Voice Rehabilitation After Laryngectomy: A Regional Cancer Centre Experience and Review of Literature

Abstract

Alaryngeal speech in laryngectomees has revolutionized the patient outlook toward the morbid procedure and the concept of permanent stoma unlike olden era when stigma of stoma with loss of voice was rampant. To analyse acceptance of voice rehabilitation options and their success and management of complications in a tertiary care centre. All patients who underwent laryngectomy from August 2014 to 2018 June at our institution were included in the study. The voice rehabilitation options like oesophageal speech, tracheao-oesophageal puncture and voice prosthesis insertion (TEP), and electrolarynx were explained to the patients. The options put forward to the patients, the importance of Taub test, Interval between treatment and secondary TEP insertion, life span of the prosthesis, Patients acceptance and success rates and the troubleshooting were noted. A total of 96 patients underwent total laryngectomy, 72 patients were willing for rehabilitation. 15% (11) patients had primary TEP, 22% (16) had secondary TEP insertion, esophageal speech in 36% (26) patients and 27% (19) patients opted for the electrolarynx. The rest 24 patients were not keen on any further interventions after laryngectomy. Speech rehabilitation is an integral part in surgical management of carcinoma of the larynx. Alaryngeal speech in laryngectomees have revolutionized the patient outlook towards the morbid procedure. Esophageal speech is the least successful method of rehabilitation but still the cheapest method and requires a lot of motivation. Primary and Secondary TEP insertions have similar success rates. Successful treatment for cancer of larynx ends with successful voice rehabilitation.

Introduction

In 1859, Czermak et al. [1, 2] described a girl with laryngeal stenosis who was able to vocalize by deflecting airflow from a tracheostomy to the tongue base., The first case of producing an intelligible speech after total laryngectomy (TL) was described by Gussenbauer [3] in 1874 at the third Congress of the German Company of Surgeons in Berlin 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 the evolution of voice rehabilitation has undergone lot of improvement due to innovative thinking, research and development. Esophageal speech was introduced in the mid-nineteenth century, electrical devices for sound generation were invented in the early nineteenth century and then came the creation of mucosal or skin fistulas channelizing 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].

Total laryngectomy (TL) or laryngopharyngectomy is still the treatment of choice for advanced laryngeal/hypopharyngeal carcinoma, either as a primary procedure or as salvage following irradiation alone or concurrent chemoradiation therapy [4]. Innumerable studies have proved that psychosocial quality of life (QOL) decreases dramatically after TL. Babin et al. [5] in their study of 150 patients suggests that there are significant 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 [6]. 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 which is pivotal to the prevention of potential psychosocial and economic impact [7].

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. Although there are 3 primary modalities of voice restoration viz., esophageal speech, the electrolarynx, and tracheoesophageal puncture (TEP), the acceptance and success of the usage is varied in a developing multilinguistic multicultural country like India.

Although, no single method is considered to be the best for every patient, the tracheoesophageal puncture has become the most preferred method in the past decade [8]. A study by Finizia and Bergman [9] suggests that successful speech rehabilitation with a TEP after laryngectomy may be as effective as conservative treatment with radiotherapy for laryngeal cancer with regard to psychosocial adjustment and functional ability, as measured with generic QOL instruments. Another study by Eadie and Doyle [10] suggests that patients had a high level of self-perceived QOL after TEP in the domains of communication, eating, pain, and emotion that was empirically better than results found in a previous study involving individuals who had undergone TL without voice restoration.

In a previous study done at our centre in 2011 on 113 patients, QOL scores on the European Organisation for Research and Treatment of Cancer QOL Questionnaire were significantly higher in those patients with voice restoration after TL compared with those without voice restoration [11]. Although surgical disease clearance is an important element in the treatment, it should not be the end point, voice rehabilitation should be the ultimate goal for every individual who undergoes TL.

Aims of the Study

We herein assess the clinical experience with usage of the various methods of rehabilitation after laryngectomy over a period of 2014–2018 which includes consistent use of various rehabilitations after total laryngectomy in a large unselected cohort of patients. The prosthesis we used was Provox 1, Provox 2, Provox 2, Vega And Bloom Singer. We also analysed the acceptance, success rates and adverse events and the management of the adverse events practised at our institution.

