An overview of vocal rehabilitation after laryngectomy

An overview of vocal rehabilitation after laryngectomy
A Short Scientific communication by, Dr. Rehan A. Kazi,
Dept. of Oncology, Masina Hospital, Bombay, India

For more than a century laryngologists have been faced with the challenge of voice restoration following major laryngeal surgery. After some preliminary experimental work, Billroth performed the first total laryngectomy cancer in 1973.

Form the beginning, his assistant, Gussenbauer⁽¹⁾, used a reed - valve which he placed through the pharyngostome so that expired air could be set into vibration by the valve and redirected up through the pharynx and buccal cavity allowing speech production. As the early laryngectomies were carried out with a planned temporary pharyngostome, in order to prevent pulmonary complications secondary to wound breakdown, this technique was easy to effect. Gussenbauer's reed - valve underwent a number of minor modifications but fell into disuse due to the introduction of operative techniques avoiding the necessity of a temporary pharyngostome and enabling an early return to a normal. Without a pharyngostome the reed - valve could no longer be used.

With the introduction of radiotherapy the number of total laryngectomies carried out started to fall, a trend confirmed during the 1950s with the development and use of Coblt-60. Since then, the indications for both radiotherapy and surgery have been refined, each modality now treating about half of the cases of laryngeal cancer that are seen. Total laryngectomy continues to play an important role in treatment of cancer of the larynx. Since the 1950s, and particularly as a result of the work of Alonso⁽²⁾ and Leroux - Robert, partial laryngeal surgery with conversation of the voice has achieved wide acceptance. In the past 15 years in Europe, subtotal laryngectomy (cricohyoidopexy) has also found a place in the surgical armamentarium: although seldom indicated, it offers a better alternative to total laryngectomy. Its advantages and results will be discussed later.

It is important, when selecting patients for partial or subtotal laryngectomy, that top priority be given to oncological consideration: conserving laryngeal function, to whatever degree can only be achieved once the appropriate treatment has been selected for the individual tumor.

Total laryngectomy, with its complete loss of voice, has stimulated the imagination of laryngologists and speech therapists to develop methods of voice production. The are numerous technique now available, some of which involve the use of technical equipment of varying complexity. They can be broadly subdivided under three headings:

Esophageal Speech
Surgical Methods
(a) External method / external fistulae
(b) Internal method / internal fistulae
(c) Functional or reconstructive techniques
Artificial Larynges

ESOPHAGEAL SPEECH

This is certainly the most commonly used technique and has been used with success for decades. However, it is worth noting that it was almost certainly Seeman⁽³⁾ who in 1922 first recognized the role of the cervical esophagus as the neoglottis, and also the air reservoir in the esophagus it. Since then the technique of regurgitating swallowed air has been made use of widely.

Although esophageal speech many not be easy to acquire, it has the advantages of not requiring a surgical procedure or prosthesis, and it is devoid of any complications.

SURGICAL METHODS

Methods involve the creation of an internal or external fistula. Table 1 shows the diversity of the authors and the techniques they proposed.

Table 1. Surgical Techniques for Speech Rehabilitation

	Internal Fistula			External Fistula
1	Guttman	(1931)	1	Billroth/Gussesnbauer	(1873)
2	Conley	(1958)	2	Briani	(1952)
3	Asia	(1960)	3	Conley	(1959)
4	Calcaterra	(1971)	4	Taub and Spiro	(1972)
5	Arslan/Serafini	(1975)	5	Shedd and Weinberg	(1975)
6	Stafieri	(1972)	6	Sisson and MacConned	(1975)
7	Komorn	(1974)
8	Iwai	(1975)
9	Mozolewski	(1975)
10	Amatsu	(1978)
11	Bloom and Singer	(1979)
12	Pearson	(1981)
13	Pane	(1981)
14	Grainger Prosthesis	(1981)

EXTERNAL METHODS/EXTERNAL FISTULAE

Almost all of the methods involving external fistulae have now been abandoned, largely as a result of the complexity of both the technique and the equipment required. For example, the Voice back prosthesis developed by Tub and Spiro⁽⁵⁾ required an external prosthesis connected to both the trachea and an oesophago - cutaneous fistula. It principal drawback was that it was unsuitable for use in the irradiated neck, or in a patient who had a radical neck dissection. The meticulous maintenance also made the device impractical. Aspiration of saliva and food were the risks of another technique described by Conley^(6,7).

INTERNAL METHODS/INTERNAL FISTULAE

In much more widespread use are the technique involving the transformation of an internal fistula. These can be subdivided into two main categories:

Surgical techniques involving the use of skin and/or mucosal flaps to create a tracheo-esophageal or tracheo-pharyngeal fistula.
The more recent development of a tracheo-esophageal fistula by direct puncture, either at the time of or some time after a laryngectomy. The patient wears a voice prosthesis in the fistula (such as Bloom and Singer^4,12,16, Panje¹³, Groningen ¹⁴).

