Friday, March 31, 2023

Laryngectomy Rehabilitation


Total laryngectomy (TL) significantly alters speech production. For a speech production system to be functional, the following 3 basic elements are necessary: (1) a power source, (2) a sound source, and (3) a sound modifier. For laryngeal speakers, lung air is the power source, the larynx is the sound source, and the vocal tract (ie, pharynx, oral cavity) is the sound modifier. During total laryngectomy (TL), the sound source is removed and the lungs are disconnected from the vocal tract. Successful voice restoration following total laryngectomy (TL) requires identification of an alternative sound source with a viable power source.

An image depicting laryngectomy rehabilitation can be seen below.

Diagram of tracheoesophageal puncture and prosthes

Diagram of tracheoesophageal puncture and prosthesis placement. Image courtesy of International Healthcare Technologies. Blom-Singer is a registered trademark of Hansa Medical Products.

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The 3 basic options for voice restoration after total laryngectomy (TL) are (1) artificial larynx speech, (2) esophageal speech, and (3) tracheoesophageal speech. Selection of a method should be based on input from the surgeon, speech pathologist, and patient. The decision is best made keeping in mind the patient’s communicative needs, physical and mental status, and personal preference.

Esophageal speech

See the list below:

Principle: Esophageal speech is produced by insufflation of the esophagus and controlled egress of air release that vibrates the pharyngoesophageal (PE) segment for sound production. Anatomic structures for articulation and resonance are usually unaltered.

Techniques: The 2 basic approaches to esophageal insufflation are injection and inhalation. Both techniques are based on the pressure differential principle that air flows from areas of higher pressure to areas of lower pressure. Injection involves using the articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. Inhalation involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax so air insufflates the esophagus. Proficiency in esophageal speech typically requires several months of speech therapy.

Advantages: No apparatus must be purchased or maintained, and no further surgery is required.

Disadvantages: Speech acquisition is delayed because of the learning curve, and difficulties with phrasing and loudness are possible.

Artificial larynx speech

See the list below:

Principle: An external mechanical sound source is substituted for the larynx. Anatomic structures for articulation and resonance are usually unaltered.

Techniques: Two general types of electrolarynges are available, the neck type and the intraoral type.
The neck type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted into the oropharynx and articulated normally. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. A small tube is placed toward the posterior oral cavity, and the generated sound is then articulated. The tube has minimal effect on articulatory accuracy if the patient is taught properly and learns to use it well. A third type of electrolarynx has been developed using an electromyograph (EMG) transducer in the strap muscles to activate a sound source for hands-free use.

Advantages: Voice restoration after surgery is immediate, and the maintenance for the electrolarynx is minimal (may last 2-10 y).

Disadvantages: The voice quality sounds mechanical.

Tracheoesophageal speech

See the list below:

Principle: A surgical fistula is created in the wall separating the trachea and esophagus. This puncture tract can be created primarily, at the time of total laryngectomy (TL), or secondarily, weeks or years following the total laryngectomy (TL). Several days after surgery, a one-way valved prosthesis is placed in the puncture tract, allowing lung air to pass into the esophagus. The lung air induces vibration of the PE segment for sound production. The mechanics of the one-way valve allow lung air to pass into the esophagus without food and liquids passing into the trachea.

Technique: During the initial evaluation, a speech pathologist measures the length of the puncture tract and selects a size and style of prosthesis for placement. Once in place, the patient digitally occludes the tracheostoma to direct air through the prosthesis into the esophagus for phonation. Hands-free external airflow valves are also available as accessories.

Advantages: The air supply for speech is pulmonary, phonation sounds natural, and voice restoration occurs within 2 weeks of surgery.

Disadvantages: Additional surgery is required for secondary punctures, the prosthesis must be maintained, and aspiration may occur if liquids leak through a malfunctioning valve.

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