Computerized manometry use to evaluate spasm in pharyngoesophageal segment in patients with poor tracheoesophageal speech before and after treatment with botulinum toxin

Retrospective Exploration of Botulinum Toxin Injection for Pharyngoesophageal Segment Dysfunction Post-laryngectomy

Objective

To assess our institution's experience with botulinum toxin A injection management of pharyngoesophageal (PE) segment dysfunction after laryngectomy in tracheoesophageal voice and swallowing restoration.

Study Design

A retrospective review of 43 patients who had Botox as treatment for PE dysfunction.

Setting

Tertiary academic center with fellowship-trained otolaryngologists.

Methods

Pre- and post-injection outcomes were evaluated using chart review, and the severity of symptoms was recorded based on the subjective assessment by the patient, speech language pathologists, and the treating surgeon.

Results

Forty-three patients were treated for PE dysfunction with botulinum toxin A injection. Most patients were male (n = 35, 81.4%), underwent primary cricopharnygeal myotomy (n = 36, 83.7%), and 37 (86%) had both dysphagia and speech concerns. Our injection methods included percutaneous injection by videofluoroscopy (n = 19, 44.2%), transnasal esophagoscopy (17, 40.5%), electromyography (n = 3, 7%), ultrasound (n = 1, 2.3%), or in the operating room (n = 3,7%). We found that 37 (86%) patients had subjective improvement in their symptoms, with 16 (38.1%) improving in both swallow and voice. There were no significant complications, or subjective difference in speech and swallowing outcomes by method of injection.

Conclusion

Botulinum toxin A injection appears to be safe and effective for treating difficulty with speech and swallowing due to PE dysfunction after laryngectomy. Institutions should develop standard protocols for treatment and assessment.

Dynamic Study of Oesophageal Function during Phonation: Simple but Effective

Secondary aphonia significantly affects the quality of life of the laryngectomy patient despite the excellent success of the operation. Vocal rehabilitation often does not achieve the desired results, given the innumerable prognostic variables. Tracheo-oesophageal speech is considered the standard gold method of voice restoration, but a possible spasm of pharyngo-oesophageal segment is the prominent cause of rehabilitation failure. However, the phenomenon is difficult to identify and underestimated, and diagnostic methods are inquisitive or expensive. To propose a phonatory and swallowing evaluation essay of pharynx-oesophageal segment disorders, we conducted a retrospective study from 2012 to 2017 by selecting 6 patients who underwent total laryngectomy and voice prosthesis implantation that suffered from aphonia after surgery. All patients underwent dynamic phonation videofluoroscopy and plexus bath control test with lidocaine hydrochloride. All patients were then referred for treatment with neurotoxin blocker. In all cases, the analysed patients presented an air-trapping phenomenon with the formation of a spasmodic block upstream of an interrupted aerial column. The control test with lidocaine hydrochloride resulted in a transient improvement in speech performance. The neurotoxin block therapy subsequently performed ultimately led to an improvement in the patient's rehabilitation process with a recovery of the phonatory performance. We describe the new use of a barium bolus as a diagnostic tool for identifying neopharynx disorders. Appropriately selected patients with pharynx-oesophageal segment disorders could benefit from a neurotoxin-blocking treatment to improve oesophageal speech.

The applicability of high resolution manometry in total laryngectomy

PURPOSE

This study aims to measure the pressure of the pharynx and the pharyngoesophageal segment (PES) at rest and during phonation in total laryngectomized patients, with different levels of voice production.

METHODS

four total laryngectomized individuals participated in the study, All patients underwent High Resolution Manometry (MAR) at rest and during phonation. After this process, a descriptive analysis of the results was performed.

RESULTS

we observed that during rest the patients had PES pressure below normal and this data may be related to changes in the muscular connections at the level of the upper esophageal sphincter (UES) especially the interruption of the cricopharyngeal plexus. During phonation, two patients presented higher UES pressure values during phonation, when compared to the values found at rest, suggesting that introduction of air into the esophagus is followed by pharyngoesophageal contraction and that during phonation the patients with good esophageal speech may develop more pressure in this region.

CONCLUSION

Studies with a greater number of participants may help define, for example, subjects who may benefit from procedures such as cricopharyngeal myotomy or other medical conduct in order to facilitate the acquisition of esophageal voice in these patients.

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.

Correlation of maximum phonation time and vocal intensity with intraluminal esophageal and pharyngoesophageal pressure in total laryngectomees

OBJECTIVE

This study aimed to correlate maximum phonation time, vocal intensity, and dynamic extension with intraluminal esophageal and pharyngoesophageal segment pressure during tracheoesophageal phonation.

DESIGN

Prospective analysis.

SETTING

Tertiary academic hospital.

METHODS

The study was conducted on 20 total laryngectomees with alaryngeal speech and with secondary insertion of a tracheoesophageal prosthesis who were submitted to vocal recording of maximum phonation time and vocal intensity (minimum, habitual, and maximum). The participants were then submitted to manometry for the determination of the amplitude of intraluminal esophageal (proximal, middle, and distal) and pharyngoesophageal segment pressure during phonation.

RESULTS

A significant positive correlation was detected between habitual vocal intensity and the middle (0.004) and distal (0.05) esophagus, in addition to a correlation of maximum intensity with the middle esophageal portion (0.03). Dynamic extension showed correlation with the amplitude of esophageal pressure. There was no significant correlation between the variables studied and pressure of the pharyngoesophageal segment or between maximum phonation time and esophageal pressure amplitude.

CONCLUSION

The middle and distal regions of the esophagus were found to be compliant, permitting an adjustment of vocal intensity. There was no correlation between maximum phonation time and the amplitude of esophageal and pharyngoesophageal segment pressure.

Correlação entre voz e fala traqueoesofágica e pressão intraluminal da transição faringoesofágica

TEMA: reabilitação do laringectomizado total. OBJETIVO: correlacionar a proficiência de voz e de fala de laringectomizados totais usuários de prótese traqueoesofágica com a pressão intraluminal da transição faringoesofágica no repouso e durante a fonação. MÉTODO: foram estudados 12 laringectomizados totais com voz traqueoesofágica, usuários de prótese fonatória, submetidos à coleta e registro do material de voz e da fala, que foram avaliados por três expertos, utilizando-se um protocolo de julgamento geral da comunicação traqueoesofágica. Em seguida, os indivíduos foram encaminhados à manometria esofágica para avaliar a pressão intraluminal da transição faringoesofágica durante a fonação e no repouso. RESULTADOS: durante a fonação, os indivíduos caracterizados como bons falantes (16,7%) pelos expertos apresentaram valores médios de amplitude de pressão na transição faringoesofágica de 27,48mmHg. Entre os falantes moderados (52,5%), obteve-se amplitude média de 30,63mmHg e para os piores falantes (30,8%), 38,72mmHg. Durante o repouso, os melhores falantes apresentaram pressão média de 14,72mmHg, os moderados, 13,04mmHg e os piores falantes, 3,54mmHg. CONCLUSÃO: os melhores falantes apresentaram os menores valores de amplitude de pressão durante a fonação. Em contrapartida, a pressão em repouso foi maior para os bons falantes e menor para os piores, sugerindo que a elevação da pressão na transição faringoesofágica durante a fonação prejudica a qualidade da comunicação traqueoesofágica com a prótese fonatória.