Fatal bilateral pneumothorax and generalized emphysema following contraindicated speaking-valve application.

We report a case of a contraindicated attachment of a speaking valve to a tracheal tube with an inflated cuff, which rapidly resulted in the patient's death. The attached one-way valve allowed unrestrained inspiration through the tracheal tube but prevented physiological expiration. The increased pulmonary pressure resulted in alveolar rupture and replaced expiration with a steady release of air into the peribronchial sheaths and the mediastinum, resulting in what is commonly known as the Macklin effect. From the mediastinum, air inflated both pleural cavities, the peritoneum, and the subcutaneous tissue of the entire body. No gas was found in the blood vessels, the brain, the bones, or in the inner organs. The entire air volume was estimated by radiological segmentation to be more than 25 l. This implies continuous inspiration, while expiration turned into an aberrant pulmonary decompression by whole-body gas-enclosure. Death ultimately resulted from asphyxia following bilateral (tension) pneumothorax.

An Investigation of Reliability of the Sunderland Tracheosophageal Voice Perceptual Scale.

BACKGROUND: The Sunderland Tracheosophageal Voice Perceptual scale (SToPS) is the only perceptual rating scale designed specifically for tracheosophageal voice [Hurren et al.: Clin Otolaryngol. 2009 Dec; 34(6): 533-8]. OBJECTIVE: To investigate the inter rater reliability of the SToPS when analyzing alaryngeal voice. METHODS: Prospective evaluation of inter rater reliability of the SToPS based on audio recordings of 230 voice samples from 41 laryngectomy patients rated by 3 experts. Interval data were analyzed using intraclass correlation coefficients (ICC) while categorical data were analyzed using Kappa. RESULTS: ICC of above 0.6 was observed between raters for each prosthesis on a majority of parameters demonstrating a good level of reliability. Reliability was fair (ICC of between 0.40 and 0.59) on Q11 (Articulatory precision) and Q12 (Paralinguistics). Reliability was also fair (0.21-0.40) or slight (0.00-0.20) for Q2 (Tonicity), which was analyzed using Kappa. Kappa above 0.61 signified a good level of reliability. CONCLUSIONS: This study demonstrates good rater reliability for the majority of parameters on the SToPS scale, supporting the use of this tool within the clinical realm. However, further research is required to ascertain if any methods of increasing inter rater reliability on those parameters which did not reach good reliability can be identified.

Development and evaluation of wheel-controlled pitch-adjustable electrolarynx.

Tone is important in tonal languages, especially in Mandarin. However, there is presently no commercially available electrolarynx (EL) for laryngectomized Mandarin speakers. Moreover, few studies have focused on this area. Our purpose is to design an EL that produces the four Mandarin tones and to evaluate its performance. We designed a wheel-controlled pitch-adjustable EL and manufactured a prototype (Wheel-EL). Using monosyllables, disyllabic segments, and frequently used phrases, we evaluated speech produced by Wheel-EL and by monotone (M-TruTone) and variable-frequency modes (V-TruTone) of the commercially available TruTone EL. The pitch contours of the high-level (HL), middle-rising (MR), and falling-rising (FR) tones produced by Wheel-EL most closely matched the natural speech characteristics of a native speaker. However, redundant sounds were generated in the high-falling (HF) tone. The statistical accuracy of Wheel-EL's tone and word perception was significantly higher than that of other EL types. However, no significant differences existed in acceptability among the three EL speech types. Wheel-EL produces better HL, MR, and FR tones in Mandarin than either M-TruTone or V-TruTone. Nevertheless, redundant sounds affect HF phonation. Accurate tone judgment can improve the intelligibility of EL speech in Mandarin but has no obvious effect on acceptability.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves.

OBJECTIVE: To investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves. STUDY DESIGN: Case series with planned data collection. SETTING: Large, urban, tertiary care teaching hospital. SUBJECTS AND METHODS: Referred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1-10, saying the days of the week, and reading aloud the sentence, "There is according to legend a boiling pot of gold at one end." RESULTS: There were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001). CONCLUSIONS: The Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings. LEARNING OUTCOMES: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities.

Results of Voice Rehabilitation With Provox Prosthesis and Factors Affecting the Voice Quality.

