Can objective parameters derived from videofluoroscopic assessment of post-laryngectomy valved speech replace current subjective measures? An e-tool-based analysis

Exploring Reliable and Identifiable Quantitative Anatomical, Timing, and Displacement Measures in the VFS of Speech

AIM

Videofluroscopy studies of speech are a recognized assessment of velopharyngeal insufficiency (VPI). Yet, this method is subjective and has low inter-rater reliability. Quantitative measures of timing, distance, and area in videofluoroscopic studies of swallowing have been shown to be valid and reliable, but quantitative measures are not routinely used in videofluroscopy studies for VPI. This study explored the use of quantitative measures in patients with VPI in terms of feasibility and reliability.

METHODS

Forty patients of mixed etiology diagnosed with VPI through perceptual speech assessment underwent videofluroscopy. Anatomical landmarks and timing, distance, and area measurements were taken of the velopharyngeal port at rest and during speech tasks using specialized Swallowtail software. 50% of measures were double-blind rated to test inter-rater reliability. Raters reported on the time they took to complete each assessment and the challenges they had. Associations between measures were explored.

RESULTS

Ten timing, line, and area measures were developed based on 3 landmarks. Measures had moderate-substantial inter-rater reliability (intraclass coefficient: 0.69-0.91) except for time to lift (secs), which only achieved fair agreement (intraclass coefficient: 0.56). Measures demonstrated internal consistency ( R >0.60). Raters took, on average, 15 mins per patient and reported some challenges with image resolution, especially in timing measures where structures were blurred by movement.

CONCLUSION

Quantitative measures are reliable and have the potential to add novel information regarding VPI to support multidisciplinary decision-making. Further research with larger patient cohorts is needed to clarify how quantitative measures can support tailored decisions about surgical and therapeutic interventions in order to maximize outcomes for individuals.

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.

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.

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.

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.

A new proposal for evaluation of the pharyngoesophageal segment and its relation with the narrow-band spectrogram in tracheoesophageal speakers

PURPOSE

The primary purpose of this study was to assess the relationship between pharyngoesophageal segment (PES) configuration and narrow-band spectrogram of tracheoesophageal voices.

METHODS

This study included 30 total laryngectomees tracheoesophageal speakers. Patients were assessed by videofluoroscopy (VF), during deglutition and voicing, and the vowel /a/ was recorded for spectrographic analysis. The evaluation of VF recording consisted of visual perceptual rating of degree of contact between the prominence of PES and its anterior wall, defined as absent/mild (hypo contact), moderate (normo contact) and intense (hyper contact); and quantitative measures of PES: anteroposterior distance (APD) and length of the PES (lenPES); PES surface area in swallowing (areaSw), and phonation (areaPh), and the area of the air reservoir (areaAir). Visual inspection of a narrow-band spectrogram was made and four different acoustic signal typing were defined as Type I, II, III or IV.

RESULTS

Type I-II is correlated with moderate contact; Type III, with intense and Type IV, with absent/mild contact. Type I-II has bigger APD and PES with lower length than Type IV. There is a correlation between bigger APD and shorter PES.

CONCLUSION

The group with I-II signal typing has PES with normo contact; Type III with hyper contact and Type IV has PES with hypo contact. The best tracheoesophageal voices are achieved by PES with moderate contact of the prominence and with shorter and larger anteroposterior PES distances. What differentiates the PES with hyper contact from PES with normal one is only the degree of contact between the prominence of the PES and its anterior wall.

Substitute voice production: quantification of PE segment vibrations using a biomechanical model

After total larynx excision due to laryngeal cancer, the tracheoesophageal substitute tissue vibrations at the intersection between the pharynx and the esophagus [pharyngoesophageal segment (PE segment)] serve as voice generator. The quality of the substitute voice significantly depends on the vibratory characteristics of the PE segment. For improving voice rehabilitation, the relationship between the PE dynamics and the resulting substitute voice quality is a matter of particular interest. Precondition for a comprehensive analysis of this relationship is an objective quantification of the PE vibrations. For quantification purposes, a method is proposed, which is based on the reproduction of the tissue vibrations by means of a biomechanical model of the PE segment. An optimization procedure for an automatic determination of appropriate model parameters is suggested to adapt the model dynamics to tissue movements extracted from high-speed (HS) videos. The applicability of the optimization procedure is evaluated with ten synthetic data sets. A mean error of 8.2% for the determination of previously defined model parameters was achieved as well as an overall stability of 7.1%. The application of the model to six HS recordings presented a mean correlation of the vibration patterns of 82%.

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.