Dr.

Supreet Singh Nayyar, AFMC

2011

Alaryngeal Speech
(for more ENT topics & presentations, visit www.nayyarENT.com)

Role of larynx in Voice Production

Generator o Diaphragm , chest muscles, ribs, abdominal muscles and lungs o Provides and regulates air pressure to cause vocal folds to vibrate Phonator o Larynx , vocal folds o Vibrate changing air pressure to sound waves producing voiced sound/buzzy sound o Varies pitch of the sound Resonator o Pharynx, oral cavity, nasal passages. o Changes the buzzy sound into recognizable voice

Voice restoration options:

o o o Esophageal External vibratory voice Fistula (or shunt) based

Oesophageal speech
Trapping air in the mouth or pharynx and propelling it into the esophagus o Closure of lips o Relaxation of PE segment o Retropulsion of tongue Approximately 80ml of air can be stored in the esophagus or stomach (Bellow) Using gentle contraction of abdominal & chest muscles, Controlled regurgitation of air past the mucosa of PE segment (Neoglottis / pseudoglottis) Mucosa of ant & post walls approx. because of a bulge in the post pharyngeal wall bteween 4th & 7th vertebra Neoglottis can be tuned to some degree by thyropharyngeus or middle constrictor muscle Produces a belch-like sound Articulated by the tongue, lips, and teeth Patient learns how to rapidly insufflate and eject air through his or her esophagus to produce understandable speech Advantages o Vs Electrolarynx Less conspicuous than artificial larynx Requires no batteries Does not sound mechanical Hands free o Vs TEP No additional surgery In motivated patients with contraindications for TEP Freedom from prosthesis maintenance
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Dr. Supreet Singh Nayyar, AFMC

2011

Lower Cost Comparable speech quality Disadvantage o Low success rates (upto 50%)(Stell Maran) o Only 4-6 words per breath, Duration of phonation o Choppy, low amplitude o Pitch modulation difficult o Delay in acquiring speech Two types o External Pneumatic Electric o Transoral type Both types are electrically driven and produce a mechanical sound Sound is articulated by the tongue, lips, and teeth as understandable speech Most common type is external type Intraoral type indicated for patients whose cervical tissues cannot transmit the sound such as those that have received radiation to the neck Advantages o Short learning time o Ability to use immediately postop o No interference with post op healing o Relative availability o Low cost Disadvantages o Mechanical sound monotone , single pitch o Dependence on batteries o Maintenance of the intraoral tubes

External vibratory voice

Fistula based voice

Principle o Restoration of lungs as primary energy source o Uses lungs as bellow for pumping air o Fistula between trachea and oesophagus with one way valve o Entire inspiratory capacity (3000 ml) at disposal of the patient o Placement of fistula determines region of PE segment vibration o Modern methods direct prosthesis into cervical esophagus immediately posterior to tracheostoma o Greater air pressure occurs & PE segment generates voice with a higher frequency Pre-Surgical Counselling o Anatomical Changes
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Dr. Supreet Singh Nayyar, AFMC

2011

o Options available o Informed expectations o Answer questions; create rapport o Group consultation with laryngectomee with TEP patients Contraindication for TE Speech o Inability to care for stoma o Stenotic stoma o Poor eyesight o Oesophageal stenosis o Poor motivation o Poor manual dexterity Advantages o Rapid speech restoration o Natural sound o Normal utterance length o Indwelling = minimal maintenance; Hands-free is possible o Tonal language is intelligible Disadvantages o Surgery required o Puncture stenosis o Aspiration of dislodged prosthesis o Aspiration of liquids leaking through and/or around prosthesis o Candida growth Timing o Secondary TE Puncture In case not performed at time of surgery, it is delayed until 2-4 wks to allow healing of tracheostoma Some choose to delay therapy until after radiation therapy or in case of significant premorbid condition Singers procedure Rigid esophagoscopy into neopharynx TEP site selection o Should allow easy access to prosthesis o Must allow unobstructed closure of stoma by patients finger o Usually 5-15 mm from mucocutaneous junction Needle passed under vision into hole of oesophagoscope Serial dilatation of the puncture site 14 Fr rubber catheter passed o Primary TE puncture Advantages No second procedure Myotomy & nurectomy at the time of puncture Early voice development No need for NG tube/gastrostomy
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Dr. Supreet Singh Nayyar, AFMC

