The influence of stoma occlusion on aspects of tracheoesophageal voice

Ex vivo humidifying capacity and patient acceptability of stoma cloths in laryngectomized individuals

BACKGROUND

Heat and moisture exchangers (HMEs) improve respiratory function after laryngectomy, but there is virtually no information on the benefit of traditional stoma cloths or other covers.

METHODS

Two sequential studies were performed: (1) an ex vivo test was used to compare the humidifying capacity of stoma cloths to other coverings; and (2) a 4-week randomized trial was then performed to assess patient acceptability of cloths both alone and with an HME (N = 18).

RESULTS

The humidifying capacity of the coverings tested varied widely. For stoma cloths, a humidifying capacity of 13.7 mg/L was found to decrease to 8.5 mg/L if air-leaks around the cloth occurred. Patients who used HMEs disliked stoma cloths because they interfered with voicing, they became soiled more easily, and were less effective at reducing coughing and mucus production.

CONCLUSION

Although less acceptable to patients who use an HME, stoma cloths do provide significant humidifying capacity and should be encouraged when HMEs are unavailable or inappropriate. © 2017 Wiley Periodicals, Inc. Head Neck 39: 921-931, 2017.

A prospective multicenter clinical feasibility study of a new automatic speaking valve for postlaryngectomy voice rehabilitation

Evaluation of short- and long-term clinical feasibility and exploration of limitations and advantages of a new automatic speaking valve (ASV) for laryngectomized patients with integrated HME, the Provox FreeHands FlexiVoice (FlexiVoice). This ASV not only enables automatic, but also manual closure of the valve. A multicenter, prospective clinical study in 40 laryngectomized patients was conducted. Participants were asked to use the FlexiVoice for 26 weeks. The primary outcome measure was long-term compliance. Secondary outcome measures were: patient preference, hours of FlexiVoice use, device life of adhesive, voice and speech quality, and quality of life. After 26 weeks, 15 patients (37.5 %) were using the FlexiVoice on a daily basis, for a mean of 12.64 h/day (SD ± 5.03). Ten patients (25 %) were using the device on a non-daily basis, for a mean of 3.76 h/day (SD ± 2.07). The remaining 15 patients (37.5 %) discontinued using the FlexiVoice. Sixty percent of the 25 long-term users applied both automatic and manual closure of the valve. Unpredictable fixation of the adhesive was the main reason for discontinuing or not using the FlexiVoice on a daily basis. Overall, 18 patients (45 %) preferred the FlexiVoice, 16 patients (40 %) their usual HME, 3 patients (7.5 %) their usual ASV, 1 patient (2.5 %) preferred no device at all, and in 2 patients preference was not recorded. The minor technical issues identified could be corrected. The Provox FreeHands FlexiVoice appears to be a useful ASV, which allows for hands-free speech in a larger proportion of laryngectomized patients in the present cohort. The additional manual closure option of the device is beneficial for maintaining the adhesive seal longer.

[Satisfaction of patients with tracheostomal epithesis]

BACKGROUND

The utilization of craniofacial prosthesis has proven to be very successful for craniofacial defects. However, there is a lack of knowledge about the value of an epithesis for voice rehabilitation in patients with tracheostomy. The aim of this study was to describe application of the tracheostomy epithesis and to present a systematic analysis of the functional results of this prosthetic technique.

MATERIALS AND METHODS

This retrospective analysis included 48 patients on follow-up being treated in three different centers after laryngectomy and/or tracheostomy between 2008 and 2014. Subjects were given a questionnaire with items such as speech quality, quality of life, free hand speech ability, respiratory quality and sufficient tracheostomal sealing comparing values before and after application of an individually custom-made tracheostomy epithesis. Twenty-eight answered the questionnaire and could be reported.

RESULTS

Twenty-eight of 48 patients were consistently being included in follow-up. The statistical analysis revealed a significant improvement of tracheostoma occlusion (p < 0.05) and improvement in free hand speech ability (p < 0.05). A leakage of air during voice production could be prevented in 59.3% after application of an epithesis. Quality of life correlated directly with successful utilization of an epithesis.

