Cineradiography of the pharyngoesophageal segment in postlaryngectomy patients

Has Esophageal Speech Returned as an Increasingly Viable Postlaryngectomy Voice and Speech Rehabilitation Option?

PURPOSE

The literature on postlaryngectomy voice and speech rehabilitation is long-standing. Although multiple rehabilitation options have existed over the years, the acquisition and use of esophageal speech (ES) has decreased significantly over the past 40 years. This reduction coincides with the increased application of tracheoesophageal puncture (TEP) voice restoration. The literature suggests that voice acquisition failures observed secondary to TEP may represent a similar phenomenon that led to ES acquisition failures.

METHOD

A comprehensive review of the literature on ES and TEP voice/speech was conducted. Specific attention was directed toward information on ES and TEP speech failures. Information on pharyngoesophageal segment (PES) spasm in the context of ES and TEP voicing failures was of specific importance.

RESULTS

Similarities between voicing failures with both ES and TEP were identified. In order to resolve spasm in TEP speech, proactive efforts to eliminate it were undertaken, and regardless of the method used, voicing improvements were observed. These data suggest that both ES and TEP speech acquisition failures may be related to the same control mechanisms influencing the PES.

CONCLUSIONS

The elimination of PES spasm provides evidence that justifies the reconsideration of ES. Consequently, ES may return as an increasingly viable postlaryngectomy voice and speech rehabilitation option.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Importance

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures.

Objective

To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP.

Design, Setting, and Participants

This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019.

Main Outcomes and Measures

Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed.

Results

Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type.

Conclusions and Relevance

This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

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.

Intraluminal Esophageal Pressures in Speaking Laryngectomees

Objectives

The objective of the present study was to evaluate intraluminal esophageal pressure during voice and speech emission in speaking laryngectomees with a tracheoesophageal prosthesis.

Methods

In our prospective analysis in a tertiary-care academic hospital, 25 laryngectomees were divided into 2 groups: 11 speaking individuals with a tracheoesophageal prosthesis and a control group of 14 nonspeaking laryngectomees. All patients were subjected to manometry during voice and speech emission tests. We determined the pressures achieved in the distal, middle, and proximal parts of the esophagus.

Results

Statistical analysis revealed that the amplitude of pressure in the distal esophagus during sound emission was higher in speaking laryngectomees; in the middle esophagus, intraluminal pressure during emission of the sentence was higher in speaking subjects, and in the proximal esophagus there was no difference between the groups.

Conclusions

During the manometric evaluation of the distal and middle esophagus in the presence of voice and speech emission, the intraluminal pressure revealed a significant difference for the speaking laryngectomees with a tracheoesophageal prosthesis. The proximal esophagus behaved similarly in the groups of speakers and nonspeakers. Speaking laryngectomees with a tracheoesophageal prosthesis depend on a differentiated performance of the middle and distal parts of the esophagus.

Design and Evaluation of a Mechanically Driven Artificial Speech Device

This paper presents the design of a mechanically driven artificial speech device to be used by laryngectomees as an affordable alternative to an electrolarynx (EL). Design objectives were based on feedback from potential end users. The device implements a mainspring powered gear train that drives a striker. The striker impacts a suspended drum-like head, producing sound. When pressed against the neck, the head transmits sound into the oral cavity, allowing the user to produce intelligible speech. The dynamics of the vibrating head and sound pressure levels (SPLs) produced at the mouth were measured to compare performance between the device and a common, commercially available EL. The results showed comparable performance and sound output.

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.

[Anterior diverticulum after total laryngectomy]

Pharyngeal anterior diverticulum, also known as pseudoepiglottis is one of the most common disorders after total laryngectomy.

THE AIM OF THIS STUDY

was to evaluate frequency of diverticulum after different types of total laryngectomy and severity of dysphagia in patient with developed pseudoepiglottis.

MATERIAL AND METHODS

The material consisted of 80 patients after following surgeries: total laryngectomy with hyoid bone resection, total laryngectomy without hyoid bone resection, total laryngectomy with hyoid bone and base of tongue resection, total laryngectomy and partial pharyngectomy with hyoid bone resection and total laryngectomy and partial pharyngectomy with hyoid bone and base of tongue resection. To evaluate morphologic and functional disorders clinical examination, videopharyngoscopy and cineradiography of swallow act were performed.

RESULTS

Pseudoepiglottis was present in 34 (43%) of patients, mainly after surgeries without hyoid bone resection. There was no correlation between diverticulum formation and pharyngeal closure (muscular or non-muscular), shape of closure (vertical or "T"), pharyngocutaneous fistula, radiotherapy.

CONCLUSIONS

This study indicates that leaving hyoid bone is a major risk factor for developing pseudoepiglottis.