OBJECTIVES: Voice prosthesis is the standard of care for postlaryngectomy voice rehabilitation. We aimed to assess functional outcomes of Provox voice prosthesis, to study the impact of several clinical factors (timing of Provox insertion, type of pharyngeal closure, requirement of reconstruction, performance of myotomy, and radiotherapy) on the functional outcomes, and to record the complications associated with Provox voice prosthesis. STUDY DESIGN: Prospective nonrandomized cross-sectional observational study. METHODS: Thirty patients with postlaryngectomy speech rehabilitation with Provox prosthesis were studied. After the procedure, the patients were evaluated by a speech-language pathologist and assessed at immediate postoperative period and 6-month and 1-year interval using the parameters of functional outcomes GRBAS scale, maximal phonatory duration (MPD), and words per breath (WPB). SPSS Version 19 was used for statistical analysis. RESULTS: All patients had average good voice at the end of 1 year after Provox insertion with voice quality results improving with time. Number of patients having MPD more than 7 was 21, 29, and 30 at 0 months, 6 months, and 1 year, respectively. At the end of 1 year, 11 patients had WPB score between 15 and 19. Seven patients had complications: periprosthetic leak (4), central leak (1), hypertonic segment (1), and stricture of the neopharynx (1). Primary Provox insertion, nonrequirement of postoperative radiation, cricopharyngeal myotomy, and primary and vertical closure of neopharynx had a better influence on the outcome; however, the results were not statistically significant. CONCLUSIONS: Provox voice prosthesis provides consistent and good voice results, which improve with time. Periprosthetic leak is the most common complication.

Detection of ideal reservoir level after laryngectomy using endoilluminator in voice rehabilitation.

OBJECTIVE: To assess the diagnostic value of a novel device, the endoilluminator, in patients who can or cannot attain effective speech after application of voice prosthesis. STUDY DESIGN: Prospective clinical study. METHODS: Thirty-four patients who underwent total laryngectomy and whose insufflation test was positive were included. As a result of efforts to develop an insufflation test that includes a light apparatus, we attained a device that we call an endoilluminator. We found that the area it illuminated when a patient achieved effective speech was a predictive factor for the test result. That is, patients for whom the upper part of the tracheostomy (where the standard tracheoesophageal fistula will be opened) was illuminated were categorized as the positive test group, whereas those for whom the neck skin above this region was illuminated were categorized as the negative test group. RESULTS: In 27 of the 34 patients, appropriate localization was determined using the endoilluminator, and these patients achieved effective speech. In the remaining seven patients, localization was inappropriate and they did not achieve effective speech during the first week, first month, or third month postpuncture. In further investigations of these seven patients, a pharyngoesophageal spasm was detected in five, and a pharyngoesophageal stricture was detected in two. CONCLUSION: Endoilluminator increases the success rate of the insufflation test by accurately predicting a patient's ability to achieve effective speech after application of voice prosthesis.

Primary prosthetic voice rehabilitation in patients after laryngectomy: applications and pitfalls.

The use of the tracheoesophageal (T-E) silicone rubber voice prosthesis is the most effective and well-established procedure to restore the voice in patients after laryngectomy. The prosthesis is usually well-tolerated with only minor complications. Severe complications are rare. In this article we present our experience with the prosthetic technique at the Clinic of Otorhinolaryngology and Head and Neck Surgery in University Hospital in Martin, Slovakia between the years 2005-2013 and report a case of a 48-year-old man with secondary prosthesis inserted through a T-E shunt 16 months after laryngectomy. On the 6th day after the insertion, the shunt decayed. After prosthesis removal the tissue defect was sutured. Due to repetitive tissue decay, reconstruction of the trachea and esophagus became necessary. On the 10th day, peritracheoesophageal fistula developed and gastrostomy was performed. Because of intense fibrotic and inflammatory changes, further reconstruction was not indicated. After 6 months, esophageal stenosis occurred and endoscopic dilation under local anaesthesia was performed. The T-E voice prosthesis has become one of the choices for voice rehabilitation following total laryngectomy and may improve the patient's long-term quality of life. The overall risk of severe complications seems relatively low. Nonetheless, some complications might be challenging and might require specific management.

Aspiration of a speaking valve.

Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.

A new custom moldable external neck brace (ENB 2.0) to improve hands-free speech in laryngectomized patients.