CONCLUSION

In the literature, different industrialized products are described to realize occlusion of the tracheostoma for sufficient speech production without using the hands. In numerous cases commercial solutions fail and the patients need individual modifications. Our study first describes the evaluation of custom-made tracheostomal epithesis. From our observed results we advocate the individual tracheostomal epithesis as a durable solution for voice rehabilitation.

Correlation of intraluminal esophageal pressure with the dynamic extension of tracheoesophageal voice in total laryngectomees

PURPOSE

To evaluate and correlate the amplitude of esophageal contractions triggered by swallowing water with dynamic extension and habitual, strong and weak sound intensity in total laryngectomees wearing a tracheoesophageal prosthesis.

METHODS

Thirty total laryngectomees using tracheoesophageal voice with a phonatory prosthesis were evaluated by measuring the amplitude of contractions in the proximal, middle and distal esophagus and the pressure of the pharyngoesophageal transition by manometry. In order to measure vocal intensity the subject was asked to emit phonation of the vowel /a/ at habitual, strong and weak intensity which was captured with a sound pressure meter. Dynamic extension was calculated by subtracting strong intensity from weak intensity.

RESULTS

A positive correlation was observed between contraction amplitude and dynamic extension in the proximal (rho: 0.45; p=0.01) and distal (rho: 0.41; p=0.02) esophagus There was no correlation with other parameters.. Total laryngectomees wearing a phonatory prosthesis with a dynamic extension above 21 dBNPS had greater contraction amplitude than laryngectomees with a dynamic extension below this value.

CONCLUSIONS

There was a positive correlation between pressure amplitude in the proximal and distal esophagus and increased dynamic extension. The individuals with normal dynamic extension had greater contraction amplitude in the proximal esophagus than individuals with dynamic extension lower than the expected values for age.

[Quality of life evolution in patients after surgical treatment of laryngeal, hypopharyngeal or oropharyngeal carcinoma]

INTRODUCTION

The assessment of quality of life in patients with head and neck cancer is dependent on many variables.

OBJECTIVE

The aim of this study was to evaluate the differences in quality of life among patients treated with conservative or radical surgery for laryngeal, oropharyngeal or hypopharyngeal cancer, evaluated before and at 3 and 6 months after definitive therapy.

MATERIAL AND METHOD

Prospective study between November 2008 and June 2009 on 53 patients diagnosed and treated for head and neck carcinoma with surgery: partial (n=32) and radical (n=21). Quality of life was evaluated using the European Organization of Research and Treatment of Cancer (EORTC) general questionnaire EORTC QLQ-C30 and its specific head and neck EORTC QLQ-H&N35 before treatment, and at 3 and 6 months afterwards.

RESULTS

No significant differences were found in overall health. Patients experienced the greatest changes in functional scale. There were no changes in swallowing problems or feeling of disease, while evident phonation problems were present in both groups.

DISCUSSION AND CONCLUSIONS

The routine application of quality of life questionnaires in cancer patients improves information regarding how and to what extent patients feel that treatment and its sequelae modify it, making it possible to adapt rehabilitation and support programs to their real needs. This data helps in choosing between different options depending on the results, delivering improved care to patients.

The effect of a Heat and Moisture Exchanger (Provox HME) on pulmonary protection after total laryngectomy: a randomized controlled study

The goal of this randomized controlled study was to investigate the effect of Heat and Moisture Exchanger use on pulmonary symptoms and quality of life aspects in laryngectomized patients. Eighty laryngectomized patients were included and randomized into an HME and Control group. The effect of the HME was evaluated by means of Tally Sheets and Structured Questionnaires. The results showed a significant decrease in the frequency of coughing, forced expectoration, and stoma cleaning in the HME group. There were trends for the prosthetic speakers to report more fluent speech with the HME and for the HME group to report fewer sleeping problems. In conclusion, this study, performed in Poland, confirms the results of previous studies performed in other countries, showing that pulmonary symptoms decrease significantly with HME use and that related aspects such as speech and sleeping tend to improve, regardless of country or climate.

