Current status of voice restoration following total laryngectomy.

Total laryngectomy is the surgical procedure traditionally used to treat patients with advanced-stage cancer of the larynx. The impairments resulting from removal of such a small organ are, indeed, profound. They include loss of voice and speech; altered respiration, necessitating a permanent breathing opening in the neck; and diminished sense of smell and taste. When one considers these factors, successful treatment of laryngeal cancer cannot be measured by survival rate alone. Rapid, effective restoration of voice and speech is one of the primary focuses of rehabilitation and is pivotal to the prevention of the potential psychosocial and economic consequences of total laryngectomy. This article focuses on the methods of voice restoration currently being employed to reestablish the ability to speak.

Frontal sinus stents.

OBJECTIVES: The formation of scar tissue, synechiae, or osteogenesis in the narrow frontal outflow tract after instrumentation of the frontal sinus has led to attempts to enlarge the frontal duct or stenting. STUDY DESIGN: Prospective pilot study. RESULTS: Sixty-four Freeman frontal sinus stents were used to maintain patency in 46 patients. Stents were inserted using an endoscopic technique in 26 sinuses containing polyps, 20 with pansinusitis, and 18 cavities with stenosis of the frontal duct. External incisions with frontal sinusotomy were required to remove the stenosis and insert the stent in nine sinuses. Polypoid degeneration, granulation, purulent drainage, and lateralization of the middle turbinate were encountered infrequently. Frontal obliteration was subsequently required in six sinuses. CONCLUSION: The Freeman frontal sinus stent prevented blockage of the outflow tract in patients who had removal of disease in the sinus or duct or treatment of frontal stenosis.

Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation.

Pharyngeal constrictor and cricopharyngeal spasm have been implicated as deterrants to esophageal speech acquisition as well as tracheoesophageal phonation. Recent efforts to reduce the resultant hypertonicity include pharyngeal constrictor myotomies and modifications of pharyngeal reconstruction during laryngectomy. Investigation of the innervation of the muscular wall of the pharynx led to the development of a pharyngeal plexus neurectomy technique to alter the tonicity of the pharynx without myotomy. The resultant alaryngeal speech is fluent, and acoustic parameters compare favorably to esophageal speech.

Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part I: Speech characteristics.

The speech characteristics of 29 patients with primary tracheoesophageal puncture who received either a pharyngeal constrictor myotomy, a unilateral pharyngeal plexus neurectomy, or a unilateral pharyngeal plexus neurectomy with drainage myotomy limited to the cricopharyngeus were studied. All patients used a Blom-Singer low-pressure voice prosthesis. Audio recordings of each patient speaking with both the Blom-Singer tracheostoma valve and manual occlusion of the tracheostoma were recorded at 3 weeks, 6 months, and 12 months after surgery. The three surgical variations were equally effective at preventing pharyngospasms; only 1 patient (10%) in each group had some loss of fluency during the 12-month study period. Neurectomized patients produced significantly higher fundamental frequencies during reading than did patients in the other groups. Residual resting tone in the neurectomized pharyngoesophageal segment may contribute to more favorable speaking frequencies in this group.

An efficiency comparison of four heat and moisture exchangers used in the laryngectomized patient.

Bypassing the upper airway places the burden of humidification on the lower airway. For this reason passive heat and moisture exchangers (HMEs) are used in the laryngectomized patient in an attempt to minimize the effect of lost upper airway function. We measured efficiency and airflow resistance and calculated the costs of four HMEs used in the laryngectomized patient. The HMEs were measured according a modified International Standards Organization (ISO) 9360 standard. The airflow resistance was measured at flow rates of 15, 30, and 60 L/min. The measurements were repeated three times. Costs were calculated with two realistic scenarios. The study found that there are significant differences in moisture output and airflow resistance between the HMEs tested. There are major daily cost differences between these devices. This study shows that filter material and size influence the HME's moisture output efficiency and airflow resistance considerably. The construction differences and filter and housing type have great influence on the HME's daily costs. We believe that knowledge of the efficiency in combination with the average daily costs of the HMEs allows the clinician to make a balanced choice of which filter to use.

Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part II: Swallow characteristics.

The swallowing function of 29 patients with primary tracheoesophageal puncture who received either a pharyngeal constrictor myotomy, a unilateral pharyngeal plexus neurectomy, or a unilateral pharyngeal plexus neurectomy with a small drainage myotomy limited to the cricopharyngeus was studied. Swallowing function data were collected on each patient at 3 weeks, 6 months, and 12 months after surgery using videofluoroscopy. Differences in swallowing function among the treatment groups were primarily the amounts and loci of oral and pharyngeal residues. The differing patterns of bolus residue may reflect the different mechanisms that were affected by the various procedures. Despite significant changes in some swallow measures, the patients did not complain of dysphagia. Oropharyngoesophageal swallow efficiency--a clinical measure that weighs the amount of bolus swallowed by total transit time--fell within normal limits for each patient group at each evaluation. This measure may be a better index of the patients' perceived normal swallow than the component variables of residue and transit times would suggest.

A prospective study of tracheoesophageal speech.

