Novel esophageal speech therapy method in total laryngectomized patients: biofeedback by intraesophageal impedance.

The loss of the best communication port after total laryngectomy surgery makes speech rehabilitation an important goal. Our aim was to improve the quality of esophageal speech (ES) using online esophageal multichannel intra-luminal impedance (MII) as a new biofeedback method. Twenty-six total laryngectomized patients were included. Before ES therapy, an esophageal motility test was carried out. MII catheters were placed in all subjects who were then randomized into two groups. Group 1 included 13 cases, who were retrained according to the classical method. Group 2 included 13 cases, who were retrained according to the simplified animation of air movements within the esophagus and upper stomach resulting from the modifications of intra-esophageal air kinetics gained by MII. The level of speech proficiency was evaluated relative to pretraining levels using perceptual scales in the third and sixth months. Acoustic voice was analyzed. The number of syllables read per minute and the intelligibility of monosyllabic and dissyllabic words were calculated. In this study, MII was used for the first time in alaryngeal speech rehabilitation as a biofeedback method; an overall sufficient speech level was achieved by 68.4% at the end of therapy, whereas attendance was 90%. A statistically significant improvement was found in both groups in terms of ES level compared with the pretraining period although there was no significant difference between groups. Although we did not observe the expected difference between groups suggested by our hypothesis, MII may be used as an objective tool to show patients how to swallow and regurgitate air during training, and may thus expedite ES therapy both for the speech therapist and the patient in the future.

A prospective, randomized comparative study of patient perceptions and preferences of two types of indwelling voice prostheses.

BACKGROUND: Technical and device life issues are frequently the focus of post-laryngectomy rehabilitation studies examining indwelling voice prostheses. Patient perceptions and preferences are considered less often. AIMS: To determine patient perceptions of two indwelling voice prostheses across parameters relating to device use and maintenance and to determine what factors contribute to patient preferences. METHODS & PROCEDURES: In a randomized, cross-over study, 31 laryngectomy patients completed a 3-week trial of both the new indwelling Provox Vega and a comparator device, the Blom-Singer Classic Indwelling. Patient perceptions of the insertion process, cleaning and care, and voicing were explored after each trial. At the end, overall preference and factors influencing device preference were examined. OUTCOME & RESULTS: At the conclusion of the crossover trial, a significantly higher proportion of patients felt voice effort, overall voicing, bloating, and ease and effectiveness of cleaning were superior for the Provox Vega. No preference was noted for insertion processes. Overall device preference was influenced by improved voicing followed by cleaning and care. CONCLUSIONS & IMPLICATIONS: Patients do not perceive all indwelling devices as equal and should have the opportunity to trial different devices to find the best device for their needs.

[An influence of some factors on the logopedic rehabilitation of patients after total laryngectomy]. / Wplyw wybranych czynników na rehabilitacje logopedyczna chorych po calkowitym usunieciu krtani.

INTRODUCTION: The operation of total laryngectomy deprives patients of the ability of voiced communication, causes isolation and loneliness. The loss of voice and speech leads to a predominant cripplehood, disturbs verbal communication in the social and family circle. The best ways of voiced communication of the patients after laryngectomy are an esophageal speech and the speech using voice prosthesis. AIM: The aim of the study is to estimate the voice and speech rehabilitation of the patients after total laryngectomy. MATERIAL AND METHODS: The study comprised 30 patients who in the years 2007-2009 underwent an operation of laryngectomy at the Department of the Surgery of the Head and Neck and the Laryngological Oncology in the Greater Poland Cancer Center in Poznan. In this group 9 patients used voiced speech after grafting the voice prosthesis, 15 patients (12 men and 3 women) underwent a classical rehabilitation of the esophageal speech, 6 patients (4 men and 2 women) used an electronic voice prothesis. The most important factors which influenced on mastering an esophageal speech were: pressure inside the esophagus, appearing a reverberation, time of training at home, length of time of logopedic rehabilitation, age and education. RESULTS: Necessary time to master a speech in the group of 9 patients with voice prothesis was 4-5 days. Length of time of the classical speech rehabilitation lasted from 3 to 8 months. 3 persons (20%) mastered a very good degree of esophageal speech, 7 patients a good degree (46.67%) and 2 patients (13.33%) - a sufficient degree of esophageal speech despite of low pressure inside the esophagus and appearing a reverberation quickly. 3 patients (20%) used an oral and guttural pseudo-whisper, a voiced reverberation was not obtained during the whole time of logopedic rehabilitation. CONCLUSIONS: The surgical voice rehabilitation, in spite of the possibility of complications, enjoys a great popularity among patients. The classical rehabilitation of the esophageal speech was more difficult for the tasted group of patients but mastering a speech to a very good and good degree lets communicate naturally.