[Finger-free speech with the Provox FreeHands HME Automatic Tracheostoma Valve system. Clinical long-term experience]

INTRODUCTION

The use of voice prostheses allows excellent rehabilitation of laryngectomized patients but it is considered a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gestures or to work with both hands. An automatic tracheostoma valve helps patients to overcome this problem.

PATIENTS, MATERIAL AND METHODS

A total of 17 laryngectomized patients were asked to join a long-term study 18 months after having been fitted with a Provox FreeHands HME Automatic Tracheostoma Valve system. The patients completed a questionnaire in order to assess satisfaction, voice quality, wearing comfort, fixation, potential problems and the effectiveness of the HME cassette.

RESULTS

Of the 17 patients 4 discontinued the study due to problems of securing the valve to the skin (n=2) or fistula leakage (n=2). Of the remaining patients 7 wore the valve daily for an average of 6 h. Of the patients 76% considered it a great advantage to be able to speak without using their hands. With the Provox FreeHands HME Automatic Tracheostoma Valve system, maximum phonation time was 8.5 s (+/-6.8) and the dynamic range was 21.7 decibels (+/-5.6).

CONCLUSION

The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent long-term compliance and good voice rehabilitation.

The effects of a total laryngectomy on speech breathing

PURPOSE OF REVIEW

Alaryngeal speech rehabilitation following a total laryngectomy is a multifactorial disorder that includes changes in phonation, respiration, and overall general health. Tracheoesophageal speech is the preferred method of rehabilitation. In this approach, pulmonary air support is diverted from the trachea into the esophagus to generate voicing. Tracheoesophageal speakers must overcome radical upper airway changes, increased resistance in the phonatory source, reduced sensory feedback from the respiratory system, and probable respiratory compromise. This review integrates previous laryngectomy research with recent studies investigating kinematics in tracheoesophageal speakers.

RECENT FINDINGS

Tracheoesophageal speakers are often very intelligible and communicate effectively, but little has been done to investigate the physiological demands of tracheoesophageal speech on speakers. Two recent studies have specifically investigated speech breathing behaviors in tracheoesophageal speakers. Both investigations reported increased effort and differences in speech breathing compared to laryngeal speakers; however, continued research is needed to understand the effects of a total laryngectomy on speech breathing.

SUMMARY

The physiological changes following a laryngectomy, especially in the ability to produce tracheoesophageal speech, are not well known. Rehabilitation for these individuals requires an understanding of the changes in respiration that might influence speech breathing behaviors.

Hands-free speech after surgical voice rehabilitation with a Provox® voice prosthesis: experience with the Provox FreeHands HME tracheostoma valve® system

Excellent results have been reported with the use of voice prostheses for the rehabilitation of laryngectomees. Patients, however, consider it a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gesture or to work with both hands. An automatic tracheostoma valve helps patients overcome this problem. We describe a prospective clinical trial evaluating our experience with the Provox FreeHands HME Automatic Tracheostoma Valve system. Twenty-four laryngectomees were randomly selected from the patients who had undergone laryngectomy at the ENT Department. Immediately, after 4 weeks and 6 months later having been fitted with a Provox FreeHands HME, the patients were asked to complete a questionnaire in order to assess their satisfaction, voice quality, wearing comfort, fixation, potential problems, and the effectiveness of the HME cassette. In addition, we investigated relevant voice quality parameters including dynamics range, frequency range of the speaking voice, and maximum phonation time. Seven patients discontinued the study due to problems of securing the valve to the skin (four patients) or recurrent cancer (three patients). Ten of the remaining 17 patients wore the valve daily for an average of 8.4 h. A total of 88% of the patients considered it a great advantage to be able to speak without having to use their hands. With the Provox FreeHands HME, maximum phonation time was 8.7 (+/-6.2) s and the dynamic range was 21.9 (+/-5.8) decibels. The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent compliance and good voice rehabilitation.

