Tracheoesophageal Speech

Starting from the first total laryngectomy, devices that shunted air from the lungs towards the pharynx were the first used as means of voice rehabilitation. The philosophy behind the development of these devices is logical. The lungs provide a "large" air volume that can be used to generate voice.32 All tracheoesophageal speech methods are based on this concept. Previously, relatively big devices were used to shunt air from the lungs towards the pharynx, until the introduction of surgical fistulas in the late 1950s.

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Tracheoesophageal Puncture (TEP)

Singer and Blom were the first to introduce an efficient and safe tracheo-esophageal puncture technique, with insertion of a silicone voice prosthesis, for voice rehabilitation after total laryngectomy (figure 1.4).45 In their first publication on this technique, they described 60 patients who underwent this procedure. All patients had an insufflation test before the secondary puncture. Ninety percent of the patients had a fluent speech, a remarkable high percentage that was never achieved before with other techniques of voice rehabilitation. They also reported no operative complications and frequent leakage from the esophagus to the airway was non existent. This technique meant a major break through and is still considered, apart from modifications, to be the method of choice for voice rehabilitation in most patients. Later, they showed that there is some decrease over time in success rate from 94% to 83%.46 High voice rehabilitation success rates were also reported by others.47,48

The original voice prosthesis was a hand crafted piece of tubing which worked as a one way valve. It allowed air to pass towards the esophagus to enable voicing and kept esophageal content out of the airway. The commercially available Duckbill, which was a derivative of the hand grafted device, followed shortly. The Duckbill prosthesis is inserted into the fistula through the tracheostoma (anterograde or frontloading insertion) and is taped to the peristomal skin.

Soon others jumped onto the bandwagon and started modifying and deve-loping their own voice prosthesis.49-55

Panje introduced a prosthesis that was quite similar but which had an additional flange that helped the voice prosthesis to stay in the fistula, a concept refined with the Groningen prosthesis. This fixation method is currently known as indwelling or semi-permanent fixation.49

Since the Duckbill prosthesis, that has a relatively high resistance to airflow, the emphasis on making low resistance prostheses started in the second half of the eighties.

The main advantages of this method are: the relatively good voice quality compared to the other voice rehabilitation techniques, and the high success rate of achieving usable voice requiring limited teaching.

Major disadvantages of this method are: the daily maintenance of the prosthesis by the patient, the recurrent leakage of the prosthesis after a period of time and the therefore required replacement by the clinician, the costs, and for most patients needing a hand to occlude the tracheostoma. Although complications associated with TEP are infrequent, they may occur. Leakage around the prosthesis due to TEF enlargement is reported in 5-8% of the patients.56-58 Occurrence of granulation tissue formation around the voice prosthesis is reported in approximately 5%. The more serious complication of aspiration of the voice prosthesis is seen in 1-5%.57,58 The last complication is dependent of the type of voice prosthesis used.

Good voice prostheses nowadays have the following characteristics: reliable and safe use, frontloading insertion technique, indwelling fixation and low resistance to airflow.

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Copyright 1998 Medical Illustrations
Last modified: January 07, 1999

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