Objective and Subjective Assessment of Tracheoesophageal Prosthesis Voice Outcome

Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Temporal and Spectral Models as Correlates to Auditory-Perceptual Judgments of Overall Severity and Listener Comfort in Tracheoesophageal Voice

INTRODUCTION

This study pursued two objectives: (1) to determine the potential association between listener (n = 51) judgments of 20 male tracheoesophageal speaker samples for two auditory-perceptual dimensions of voice, overall severity (OS) and listener comfort (LC); and (2) to assess the temporal and spectral acoustic correlates for these auditory-perceptual dimensions.

METHODOLOGY

Three separate correlation analyses were performed to evaluate the association between OS and LC. First, scores of OS and LC from all listeners were pooled together, and then the correlation between OS and LC was computed. Second, scores of OS and LC were averaged over all listeners to derive a single estimate of OS and LC for each TE speaker sample; the correlation between the average OS and LC was then computed. Third, listener-to-listener variability in the association between OS and LC was evaluated by computing the correlation between OS and LC scores from each listener across all TE samples. Finally, two stepwise multiple regression models were created to relate the average LC score to spectral and temporal variation in the acoustic signal.

RESULTS

While the pooled OS and LC scores had a moderate positive correlation (r = 0.66, p < 0.00001), the averaged OS and LC exhibited a near perfect positive correlation (r = 0.99, p < 0.00001). The significant differences between the pooled and averaged scores were explained by significant listener-to-listener variability in the association between OS and LC. OS and LC scores from 5 listeners had non-significant correlations, 10 had moderate correlations (r < 0.7), 35 listeners had high correlations (0.7 < r < 0.9), and 1 listener had a very high correlation (r < 0.9 < 1). Finally, the acoustic models created based on the spectral and temporal variations in the signal were able to account for 87.7% and 61.8% of variation in the average LC score.

CONCLUSIONS

The strong correlations between OS and LC suggest that LC may, in fact, provide a more comprehensive auditory-perceptual surrogate for the voice quality of TE speakers. Although OS and LC are distinct conceptual dimensions, LC appears to have the advantage of assessing the social impact and potential communication disability that may exist in interactions between TE speakers and listeners.

Listener impressions of alaryngeal communication modalities

Purpose: Following a total laryngectomy in which the larynx is completely removed, individuals in the USA have three primary options for alaryngeal verbal communication including tracheoesophageal speech (TES), oesophageal speech (ES) and electrolarynx (EL). Using a large sample of participants from across the USA, this study investigated listener impressions of each primary type of alaryngeal communication. As these are the individuals more likely to be participating in social interactions and in positions of hiring for employment, the general public's impressions of TES, ES and EL may be a vital consideration during the treatment process.Method: A total of 381 individuals rated eight speech samples, including samples from speakers of each alaryngeal communication modality as well samples from age and sex matched laryngeal speakers, with regards to three outcome measures: intelligence, likability and employability.Result: Listener impressions of alaryngeal speech samples were modulated by the type of communication mode. Further, the patterns of results differed by speaker sex, with ES speech rated consistently more favourable for female speakers across all outcome measures and TES rated consistently more favourable for male speakers across all outcome measures.Conclusion: An overall preference for laryngeal speech was noted, particularly with male speakers. The female ES stimuli, interestingly, was the highest rated alaryngeal communication modality. Regardless of speaker sex, all alaryngeal modes greatly affected impressions of employability relative to impressions of likeability and intelligence.

A one-year time frame for voice prosthesis management. What should the physician expect? Is it an overrated job?

Management of late complications represents the main reason for reluctance in using voice prosthesis rehabilitation. The aim of this paper is to report our experience by describing the one-year management of a large cohort of patients in order to clarify how demanding management is in terms of burden on clinicians. Between June 2017 and June 2018, each access made at the Otolaryngology Clinic of our Institute for issues related to prosthesis by 70 laryngectomised patients rehabilitated by voice prosthesis was registered in a specific database. A review of the data provided information on the incidence, management and outcomes of adverse events encountered during the selected time frame. In addition, a T test was used to evaluate the differences between irradiated and non-irradiated patients and between primary and secondary tracheo-oesophageal-puncture. Leakage through the prosthesis was the most common cause for access (51.86%). The median number of accesses per patient per year was 3.47. The speech therapist autonomously managed 18.1% of accesses. The median number of accesses per patient per year needing a physician was 2.84. The median lifetime of the prosthesis was 4.85 months. Radiotherapy or modality (primary or secondary) of the puncture did not influence the number of accesses per year or the prosthesis lifetime. This retrospective analysis of results highlighted the most frequent issues and the most effective measures to deal with them, which allowed us to define a systematic algorithm to standardise and ease long-term outpatient management.

