The Singer-Blom speech rehabilitation procedure

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.

Surgical complications of tracheo-oesophageal puncture and speech valves

PURPOSE OF REVIEW

Speech rehabilitation following total laryngectomy is central to future quality of life. Although other options exist, surgical voice restoration has emerged as the 'gold standard' management strategy in the majority of laryngectomees. Taking this into account, what are the complications of this technique and how should they be successfully managed? The purpose of this review is to provide a comprehensive review of the subject, with particular reference to technique, complications and outcome.

RECENT FINDINGS

As with any surgical intervention, complications may occur in the early postoperative period or later. The article provides a detailed explanation of the varying problems detailed in individual reports, and in case series. Primary or secondary tracheo-oesophageal puncture is also discussed, along with complications resulting from the speech valve itself.

SUMMARY

The positive impact of surgical voice restoration on quality of life in the alaryngeal patient considerably outweighs the complications commonly associated with the procedure. Greater knowledge of the potential problems should continue to reduce the complication rate. Primary puncture, in a patient selected and subsequently managed in a multidisciplinary environment, would appear to provide the best outcome for the patient.

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture

OBJECTIVES/HYPOTHESIS

Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature.

STUDY DESIGN

Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996.

METHODS

Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y).

RESULTS

All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications.

CONCLUSIONS

Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Voice intelligibility in patients who have undergone laryngectomies

In this paper, we evaluate the speech intelligibility of two groups of Spanish-speaking people who have undergone laryngectomies: a group who used esophageal speech and a group who used tracheoesophageal (TES) prostheses. Audio recordings of 24 Spanish words produced by each talker were presented to a group of normal-hearing naive listeners who phonetically transcribed their responses. Listeners' responses were registered in confusion matrices. Results indicate that differences between these two groups of patients appear when we consider phoneme types. The difficulty in producing the voicing distinction appeared in both TES and esophageal talkers. This finding is consistent with studies of English-speaking laryngectomized patients. Considering manner of production, fricative consonants had the highest number of confusions with other phoneme class in the TES group, whereas in the esophageal group nasals resulted the highest number of confusions. However, ANOVA showed that differences between the two groups were not significant.

A pneumatic artificial larynx popularized in Hong Kong

The 'Taiwan tube' is an inexpensive pneumatic artificial larynx made in Taiwan. The device, which is a tracheo-oral shunt containing a resonator, is popular with laryngectomees in Hong Kong. This paper reports its use and describes its working dynamics which compare favourably with those of other forms of voice restoration.

Laryngoplasty with a radialis pedicle flap from the forearm: a surgical procedure for voice rehabilitation after total laryngectomy

Tracheoesophageal puncture and insertion of a prosthetic voice device is currently the most widely surgical procedure for vocal rehabilitation after total laryngectomy. The disadvantages of voice prostheses are high initial phonation pressure, formation of granulation tissue around the voice shunt, blockage, displacement of the prosthesis, leakage of the prosthesis or the voice shunt, spontaneous occlusion when the prosthesis is accidentally removed and difficulties in replacing and cleaning the prosthesis. In an effort to avoid these problems, a substitute laryngeal tube (laryngoplasty) was fashioned from a revascularized forearm flap and connected to the trachea and pharynx in seven patients with extensive laryngohypopharyngeal carcinoma. All seven developed a voice comparable with patients fitted with a voice prosthesis. An advantage of this graft is the low phonation pressure required for voice production. Problems with aspiration have not occurred even after radiotherapy. While still in the hospital, five patients learned to speak without using their hands through the use of a tracheostomal valve. Judging by these results, this surgical procedure is a practical alternative to a voice prosthesis.

Location of the vibratory segment in tracheoesophageal speakers

The Singer-Blom tracheoesophageal puncture procedure for surgical-prosthetic voice restoration has proved to be a viable option for alaryngeal speech rehabilitation. Following tracheoesophageal puncture, occlusion of the tracheostoma shunts pulmonary air through the Blom-Singer prosthesis into the cervical esophagus. The pulmonary air passing through the cervical esophagus and into the hypopharynx causes a portion of the upper alimentary tract to vibrate in a manner similar to that of the pharyngoesophageal segment during the production of esophageal speech. To study the location and shape of the vibratory segment in tracheoesophageal speakers, videofluoroscopy and simultaneous voice recording were performed with 16 patients. To analyze the vibratory segment(s), photographs were made of the videotaped image while it was stopped during the patients' production of the /a/ sound. The most frequent location of the vibratory segment was in the lower third of the neck, which corresponds to cervical vertebrae C5 through C7. Five of the subjects had two separate vibratory segments and two other subjects had long vibratory segments. The vibratory segment(s) in tracheoesophageal speakers was found to be similar to the vibratory segment(s) in esophageal speakers.

Tracheoesophageal puncture for voice restoration: modification of the Blom-Singer technique

We have used a modification of the Blom-Singer technique in our last 24 tracheoesophageal punctures, performed on 20 patients. At the time of puncture a surgical stent with an indwelling Dacron polyester suture is placed to form the fistula. Forty-eight to 72 hours later the stent is backed out of the puncture site but the suture is allowed to remain. The Blom-Singer duckbill prosthesis is fitted and taped in the routine fashion. The suture is left to traverse the tracheoesophageal tract until the time of discharge, when it is removed. At discharge the patient is given a Silastic dilator, to be used if the puncture site becomes too small to allow for insertion of the duckbill prosthesis. Seventeen of the 20 patients in this group obtained good voice. Six operations would have been failures because of the loss of the patient's prosthesis in the immediate postoperative period if the modified technique had not been used.

Groningen prosthesis for voice rehabilitation after laryngectomy

Singer and Blom's endoscopic technique, using a single valved silicone prosthesis, constituted a dramatic advance in speech rehabilitation following total laryngectomy. Since 1980, we have developed a silicone biflanged prosthesis that overcomes some of the inconveniences of previous prostheses. Insertion via the mouth and the oesophagus, or as a primary procedure during total laryngectomy is easily done with the use of specially developed instruments. The success rate in 36 patients in which the voice button was inserted at the time of total laryngectomy was 86.2%.

Prognostic factors affecting the success of duckbill vocal restoration

This study analyzed a group of 20 patients undergoing duckbill vocal restoration at Ohio State University to determine if certain variables could predict success. Of the 20 patients, 19 developed successful speech. The 10 variables studied were age, alcohol use, living environment, stoma size, hearing acuity, educational level, work status, eye-hand coordination, concomitant medical problems, and current mode of communication. A multiple correlation analysis of this data was undertaken and alcohol abuse and stoma size were found to have the highest correlation with developing successful duckbill speech. A formula based on these two variables has been derived that will predict the patient's success. It is the conclusion of this study that since patients are not uniformly successful in developing duckbill speech such a formula is of value in predicting success and should help the clinician identify patients who may have difficulties.

Acoustic characteristics: tracheoesophageal speech

This study examined differences among five tracheoesophageal, four esophageal, and five laryngeal speakers on the acoustic parameters of intensity and duration. Each subject repeated 14 prerecorded model sentences and prolonged phonation of three vowels. Analogue prints of the voice samples were obtained, and measures were subjected to parametric statistical analysis. Differences among groups indicate that the tracheoesophageal speakers are more like normal speakers than are esophageal speakers, indicating that surgical procedures such as the tracheoesophageal puncture are a significant rehabilitative alternative for the laryngectomee.