OBJECTIVES/HYPOTHESIS: The majority of laryngectomy patients fail to use a hands-free valve on a daily basis, mainly due to fixation problems of the adhesive baseplate housing. To support adhesive housings during hands-free speech a new external neck brace (ENB 2.0) was developed. The effect of the brace was assessed in terms of a qualitative assessment, adhesive lifetime, maximum phonation time and patient self-reports. STUDY DESIGN: Twenty laryngectomees participated in this randomized, prospective, crossover trial. METHODS: All participants used the Provox hands-free HME valve with an Xtrabase adhesive for 1 month, 2 weeks with an ENB 2.0, and 2 weeks without. Outcomes were compared with the previous model of the external neck brace (ENB 1.0). RESULTS: The average total number of adhesive baseplates used during the trial was 16.7 in the non-brace group versus 10.9 in the brace group (P = 0.05). The number of daily replacements was 1.4 in the non-brace group and 1.1 in the brace group (P = 0.025). The average time a hands-free valve was worn per baseplate was 9.5 hours when wearing a neck brace versus 7.3 hours without brace (P = 0.09).The majority (81%) of the patients considered the neck brace 2.0 as a welcome addition to improve hands-free speech after laryngectomy and would use it if prescribed (88%). CONCLUSION: The new model of the neck brace reduces the number of baseplate replacements during hands-free speech and is considered as a helpful device by 81% of the participants.

Improvement of electrolaryngeal speech quality using a supraglottal voice source with compensation of vocal tract characteristics.

Electrolarynx (EL) is a medical speech-recovery device designed for patients who have lost their original voice box due to laryngeal cancer. As a substitute for human larynx, the current commercial EL voice source cannot reconstruct natural EL speech under laryngectomy conditions. To eliminate the abnormal acoustic properties of EL speech, a supraglottal voice source with compensation of vocal tract characteristics was proposed and provided through an experimental EL(SGVS-EL) system. The acoustic analyses of simulated EL speech and reconstructed EL speech produced with different voice sources were performed in the normal subject and laryngectomee. The results indicated that the supraglottal voice source was successful in improving the acoustic properties of EL speech by enhancing low- frequency energy, correcting the shifted formants to normal range, and eliminating the visible spectral zeros. Both normal subject and laryngectomee also produced more natural vowels using SGVS-EL than commercial EL, even if the vocal tract parameter was substituted and the supraglottal voice source was biased to a certain degree. Therefore, supraglottal voice source is a feasible and effective approach to improving the acoustic quality of EL speech.

Development and evaluation of on/off control for electrolaryngeal speech via artificial neural network based on visual information of lips.

OBJECTIVE: To realize an accurate and automatic on/off control of electrolarynx (EL), an artificial neural network (ANN) was introduced for switch identification based on visual information of lips and implemented by an experimental system (ANN-EL). The objective was to confirm the feasibility of the ANN method and evaluate the performance of ANN-EL in Mandarin speech. STUDY DESIGN AND METHODS: Totally five volunteers (one laryngectomee and four normal speakers) participated in the whole process of experiments. First, trained ANN was tested to assess switch identification performance of ANN method. Then, voice initiation/termination time, speech fluency, and word intelligibility were measured and compared with button-EL and video-EL to evaluate on/off control performance of ANN-EL. RESULTS: The test showed that ANN method performed accurate switch identification (>99%). ANN-EL was as fast as normal voice and button-EL in onset control, but a little slower in offset control. ANN-EL could provide a fluent voice source with rare breaks (<1%) for a continuous speech. The results also indicated that on/off control performance of ANN-EL had a significant impact on perception, lowering the word intelligibility compared with button-EL. However, the words produced by ANN-EL were more intelligible than video-EL by approximately 20%. CONCLUSIONS: The ANN method was proved feasible and effective for switch identification based on visual information of lips. The ANN-EL could provide an accurate on/off control for fluent Mandarin speech.

Prevention of voice prosthesis biofilms: current scenario and future trends in prolonging prosthesis lifetime.

Voice rehabilitation after a total laryngectomy is an important requisite for patients' rehabilitation. Oesophageal speech using tracheo-oesophageal-valved prostheses is now considered the state-of-art in postlaryngectomy voice rehabilitation. One of the major drawbacks of voice prostheses is their limited device lifetime. This is due to the deterioration of the silicone rubber material by different bacterial and yeast species, which are organised in the form of a biofilm resulting in internal leakage, increased airflow resistance, impeding speech, respiration and swallowing. The use of antimicrobials though easily applicable is associated with development of resistance if used on long-term basis. Other techniques in the form of modification of physicochemical properties of the silicon surface or covalent binding of antimicrobial agents to the silicon surface have been employed. This article reviews the different strategies investigated until now and the future trends in preventing biofilm formation for prolonging the lifetime of the silicon voice prostheses. Data was collected by conducting a computer aided search of the MED-LINE and PUBMED databases, supplemented by hand searches of key journals. Over 35 articles in the last two decades on the topic have been reviewed out of which 27 were found to be of relevant value for this article.

