Radiol Oncol 2001; 35(4): 249-54. Communication after laryngectomy Irena Hočevar-Boltežar and Miha Žargi Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Center, Ljubljana, Slovenia Background. Laryngectomy is the mode of treatment of the patients with advanced laryngeal and hy- popharyngeal cancer. It affects many important functions, including speech. Patients and methods. Various alaryngeal speech modes are available so that no laryngectomee should be left without a means of communication. Results. There is a variety of artificial devices, including electronic ones that produce their own battery driv- en sound. Alternatively, the patient can learn a new form of voicing using a muscular segment of the upper esophagus as a source of sound (esophageal speech). A puncture can be created surgically through the esophageal wall and a prosthesis placed in it to divert pulmonary air into the esophagus and through the same muscular segment to produce sound. Conclusions. Many factors influence the choice of an alternative to be used with a particular patient. In Slovenia, esophageal speech is the most frequently used alaryngeal speech mode. Key words: laryngeal neoplasms; laryngectomy; speech, alaryngeal; speech, esophageal Epidemiology and etiology of laryngeal and disease was discovered in a localized stage. In hypopharyngeal cancer all other patients, the malignant disease was in an advanced stage and required more ag- Laryngeal and hypopharyngeal cancers are gressive treatment.1 quite common in Slovenia. In 1995 they rep- Laryngeal and hypopharyngeal cancers resented 1.9 % of all new malignant diseases usually occur in men aged 50-65 years with a in Slovenia. The incidence of laryngeal cancer long history of tobacco consumption fre- was 9.1/100.000 inhabitants in men, and quently associated with alcohol abuse. The al- 0.5/100.000 inhabitants in women. The inci- cohol-related nutritional deficiencies could be dence of hypopharyngeal cancer was involved in the etiology of these cancers.1,2 As 4.5/100.000 inhabitants in men, and a result, the patients often present with no- 0.3/100.000 inhabitants in women. In 55 % of table co-morbidities. In addition, the socio- patients with laryngeal cancer and only 12 % of patients with hypopharyngeal cancer, the Correspondence to: Irena Hočevar-Boltežar, MD, PhD, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, SI-1000 Ljubljana, Slovenia. Received 15 October 2001 Phone: +386 1 522 24 65; Fax: +386 1 52 24 815; E-mail: Accepted 10 November 2001 [email protected] 250 Hočevar-Boltežar I and Žargi M /Communication after laryngectomy cultural level is rather poor in the majority of quisition, which showed that 26 % of their la- cases. This particular characteristic of laryn- ryngectomy study group were able to acquire geal and hypopharyngeal cancer patients ex- ES.6 In a more recent prospective study, plains the delay in diagnosis and the prob- Hillman et al. found that only 6 % of their pa- lems linked to treatment compliance. tients developed usable ES.12 ES is produced by compressing the air into the esophagus; the released air vibrates the Laryngectomy and its consequences pharyngeal-esophageal segment and pro- duces the esophageal tone used for speech. Laryngectomy is a surgical procedure usually The sound produced enters the oral cavity reserved for patients with advanced laryngeal where it is articulated and shaped into words. or hypopharyngeal carcinoma or patients Generally, there are three primary meth- who fail radiation treatment.3 Loosing the lar- ods used to teach esophageal speech: conso- ynx means adapting to a living without some nant injection, glossopharyngeal press, and basics that characterize us as human. inhalation. Regardless the method used, the Respiration and speech are altered for ever; goals are for the patient to be able to im- swallowing needs to be re-learned; smell and pound rapidly the air into the esophagus, ex- taste are attenuated; lifting, straining and pel it from there in a controlled manner, and coughing (all of which are dependent on a produce fluent ES. Esophageal speakers have closed glottis) are compromised. Although a much lower air reservoir (less than 100 cm3) there are numerous potential problems (emo- than is available to laryngeal speakers from tional, psychological, physical, economic, so- the lungs (even > 5 litres). The small air sup- cial, surgical, and communicative), the inabil- ply will limit the esophageal speaker’s ability ity to speak is considered the greatest of the to produce long utterances on a single charge difficulties the patient is faced by.4 of air. The advantages of the ES are: • The sound of ES is more natural and closer Voice restoration after laryngectomy to the laryngeal voice. • ES requires no dependence on mechanical After the removal of the larynx, the patient no instrument. longer has a source of sound for speaking. • The patient is able to achieve some meas- Currently, there are two