Gates et al suggested that commonly accepted statistics on esophageal speech acquisition may be inflated because they are compiled from retrospective observations that tend to exclude high-risk or poor-outcome patients who are unavailable or unwilling to be assessed. Using a multi-institution prospective study design, they demonstrated that at six months following laryngectomy only 12 (26%) of their 47 patients used esophageal speech. We prospectively assessed a group of 47 laryngectomees' pretracheoesophageal puncture and posttracheoesophageal puncture to determine the efficacy of this speech-rehabilitation method. Forty-four patients (94%) achieved good to superior tracheoesophageal speech, and, at one year, 39 patients (83%) continued to use their voice prosthesis. Results of this study reveal (1) preoperative speech intelligibility and acceptability, (2) predictive value of the preoperative esophageal insufflation test, (3) speech intelligibility and acceptability four days following initial voice prosthesis placement, (4) cost profiles, and (5) results and experiences at one year.

An endoscopic technique for restoration of voice after laryngectomy.

Reports of restoration of voice after total laryngectomy include diversion of exhaled pulmonary air though planned or spontaneous fistulae with a variety of modified tracheal cannulas and valves. Limitations of these techniques include aspiration, scar closure of the shunts, wound complications, and failure to achieve voice consistently. We report a two-year experience with an endoscopic method using a unique valved prosthesis eliminating complicated surgical reconstructions, aspiration, and stenosis. Fifty-four of 60 patients (90%) achieved fluent voices with one deglutition problem. Radiation therapy preceded voice restoration in 63% of the patients and radical neck dissection in 72%. The endoscopic procedure, hospitalization and period of speech therapy are short and constitute a cost-effective voice rehabilitation program. The results of this simple method and lack of complications are encouraging.

Tracheostoma valve for postlaryngectomy voice rehabilitation.

Newer surgical techniques for postlaryngectomy voice rehabilitation provide a simple, effective method of communication but require manual occlusion of the tracheostoma during speech. We report the development of a unique tracheostoma valve that avoids the necessity for covering the stoma. This airflow-sensitive valve closes during speech and remains open with normal respiration. Results of a clinical trial with 50 patients over a ten-month period are encouraging. Our experience suggests that excessive vocal tract resistance to airflow is the principal limitation to effective valve use. Approaches to decreasing airflow resistance through the vocal tract to improve both voice production and tracheostoma valve use are discussed.

Applications of the voice prosthesis during laryngectomy.

With the recent introduction of the voice prosthesis for alaryngeal speech rehabilitation, its application in the early postlaryngectomy period is gaining acceptance. One hundred twenty-eight patients received a tracheoesophageal puncture and adjunctive pharyngeal constrictor relaxation during laryngectomy. The voice prosthesis was applied as early as 10 days after surgery, and the results of a 9-year experience are presented. Eighty percent of the population achieved a durable voice, and the complications were infrequent. The results support the primary use of tracheoesophageal phonation as a relatively safe and reliable alternative to total laryngectomy alone.

Vocal rehabilitation after laryngectomy.

The evolution of treatment of laryngeal cancer has passed a number of milestones. The maintenance of useful communication is of paramount importance in all cases and, with the newer modalities of tracheoesophageal phonation and voice prostheses, the quality of life after laryngectomy is clearly improved. Future advances may restore continuity of the upper respiratory tract with resumption of normal nasal function, humidification of the lower respiratory tract, and elimination of the permanent tracheostoma.

Reconstructive and rehabilitative aspects of head and neck cancer in the elderly.

Age should not be considered a contraindication to adequate head and neck oncologic surgery. Reconstructive efforts should be by the most direct means to attain restoration of form and function in one stage. The next significant breakthroughs in the battle against cancer may well come on the cellular or molecular level. We endorse the plea of Endicott for increased education and research directed at the problem of head and neck cancer and rehabilitation as they relate to the geriatric patient.

Pharyngeal reconstruction after total laryngectomy with preservation of phonation.

The goal of pharyngeal reconstruction after laryngectomy is to prevent fistulization and to permit rapid resumption of satisfactory deglutition. Alaryngeal speech acquisition by the traditional method of esophageal speech is effective if insufflation is rapidly learned and tolerated by the pharyngoesophageal segment. Experience with tracheoesophageal phonation revealed an incidence of pharyngoesophageal spasm in 40% of an esophageal speech failure population which prevented useful air flow for speech production. This is related to esophageal distention and reflexive upper esophageal sphincter hypertension. It is suggested that pharyngeal reconstruction after total laryngectomy may permit higher wall tension than is desirable for speech acquisition. The problem of post laryngectomy pharyngoesophageal spasm may be reduced by myotomy of the pharyngeal constrictors with resultant higher air flows in the residual vocal tract for speech. Alterations in the pharyngeal wall tonicity will affect the pitch of the speech and listener acceptability. Recently identification and division of the pharyngeal plexus has produced a similar result in improved phonatory air flows with subjective vocal pitch approximating more normal voices. The above mentioned techniques are readily applied to the laryngectomy procedure and enhance the likelihood of alaryngeal speech acquisition.

Tobacco free at the Indianapolis 500.

Most children are highly impressionable and easily influenced, particularly by people they admire. Role models in sports and entertainment who publicly use or commercially promote tobacco products potentially influence children to do the same. Motorsports events are saturated with tobacco sponsorship. We describe the counter-promotion of tobacco at the famed Indianapolis 500 and suggest other venues to continue this "Tobacco Free America" theme.