Two methods in the first group merit description. The first, the Asai procedure⁽⁸⁾ initially needed three separate operative procedures, although in a subsequently modified version only one procedure was required to create a tracheo-esophageal shunt using local mucosal flaps. Of 72 cases reported by Asai, the shunt broke down in 10 cases, stenosed in 10 cases, and aspiration pneumonia developed in 2 cases, Miller⁽⁹⁾ achieved a good result in 8 of 40 patients using the same procedure. The second technique that of Staffieri⁽¹⁰⁾ has been used widely in Europe. It consists of a total laryngectomy with diversion of the postcricoid mucosa.

A tracheotomy is fashioned in the anterior tracheal wall, the superior end of the trachea being covered by postcricoid mucosa end of the trachea being covered by postcricoid mucosa like the skin of a drum. An incision through this mucosa provides the patient with a neoglottis for speech. The voice is usually considered "good" (60 percent of patients), but problems with salivary leaks and the frequent stenosis of the neoglottis has led to this technique falling into general disuse.

More recently, Amatsu⁽¹¹⁾ proposed a one - stage procedure in which the first four tracheal rings are retained, with the posterior tracheal wall mucosa being tubed at this level and implanted into a small opening in the esophagus, thereby linking the two structures. The voice acquired by using this technique was reported as good in 23 out of 30 patients, although a salivary leak occurred in 9 patients.

A number of other surgical techniques of lesser or greater complexity, with or without the use of distant flaps, have been described, although their use has not been widespread.

Of much greater interest is the second group of surgical techniques. There are the tracheo-esophageal fistulae, with insertion of voice prosthesis; the most widely used having been described by Bloom and Singer⁽¹²⁾ and Groningen⁽¹⁴⁾. By virtue of their relative simplicity, and the ease with which they can be carried out, these techniques are now in the process of replacing those mentioned previously.

The operative details of the techniques have been widely described in the literature and will not be detailed in the text.

For several years the Bloom - Singer type of prosthesis was though to have provided the definitive solution to the problem of speech rehabilitation by returning voice to almost all laryngectomees, carrying a very low complication rate, and allowing patients a speedy return to a normal social and professional life, without them having to pay too high a price. Since the publication of the long - term results and complications of this technique, it has been necessary to temper the initial enthusiasm a little, although in experienced hands this certainly remains the best of the prosthetic techniques.

Laryngectomees who will best benefit from the technique must meet strict selection criteria, such as those set out by Andrews⁽¹⁵⁾.

They should be motivated and mentally stable.
They must have an adequate understanding of their anatomy, and the mechanics of the prosthesis.
They must have sufficient manual dexterity and visual acuity to care for the stoma and the prosthesis.
They should not have significant stenosis of the hypopharynx.
They should be able to produce speech following esophageal insufflation via a properly positioned esophageal catheter (the Taub test).
They must have and adequate pulmonary reserve.
They should have a stoma of adequate depth and diameter to accept a prosthesis without airway compromise.

It is worth noting that several of these requirements ^(1,2,4,5) are also necessary for good esophageal speech.

The fitting of the prosthesis can be carried out as a secondary procedure - as originally described by Bloom and Singer - or during the course of a total laryngectomy. After laryngectomy it is advisable to wait three weeks before making initial attempts at phonation, so that the recently sutured pharynx is not submitted to a high intraluminal pressure. This delay, and the use of postoperative radiotherapy, has led in some cases to postponing the fitting of the prosthesis until later⁽¹⁵⁾. Acquiring a voice using this technique requires close cooperation among the patient, the surgeon, and the speech therapist. A good result (a sufficiently powerful distinct and well - sustained voice) is achieved in about 60 to 70 percent of patients, but this varies significantly with patient selection.

Hamaker16 reported satisfactory result in 69 percent of his 68 cases. The causes o failure in the remaining 15 patients were refusal to use the prosthesis (4 patients), psychiatric problems (1 patient), refusal to touch the prosthesis with dirty fingers (1 patient), intermittent use only (1 patient), central nervous system disorders (3 patients), residual tumor (4 patients) and the acquisition of esophageal speech (1 patient).

Wetmore⁽¹⁷⁾ reported good long - term results in 64 percent of patients (in a study of 66) with a follow-up time of between 1 and 31/2 years. This rate was increased to 83 percent (of 24 patients) by more careful patient selection. The principal causes of failure were technical problems related to the tracheo-esophageal puncture procedure (8 patients), inadvertent loss of the prosthesis (3 patients), aspiration (2 patients), medical problems (6 patients), poor motivation or compliance (5 patients), and multiple problems (5 patients). Wetmore recommended that the prosthesis should be inserted one month after the laryngectomy, or one month after the completion of postoperative radiotherapy. We also believe that patients over the age of 70 years were unsuitable candidates for a prosthesis.