2011

Psychological benefit Cost saving Disadvantages Lost opportunity for esophageal speech Post op RT - access problem Mucositis induced inhibition of voice production More complications Procedure Selection of fistula site after laryngectomy but before closure of pharyngeal defect Simplest way grasp post wall with gentle traction & raise it from mediastinum to estimate its final position relative to skin flaps & sternal notch Puncture site is selected 1-1.5 cm from the superior edge Right angled clamp placed against TE party wall Small vertical incision Newer Provox 2 are injection loaded Placed retrogradely from oesophageal side into created stoma & piston pressed Flanges open on oesophageal side while button fixes on pharyngeal side Prosthesis Indwelling o Groningen o Provox o Provox 2 o Blom singer indwelling Non indwelling o Panje voice button o Blom Singer duckbill Most commonly used presently Blom-Singer Indwelling o Gel-cap loading with delayed opening of esophageal flange o Largest Diameter = 20 Fr o Anterograde placement at time of surgery o Approx. Rs 4000 replacement Provox 2 o Loading tool with instantaneous opening of esophageal flange o Largest Diameter = 22 Fr o Retrograde placement at time of surgery; Anterograde replacement o Approx. Rs 10000 replacement Prosthesis maintenance Prosthesis must be cleaned
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Dr. Supreet Singh Nayyar, AFMC

2011

Non indwelling prosthesis cleaned regularly In dwelling prosthesis regular syringing Device life 2-10 months Prevention of pharyngeal spasm Oesophageal distension Secondary spasm of oesophageal sphincter Methods to reduce hypertonicity o Cricopharyngeal myotomy Risk of mucosal dehiscence & fistula formation Posterolat cricopharyngeal & constrictor myotomy o Pharyngeal plexus neurorrhaphy Identify pharyngeal plexus by electric stimulation Adv preserves blood supply to pharyngeal wall & may enhance quality of phonation due to residual elastic tone Prevention of fungal infection Common organisms Candida albicans, Candida tropicalis Results in o Prosthesis damage o Leakage o Incomplete closure Treatment : o Nystatin oral suspension around the mouth BD for 3-4 mins & swallowed or expectorated o Amphotericin B lozenge 10 mg QID dissolved slowly in mouth o Miconazole nitrate Buccal bioadhesive slow release tab containing miconazole nitrate o Candida resistant fluro plastic valve Complications of TEP Major o Prosthesis dislodgement o Aspiration pneumonia o False passage o Mediastinitis o Deep neck abcess o Esophageal stenosis o Vertebral osteomyelitis o Necrosis of TE party wall Minor o Device failure o Leakage o Mucosal hypertrophy o Scarring o Granulation tissue o Low grade infection
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Dr. Supreet Singh Nayyar, AFMC

2011

Voice Outcome of TEP o 70% of patients achieve functional spoken communication (Stell Maran) o Predictors : Prelaryngectomy communication status Major pre existing communication disorder success Age age = success Acute local complication Adverse prognostic factor for long term acquisition of good speech Tracheostomal Valve / Heat Moisture Exchanger(HME) o Pressure sensitive valve o Closes with expiratory pressures needed for speech o Opens for rest breathing o Humidifies/Filters air o May reduce viscosity of mucous with regular use o Advantages Hands-free TE speech Possible positive pulmonary benefit from air humidification and filtering o Disadvantages Requires excellent seal of housing to skin Must be removed for coughing May need to be removed for exercise Cost Humidifilters are replaced daily Recent advances o Provox 2 hands-free speaking valve o Barton-Mayo Button o Groningen Indwelling with embedded pneumatic device Female laryngectomees Laryngectomee with hypotonicity of the PE segment

(for more ENT topics & presentations, visit www.nayyarENT.com)

www.nayyarENT.com