Patients With Voice Prosthesis Rehabilitation During the COVID-19 Pandemic: Analyzing the Effectiveness of Remote Triage and Management

Objective

To describe a remote approach used with patients with voice prosthesis after laryngectomy during the COVID-19 pandemic and the resulting clinical outcomes in terms of voice prosthesis complications management, oncological monitoring, and psychophysical well-being.

Study Design

Prospective cohort study.

Setting

Otolaryngology Clinic of the University Polyclinic A. Gemelli, IRCCS Foundation.

Subjects and Methods

All patients with voice prosthesis who underwent laryngectomy followed by our institute were offered enrollment. Patients who agreed to participate were interviewed to inquire about the nature of the need and to plan a video call with the appropriate clinician. Before and 1 week after the clinician’s call, patients were tested with the Hospital Anxiety and Depression Scale. Degrees of satisfaction were investigated with a visual analog scale. A comparison between those who accepted and refused telematic support was carried out to identify factors that influence patient interest in teleservice.

Results

Video call service allowed us to reach 37 (50.68%) of 73 patients. In 23 (62.16%) of 37 cases, the video call was sufficient to manage the problem. In the remaining 14 cases (37.83%), an outpatient visit was necessary. Participants who refused telematic support had a significantly shorter time interval from the last ear, nose, and throat visit than patients who accepted (57.95 vs 96.14 days, P = .03). Video-called patients showed significantly decreased levels of anxiety and depression (mean Hospital Anxiety and Depression Scale total score pre– vs post–video call: 13.97 vs. 10.23, P < .0001) and reported high levels of satisfaction about the service.

Conclusion

Remote approach may be a viable support in the management of patients with voice prosthesis rehabilitation.

Integrated rehabilitation after total laryngectomy: a pilot trial study

BACKGROUND

Acquisition and acceptance of the alaryngeal voice, psychological state, and Quality of Life (QoL) of laryngectomized patients.

METHODS

Thirty-two patients who underwent total laryngectomy were included in the study; 17 of them were treated by a psychologist and a speech therapist (experimental group); 15 performed only speech therapy (control group).

RESULTS

The experimental group showed a significant improvement in all parameters of the INFVo scale, in the score of the Environment subscale and in the total score of the I-SECEL (Self-Evaluation of Communication Experiences after Laryngeal Cancer); in the Depression, Obsession-Compulsion and Paranoia areas of the SCL-90-R (Symptom Check List-90-Revised); and in the Social area (REL) of the WHOQOL-B (World Health Organization Quality of Life Scale-Brief).

CONCLUSIONS

An integrated rehabilitative approach to laryngectomized patients improves emotional state and psychosocial aspects and promotes acceptance and use of the new voice and recovery of a better quality of life.

An Investigation of Reliability of the Sunderland Tracheosophageal Voice Perceptual Scale

BACKGROUND

The Sunderland Tracheosophageal Voice Perceptual scale (SToPS) is the only perceptual rating scale designed specifically for tracheosophageal voice [Hurren et al.: Clin Otolaryngol. 2009 Dec; 34(6): 533-8].

OBJECTIVE

To investigate the inter rater reliability of the SToPS when analyzing alaryngeal voice.

METHODS

Prospective evaluation of inter rater reliability of the SToPS based on audio recordings of 230 voice samples from 41 laryngectomy patients rated by 3 experts. Interval data were analyzed using intraclass correlation coefficients (ICC) while categorical data were analyzed using Kappa.

RESULTS

ICC of above 0.6 was observed between raters for each prosthesis on a majority of parameters demonstrating a good level of reliability. Reliability was fair (ICC of between 0.40 and 0.59) on Q11 (Articulatory precision) and Q12 (Paralinguistics). Reliability was also fair (0.21-0.40) or slight (0.00-0.20) for Q2 (Tonicity), which was analyzed using Kappa. Kappa above 0.61 signified a good level of reliability.

