Primary Tracheoesophageal Puncture vs Esophageal Speech Miquel Quer, MD, PhD; Joaquim Burgu\l=e'\s-Vila,MD, PhD; studied the cost-efficiency profile of tracheoesophageal puncture with prosthesis insertion in alaryngeal patients who were given the opportunity of choosing between esophageal and prosthetic voice. A primary tracheoesophageal puncture was made in 28 patients who were undergoing total laryngectomy. Five of the patients were excluded from the study because of failure to phonate correctly with their prostheses. The remainder were given esophageal speech instruction while they were using tracheoesophageal speech, and were permanently allowed to shift between both techniques of alaryngeal voice. Seventy percent of the patients (16/23) left the prosthetic voice to use only esophageal speech, even though they agreed that prosthetic voice was superior to esophageal voice. The remaining 30% (7/23) continued to use tracheoesophageal speech almost exclusively. In the authors' opinion, primary tracheoesophageal punctures significantly provide both psychological and practical help, as they supply an immediate and clear postoperative voice, and one of every three patients will use them for daily oral communication. Nevertheless, esophageal speech is still the method of voice restoration preferred in our region by those of our patients who managed to learn it. (Arch Otolaryngol Head Neck Surg. 1992;118:188-190) \s=b\ We

be

rehabilitation laryngectomized patients Voiceattained by surgical (tracheoesophageal communi¬ meth¬ without in

can

prosthesis) or conservative artificial larynx).1"10 On the one hand, tracheoesophageal speech provides a voice similar in quality to laryngeal voice and is feasible early in the postoperative period. On the other hand, it requires fin¬ ger closure of the tracheostoma, making the use of the hands for body expression impossible, a fact of great rel¬ evance, particularly in Mediterranean cultures. Although there is no doubt that prosthetic valves bypass this short¬ coming of tracheoesophageal speech, it is also true that not every patient manages to use them effectively. In ad¬ dition, prosthetic and valve maintenance of primary tracation with

ods

or

(esophageal voice

or

Accepted

for publication June 27, 1991. From the Otorhinolaryngology Service, Hospital de la Santa Creu i Sant Pau, Universitat Aut\l=o`\noma,Barcelona, Spain.

Reprint requests to Otorhinolaryngology Service, Hospital de la Barcelona, Spain (Dr Quer). Santa Creu i Sant Pau, Avgda Sant A. M. Claret 167,08025

Pedro

Garc\l=i'\a-Crespillo,MD

Table 1.—Classic Contraindications to

Tracheoesophageal

Puncture

Primary

Absence of interest in oral communication General bad health

Pulmonary function severely impaired Motor incapacity or poor hand coordination High visual acuity loss Moderate to severe drug dependence (alcohol included) Low intelligence quotient

cheoesophageal puncture (TEP) as well as aspiration are negative aspects of tracheoesophageal voice that must be considered.

Esophageal speech has the advantage of not necessi¬ tating finger closure, and the disadvantage of requiring a difficult, time-consuming learning process in which a certain percentage of patients will not succeed. It also re¬ sults in a lower quality of voice than that produced by surgical methods.

We had observed that some of our patients who had a primary TEP and a prosthesis stopped using this method of alaryngeal voice once they had learned the efficient esophageal voice method. This made us think that we might be subjectively overestimating the usefulness of tracheoesophageal prosthetic voice, with no clear evi¬ dence of success from the patient's point of view. There¬ fore, we decided to study usage and cost-efficiency features of voice prosthesis, while encouraging patients to learn the esophageal speech method. In this study we are not dealing with the issue of the usefulness of secondary TEP in patients who have failed to learn esophageal voice or who need or merely desire an alaryngeal voice of better quality.1-2-9-13 PATIENTS AND METHODS Between September 1986 and lune 1989, 28 patients who were eligible for total laryngectomy because of cancer of the larynx were selected for the present study. None of them had any of the classic contraindications for primary voice prosthesis (Table 1). All of them were male; their average age was 56 years (Table 2). Three surgical techniques of TEP were used (Table 3): Herrmann and colleagues'8 technique (five patients); simple puncture plus partial low myotomy (11 patients); and a personal technical innovation of Herrmann and colleagues' method (12 patients).14 The latter consists of a simple TEP, the creation of a

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trachéal chimney, and the closure of this chimney with one of the lobes of the thyroid gland, conventional suture of the pharynx, and a low myotomy. The details and justification of this innova¬ tion have been described elsewhere.14 All surgical procedures were performed by the same team. Five patients were excluded from the study because of post¬ operative problems or failure to obtain a useful voice because of personal limitations. In the remaining 23 patients, prostheses were inserted in the TEP sites before discharge (Table 2). BlomSinger and Herrmann's prostheses were used. After discharge, all 23 patients attended esophageal speech classes; however, 17 of them temporarily left the classes to un¬

dergo postoperative radiotherapy. Follow-up has been undertaken by the surgical team. Deci¬ sions relating to prosthesis removal were made in tandem with the

patients on an individual basis, and the criteria for removal absence of use and patient inclination toward the esoph¬

were

method. In each case, follow-up lasted until pros¬ thesis removal, death of the patient, or the study's end (lanuary

ageal voice 1, 1991).

