Vo i c e R e s t o r a t i o n A f t e r Tot al L ary n ge ct o my Christopher G. Tang,
MD
a
, Catherine F. Sinclair,
MD
b,
*
KEYWORDS Total laryngectomy Voice restoration Electrolarynx Esophageal speech Tracheoesophageal puncture KEY POINTS Loss of voice after total laryngectomy can lead to a significant decrease in a patient’s quality of life, which can be improved with voice restoration. The 3 main modalities of voice restoration are esophageal speech, electrolarynx, and tracheoesophageal puncture. Esophageal speech is the most difficult to teach and for patients to learn; however, it is the most economical. Speech with the electrolarynx is easier to learn than esophageal speech, but requires the purchase and maintenance of an electrolarynx device. Tracheoesophageal puncture with voice prosthesis placement is the gold standard for voice restoration and can be done at the time of total laryngectomy or as a secondary procedure afterward.
HISTORY OF VOICE RESTORATION
Achieving voice in the absence of a functional larynx has been described for more than 150 years.1 In 1859, Czermak and colleagues1,2 described a girl with laryngeal stenosis who achieved voice by deflecting airflow from a tracheostomy to the tongue base. In 1874 at the third Congress of the German Company of Surgeons in Berlin, the first case of creating intelligible speech after total laryngectomy (TL) was described by Gussenbauer3 when he fitted Billroth’s first TL patient with a reedlike device mounted onto a double-lumen tracheostomy tube with a port extending into the pharynx. Since then numerous surgical modifications and devices have been described, including
Disclosures: The authors have no financial disclosures. a New York Center for Voice and Swallowing Disorders, 425 West 59th Street, 10th Floor, New York, NY 10019, USA; b Department of Otolaryngology, Mount Sinai Icahn School of Medicine, 425 West 59th Street, 10th Floor, New York, NY 10019, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.otc.2015.04.013 0030-6665/15/$ – see front matter Published by Elsevier Inc.
oto.theclinics.com
2
Tang & Sinclair
Abbreviations EMG PCF QOL SIP TEP TL UWQOL VHI-10
Electromyography Pharyngocutaneous fistula Quality of life Sickness Impact Profile Tracheoesophageal puncture Total laryngectomy University of Washington Quality of Life scale Voice Handicap Index 10
esophageal speech in the mid-nineteenth century, electrical devices for sound generation in the early nineteenth century, and then creation of mucosal or skin fistulas directing air from the lungs to the upper esophagus and pharynx and implantation of unidirectional prosthetic valves between the trachea and upper esophagus in the mid-twentieth century.1 OVERVIEW OF VOICE RESTORATION
What is voice restoration? According to the Merriam-Webster dictionary, human voice is defined as sound produced by means of the lungs and larynx or the faculty of utterance.4 Three elements are necessary for voice production with an anatomically normal vocal tract (Fig. 1): 1. An air generator: during expiration, the lungs generate a burst of air, which is channeled though the larynx
Fig. 1. Normal anatomy. Three elements are necessary for sound production: an air generator, a vibrating apparatus, and an articulating tract. (Courtesy of Jason Gilde, MD, Oakland, CA.)
Voice Restoration After Total Laryngectomy
2. A vibrating apparatus: vibrations produced by vocal fold adduction allow sound production to occur 3. An articulating tract: sound is channeled and modified through an articulating apparatus (pharynx, oral cavity) to produce an audible, understandable voice After TL, patients maintain their air generator and articulating tract (to varying degrees depending on the extent of concomitant pharyngeal or tongue base resection). However, they lose their ability to make sound5 (Fig. 2). The goal of voice restoration is to artificially create a sound source and, more specifically, to create vibratory motion of air that can be projected through and modified by the vocal tract. The 3 primary modalities of voice restoration are esophageal speech, the electrolarynx, and tracheoesophageal puncture (TEP).6 IMPORTANCE OF VOICE RESTORATION AFTER TOTAL LARYNGECTOMY
Numerous studies have shown that psychosocial quality of life (QOL) decreases dramatically after TL. A study of 150 patients by Babin and colleagues7 suggests that there are significant increases in feelings of solitude after TL and that voice deprivation is a limiting factor in social relationships, tending to push individuals into social withdrawal. Reduced sexual enjoyment and libido are also common problems after laryngeal and hypopharyngeal cancer surgery.8 Thus, successful treatment of laryngeal cancer cannot be measured by survival rates alone. Rapid, effective restoration of voice and speech is one of the primary focuses of postoperative TL rehabilitation and is pivotal to the prevention of potential psychosocial and economic consequences.9 One study showed that indwelling vocal
Fig. 2. After TL the patient loses the ability to make sound. (Courtesy of Jason Gilde, MD, Oakland, CA.)