A multicenter, prospective, clinical trial evaluating a novel adhesive baseplate (Provox StabiliBase) for peristomal attachment of postlaryngectomy pulmonary and voice rehabilitation devices.

OBJECTIVES/HYPOTHESIS: Assessment of a novel adhesive baseplate (Provox StabiliBase) for heat and moisture exchanger (HME) and/or automatic speaking valve (ASV) application. STUDY DESIGN: Prospective, clinical, multicenter trial. METHODS: This was a trial in laryngectomized patients comparing their usual adhesive with the trial adhesive. Primary outcome measure was overall patient preference; additional outcome parameters possibly explaining patients' preferences were 1) patient tolerance and preference with respect to daily handling of the adhesive; 2) adhesive lifespan, and 3) voice and speech with the adhesives. Study specific questionnaires, visual analog scales, patients' diaries, and stoma assessments were used for data collection. RESULTS: In total, 58 of the 65 laryngectomized individuals entered in the study completed the trial. Patients' overall preference for the new device was high (76%; P < .001). Significantly better performance was found for the trial adhesive with respect to ease of application (P = .034), fit (P < .001), and air leakage through the adhesive (P < .001). Comfort and stoma depth correlated weakly (r = 0.297; P = .024; deeper stoma-more comfort with StabiliBase). The adhesive lifespan with HME is significantly increased (1.7 times and 15.7 hours-plus airtight use; P < .001). This longer lifespan coincided with somewhat increased dirtying of the adhesive (P = .02). There were no serious adverse events. CONCLUSIONS: The StabiliBase adhesive for peristomal attachment of HMEs and/or ASVs was preferred by 76% of study participants and showed a promising prolonged lifespan. This new device further increases the options for stoma attachment in laryngectomized individuals, and subsequently the availability of optimal voice and pulmonary rehabilitation for a larger proportion of patients.

Clinical use of a neck brace to improve hands-free speech in laryngectomized patients.

OBJECTIVES/HYPOTHESIS: Time of adherence of adhesive baseplate housings to the neck of a laryngectomized patient is one of the main problems that account for the low number of laryngectomy patients who benefit from hands-free speech. An external neck brace (ENB 1.0) was introduced to support peristomal fixation of adhesive baseplates. STUDY DESIGN: A prospective randomized controlled clinical cross-over trial. METHODS: A total of 28 laryngectomy patients participated in this randomized, prospective, crossover trial. All used the Provox hands-free heat and moisture exchanger (HME) valve for 1 month: 2 weeks with an ENB and 2 weeks without. RESULTS: The median lifetime of an adhesive baseplate without a brace was 52.5 minutes versus 210 minutes with a brace (P = .03). Four participants considered the ENB as "a little" bit of a welcome addition, nine as "quite a bit," and six as "very much" (79%) to improve hands-free speech. CONCLUSIONS: The ENB significantly increases the lifetime of an adhesive baseplate and therefore contributes to achieving hands-free speech for a greater number of patients with laryngectomy.

Three-dimensional stereophotogrammetrical analysis of peristomal fixation of adhesive base plates during hands-free speech among laryngectomised patients related to tracheostoma volumes.

OBJECTIVES: This study evaluates the relation between stoma volumes by means of objective three-dimensional measurements of laryngectomised individuals and peristomal fixation of adhesive baseplates during hands-free speech. DESIGN: A three-dimensional stereophotogrammetrical image was captured of the tracheostoma and its surrounding tissue for each participant. The placement of a baseplate adhesive was virtually simulated. Individual stoma volumes were calculated and related to the duration of lifetime of adhesive baseplates. SETTING: Prospective trial in a university hospital setting. PARTICIPANTS: Twenty-four laryngectomised patients. MAIN OUTCOME MEASURES: Stoma volume in cm(3) and adhesive baseplate adherence in minutes. RESULTS: For the 24 three-dimensional images captured, the mean volume of the area under the adhesive (stoma volume) was 9.5 cm(3) (range 3.5-22.5). After relating the different volumes of all patients to their individual fixation score, a significant decrease in duration of adhesive lifetime was found with increasing volumes of the stoma (P = 0.001). An increase of 1 cm(3) in tracheostoma volume resulted in a decrease of 21% in median adhesive lifetime (95% confidence interval 10-31%). CONCLUSIONS: Longer lifetime of the adhesive baseplate in patients with smaller volume outcomes suggests that a more accurate fit between baseplate and stoma leads to better fixation. This should be taken into account when shaping a stoma during laryngectomy. On the other hand, a more custom-made patch that has a more accurate fit could increase the lifetime of fixation. We believe that our three-dimensional volumetric data can contribute to the development of such an adhesive.

