Re: Kazi R, Sayed SI, Dwivedi RC. Post laryngectomy speech and voice rehabilitation: past, present and future. (ANZ J. Surg. 2010; 80: 770–1)
The article by Kazi et al.1 states that surgical voice restoration using voice prostheses has made this modality the ‘gold standard’ in post-laryngectomy voice rehabilitation. The prosthesis converts the phonatory source of speech from the vocal cords to the pharyngo-oesophageal (PE) segment. The ability of the PE segment to freely vibrate is therefore paramount to successful voice restoration. Here we outline some operative manoeuvres and post-operative steps at troubleshooting voice problems that we feel deserve additional attention.
During total laryngectomy, we detach the sternal heads of the sternocleidomastoid muscles; this creates a ‘flatter’ suprastomal region which allows easier thumb occlusion of the stoma and may reduce tension lateral to the stoma. The PE segment lies superior to the tracheoesophageal fistula and includes fibres of cricopharyngeus. If these are left, the pressure in the PE segment will be too hypertonic to allow adequate speech. It is imperative to perform a cricopharyngeal myotomy at the time of surgery.2
Whereas leakage through the valve may represent valve failure, leakage around the valve may be a result of tumour recurrence and we would like to highlight that this should be excluded. Dysphonia can be because of problems with the PE segment which may be hypertonic, hypotonic or spastic. Contrast imaging may help to elucidate the cause of potential problems but another technique to consider is insufflation testing. A catheter is placed through the nose until the end is distal to the PE segment. Air is passed to insufflate the PE segment stimulating phonation. The required pressure is measured manometrically. If hypertonicity or spasticity is a problem, then BoTox, pharyngeal neurectomy or secondary cricopharyngeal myotomy may be beneficial.3 If hypotonicity is the cause, then bulking4 may be of use.
Jonathan C. Hobson, BM BCh, MA, FRCS (ORL-HNS)
A. Simon Carney, BSc (Hons), MBChB, FRCS, FRACS, MD
Department of ENT, Flinders Medical Centre, Bedford Park, South Australia, Australia
References
1. Kazi R, Sayed SI, Dwivedi RC. Post laryngectomy speech and voice rehabilitation: past, present and future. ANZ J. Surg. 2010; 80: 770–1.
2. Elmiyeh B, Dwivedi RC, Jallali N et al. Surgical voice restoration after total laryngectomy: an overview. Indian J. Cancer 2010; 47: 239–47.
3. Bayles SW, Deschler DG. Operative prevention and management of voice-limiting pharyngoesophageal spasm. Otolaryngol. Clin. North Am. 2004; 37: 547–58.
4. Luff DA, Izzat S, Farrington WT. Viscoaugmentation as a treatment for leakage around the Provox 2 voice rehabilitation system. J. Laryngol. Otol. 1999; 113: 847–8.
