        • Selection of fistula site after laryngectomy but before closure of pharyngeal defect

        • Simplest way  grasp post wall with gentle traction & raise it from mediastinum to estimate it’s final position relative to skin flaps & sternal notch

        • Puncture site is selected 1-1.5 cm from the superior edge

        • Right angled clamp placed against TE party wall

        • Small vertical incision

        • Newer Provox 2 are injection loaded

        • Placed retrogradely from oesophageal side into created stoma & piston pressed

        • Flanges open on oesophageal side while button fixes on pharyngeal side

      • Prosthesis

        • Indwelling

          • Groningen

          • Provox

          • Provox 2

          • Blom singer indwelling

        • Non indwelling

      • Most commonly used presently

        • Blom-Singer Indwelling

          • Gel-cap loading with delayed opening of esophageal flange

          • Largest Diameter = 20 Fr

          • Anterograde placement at time of surgery

          • Approx. Rs 4000 replacement

        • Provox 2

          • Loading tool with instantaneous opening of esophageal flange

          • Largest Diameter = 22 Fr

          • Retrograde placement at time of surgery; Anterograde replacement

          • Approx. Rs 10000 replacement




      • Prosthesis maintenance

        • Prosthesis must be cleaned

        • Non – indwelling prosthesis cleaned regularly

        • In dwelling prosthesis – regular syringing

        • Device life 2-10 months

      • Prevention of pharyngeal spasm

        • Oesophageal distension  Secondary spasm of oesophageal sphincter

        • Methods to reduce hypertonicity

          • Cricopharyngeal myotomy

            • Risk of mucosal dehiscence & fistula formation

            • Posterolat cricopharyngeal & constrictor myotomy

          • Pharyngeal plexus neurorrhaphy

            • Identify pharyngeal plexus by electric stimulation

            • Adv  preserves blood supply to pharyngeal wall & may enhance quality of phonation due to residual elastic tone

      • Prevention of fungal infection

        • Common organisms  Candida albicans, Candida tropicalis

        • Results in

          • Prosthesis damage

          • Leakage

          • Incomplete closure

        • Treatment :

          • Nystatin oral suspension around the mouth BD for 3-4 mins & swallowed or expectorated

          • Amphotericin B lozenge 10 mg QID  dissolved slowly in mouth

          • Miconazole nitrate  Buccal bioadhesive slow release tab containing miconazole nitrate

          • Candida resistant fluro plastic valve

      • Complications of TEP

        • Major

          • Prosthesis dislodgement

          • Aspiration pneumonia

          • False passage

          • Mediastinitis

          • Deep neck abcess

          • Esophageal stenosis

          • Vertebral osteomyelitis

          • Necrosis of TE party wall

        • Minor

          • Device failure

          • Leakage

          • Mucosal hypertrophy

          • Scarring

          • Granulation tissue

          • Low grade infection



  • Voice Outcome of TEP

    • 70% of patients achieve functional spoken communication (Stell Maran)

    • Predictors :

      • Prelaryngectomy communication status

        • Major pre existing communication disorder ↓ success

      • Age ↓ age = ↑ success

      • Acute local complication  Adverse prognostic factor for long term acquisition of good speech

  • Tracheostomal Valve / Heat Moisture Exchanger(HME)

    • Pressure sensitive valve

    • Closes with expiratory pressures needed for speech

    • Opens for rest breathing

    • Humidifies/Filters air

    • May reduce viscosity of mucous with regular use

    • Advantages

      • Hands-free TE speech

      • Possible positive pulmonary benefit from air humidification and filtering

    • Disadvantages

      • Requires excellent seal of housing to skin

      • Must be removed for coughing

      • May need to be removed for exercise

      • Cost

      • Humidifilters are replaced daily

  • Recent advances

    • Provox 2 hands-free speaking valve

    • Barton-Mayo Button

    • Groningen Indwelling with embedded pneumatic device

      • Female laryngectomees

      • Laryngectomee with hypotonicity of the PE segment

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