Perspectives on voice rehabilitation following total laryngectomy

Total laryngectomy or laryngopharyngectomy is still the treatment of choice for advanced laryngeal/hypopharyngeal carcinoma, either as a primary procedure or as salvage following a failed irradiation and/or chemoradiation therapy. However, the procedure is associated with important consequences over and above the loss of normal voice. There is loss of nasal function, poor coughing abilities, swallowing difficulties, lung function changes, tracheostomal complications, and lifelong functional and psychological consequences. Rehabilitation of these patients has long been a major challenge, but it is only in the last three decades that the emphasis on restoration of function and quality of life has become as important as cure and survival. Successful voice restoration for alaryngeal speakers can be attained with any of three available speech modalities, namely oesophageal speech, electrolarynx and tracheoesophageal speech. The final decision regarding which communication technique will be used depends entirely on the patient, but tracheoeseophageal speech has gained ground rapidly in the last two decades and has become the most preferred method of speech rehabilitation in laryngectomy patients. The role of the physician and the speech-language therapist is to provide the laryngectomy patient with sufficient information to make an informed choice depending upon their individual needs, preferences and abilities.

For oesophageal speech two methods are described, namely the injection method and the inhalation method. Most successful oesophageal speakers use both the types while speaking. The major advantage of oesophageal speech is that it is hands free and requires no equipment, so no costs are incurred for any new equipment or repairs. The major problem is the amount of speech therapy training required to become a proficient speaker. Forty to 74% of laryngectomy patients fail to acquire functional oesophageal speech (Graham 1997) and improper training can lead to failure to achieve any useable speech (Gilmore 1991). Considerable amounts of time and practice are required to refine articulatory precision, increase the duration of utterances and develop good rate and phrasing. Controlling pitch, loudness and the rate of speech can be difficult for oesophageal speakers. Achievable speech intensity levels can be 6 to 10 dB lower than laryngeal speech which often makes noisy environments problematic for oesophageal speakers (Robbins et al. 1984). Electrolarynx is therefore an artificial electronic device used by patients with a laryngectomy for the purpose of speaking. The commonest complaint from its users is mechanical sound quality and the attention it attracts in public places (Casper & Colton 1993). Other disadvantages are that they are not hands free, and frequent battery changes or recharging are required. Older devices were relatively big and heavy, but modern devices are very lightweight and are only few centimetres in size making them much more acceptable for patient usage.

Thirty-five years ago the very first voice prosthesis for voice rehabilitation after total laryngectomy was described by Mozolewski (1972). Major conceptual developments were made in the late 1970s by Eric Blom and Mark Singer (Singer & Blom 1980). Their technique involved creating a simple tracheoesophageal puncture between the posterior wall of the tracheostomy and the upper oesophagus, into which was inserted a one-way silicone valve for tracheoesophageal speech production. In 1980, the first commercially available prosthesis was introduced by Singer and Blom and the first indwelling voice prosthesis (Groningen) was developed in 1982 (Nijdam et al. 1982). A number of indwelling devices are available today, namely the Blom-Singer, Provox 1 and 2, Groningen, VoiceMaster, Nijdam, and Bordeaux voice prostheses. Each has their own advantages and disadvantages. However, in the last two decades these valves have improved significantly and several handsfree, low-pressure, non indwelling and fungal-resistant valves have been introduced by manufacturers in order to make their use more easy. The Provox voice prosthesis developed by the Netherlands Cancer Institute is currently one of the most popular and widely used prosthetic devices used (Hilgers & Schouwenburg 1990; Hilgers et al. 1993). Advantages of the Provox voice prosthesis include immediate voice production, high success rates compared to the oesophageal speech, relatively low complication rates, and the possibility of sustained speech with a more fluent quality than that gained with oesophageal speech. A number of problems with the device are reported however, such as obstruction of the prostheses, leakage through the devices, hypertonic speech and hypotonic speech, so these problems should be anticipated and managed appropriately.

Another major problem with all voice prostheses is microbial colonisation and biofilm formation. Several antimicrobial agents have been used with success to solve this problem, but long-term medication may increase the risk of developing resistant strains which may be difficult to treat. Recent research has consequently focused on the development of alternative means to prevent biofilm formation on voice prostheses. Numerous techniques have been devised with varied results, including modification of the physicochemical properties of the biomaterial surface, achieving an antifouling improvement for the silicone rubber material by the development of new biomaterials, and development of alternative prophylactic and therapeutic agents, including probiotics and biosurfactants (Rodrigues et al. 2007).

In the early years, the tracheoesophageal puncture technique commonly used to place voice prosthesis was a secondary procedure in post-laryngectomy patients who failed to achieve oesophageal speech instead of a primary tracheoesophageal puncture. Consistently good results and the superior quality of voice with secondary tracheoesophageal puncture technique prompted Hamaker et al. (1985) to incorporate the tracheoesophageal puncture as a primary procedure at the same time that the laryngectomy was conducted with equally good results. A more recent study by Brown et al. (2003) demonstrated that there is no significant difference in patient satisfaction on subjective or objective assessments of voice quality in patients undergoing either primary or secondary tracheoesophageal puncture. They also found that perceptions of voice quality were the same or slightly better with an indwelling prosthesis, and that its maintenance was easier.

Tracheoesophageal speech using voice prostheses has revolutionised vocal rehabilitation following total laryngectomy and in many centres, this is now considered to be the gold standard for voice rehabilitation in these patients. There has been considerable progress with the development of automatic tracheostomy valves, and therefore even hands-free speech is now possible. Today, rehabilitation of patients undergoing laryngectomy focuses not only on optimal voice rehabilitation, but also on adequate pulmonary and olfactory rehabilitation. Working with laryngectomy patients involves much more than speech rehabilitation in isolation. Biofilm formation on voice prostheses is still a major problem, limiting the life of all types of prostheses, and the development of novel alternative prophylactic and therapeutic agents are expected to gain prominence in the future to prevent biofilm formation. We also hope that continued efforts will further decrease the costs of prostheses so that more patients, including those from developing countries can benefit from the best available speech rehabilitation modalities following a total laryngectomy. Clinicians and therapists need to be aware of the wide range of issues which can influence rehabilitation as patients who are better informed and better prepared to deal with all aspects of their condition are most likely to achieve successful rehabilitation. The aim should be to offer the best possible information and support for laryngectomy patients in a clinical speciality which is both challenging and fulfilling for those engaged in voice rehabilitation. This is only possible however, if all concerned act together as part of a fully functioning rehabilitation team and not as individuals, since voice restoration is an ongoing therapeutic process and not just a prosthesis!