Botulinum toxin A prolongs functional durability of voice prostheses in laryngectomees with pharyngoesophageal spasm

PURPOSE

Laryngectomized patients with pharyngoesophageal spasm frequently have poor voice quality and dysphagia. Local botulinum toxin A (BTA) injection can relieve muscular hypertonicity and improve symptoms. This procedure should also prolong the functional life span of the tracheoesophageal voice prosthesis.

MATERIALS AND METHODS

This study evaluates 33 BTA treatments in 11 laryngectomees. All patients were having poor voice quality; 6 patients had additional dysphagia. In 10 patients, the BTA injection has been carried out during rigid pharyngoscopy under general anesthesia. One patient was treated in local anesthesia.

RESULTS

A subjective improvement of voice quality was reported in 94%. This lasted on average for 20 weeks. The swallowing function improved moderately. For the first time, the functional life span of voice prostheses was examined. After treatment of pharyngoesophageal spasm, their durability was almost tripled. The BTA therapy has a significant effect.

CONCLUSIONS

The BTA treatment improves voice quality and prolongs functional durability of voice prostheses in laryngectomees with pharyngoesophageal spasm. The success of treatment is of limited duration but can be repeated in the long-term.

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

OBJECTIVES

The primary purpose of this study was to assess the pharyngoesophageal segment in total laryngectomy patients using a videofluoroscopy e-tool.

STUDY DESIGN

Cross-sectional study.

SETTING

Head and Neck Oncology Unit, Tertiary Referral Centre.

PATIENTS

Forty-two patients following total laryngectomy.

INTERVENTION

Videofluoroscopy using an e-tool (JRuler).

MAIN OUTCOME MEASURES

Subjective and objective videofluoroscopy parameters correlated with the GRBAS scale and treatment variables.

RESULTS

Of 32 men and 10 women, mean age 63.5 years (10.8) the majority (64.3%) had a reasonable voice (good = 11 and poor = 4 patients). Comparing subjective and objective parameters, significant correlations were only seen with a smaller minimal neoglottic distance at phonation with no regurgitation of barium at phonation (P = 0.05) and a type 1 shape of neoglottis at phonation (P = 0.02). There were also significant correlations between smaller maximum sub-neoglottic distance at phonation and type 1 shape of neoglottis (P = 0.02), smaller maximum sub-neoglottic distance at rest and absence of stasis of barium at phonation (P = 0.05) and the length of neoglottis at phonation and type 1 shape of neoglottis (P = 0.01). For perceptual evaluation, significant correlation was seen only between G1 voice and a smaller minimal neoglottic distance at phonation (P = 0.03) amongst the subjective and objective parameters. There were no correlations between visual parameters and the clinical parameters.

CONCLUSIONS

Our observations suggest that this interesting concept has limitations. While objective and quantifiable data can be obtained using videofluoroscopy in laryngectomees, only a few correlate with each other and with voice quality.

Behavior of the cricopharyngeal segment during esophageal phonation in laryngectomized patients

BACKGROUND

After total laryngectomy, the interruption of the upper digestive tube and the section of the cricopharyngeal segment alter the high-pressure zone of the pharyngoesophageal transition, which will not only start to have a digestive function, but also be stimulated to take on the production of voice and speech. The pressure observed in the cricopharyngeal segment seems to act as a critical factor for the development of esophageal sound production, and manometry is the procedure capable of quantifying the pressure observed in this region.

OBJECTIVE

The objective of the current study was to assess the upper esophageal sphincter pressure in laryngectomized patients who are either successful or unsuccessful esophageal speakers, both at rest and during esophageal phonation, using manometry.

METHODS

Twenty laryngectomized persons aged 32 to 83 years (mean, 44.2 years) were submitted to evaluation by a speech pathologist and divided into two groups, ie, successful esophageal speakers (N=12) and unsuccessful esophageal speakers (N=8), according to a scale validated by Wepman et al (1953). The upper esophageal sphincter (UES) pressure was assessed by manometry both at rest and during the following voice emissions in Portuguese: the vowel "a," the monosyllable "pa," and the sentence "papai papou pipoca." The amplitude, the duration of the pressure wave, and the area under the curve were measured.

RESULTS

At rest, the mean UES pressure was 11.83 mm Hg for successful esophageal speakers and 9.92 mm Hg for unsuccessful esophageal speakers, with no significant difference between groups; the mean for the two groups as a whole was 11.06 mm Hg. During the voice and speech sequence tests, no significant difference was observed when the emissions in Portuguese of "a," "pa," and the sentence were analyzed separately.