A computerized database has been used to store and analyze both the oncological and the voice data of the patients. Our study concerns only the patients' preference for prosthetic as to esophageal voice when both are available, and does not examine voice quality or other parameters.

opposed

Table

2.—Age, Hospitalization Period, and Time of

Age, y Hospitalization period, d Day of prosthesis insertion

Minimum Maximum

SD

56.2

6.7

41

70

19.7

7.2

11

11.7

7.1

7

40 28

Patients Who Underwent Prosthesis Removal (16/23, 70%) In the follow-up, 16 (70%) of the 23 patients reached a point where they did not use prosthetic voice at all and preferred esophageal voice for daily communication. All of them presented a good esophageal voice, and although they all agreed that their prosthetic voice was of better quality, they found themselves more comfortable with esophageal speech because of the absence of maintenance and hand use. The mean period between surgery and prosthesis removal was 8.8 months (range, 2.4 to 29.1 months). In 14 cases, the residual tracheoesophageal fis¬ tula closed spontaneously within 48 to 72 hours; in one case (23 months of prosthetic voice use), the fistula was open for 16 days and eventually closed itself; and in the remaining case (29 months of prosthetic use), surgical closure by simple suture was needed. Patients With Permanent Prosthetic Voice Use (7/23, 30%) Four of the seven patients in whom the prosthesis was not removed used their prosthesis until death, which oc¬ curred between 6 and 17 months postoperatively (two patients died of local-regional disease and two as a result of distant métastases). Interestingly, none of them had esophageal voice of sufficient quality for oral expression

Prosthesis Insertion Mean

RESULTS The 23 patients included in the study, all with good immediate prosthetic voice, were taught the esophageal voice method and were divided into two groups: (1) the patients who underwent removal of the prosthesis and (2) the patients with sustained prosthetic voice use (Table 3).

Table 3.-Individual Data of the 23 Patients* Patient

1/58

Surgical Technique Puncture plus myotomy

2/41

Personal innovation

3/62 4/54

Herrmann and

No./Age, y

Puncture

colleagues'8

plus myotomy

6/69

Personal Innovation Personal Innovation

7/54 8/55

Personal innovation Personal innovation

5/48

plus myotomy Herrmann and colleagues' Puncture plus myotomy

Puncture

9/61 10/46 11/52

Personal innovation Herrmann and colleagues'

12/54

13/54

Prosthesis Situation

Nonuse (EV)

2.4

Removed Removed

Nonuse (EV)

2.9

Nonuse (EV)

3.0

Removed

Nonuse (EV)

3.0

Removed

Nonuse (EV)

3.3

Removed Removed

Nonuse (EV)

3.9

Nonuse Nonuse Nonuse Nonuse Nonuse Nonuse Nonuse Nonuse Nonuse Nonuse Death Death Death Death

4.2

Removed

Removed Removed Removed Removed Removed Removed Removed Removed Death Death Death Death

Herrmann and

16/63

Herrmann and

17/58

Puncture

18/63 19/52

Puncture

20/70

Puncture

21/57

Personal innovation

In

22/55

Personal innovation

In

colleagues'

plus myotomy plus myotomy

Personal innovation

23/55 *EV indicates

colleagues'

plus myotomy preference.

Puncture

esophageal

voice

plus myotomy

Time of Use,

Removed

14/51 15/64

Personal innovation

Cause of Removal

In

good good good

use

(valve)

5.2 5.6 9.3 9.4 10.0 10.4 16.2 23.0 29.1 6.8 9.7

17.0 17.1 22.8

30.0

use use

(EV) (EV) (EV) (EV) (EV) (EV) (EV) (EV) (EV) (EV)

(valve)

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44.5

mo

The other three patients, who had no evidence of neoplastic disease (Table 3), were still using prosthetic voice at the end of the study. Two of the latter never showed acceptable esophageal voice, and the other uses both techniques of alaryngeal voice (prosthetic in profes¬ sional events and esophageal in private life). With regard to valves, only two patients used them regularly up to the end of the study (one Blom-Singer and one Herrmann valve).

(Table 3).