Materials and Methods

All patients who underwent laryngectomy from August 2014 to 2018 June at our institution were included in the study. The voice rehabilitation options like oesophageal speech, tracheao-oesophageal puncture and voice prosthesis insertion (TEP), and electrolarynx were explained to the patients. Cricopharyngeal myotomy and Pharyngeal plexus neurectomy were done routinely. The options put forward to the patients, the importance of Taub test, Interval between treatment and secondary TEP insertion, Patients acceptance, success rates and adverse events were noted. Success rates were calculated based on the ability of the patient to communicate and phonate adequately as a part of his daily routine which would have included his professional communication also.

Results

We performed a total of 96 Total laryngectomies for advanced laryngeal and hypopharyngeal cancer out of which a total number willing for rehabilitation (TR)—72 (75%) and the rest were not keen for rehabilitation—24 (25%). Mean duration of follow up is 31 months. Primary TEP (Tracheoesophageal Puncture) was done and prosthesis was inserted in 11 patients (15% of the rehabilitated patients), all these being advanced stage carcinoma of larynx without any history of radiation and without any flap for reconstruction. TEP was inserted in a secondary setting for 16 patients (22%) for those who had undergone irradiation or for those who required a flap for reconstruction. Mean interval between surgery and secondary TEP insertion was 7.2 months for primary surgery and 14 months in salvage surgery. Esophageal speech was encouraged in those who were not willing/afford a TEP prosthesis (26) amounting to 36% of the patients. Electrolarynx was offered to 19 patients (27%) and also to those who were unsuccessful with esophageal speech.

Primary TEP failure was noted in 3 patients and secondary TEP failure was noted in 4 patients. Those who failed with TEP were counseled regarding Electrolarynx and 3 of them were willing for the same. Esophageal speech failed in 19 patients out of which 5 were rehabilitated with Electrolarynx.

Modality	N	Percentage of total rehabilitated (%)	Failed (n)	Success rates (%)
Primary TEP	11	15	3	72
Secondary TEP	16	22	4	75
Esophageal speech	26	36	19	28
Electrolarynx	19	27	2	89

TEP complications	N	Troubleshooting	Resolved
Periprosthetic leak	6	Remove TEP → insert RT and reinsert after 3–4 months Freshen edges → purse string sutures with 3-0 round body Vicryl Use a washer for the TEP	2 2 2
Intra prosthetic leak	6	Change TEP	6
Dislodgement	3	Reinsertion	2

The average Indwelling TEP life span was 7.4 months. The TEP complication rate was 62% which included leak and dislodgement. TEP leak rate (Intra and periprosthetic) was around 22%.

Discussion

Voice rehabilitation techniques, after laryngectomy has emerged in a better and acceptable way, changing the outlook and quality of life of the laryngectomees. The various options available at present include esophageal speech, electro larynx and tracheoesophageal voice prosthesis. Though the promotion of esophageal speech was common earlier, the introduction of newer models of voice prosthesis and their ease in insertion has increased their utility in the recent years. They are inserted primarily or secondarily based on either surgeons preference, patients’ motivation and or depending on whether primary or salvage scenario.

Any speech is considered as a successful voice rehabilitation. But still around 10% patients do not acquire any voice [2, 3]. Social acceptability intelligibility [10, 11], pitch [12], and speed [13] of the voice, both from the perspective of the patient and when measured objectively are ideally the means to assess the success of rehabilitation.

Unlike age, appropriate psychological, speech and medical guidance are the limiting factors for successful voice prosthesis rehabilitation [5]. Though the preferred mode of voice rehabilitation in laryngectomees is esophageal voice, only few patients can master it at first. Recent trend is showing a shift towards voice prosthesis usage. Esophageal voice has success rate of 24–26% [6, 12], with reasonable better vocal quality and acoustic performance [14–17]. The voice intelligibility increases with time during the first year after total laryngectomy.especially in esophageal speakers. However, electronic device is an acceptable alternative as it helps in speeding up the rehabilitation process.

TEP is superior to all other rehabilitation methods in most of the phoniatric parameters, such as pitch, intelligibility, and range [18, 19]. though volume and maximum phonation time are equal in prosthesis and esophageal speakers [20]. TEP can be performed primarily or secondarily. This approach provides serviceable and satisfactory vocal function after laryngectomy in the vast majority of patients, with an overall success rate that ranges between 80 and 92% [3, 4, 14]. TEP users have the earliest success in speech rehabilitation while esophageal speech users improve and acquire a good voice over time.