CONCLUSIONS

This study demonstrates good rater reliability for the majority of parameters on the SToPS scale, supporting the use of this tool within the clinical realm. However, further research is required to ascertain if any methods of increasing inter rater reliability on those parameters which did not reach good reliability can be identified.

The Pharyngoesophageal Segment After Total Laryngectomy

Objective:

The aim of the present study was to characterize the pharyngoesophageal segment in laryngectomees who rated themselves as functional tracheoesophageal speakers.

Methods:

Voice perceptual assessment, high-resolution videomanometry of swallowing and phonation, and high-speed camera recording during phonation provided information about the anatomy and function of the pharyngoesophageal segment.

Results:

Fourteen patients were included in the study. The voice assessments presented high intra/inter-listener reliability. We found a significant correlation between roughness and poor voice quality, hyperfunction and poor intelligibility, and poor voice quality, long time since the operation, and old age. High-resolution videomanometry during phonation revealed decreasing mean pressures from the distal esophagus to the pharynx and confirmed low resting pressures at the pharyngoesophageal segment and low esophageal peristaltic contraction pressures after laryngectomy in comparison to normal subjects. The neoglottis shape was mainly circular and presented a strong mucosal wave in most of the patients on the high-speed camera recording.

Conclusions:

Perceptual voice assessment and high-speed camera recordings provided baseline information about voice characteristics and vibration regularity of the neoglottis. Additionally, the quantitative measures obtained with high-resolution videomanometry may have clinical applicability as reference data in voice rehabilitation after total laryngectomy.

Electrophysiological activity of the pharyngoesophageal transition of total laryngectomees

OBJECTIVES/HYPOTHESIS

To determine the association of the electrophysiological activity of the pharyngoesophageal transition with tracheoesophageal speech proficiency in total laryngectomees.

STUDY DESIGN

An observational (nonexperimental) study of the correlation type with a descriptive approach.

METHODS

Thirty-four individuals (26 males), average age 62.5 years, total laryngectomees rehabilitated with the use of a tracheoesophageal prosthesis, were assessed for tracheoesophageal speech proficiency using an adapted protocol and classified as good, moderate, or poor speakers. Next they were submitted to electromyography of the muscles of the pharyngoesophageal transition with a needle electrode. The area to be examined was located by videofluoroscopy. Electromyographic analysis was characterized as normal, neurogenic injury (moderate to severe, severe, severe to total), myopathic injury, or inconclusive. The Fisher exact test was used to determine the association between the speech proficiency variables and electromyography.

RESULTS

in the final rating of tracheoesophageal speech proficiency, most laryngectomees were categorized as moderate (n = 24) and a few as good (n = 3). Electromyography revealed neurogenic injury in all laryngectomees, which was severe in most cases (n = 20), followed by severe to total (n = 10), and moderate to severe injury (n = 4). There was no significant association between he electromyographic analyses of neurogenic injuries and tracheoesophageal speech proficiency.

CONCLUSIONS

Whether or not the musculature of the pharyngoesophageal transition of tracheoesophageal speakers had a preserved motor unit, did not prevent voice acquisition and was not associated with tracheoesophageal speech proficiency. However, further studies are needed in this area.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1369-1375, 2017.

The Effect of Noise on Relationships Between Speech Intelligibility and Self-Reported Communication Measures in Tracheoesophageal Speakers

PURPOSE

The purpose of this study was to examine how sentence intelligibility relates to self-reported communication in tracheoesophageal speakers when speech intelligibility is measured in quiet and noise.

METHOD

Twenty-four tracheoesophageal speakers who were at least 1 year postlaryngectomy provided audio recordings of 5 sentences from the Sentence Intelligibility Test. Speakers also completed self-reported measures of communication-the Voice Handicap Index-10 and the Communicative Participation Item Bank short form. Speech recordings were presented to 2 groups of inexperienced listeners who heard sentences in quiet or noise. Listeners transcribed the sentences to yield speech intelligibility scores.

RESULTS

Very weak relationships were found between intelligibility in quiet and measures of voice handicap and communicative participation. Slightly stronger, but still weak and nonsignificant, relationships were observed between measures of intelligibility in noise and both self-reported measures. However, 12 speakers who were more than 65% intelligible in noise showed strong and statistically significant relationships with both self-reported measures (R2 = .76-.79).