Further experience with modification of an intraluminal button for hands-free tracheoesophageal speech after laryngectomy.

Tracheoesophageal (TE) speech using a voice prosthesis and hands-free speaking valve with an intraluminal attachment is the gold standard for voice restoration after total laryngectomy. Modification of a standard self-retaining silicone cannula or laryngectomy button often aids in the attachment of a speaking valve within the tracheal lumen for hands-free TE speech production. An increased number of laryngectomized individuals are able to achieve hands-free TE speech when the standard length, flange, and diameter of a silicone button is customized to accommodate individual tracheostomal contours. A technique is presented for modification of a standard silicone laryngectomy button to facilitate hands-free TE speech after total laryngectomy.

[Results of rehabilitation of voice and speeches after implantation of valve vocal prosthesis at ill after total removal of larynx]. / Wyniki rehabilitacji glosu i mowy po wszczepieniu wentylowych protez glosowych u chorych po calkowitym usunieciu krtani.

Ill applying with extensive infiltration of new-growth within of larynx will demand radical therapeutic procedure, which is operation completely removals of organ. Aim of work was estimation of voice and speeches ill with vocal fistula in comparison with oesophageal voice and speech and with physiological. With research one embraced 81 men in age 42-75 of years. Group I--32 ill with cancer of larynx, to which executed total laryngectomy and placed the voice prosthesis Provox 2. Group II--30 ill after operation total removals of larynx, whiches used oesophageal speech. The control group III--19 persons with physiological voice. Research one began from subjective estimation of replacement voices. Then one executed measurements maximum phonation time of vowel "a". To objective estimation of voice one used polish programme "IRIS". One compared: maximum intensities of voices for colloquial speech, F0, Jitter, Shimmer and NHR. In subjective estimation voice of the patients with voice prostheses was greater freedom of production and voice of the patients with voice prostheses appeared to be more loud in relation to oesophageal voice. Greatest statistical essential differences one obtained between maximum phonation times of vowels "a" where clearly is visible, that values obtained for voices of the patients with voice prostheses are to nearer values for physiological voices. Obtained averages values of acoustic analysis: F0, Jitter, Shimmer and NHR did not show statistical of essential differences between voices supplementary, though parameters of voice of the patients with voice prostheses one was to nearer parameters of physiological voice. Characterization perceptive and acoustic speech of the patients with voice prostheses in comparison with oesophageal speech is to nearer characterization of physiological speech. Lack of satisfactory effects of rehabilitation of oesophageal speech, should be effective secondary implantation vocal prosthesis.

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.

Development and evaluation of a novel tracheostoma button and fixation system (Provox LaryButton and LaryClip adhesive) to facilitate hands-free tracheoesophageal speech.

CONCLUSION: This newly developed tracheostoma button and fixation system was appreciated by the majority of the patients in this study and led to an increased use of automatic speaking valves (ASVs). OBJECTIVE: Development and prospective clinical evaluation of a new tracheostoma button and fixation system to enhance hands-free speech in laryngectomized patients. PATIENTS AND METHODS: The Provox LaryButton and LaryClip adhesive system were prospectively evaluated in 11 patients: 10 male, 1 female; mean age 60.5 years, range 46-80 years; median follow-up since laryngectomy 4.9 years, range 9 months to 21 years. A study-specific questionnaire was used and the observation period was 3 weeks. RESULTS: Eight patients were compliant, three dropped out of the study. The LaryClip adhesive system was tried by seven of these compliant patients, and ultimately used by six. At the start of the study two patients used an ASV on a daily basis, three alternated between an ASV and regular, manually operated heat and moisture exchangers (HME), three only used a HME. At the end of the study, three used the ASV daily, five alternated between ASV and HME. Seven patients indicated that they would continue using the new system, six with clips and one with the button only.

Effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox silicone tracheoesophageal voice prosthesis.