Rehabilitation success with TEP increase to 58–94% for immediate results with primary TEP and 61–64% for secondary TEP [6, 8, 10, 11, 13–17]. Long-term results in the literature with one-year follow up showed 65–85% in primary and 69–83% in secondary TEP [6, 10, 13–15, 17–22] But our results show that primary and secondary TEP insertion have similar success rates. Possible reasoning is that after laryngectomy, a patient feels depressed that he is unable to communicate and that may lead to a eagerness, excitement and motivation to get a TEP inserted. Also majority of the secondary TEP were done in the setting of a salvage surgery. The higher success rate tendency is in patients submitted to primary than to secondary TEP. This is due to relatively smaller numbers in the secondary TEP groups, early rehabilitation initiation and motivation in primary TEP, longterm disuse and loss of myomucosal plasticity in secondary TEPs, development of vocal adaptation mechanisms, such as pharyngeal phonation, which hinder vocal rehabilitation with voice prosthesis in secondary TEP or inclusion of failed esophageal voice trainees, probably because of some PES tonicity issues. However, postoperative radiotherapy and success of voice prosthesis use revealed controversial studies [9, 14, 23, 24].

Primary TEP, other than avoiding a second procedure, gives immediate good voice restoration and hence a psychological boost to patients. The possibilities of postoperative complications that may occur during a secondary puncture are lesser in primary scenario where the incidence varies from 15 to 25%. They include para-oesophageal abscess cellulitis, aspiration of the prosthesis, enlarged fistula, oesophageal perforation, oesophageal stenosis, death from aspiration pneumonia, fracture of the cervical spine, osteomyelitis, subcutaneous emphysema, and wound infection [15–17].

Proponents of secondary TEP believe that the interim period helps to assess the real motivations of the patient to trachea-oesophageal voice and the pliability and tonicity of the pharyngo-oesophageal segment (PE segment) both post surgery and radiation. Maintenance with systemic or topical nystatin for daily application with cleaning brush is necessary for most patients with any type of VP to prevent fungal colonization and leaks.

In our study the average in dwelling life span of a TEP was around 7.4 months. The life of the voice prosthesis has been reported to be anywhere between 2 and 14 months based on the different group of patients, devices, and regions studied [25–39]. In a very recent retrospective observational study of 390 laryngectomized patients, the authors reported a prosthesis device life much lower durability (mean 61 days) than historically reported which they attribute to the intensification of treatment regimens in an era of organ preservation which eventually complicates the TEP management [12]. The much longer prosthesis device life has been reported in studies from Africa, Portugal, and also from the Indian sub-continent. Cornu et al. [25] who reported device life of 303 days in a South African patient population describe this phenomenon as patients taking Ba more conservative approach and this may have contributed to longer mean device life. In a review by Sara Cruz et al. in Portugal, mean device life were 1–74 months for primary prosthesis and 1–24 months for secondary prosthesis [26]. Two Indian studies reported mean prosthesis longevity of 18 and 15 months, respectively [36]. The mean life of our prosthesis was 16 months (1–42 months), which is similar to the experience of the other published Indian series.

Authors (number of patients)	Prosthesis type	Mean device life in months (range)
Cornu [25] (n = 128)	Provox I	10
Hilgers [26] (n = 79)	Provox I	7.8 (0.2–24)
de Carpentier JP [27] (n = 39)	Provox	4.5 (1.0–12)
Laccourreye O [28] (n = 37)	Provox	10.3
Heaton [29] (n = 40)	Provox II	4.1 (1.0–21)
Ackerstaff [30] (n = 292)	Provox I	4.2 (0.3–19.4)
Graville [31] (n = 30)	Provox II	4.9 (0.5–11)
Op de Coul [32] (n = 318)	Provox I	5.4
Schafer [33] (n = 58)	Provox I	224
	Provox II	94
	Bloom singer	107
Free [34]	Provox II	2.8 (0.3–12.4)
Lequeux T [35] (n = 38)	Provox I	10
	Provox II	5
Ramalingam [36] (n = 41)	Provox I	15
Yenigun [37] (n = 28)	Provox	17.1 (1.0–36)
Krishnamurthy et al. [38] (n = 60)	Provox I/II	16 (1–42)

Spasm of PES [40–43] is one of the causes of failure in vocal rehabilitation with TEP. This motor affection of PES is a reflex triggered by input of air into the esophagus preventing progression of airflow to the pharynx. Hindering vibration of pharyngeal mucosa and hence failing to phonate [1–6]. In such cases, dilation of PES [12, 27, 35] is to be done. Though, it is a natural protection mechanism against gastroesophageal reflux, it becomes an obstacle for phonation rehabilitation [10, 33, 34]. These are tackled intraoperatively by myotomy of medial and inferior pharyngeal constrictor muscles, neurectomy of pharyngeal plexus, and or recently popularized chemical denervation of LPS with botulinum toxin [44–48].