The complication of this technique, underestimated for a long time, have been the subject recently of a number of articles in the literature, the most important of which is that by Andrews et al. 15 of 104 patients, the total number of complication in his series was 25 percent. The immediate or early post-operative complications included I esophageal perforation, 2 allergic reaction, 3 cases of peristomal, cellulitis, and I death secondary to aspiration. Late complications were 6 cases of fistula enlargement, 5 recurring aspiration pneumonias, 7 cases of aspiration of the prosthesis, 2 fistula migrations, 3 cases of major infection or cellulitis, 2 stomal stenoses, and 5 cases of esophageal stenosis secondary to the prosthesis. Surprisingly, there were no differences between the irradiated and the non - irradiated patients.

Stiernberg et al.⁽¹⁸⁾ reported good results in 65 percent of patients (13 out of 20 cases); the causes of failure were poor motivation or noncompliance with technique (4), spasm (2), and infection at the site of the tracheostome (1).

Trudeau⁽¹⁹⁾ stressed that excellent results were obtained if the tracheo-esophageal fistula was crated during the course of the laryngectomy whereas 27 percent of patients failed to achieve any voice when the fistula was created as a secondary procedure.

It is apparent that a prosthesis can be used just as effectively after a total laryngectomy and partial pharyngectomy as after a total laryngectomy alone, even though the size of the pharynx has been reduced. Nearly all surgeons stress the importance of a myotomy, whether out at the time of the puncture or performed as a secondary procedure, because of pharyngeal spasm preventing the acquisition of a voice.

The effects of using the prosthesis long - term remains unknown. Even so, there are many patients who achieve a good initial result but do not continue to do so. The fact that the "ideal" prosthesis, if it exists, has yet to be found is reflected by the great number of different voice prostheses currently available.

FUNCTIONAL OR RECONSTRUCTIVE SURGERY TECHNIQUES

Our experience with "subtotal surgery" provides an excellent alternative to total laryngectomy, providing the criteria for the technique can be met⁽²⁰⁾. It's aims are adequate excision of the tumor with conservation of the voice and avoidance of a permanent tracheostomy. Broadly, the indications for subtotal surgery are glottic tumors involving the supraglottis, tumors arising from the ventricle, and supraglottic tumors involving the glottis. The mobility of the larynx must be normal or only partially reduced on the side of the lesion and there must be no subglottic extension.

Regional lymph node involvement should be extensive. More general contraindication include patients over 70 years of age and poor pulmonary status (because of the risk of postoperative with aspiration of food and saliva).

The operative techniques are relatively simple. The cricoid and one or both of the arytenoids are left attached to the trachea. After the excision, the cricoid is sutured to the hyoid bone (crichyoidopexy) and the temporary tracheostomy is usually closed off on or about the tenth postoperative day. As with the various off on or about the tenth post-operative day. As with the various partial laryngectomies, the major postoperative problem is reeducating the patient to swallow.

In a series of 89 cases, with a follow-up period of at least four years the technique produced favorable results from and oncological point of view, with an 82 percent survival at five years. "Normal" voice conversation was achieved in a large proportion of the cases, although 11 percent (10) of the patients required a subsequent total laryngectomy because of persistent difficulties with swallowing and aspiration, and consequent chest infection. The voice was considered to be good in 66 percent of the patients. The absence of a tracheostomy allows and easy rehabilitation for the well - motivated patients. In our department, this technique now accounts for between 15 and 20 percent of the laryngectomies performed.

ARTIFICIAL LARYNGES

We regard electronic prosthesis such as the artificial larynx as the last resort, suitable for those patients in whom none of the other techniques have been successful in producing any voice. The quality of the voice provided by these appliances is monotonous and metallic and immediately focuses attention on the people using them. However, they can be useful in noisy environments, when other method of voice restoration have provided the patient with only a voice of weak or moderate volume.

CONCLUSION

When considering speech rehabilitation following a total laryngectomy the decision rests between a tracheo-esophageal fistula with prosthesis, and esophageal speech.

The advantages of esophageal speech must not be underestimated. Although its acquisition is often a long process demanding close participation of both the patient and the speech therapist, it provides the patient with a very satisfying independence, which does not exist when the patient has to rely on a voice prosthesis. In a survey conducted by Savary for the First World Congress for laryngectomy (Quebec 1974), the percentage of patients who acquired esophageal speech was 52 percent in Canada, 64 percent in North America, 69 percent in France, and 82 Holland. It is worth noting that the number of patients getting a good voice following a tracheo-esophageal fistula and insertion of prosthesis is also in the area of 70 percent.

We recognize two distinct of patients for whom the creation of a tracheo-esophageal fistula is indicated. In the first group, the procedure is performed immediately in those patients who are very anxious to start talking again as quickly as possible after their laryngectomy. They continue to learn the technique of esophageal speech, which remains, in our opinion, the ultimate goal. In the second group, the procedure is performed on those patients who have failed to develop esophageal speech.

Whatever method is chosen to rehabilitate the laryngectomee, it is important that he be motivated and encouraged by a team comprising the surgeon, the speech therapist, and someone from the local laryngectomee association. The team itself must be equally well motivated. Occasionally the help of a psychologist may be useful for very difficult cases.

Unfortunately, and in spire of all efforts, between 10 and 15 percent laryngectomees fail to require any form of verbal communication. For them, the solution still remains to be found.

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