3
4
Tang & Sinclair
prostheses improved QOL, self-esteem, and sexual function (P
MD
a
, Catherine F. Sinclair,
MD
b,
*
KEYWORDS Total laryngectomy Voice restoration Electrolarynx Esophageal speech Tracheoesophageal puncture KEY POINTS Loss of voice after total laryngectomy can lead to a significant decrease in a patient’s quality of life, which can be improved with voice restoration. The 3 main modalities of voice restoration are esophageal speech, electrolarynx, and tracheoesophageal puncture. Esophageal speech is the most difficult to teach and for patients to learn; however, it is the most economical. Speech with the electrolarynx is easier to learn than esophageal speech, but requires the purchase and maintenance of an electrolarynx device. Tracheoesophageal puncture with voice prosthesis placement is the gold standard for voice restoration and can be done at the time of total laryngectomy or as a secondary procedure afterward.
HISTORY OF VOICE RESTORATION
Achieving voice in the absence of a functional larynx has been described for more than 150 years.1 In 1859, Czermak and colleagues1,2 described a girl with laryngeal stenosis who achieved voice by deflecting airflow from a tracheostomy to the tongue base. In 1874 at the third Congress of the German Company of Surgeons in Berlin, the first case of creating intelligible speech after total laryngectomy (TL) was described by Gussenbauer3 when he fitted Billroth’s first TL patient with a reedlike device mounted onto a double-lumen tracheostomy tube with a port extending into the pharynx. Since then numerous surgical modifications and devices have been described, including
Disclosures: The authors have no financial disclosures. a New York Center for Voice and Swallowing Disorders, 425 West 59th Street, 10th Floor, New York, NY 10019, USA; b Department of Otolaryngology, Mount Sinai Icahn School of Medicine, 425 West 59th Street, 10th Floor, New York, NY 10019, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.otc.2015.04.013 0030-6665/15/$ – see front matter Published by Elsevier Inc.
oto.theclinics.com
2
Tang & Sinclair
Abbreviations EMG PCF QOL SIP TEP TL UWQOL VHI-10
Electromyography Pharyngocutaneous fistula Quality of life Sickness Impact Profile Tracheoesophageal puncture Total laryngectomy University of Washington Quality of Life scale Voice Handicap Index 10
esophageal speech in the mid-nineteenth century, electrical devices for sound generation in the early nineteenth century, and then creation of mucosal or skin fistulas directing air from the lungs to the upper esophagus and pharynx and implantation of unidirectional prosthetic valves between the trachea and upper esophagus in the mid-twentieth century.1 OVERVIEW OF VOICE RESTORATION
What is voice restoration? According to the Merriam-Webster dictionary, human voice is defined as sound produced by means of the lungs and larynx or the faculty of utterance.4 Three elements are necessary for voice production with an anatomically normal vocal tract (Fig. 1): 1. An air generator: during expiration, the lungs generate a burst of air, which is channeled though the larynx
Fig. 1. Normal anatomy. Three elements are necessary for sound production: an air generator, a vibrating apparatus, and an articulating tract. (Courtesy of Jason Gilde, MD, Oakland, CA.)
Voice Restoration After Total Laryngectomy
2. A vibrating apparatus: vibrations produced by vocal fold adduction allow sound production to occur 3. An articulating tract: sound is channeled and modified through an articulating apparatus (pharynx, oral cavity) to produce an audible, understandable voice After TL, patients maintain their air generator and articulating tract (to varying degrees depending on the extent of concomitant pharyngeal or tongue base resection). However, they lose their ability to make sound5 (Fig. 2). The goal of voice restoration is to artificially create a sound source and, more specifically, to create vibratory motion of air that can be projected through and modified by the vocal tract. The 3 primary modalities of voice restoration are esophageal speech, the electrolarynx, and tracheoesophageal puncture (TEP).6 IMPORTANCE OF VOICE RESTORATION AFTER TOTAL LARYNGECTOMY
Numerous studies have shown that psychosocial quality of life (QOL) decreases dramatically after TL. A study of 150 patients by Babin and colleagues7 suggests that there are significant increases in feelings of solitude after TL and that voice deprivation is a limiting factor in social relationships, tending to push individuals into social withdrawal. Reduced sexual enjoyment and libido are also common problems after laryngeal and hypopharyngeal cancer surgery.8 Thus, successful treatment of laryngeal cancer cannot be measured by survival rates alone. Rapid, effective restoration of voice and speech is one of the primary focuses of postoperative TL rehabilitation and is pivotal to the prevention of potential psychosocial and economic consequences.9 One study showed that indwelling vocal
Fig. 2. After TL the patient loses the ability to make sound. (Courtesy of Jason Gilde, MD, Oakland, CA.)
3
4
Tang & Sinclair
prostheses improved QOL, self-esteem, and sexual function (P