Cricopharyngeal myotomy may be related with incidence of postoperative salivary fistula [8, 28, 34]. The real need of myotomy in TEP is controversial in the literature [1, 8–11, 25, 27, 30, 31, 33–35]. In secondary TEP, the conduction of myotomy is related to 10–20% of incidence of salivary fistulae [5]. Persistence of spasms even after myotomy of constrictors may be due to muscle fiber approximation [1, 9, 11, 32, 33], where botulinium toxin injections are useful. There are reports of [46] botulinum toxin injection in LPS to treat the spasm after TEP with insertion of VP in 1995.

Periprosthetic leak may occur in case of a lose fitting prosthesis where in the saliva/swallowed contents pass around the circumference of the TEP and enter the trachea causing aspiration. This can tackled by

1. purse string sutures around the TEP after freshening the edges using a 3-0 vicryl with round body. However this technique is quite cumbersome and almost impossible if the TEP is quite deep inside the stoma i.e., if the TEP lies at a distance of greater than 1 cm from the stoma. This suturing can be done under Local anaesthesia after spraying 10% topical Lignocaine in the stoma.

2. Removing the TEP and inserted a Ryles tube smaller in diameter than the TEP after freshening the edges can also be done. But the freshened edges are only at the outer edge of the TEP whereas the inner edge will have the same dimensions and hence the success rates are quite less. It can be done only if there is a small discrepancy between the prosthesis size and the puncture size.

3. A washer can be inserted onto the prosthesis, however there are no specific sizes available for the washer and hence sometimes there may be a discrepancy between the prosthesis and the washer resulting in an inadequate repair of the periprosthetic leak.

Intra TEP leaks either due to

• (A)overzealous TEP cleaning with brush resulting in the opposite displacement of the voice prosthesis valve which can be corrected by doing a fibreoptic endoscopy and pushing the valve back into position from the neopharyngeal side.
• (B)Fungal colonization is also a common cause for valve dyspunction resulting in Intra prosthetic leak which can be corrected by flushing the neopharyngeal side with saline under fibreoptic endoscopic vision.
• (C)If the valve is damaged, this will mandate for a change of the prosthesis.

Reflux and trachea esophageal fistula problems, namely TEP site granulomas and peri TEP leaks lead to potential rehabilitation failure [31]. The rate of fistula enlargement and periprosthetic leakage is 7–10% [33, 34]. Radiotherapy, malnourishment, diabetes, smoking, oesophageal stricture, hypothyroidism, VP inappropriate sizing, timing of TEP placement and flap reconstruction are factors attributed to it [34].

Radiation effects on vocal rehabilitation remains controversial. Probably lack of wound healing tissue necrosis, scarring and vascular insult that alter the pliability of the pharyngo-oesophageal mucosa [36–41] can be correlated. Post adjuvant radiation, causing reduced saliva formation and previously persisting refllux plays a significantly synergestic role in fistula issues causing delayed voice recovery.

Though revolutions in voice rehabilitation pertaining to laryngectomees have progressed to better horizons, and TEPs are suggested to be gold standards, esophageal speech still continues to stay in developing nations due to logistic constrains and availability.

Conclusion

Speech rehabilitation is an integral part in surgical management of Carcinoma of the larynx. Alaryngeal speech in laryngectomees have revolutionized the patient outlook towards the morbid procedure. Esophageal speech is the least successful method of rehabilitation but still the cheapest method and requires a lot of motivation. Primary and Secondary TEP insertions have similar success rates. Successful treatment for cancer of larynx ends with successful voice rehabilitation.

Limitation of the Study

In this study we have not co-related the factors which may have affected the life span of the TEP viz., use of flap, comorbidities like Diabetes mellitus which may affect the wound healing, the insertion of TEP done in a primary or salvage setting.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.