Compliance, quality of life and quantitative voice quality aspects of hands-free speech

CONCLUSIONS

With the use of a new automatic stoma valve (ASV) it appears possible to rehabilitate patients who have previously been unsuccessful in acquiring hands-free speech. As well as making daily ASV use possible for an additional group of patients, this new device was also appreciated by many patients as an additional rehabilitation tool for specific occasions. Despite statistically significant improvements in aspects of voice and breathing using this novel ASV, improvement of peristomal adhesion is probably the main factor needed to further increase success rates. Nevertheless, our results show that it makes sense to keep trying to achieve hands-free speech, even if previous attempts have failed.

OBJECTIVE

To make a long-term (6 months) assessment of compliance and aspects of voice, breathing and quality of life using a new ASV: the Provox FreeHands heat and moisture exchanger (HME).

MATERIAL AND METHODS

This was a prospective clinical multicentre trial in 79 laryngectomized patients (8 regular ASV users, 58 previously unsuccessful users and 13 new users). Data were collected at baseline and after 1 and 6 months by means of European Organization for Research and Treatment of Cancer Quality of Life questionnaires and specific structured questionnaires concerning compliance, skin adhesion, voicing and pulmonary aspects. An objective assessment of voice parameters (maximum phonation time, maximum phonation time while counting, dynamic loudness range and number of pauses in a standard read-aloud text) was made for comparison of different stoma occlusion methods (digital occlusion via an HME and two different ASVs). A subjective assessment of overall voice quality was made.

RESULTS

After 6 months, 19% of patients used the new ASV on a daily basis (mean 5 h/day), while 57% used it on an irregular basis as an additional rehabilitation tool for special occasions. Two-thirds of the study group indicated that they would continue to use the new ASV after the study period. With respect to the objective parameters, statistically significantly better maximum phonation times and dynamic loudness ranges were observed with the new ASV compared to the Blom-Singer ASV. However, the best results for all the objective parameters were obtained with digital occlusion via the Provox HME.

Quality of life assessment in laryngectomized individuals: do we need additions to standard questionnaires in specific clinical research projects?

OBJECTIVES

To assess, whether the EORTC questionnaires QLQ-C30 and QLQ-H&N35 give enough detailed information to study specific quality of life (QoL) related issues in laryngectomized individuals.

DESIGN

Multicentre, prospective clinical trial; baseline measurement with EORTC questionnaires and an additional questionnaire, focusing on specific postlaryngectomy problems.

SETTING

Head and Neck Department of one Comprehensive Cancer Center and three Academic Medical Hospitals in the Netherlands.

PARTICIPANTS

Eighty laryngectomized individuals, selected to participate in a prospective clinical trial on hands-free tracheoesophageal speech.

MAIN OUTCOMES MEASURES

Comparison of QoL dimensions, as assessed with the standard EORTC questionnaires, with the information obtained with additional questions, aimed at discovering in more detail, e.g. voice and respiratory problems in laryngectomized individuals.

RESULTS

Based on the EORTC QoL questionnaires a good overall and voice specific QoL-level was found. However, the additional questionnaire showed that especially concerning voice and respiration more specific information was obtained. For example, despite an overall satisfaction with many aspects of the voice in more than three-quarters of the patients, speaking in a noisy environment was reported by 63% of the patients as being a serious problem, and a significant relation could be established between pulmonary and voicing problems (r = 0.28, P < 0.05), something also undetectable with the EORTC questionnaires.

CONCLUSIONS

These findings underline the necessity to develop and use more specific additional questionnaires as an adjunct to the existing EORTC questionnaires, when studying specific symptoms in laryngectomized individuals, especially in order to detect intervention related changes over time.

Multicenter Study Assessing Effects of Heat and Moisture Exchanger Use on Respiratory Symptoms and Voice Quality in Laryngectomized Individuals

OBJECTIVE: A multicenter study based in the United States assessed the heat-moisture exchanger effect on respiratory symptoms and “voice quality” of laryngectomees.

PATIENTS AND MEASURES: The study group consisted of 81 consecutive laryngectomees (62 men and 19 women; mean age, 66 years; age range, 45 to 89 years), with a median follow-up of 3.5 years (range, 0.5 to 24 years). A structured questionnaire was used to assess 3-month results, and tally sheets recorded the frequency of cough-expectoration during first and last trial weeks.