categories of sound ure of pitch and loudness control, and restoration: alternative “natural” sound sour- good esophageal speakers are able to vary ces and mechanical speech aids. The former these dynamically during speech. category utilizes esophageal and tracheoeso- • Both hands are free during speech. phageal speech, whereas the latter an elec- tronic artificial larynx.5 ES has also some disadvantages: • ES must be learnt and may take a long time to master it. Some patients may nev- Esophageal speech (ES) er learn to produce functional ES even af- ES traditionally has been the dominant ap- ter much effort. proach to laryngeal speech rehabilitation. • A person’s ability to articulate clearly must Some retrospective studies demonstrated a be good, otherwise the intelligibility of ES range of success from 12 % to 97 %.6-11 In may be poor. 1982, Gates et al. published the results from • The patient may have difficulty being the first prospective investigation of ES ac- heard above back-ground noise.5 Radiol Oncol 2001; 35(4): 249-54. Hočevar-Boltežar I and Žargi M /Communication after laryngectomy 251 Tracheoesophageal speech (TES) • TES is smooth and fluent because of the The tracheoesophageal puncture method, cou- availability of pulmonary air. pled with the use of the voice prosthesis, was • Loudness and pitch variation is possible. introduced by Singer and Bloom in 1980.13 The • The approach is feasible in most of the la- surgery may be performed at the time of the la- ryngectomized patients and is also re- ryngectomy (primary procedure), or it may be versible if so desired. performed at a later date (secondary proce- dure). Early studies, focused on carefully se- The disadvantages of TES are: lected groups of patients who underwent the • The insertion of the voice prosthesis re- insertion of a prosthesis as a secondary proce- quires another surgical procedure if not dure, reported success rates ranging from 56% done together with the laryngectomy. to 93 %.14-16 More recent studies, which have • Occasional aspiration due to poorly seated focused on the insertion of a prosthesis as a prosthesis, or poorly functioning prosthe- primary procedure, have reported acquisition sis is possible. rates ranging from 30 % to 93 %.17-19 • A buildup of candida deposits requires fre- In this approach, a small, silicone, valved quent cleaning. prosthesis is inserted into a surgically created • The functioning period of the prosthesis is midline tracheoesophageal fistula. The uni-di- limited.5,21 rectional valved prosthesis is designed to maintain tract patency and protect against as- Artificial larynx (AL) piration. The patient can divert pulmonary air from the trachea (by occluding the tra- Previous reports of AL use among laryngecto- cheostoma with a finger) through the prosthe- my patients vary in many aspects. The esti- sis, thereby creating a sound in the pharyngo- mates of AL use range from 5 % to 66 %.6,22,23 esophageal segment. The air pressures This device uses electric power to drive a vi- required to force open the slit of the valve brator that provides the sound source. It gen- range between 2 and 25 cm H2O and depend erates a sound with approximately the same on the rate of airflow from the lungs and the frequency as is the fundamental laryngeal fre- type of the device used.20 Some patients may quency. One type of the device consists of a have considerable difficulty producing the tube that delivers sound from the vibrator to pressures. In these cases, a lower resistance the mouth. the sound is then articulated in prosthesis is suitable. Special valves are avail- the normal way. Another version consists of a able to avoid manual occlusion of the stoma. hand held vibrator that is designed to deliver These valves close automatically when greater the sound through the skin when placed on than normal thoracic pressures are present as the neck. Until recent years, the AL was con- when the patient wishes to produce speech. sidered to be the method of choice only for There are still contraindications in the se- those patients who were unable to learn ES. lection of patients for the prosthesis inser- Clinical experience has demonstrated that AL tion: inability to care for the stoma, poor man- actually may be helpful in the acquisition of ual dexterity, a stenotic stoma, poor eyesight, ES. AL may serve as a communication bridge esophageal stenosis, and poor patient’s moti- until ES or TES training is initiated. Recent vation. studies from the USA report that a majority The advantages of TES are: of laryngectomees use AL – 55 %.12 • This technique can provide the most rapid restoration of nearly normal speech in The advantages of AL: most of the laryngectomized patients. • It is easy to learn how to use it. Radiol Oncol 2001; 35(4): 249-54. 252 Hočevar-Boltežar I and Žargi M /Communication after laryngectomy • AL provides adequate volume to be heard The intensity of ES is usually lower in over- in noisy places.