Laryngology Seminar
Tracheoesophageal voice restoration
R3 謝佳穎
Introduction
1. Total laryngectomy → speech, swallowing and respiration function were altered
2. Communication options after total laryngectomy: writing, gestures, augmentive
devices, artificial larynges, traditional esophageal speech and tracheoesophageal
speech with prosthesis( more natural)
3. TE speech more similar to laryngeal speech than esophageal speech
4.
5.
TE speech superior to esophageal speech: phrase length, learning, rate of speech
Successful surgical voice restoration technique: TE puncture by Singer and Blom
in 1979
6.
7.
Maves & Lingerman(1982): introduce as primary technique
Vibratory segment: pharyngeal constrictor muscles, cricopharyngeus and upper
circular fibers of esophagus
Successful tracheoesophageal voice restoration
 Speech consistently meet daily communication needs
 Prosthesis adequately stent the puncture tract


Prosthesis prevent leakage into tracheostoma
Simple maintenance of device
Preoperative assessment
1. Manual dexterity and vision: basic self-care activities
2. Psychologic adjustment
3. Medical contraindications: possible recurrence, poor healing(type I DM,
R/T > 65Gy, fistula, malnutrition, malignancy), hypothyroidism
4. Sufficient size of stoma( 1.5cm)
5.
6.
Stricture of pharyngoesophagus
Hypertonic vibratory segment: >20mmHg during phonation
a. Seeman(1922): transnasal esophageal insufflation
b. Blom: insufflation with pulmonary air. “pass”: sustatin fluent voicing
for 8 seconds and to count continuously to 15. 1) fluent, sustained voice
2)breathy, hypotonic voice 3)Hypertonic voice 4) spasm
c. Lewin: pressure monitor
d. Combination with videofluoroscopy
e. Pharyngeal plexus block( Hamaker Cheesman):
infiltration with 2%
xylocaine at C2-C4 prevertebral area
Type of prostheses (no difference in phonatory skills): duckbill style, low-pressure
exdwelling(patient –removal) type, indwelling style
Life of prosthesis: 3~6 months
Primary voice restoration
1. Absolute contraindication: separation of the party wall at puncture site (abscess
formation, mediastinitis)
2.
3.
4.
5.
6.
7.
Relative contraindication: complexity of reconstruction, impaired mental status,
decrease in manual dexterity, severe SNHL, limited pulmonary function
Complication rate was not increased
Primary TEP is believed to be safer than secondary TEP
Procedure: laryngectomy → stoma construction(> 3cm) → TEP(1~1.5cm below
posterior cut edge of stoma) → unilateral pharyngeal constrictor myotomy or
pharyngeal plexus neurectomy → buttressing tracheoesophageal party wall
prosthesis placement: after per oral feeds. Voicing: 2 weeks postoperatively
Successful TE speech after primary TEP: 50~93%
Secondary tracheoesophageal puncture
1. Timing: 6 weeks following laryngectomy, 6~8 weeks following post-OP R/T
2. barium swallow, stoma ≧ 2cm, transnasal esophageal insufflation test
3. Procedure: Esophagoscope at level of stoma → introduce No 14 sheathed catheter
5mm below mucocutaneous junction → insertion of wire on tapered catheter →
cut of wire and introduce catheter into esophagus
Evaluation for tracheoesophageal voice restoration problems
1. Stoma : ≧2cm (visualize and change prosthesis and pulmonary function)
Stenosis → silicone laryngectomy tube, stomaplasty
Hygiene of tracheostoma, granulation or tissue necrosis
2. Neck: r/o recurrence or neck metastasis, fistula formation, position of SCM
insertion
3. Prothesis: Length
Common problems after tracheoesophageal voice restoration
 Leakage problems
Through prosthesis(most common): education of patient(prevent aspiration)
Check
a. Condition and positioning of flap valve in situ: deformity, movement of valve
b. After removal of prosthesis: color and overall condition of device( dark in
color → GER)
Around prosthesis
Prosthesis too long, tissue necrosis after R/T or hypothyroidism, recurrence
Management: bigger diameter prosthesis, smaller diameter rubber catheter,
washers, cauterizing tracheal wall tissue, local injection with fat or Hylaform,

surgery
Voicing problems
Open-tract evaluation: depth, width, angle and location of puncture
Occlusion-related problems: occlude tracheostoma lightly, Tracheostom housing
or tracheostoma valve
Segment-related problems: Pharyngeal constrictor hypertonicity, scarring,
radiation fibrosis, persistent tumor
Dworkin: effective speaker → less redundant, thinner mucosa, more
synchronous pharyngoesophageal vibratory patterns
Prevention of pharyngospasm with surgery: pharyngeal constrictor myotomy,
unilateral pharyngeal plexus neurectomy, unilateral pharyngeal
plexus neurectomy with drainage myotomy
Local injection of botulinum neurotoxin: 2% lidocaine into pharyngeal
constrictor muscle
Prosthesis-related problems: Length of prosthesis → nasoendoscopy, granulation
tissue on tracheal wall
Fungal/ biofilm overgrowth: indwelling type; Candida albicans( nystatin
suspension 4 min swish BID)
References
1. Pou AM
Tracheoesophageal voice restoration with total laryngectomy.
Otolaryngol Clin North Am. 2004 Jun;37(3):531-45
2. Bunting GW Voice following laryngeal cancer surgery: troubleshooting common
problems after tracheoesophageal voice restoration. Otolaryngol Clin North Am. 2004
Jun;37(3):597-612.
3. Gress CD Preoperative evaluation for tracheoesophageal voice restoration.
Otolaryngol Clin North Am. 2004 Jun;37(3):519-30.
4. Singer MI The development of successful tracheoesophageal voice restoration.
Otolaryngol Clin North Am. 2004 Jun;37(3):507-17.
5. Kearney Ann Nontracheoesophageal speech rehabilitation. Otolaryngol Clin North Am.
2004 Jun;37(3):613-625