CONCLUSION

As the pressure observed at rest did not differ between the successful esophageal speakers and the unsuccessful esophageal speakers, and the amplitude, the duration of the pressure wave, and the area under the amplitude x duration curve were also equal for both groups, we conclude that the cricopharyngeal segment pressure is not a preponderant factor for the acquisition of esophageal voice and speech.

Anatomical and Functional Correlates of Voice Quality in Tracheoesophageal Speech

The purpose of the current study was to assess the anatomic and functional correlates of voice quality in tracheoesophageal speech, with dynamic imaging studies of the neoglottis. Videofluoroscopy (providing a lateral view), digital high-speed endoscopy (providing a "birds-eye" view), and their relationships with perceptual evaluations of voice quality were investigated. Several significant relationships were found. Imaging with videofluoroscopy revealed that the following anatomic and functional parameters (established during phonation) are related to voice quality: presence of a neoglottic bar, regurgitation of barium, tonicity of the neoglottis, and minimal neoglottic distance. Furthermore, the index of the increase of the maximal subneoglottic distance from rest to phonation also showed a significant relationship with voice quality. Imaging with digital high-speed endoscopy revealed features relevant to voice quality, including amount of saliva, visibility of the origin of the neoglottis, shape of the neoglottis, and regularity of the vibration. Knowledge of the anatomic and functional correlates of tracheoesophageal voice quality provides prerequisite information for future (phono-) surgical and/or clinical improvements to the voice quality of postlaryngectomy (prosthetic) voice production.

Proximal Esophageal Contractions in Laryngectomized Patients

After laryngectomy for treatment of laryngeal cancer, the distal esophageal contractions have low amplitude. Our hypothesis is that proximal esophageal contractions are also impaired. We studied the proximal esophageal contractions in 20 laryngectomized patients (16 men) with a mean age of 44.2 years, 12 rehabilitated patients with esophageal speech, and 12 controls (7 men, mean age of 46.5 years). We used the manometric method with continuous perfusion. All subjects were studied in the sitting position and performed five swallows of a 5-ml bolus of water alternated with five dry swallows. The contractions were measured 2 cm below the high-pressure zone of the pharyngoesophageal transition. The results showed that the amplitude and duration of contractions were different in laryngectomized patients compared with controls. The amplitude of contractions of patients (wet swallows: 37.3+/-20.7 mmHg, mean+/-SD) was lower than that of controls (81.1+/-31.7 mmHg). The duration of contractions was also lower in laryngectomized patients (2.2+/-0.7 s) than in controls (2.6+/-0.6 s). We conclude that the proximal esophageal contraction amplitude and duration of laryngectomized patients are lower than controls, a fact suggesting that laryngectomy may affect the proximal esophageal contractions.

Voice following laryngeal cancer surgery: troubleshooting common problems after tracheoesophageal voice restoration

The introduction of tracheoesophageal voice restoration by Blom and Singer has provided laryngectomy patients with a successful alternative to the use of artificial larynx and esophageal speech. Although this method of communication provides for the rapid acquisition of intelligible, functional speech, there are common problems that may occur in these patients. Close follow-up of patients postoperatively along with thorough patient education is beneficial to improving long-term success with tracheoesophageal speech. The purpose of this article is to discuss common problems encountered in the treatment of patients who have undergone tracheoesophageal puncture and to provide systematic assessment and treatment guidelines that are essential to maintaining functional tracheoesophageal speech.

Value of digital high-speed endoscopy in addition to videofluoroscopic imaging of the neoglottis in tracheoesophageal speech

OBJECTIVE

To gain insight into the clinical value of using the relatively new evaluation tool digital high-speed endoscopy in addition to the widely used method of videofluoroscopy for imaging of the neoglottis in tracheoesophageal speech after total laryngectomy.

MATERIAL AND METHODS

Anatomical and morphologic characteristics of the neoglottis in 37 laryngectomized patients using tracheoesophageal speech were studied by means of visual assessment of digital high-speed endoscopy recordings and visual assessment and quantitative measures of videofluoroscopy recordings, using previously published protocols.

RESULTS

Digital high-speed endoscopy provides information complementary to that of videofluoroscopy with respect to the location of the vibration, presence of a mucosal wave, regularity of the vibration and closure of the neoglottis The information provided by digital high-speed endoscopy overlaps with that provided by videofluoroscopy with respect to the amount of saliva (regurgitation of barium in videofluoroscopy) and the visibility of the origin of the neoglottis (presence of a neoglottic bar in videofluoroscopy). Additionally, relationships were found between the visual assessments of the high-speed recordings and some patient characteristics.

CONCLUSIONS

Digital high-speed endoscopy provides additional insight into neoglottic characteristics that cannot be studied with videofluoroscopy. The application of both imaging methods enhances the insight into tracheoesophageal voicing.