Comparison of speech parameters and olfaction using different tracheotomy speaking valves.

BACKGROUND: The objective of this work was to obtain a controlled subjective and objective in vivo clinical comparison of the Passy-Muir, Shiley, and Ball speaking valves. METHODS: Ten patients free of laryngeal pathology but dependent on tracheotomy for respiration were tested with each of the speaking valves. Olfaction was assessed for each patient using the University of Pennsylvania Smell Identification Test (UPSIT). Acoustic and perceptual analyses included subjective assessments, noninstrumental objective assessments (including maximum phonation time, and S:Z ratio), and instrumental objective assessments (including fundamental frequency:maximum phonation range, vocal intensity, perturbation, naturalness, and turbulence). Oxygen saturation was assessed by pulse oximetry. RESULTS: There was a highly significant statistical difference in olfaction and speech naturalness, in favor of the Ball valve (The Airway Company, Forest Hill, MD). The Ball valve's speech parameters were generally better than with the Passy-Muir and Shiley valves, including maximum phonation, S:Z ratio, jitter, noise, and turbulence, although the differences were not statistically significant. There were no differences among the valves in oxygen saturation levels. CONCLUSION: This study illustrates that olfaction and certain speech parameters, most noticeably speech naturalness, are significantly improved with the Ball valve as compared to the Passy-Muir and Shiley valves.

Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy.

BACKGROUND: Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high-risk individuals, and surgical and prosthetic correlates of TEP enlargement. METHODS: Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort. RESULTS: Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (odds ratio [OR](adjusted) , 4.3; 95% confidence interval [CI], 1.0-19.1), postoperative stricture (OR(adjusted) , 3.2; 95% CI, 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (OR(adjusted) , 6.2; 95% CI, 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement. CONCLUSION: Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors.

Automatic intelligibility assessment of speakers after laryngeal cancer by means of acoustic modeling.

OBJECTIVE: One aspect of voice and speech evaluation after laryngeal cancer is acoustic analysis. Perceptual evaluation by expert raters is a standard in the clinical environment for global criteria such as overall quality or intelligibility. So far, automatic approaches evaluate acoustic properties of pathologic voices based on voiced/unvoiced distinction and fundamental frequency analysis of sustained vowels. Because of the high amount of noisy components and the increasing aperiodicity of highly pathologic voices, a fully automatic analysis of fundamental frequency is difficult. We introduce a purely data-driven system for the acoustic analysis of pathologic voices based on recordings of a standard text. METHODS: Short-time segments of the speech signal are analyzed in the spectral domain, and speaker models based on this information are built. These speaker models act as a clustered representation of the acoustic properties of a person's voice and are thus characteristic for speakers with different kinds and degrees of pathologic conditions. The system is evaluated on two different data sets with speakers reading standardized texts. One data set contains 77 speakers after laryngeal cancer treated with partial removal of the larynx. The other data set contains 54 totally laryngectomized patients, equipped with a Provox shunt valve. Each speaker was rated by five expert listeners regarding three different criteria: strain, voice quality, and speech intelligibility. RESULTS/CONCLUSION: We show correlations for each data set with r and ρ≥0.8 between the automatic system and the mean value of the five raters. The interrater correlation of one rater to the mean value of the remaining raters is in the same range. We thus assume that for selected evaluation criteria, the system can serve as a validated objective support for acoustic voice and speech analysis.

Enlarged tracheoesophageal puncture after total laryngectomy: a systematic review and meta-analysis.

BACKGROUND: Enlargement of the tracheoesophageal puncture (TEP) is a challenging complication after laryngectomy with TEP. We sought to estimate the rate of enlarged puncture, associated pneumonia rates, potential risk factors, and conservative treatments excluding complete surgical TEP closure. METHODS: A systematic review was conducted (1978-2008). A summary risk estimate was calculated using a random-effects meta-analysis model. RESULTS: Twenty-seven peer-reviewed manuscripts were included. The rate of enlarged puncture and/or leakage around the prosthesis was reported in 23 articles (range, 1% to 29%; summary risk estimate, 7.2%; 95% confidence interval [CI], 4.8% to 9.6%). Temporary removal of the prosthesis and TEP-site injections were the most commonly reported conservative treatments. Prosthetic diameter (p = .076) and timing of TEP (p = .297) were analyzed as risk factors; however, radiotherapy variables were inconsistently reported. CONCLUSION: The overall risk of enlarged puncture seems relatively low, but it remains a rehabilitative challenge. Future research should clearly establish risk factors for enlarged puncture and optimal conservative management.