CONCLUSION: Daily application of a buccal bioadhesive slow-release nystatin tablet (100,000 IU per tablet) significantly increased the voice prosthesis lifetime in laryngectomized patients compared to conventional local cleaning of the prosthesis with an antimicrobial agent on a brush. OBJECTIVE: To investigate the effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox tracheoesophageal voice prosthesis in post-laryngectomy patients. MATERIAL AND METHODS: A buccal bioadhesive tablet, based on a spray-dried Amioca/Carbopol 974P mixture containing 10% (w/w) Carbopol 974P, was loaded with 100,000 IU of nystatin. Patients were included in the study when replacement of their voice prosthesis was required and were divided into three groups. Conventional daily local cleaning of the voice prosthesis by means of an oral nystatin suspension on a brush (Group 1; n = 7) was compared with application of one nystatin buccal bioadhesive tablet per day, after breakfast, on the gingiva above the upper canine (Group 2; n = 7). The control group (n = 5) used no antimicrobial agents. The lifetime of the prosthesis was followed and expressed in days. RESULTS: The lifetime of the voice prosthesis was significantly increased in Group 2 compared to Group 1 (p < 0.05; paired t-test), indicating that sustained release of nystatin in the oral cavity, by means of erosion of the tablet over a period of approximately = 8 h, is more effective at preventing microbial colonization of the prosthesis than local cleaning.

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.

Evaluation of prophylaxis treatment of Candida in alaryngeal patients with tracheoesophageal voice prostheses.

OBJECTIVES/HYPOTHESIS: The objective of this study was to evaluate the effectiveness of nystatin and Biotène(®) mouthwash Oral Rinse for controlling Candida in total laryngectomy (TL) patients with a tracheosophageal voice prosthesis (TEP) because Biotène(®) mouthwash Oral Rinse is a less costly alternative to nystatin and requires less adherence time. STUDY DESIGN: Randomized, unblinded, crossover trial. METHODS: Twenty-one TL patients were randomized to receive nystatin followed by Biotène(®) mouthwash Oral Rinse, or the reverse order, after a basic oral-care phase (i.e., brushing teeth, cleaning dentures). A Provox(®) 2, 22.5 French TEP, which is an indwelling silicone voice prosthesis, was placed at the beginning of each phase. Patients were provided with oral care instructions at randomization and medication-specific instructions with each treatment's initiation. TEPs were processed and evaluated for Candida growth as colony-forming units (CFUs). Wilcoxon signed-rank tests were used for comparisons between treatments. RESULTS: Fifteen patients were available for comparisons of Candida counts (6 received nystatin; 9 received Biotène(®) mouthwash first). Overall, the median log10 (CFUs) remained high regardless of treatment (no medication: 8.9; nystatin: 8.7; Biotène(®) mouthwash: 8.4). However, the median counts for both nystatin and Biotène(®) mouthwash Oral Rinse were lower than those for no medication (difference [Δ]:-0.9 and -0.3, respectively), although only nystatin was significantly lower (P = 0.02). There was no significant difference between the two treatments (P = 0.22). Overall, median medication-adherence was high (97%), and Biotène(®) mouthwash adherence was significantly higher than that of nystatin (Δ: 7.6%; P = 0.03). CONCLUSION: Nystatin and Biotène(®) mouthwash Oral Rinse had similar CFU levels, with nystatin showing a significant improvement over usual oral care. Biotène(®) mouthwash is a less costly alternative to nystatin, with a less complex treatment protocol that might make it preferable to patients and clinicians. LEVEL OF EVIDENCE: 1b

Replacement of a malpositioned tracheoesophageal catheter in the radiology department.

This article describes a safe and easy method to position a tracheoesophageal catheter correctly. The procedure is carried out under fluoroscopic guidance and requires neither general nor local anesthesia. The only modification necessary was removal of the tip of the hollow rubber catheter, to create an opening through which the guide wire could be passed.

Tracheoesophageal speech: vocal rehabilitation after total laryngectomy.

Treatment of laryngeal cancer has evolved over nearly 100 years and includes many methods to conserve the function of speech. It was understood from the inception of total laryngectomy that diversion of exhaled pulmonary air into the pharynx or esophagus would produce satisfactory speech. The effect on safe deglutition of the phonatory fistulae limited the wide applicability of these techniques. The introduction of a silicone bivalve device for use in a tracheoesophageal tunnel permits large numbers of laryngectomees to use tracheoesophageal speech. Acoustic, intelligibility, and aerodynamic studies are described for four laryngectomees and reveal that this method more nearly approximates normal laryngeal speech than conventional esophageal speech. The criteria for contemporary treatment of laryngeal carcinoma are not altered by this rehabilitative method, and expected survival rates are not likely to be affected. The findings and analysis of this method of alaryngeal speech rehabilitation may have important implications for future therapy of laryngeal carcinoma.