COMMENT Most of the studies comparing prosthetic and esoph¬ ageal voice recognize the superior quality of the former,18-1112 which was also observed in our study. However, to the best of our knowledge, there are no studies concerning the patients' choice between both types of alaryngeal voice. The aim of our study was the analysis of patients' preference when they were given the opportu¬ nity to choose between prosthetic and esophageal voice. The majority of our patients (70% ) preferred esophageal voice in the long run. This might appear to conflict with the results of other studies showing a rate of prosthetic voice success of about 80%,6-7·13 but it must be borne in mind that we have not analyzed the voice quality of pri¬ mary TEP with voice prosthesis or its immediate postop¬ erative use. We tried to answer the question, "What type of voice rehabilitation would our patients prefer if they could make a choice between tracheoesophageal and

esophageal speech?"

The fact that most of our patients preferred esophageal voice to tracheoesophageal voice suggests that the choice between them is not a question of voice quality and that the decision is made according to other factors, among which the possibility of "forgetting about" tracheostoma finger occlusion for speaking and the maintenance of the prosthesis play an important role. No doubt, patient per¬ sonality, cultural background, and professional require¬ ments also influence the choice. Therefore, we disagree with those authors who con¬ sider voice prostheses to be the method of choice for voice restoration after laryngectomy3"1013 and agree with those who suggest that when esophageal voice training is pos¬ sible, primary TEP with prosthesis insertion is not sys¬ tematically warranted, at least not in our environment.2 In conclusion, we suggest that more effort should be made to delineate methods of patient selection to identify those patients who as a result of psychological features or bad oncological prognosis will obtain maximum benefit

from primary TEP restoration. Physicians should encour¬ age those patients who do not meet the established selec¬

tion criteria to practice esophageal speech, conserving TEP and prosthesis insertion for secondary treatment of failure of esophageal voice. References 1. Blom ED, Singer MI, Hamaker RC. Total laryngectomy with voice preservation. In: Fried MP, ed. The Larynx: A Multidisciplinary Approach. Boston, Mass: Little Brown & Co Inc; 1988:517-530. 2. Luboinski

B, Eschwege F, Stafford N. Voice rehabilitation after laryngectomy: controversies. In: Kagan AR, Miles J, eds. Head and Neck Oncology. New York, NY: Pergamon Press Inc;

1989:162-165. 3. Singer MI, Blom ED. An endoscopy technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol.

1980;89:529-533. 4.

Panje WR.

gectomy: the

Prosthetic vocal rehabilitation following larynvoice button. Ann Otol Rhinol Laryngol.

1981;90:116-120.

5. Maves MD, Lingeman RE. Primary voice rehabilitation using the Blom-Singer and Panje voice prostheses. Ann Otol Rhinol Laryngol. 1982;91:458-460. 6. Milford GA, Perry AR, Mugliston TA, Cheesman AD. A British experience of surgical voice restoration as a primary procedure. Arch Otolaryngol Head Neck Surg. 1988;114:1419\x=req-\ 1421. 7. Trudeau

MD, Hirsch SM, Schuller DE. Vocal restorative

why wait? Laryngoscope. 1986;96:975-977. Herrmann IF, Buchwald J, Zenner HP. Die Glottoplastik: neue Methode zur chirurgischen Stimmerehabilitation.

surgery:

8. eine HNO. 1983;32:124-129. 9. Lopez MJ, Kraybill W, McElroy TH, Guerra O. Voice rehabilitation practices among head and neck surgeons. Ann Otol

Rhinol

Laryngol. 1987;96:261-263.

10. Webster PM, Duguay MJ. Surgeons' reported attitudes and practices regarding alaryngeal speech. Ann Otol Rhinol

Laryngol. 1990;99:197-200.

11. Pindzola RH, Cain BH. Acceptability ratings of tracheoesophageal speech. Laryngoscope. 1988;98:394-397. 12. Williams SE, Watson JB. Speaking proficiency variations according to method of alaryngeal voicing. Laryngoscope.

1987;97:737-739. 13. Maniglia AJ, Lundy DS, Casiano RC, Swim SC. Speech

restoration and complications of primary versus secondary tracheoesophageal puncture following total laryngectomy. Laryn-

goscope. 1989;99:489-491.

14. Garc\l=i'\a-CrespilloP, Quer-Agust\l=i'\M,Burgu\l=e'\s-VilaJ. Rehabilitaci\l=o'\nvocal de laringectomizado mediante punci\l=o'\ntraqueoesof\l=a'\gicay pr\l=o'\tesisfonatoria. Acta Otorrinolaringol Esp.

1989;40:101-106.

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Primary tracheoesophageal puncture vs esophageal speech.

We studied the cost-efficiency profile of tracheoesophageal puncture with prosthesis insertion in alaryngeal patients who were given the opportunity o...
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