CONCLUSIONS

Speech intelligibility in quiet is a weak predictor of self-reported communication measures in tracheoesophageal speakers. Speech intelligibility in noise may be a better metric of self-reported communicative function for speakers who demonstrate higher speech intelligibility in noise.

Telephonic voice intelligibility after laryngeal cancer treatment: is therapeutic approach significant?

The aim was to investigate telephonic voice intelligibility in patients treated for laryngeal cancer using different approaches. In total, 90 patients treated for laryngeal cancer using different approaches and 12 healthy volunteers were recruited. Each patient and each healthy control read a list of words and sentences during a telephone call. Six auditors listened to each telephonic recording and transcribed the words and sentences they understood. Mean intelligibility rates for each treatment were assessed and compared. Regarding words, the poorest intelligibility was noted for type II open partial horizontal laryngectomies, followed by total laryngectomies. The best intelligibility was found for transoral laser microsurgery, followed by radiotherapy alone. For sentences, the poorest intelligibility was noted for type II open partial horizontal laryngectomies, followed by chemoradiotherapy. The best intelligibility was found for radiotherapy alone and transoral laser microsurgery. More aggressive surgery as well as chemoradiotherapy correlated with significantly poorer outcomes. Transoral laser microsurgery or radiotherapy alone ensured the best telephonic voice intelligibility. Intermediate-advanced T stages at diagnosis also showed significantly poorer intelligibility outcomes, suggesting that T stage represents an independent negative prognostic factor for voice intelligibility after treatment.

Voice quality and surgical detail in post-laryngectomy tracheoesophageal speakers

The objective of this study is to assess surgical parameters correlating with voice quality after total laryngectomy (TL) by relating voice and speech outcomes of TL speakers to surgical details. Seventy-six tracheoesophageal patients' voice recordings of running speech and sustained vowel were assessed in terms of voice characteristics. Measurements were related to data retrieved from surgical reports and patient records. In standard TL (sTL), harmonics-to-noise ratio was more favorable after primary TL + postoperative RT than after salvage TL. Pause/breathing time increased when RT preceded TL, after extensive base of tongue resection, and after neck dissections. Fundamental frequency (f0) measures were better after neurectomy. Females showed higher minimum f0 and higher second formants. While voice quality differed widely after sTL, gastric pull-ups and non-circumferential pharyngeal reconstructions using (myo-)cutaneous flaps scored worst in voice and speech measures and the two tubed free flaps best. Formant/resonance measures in/a/indicated differences in pharyngeal lumen properties and cranio-caudal place of the neoglottic bar between pharyngeal reconstructions, and indicate that narrower pharynges and/or more superiorly located neoglottic bars bring with them favorable voice quality. Ranges in functional outcome after TL in the present data, and the effects of treatment and surgical variables such as radiotherapy, neurectomy, neck dissection, and differences between partial or circumferential reconstructions on different aspects of voice and speech underline the importance of these variables for voice quality. Using running speech, next to sustained/a/, renders more reliable results. More balanced data, and better detail in surgical reporting will improve our knowledge on voice quality after TL.

The Relationship Between Acoustic Signal Typing and Perceptual Evaluation of Tracheoesophageal Voice Quality for Sustained Vowels

OBJECTIVES

To investigate the relationship between acoustic signal typing and perceptual evaluation of sustained vowels produced by tracheoesophageal (TE) speakers and the use of signal typing in the clinical setting.

METHODS

Two evaluators independently categorized 1.75-second segments of narrow-band spectrograms according to acoustic signal typing and independently evaluated the recording of the same segments on a visual analog scale according to overall perceptual acoustic voice quality. The relationship between acoustic signal typing and overall voice quality (as a continuous scale and as a four-point ordinal scale) was investigated and the proportion of inter-rater agreement as well as the reliability between the two measures is reported.

RESULTS

The agreement between signal type (I-IV) and ordinal voice quality (four-point scale) was low but significant, and there was a significant linear relationship between the variables. Signal type correctly predicted less than half of the voice quality data. There was a significant main effect of signal type on continuous voice quality scores with significant differences in median quality scores between signal types I-IV, I-III, and I-II.

CONCLUSIONS

Signal typing can be used as an adjunct to perceptual and acoustic evaluation of the same stimuli for TE speech as part of a multidimensional evaluation protocol. Signal typing in its current form provides limited predictive information on voice quality, and there is significant overlap between signal types II and III and perceptual categories. Future work should consider whether the current four signal types could be refined.