RESULTS: Compliance was 73% (n = 59); decrease in coughing, 68%; sputum production, 73%; forced expectoration, 60%; and need for stoma cleaning, 52% of these 59 patients. Regarding daily cough-expectoration frequency, a statistically significant decrease (P < 0.0001) was found between the first and last trial weeks. Regarding influence on voice quality, 46% of regular users reported improvement in intelligibility, 30% in loudness, 37% in fluency, and 40% in telephone intelligibility. Fourteen patients (19%) reported skin irritation, with discontinuation of 7 patients.

CONCLUSION: The observed decrease in pulmonary symptoms and improvement in voice quality confirm earlier reports from the Netherlands, United Kingdom, and Spain indicating improvement in postlaryngectomy quality of life. (Otolaryngol Head Neck Surg 2003;129:705-12.)

Development and clinical assessment of a heat and moisture exchanger with a multi-magnet automatic tracheostoma valve (Provox FreeHands HME) for vocal and pulmonary rehabilitation after total laryngectomy

OBJECTIVE

To develop and test the prototypes of a novel post-laryngectomy rehabilitation tool incorporating an obligatory, disposable heat and moisture exchanger (HME) and a reusable, multi-magnet automatic speaking valve (ASV).

MATERIAL AND METHODS

The study subjects comprised 20 laryngectomized individuals (15 males, 5 females), 5 of whom were already using an ASV and 15 who were not. Three successive prototypes were tested. Data were collected by means of structured questionnaires, considering for example patient compliance, skin adhesion, voicing and coughing aspects, and voice and speech quality assessments, assessing for example maximum phonation time and dynamic loudness range.

RESULTS

Of the 15 non-ASV users, 5 did not comply with the study due to peristomal skin adhesion problems. Of the remaining 15 patients, all 5 ASV users and 6/10 non-users were fully compliant with the new device. The cough-relief valve of the new device functions properly, as does the valve position adjustment for physical exertion. With this new device the maximum phonation time was longer than with a regular ASV (15.2 vs 11.6 s; p = 0.006) and the dynamic range was larger (33.0 vs 24.8 dB; p < 0.001).

CONCLUSION

The test results obtained with this new device show that its advanced features (obligatory HME and multi-magnet valve systems) offer additional benefits for further improving vocal and pulmonary rehabilitation after total laryngectomy.

"Pitch" accent in alaryngeal speech

Highly proficient alaryngeal speakers are known to convey prosody successfully. The present study investigated whether alaryngeal speakers not selected on grounds of proficiency were able to convey pitch accent (a pitch accent is realized on the word that is in focus, cf. Bolinger, 1958). The participating speakers (10 tracheoesophageal, 9 esophageal, and 10 laryngeal [control] speakers) produced sentences in which accent was cued by the preceding context. For each utterance, a group of listeners identified which word conveyed accent. All speakers were able to convey accent. Acoustic analyses showed that some alaryngeal speakers had little or no control over fundamental frequency. Contrary to expectation, these speakers did not compensate by using nonmelodic cues, whereas speakers using F0 did use nonmelodic cues. Thus, temporal and intensity cues are concomitant with the use of F0; if F0 is affected, these nonmelodic cues will be as well. A pitch perception experiment confirmed that alaryngeal speakers who had no control over F0 and who did not use nonmelodic cues were nevertheless able to produce pitch movements. Speakers with no control over F0 apparently relied on an alternative pitch system to convey accents and other pitch movements.

Comprehensive rehabilitation after total laryngectomy is more than voice alone

Comprehensive rehabilitation after total laryngectomy is more than voice alone. The removal of the larynx and the subsequent disconnection of the upper and lower airways not only has consequences for the vocal function but also for the respiratory system, and for the olfactory acuity of the patient. The results of the research program on these three subjects in the Netherlands Cancer Institute over the last 12 years are discussed in detail along with some of the relevant other literature on the topics. The considerable progress in these areas over the last 2 decades has clearly improved the quality of life of laryngectomized patients.