Aerodynamic properties of the low-resistance Groningen button.

Shunt tracheoesophageal speech is currently the most successful form of voice and speech rehabilitation in laryngectomees. Insertion of valve prostheses into the tracheoesophageal shunts has overcome drawbacks caused by stenosis of the shunt and aspiration. In 10 years of satisfactory results with the standard Groningen button valve prosthesis, the overall concept of this device has proved its value. The airflow resistance, however, is relatively high, so that a low-resistance device has been developed without changing the favorable characteristics of the standard device. The design of this low-resistance Groningen button is described. The airflow resistances of the standard and low-resistance Groningen buttons have been measured and compared. The airflow resistance of the low-resistance Groningen button is also compared with the reported airflow resistances of various other valve prostheses.

The development of successful tracheoesophageal voice restoration.

Effective treatment for laryngeal cancer concerns the preservation of voice. Progress has been made in treatment, rehabilitation,restoration of the airway, and nonsurgical treatments. With the introduction of tracheoesophageal speech and the voice prosthesis,many treated patients acquire socially acceptable speech after total laryngectomy and maintain satisfactory quality of life.

Total laryngectomy with tracheoesophageal conduit.

Tracheoesophageal puncture has made high-quality voice restoration readily available to most individuals who must undergo TL. Although none of these patients would voluntarily choose to undergo TL if not faced with a life-threatening condition, at least some achieve a better quality of life, including better vocal function, after treatment and rehabilitation. The methods involved in placement and maintenance of a tracheoesophageal prosthesis are straightforward and permit successful, long-term voice restoration for most patients. Although far from perfect, TL with TEP affords both quality and quantity of life to a group of individuals who currently have no alternative but to undergo debilitating surgery in an effort to extend their lives.

Trial production of the handy amplifier for oesophagus speech.

Oesophagus speakers cannot raise their voices. This seems to be the biggest trouble in daily life for them. Therefore, a handy amplifier has been produced by way of trial experiment to alleviate their trouble. This instrument is made up of a microphone, amplifier and speaker. The amplifier and speaker is put in a compact box 10.0 x 6.7 x 2.8 cm. The microphone is put in a cigarette holder and connected to the amplifier by a thin cord 30 cm long. When the sound is uttered whilst touching the holder with the lips it is heard through the speaker via the amplifier in the chest pocket of the coat. This instrument is recommended by many oesophagus speakers.

Characteristics of Groningen tracheo-oesophageal speaking valves prior to insertion and after removal for failure.

The Groningen valve was first used in Sheffield in 1986 in a patient who underwent laryngectomy for malignant disease. Since then it has been the main tracheo-oesophageal prosthesis used on our Unit for speech rehabilitation post-laryngectomy. This biflanged device inserted primarily or as a secondary procedure remains in situ until failure occurs either because of leakage or because increased effort is required to produce satisfactory phonation. This in vitro study we examined the differences between new valves prior to insertion and those removed for failure. The mean forward opening pressures were shown to be similar in the two populations but the mean forward resistances were increased in those valves which were defective (P less than 0.001). In addition the mean reverse opening pressure was found to be significantly lower in the defective valves when compared with their new counterparts (P less than 0.05).

Use of a portable manometer as a screening procedure in voice rehabilitation.

Abnormal tone in the pharyngo-oesophageal (PO) segment may lead to failure in developing oesophageal speech. Videofluoroscopy may give a qualitative assessment of the PO segment but is expensive, time consuming and lacks quantification. A custom built PO segment manometer was therefore assessed as a means of predicting eventual oesophageal speech outcome. Two groups of patients were studied. In group 1 (18 patients) the PO segment pressures were compared to their videofluoroscopy findings. Videofluoroscopy categorized the patients into four groups. The PO pressures corresponded to this grouping, pressures above 20 mmHg being associated with voice failure. In group 2 (12 patients) the PO pressures in the early post-operative period were compared to their eventual speech outcome. In all cases the pressures predicted the eventual speech outcome. The pressure manometer is a simple, cheap and portable device which is a reliable screening test to predict the potential for oesophageal speech.

Tracheo-oesophageal puncture: a review of problems and complications.

Tracheo-oesophageal puncture now has a well established role and in several units is now the principal means of speech rehabilitation following laryngectomy. Although not a difficult procedure, there are a number of problems and complications that may be encountered. With proper management these can usually be overcome and a useful voice achieved. This study looks at those problems in a series of 119 patients and discusses their management.