Tracheoesophageal speech failure in the laryngectomee: The role of constrictor myotomy

Abstract

Drs. Singer and Blom pioneered the development of a valved voice prosthesis and controlled fistula between the tracheal and esophagcal wall to generate fluent esophageal speech in laryngectomy patients. Since then numerous voice prostheses with different performance capacities have entered the marketplace. In spite of optimal choices and fitting of devices, there remains a population of patients refractory to this type of rehabilitation. It is our experience that a number of patients ultimately benefit from middle and inferior constrictor myotomy with marked improvement in their speech. Patient selection, evaluation, and operative techniques are discussed. Five patients who were unable to speak even after introduction of various commercially available devices showed marked improvement after middle and inferior constrictor surgical myotomy. Minimal complications were encountered even in irradiated patients. These patients were preoperatively injected with Xylocaine to produce a partial blockade. Their speech improved dramatically for the duration of Xylocaine blockade. Esophageal video fluoroscopy of attempted speech with the voice prosthesis in place confirmed constrictor spasm that opposed air flow to the oropharynx. Inferior and middle constrictor myotomy appears to be very beneficial in rehabilitation of failed alaryngeal speakers who demonstrate pharyngeal constrictor spasm.

Vocal rehabilitation of tracheoesophageal speech failures

“…Trials of different speech prostheses were advocated when they were not helpful in any of the 5 cases of tracheoesophageal speech failures reported. 2 As experience with tracheoesophageal speech has grown, the number and types of potential failures have grown. Three etiologies of tracheoesophageal speech failure have been identified: the hypotonic pharyngoesophageal segment, hy-popharyngeal stricture, and pharyngoesophageal ~p a s m .~-~ The breathy voice, the clinical correlate of the hypotonic pharyngoesophageal segment,3 is a frequent complication, particularly when myotomies are performed at the time of laryngectomy.6 As the severity of the hypotonia increases, the egress of air from the pharynx and esophagus may not generate sufficient tissue vibration to result in tracheoesophageal sound.…”

Comparison of pharyngoesophageal segment pressure in total laryngectomy patients with and without pharyngeal neurectomy

“…Baugh et al reported that in all of the patients that failed to produce speech because of PES spasm25 in their study despite intense speech therapy, tracheoesophageal speech could not be obtained until pharyngeal myotomy was performed. In studies by Henley and Souliere8 and Chodosh et al,7 despite a relatively long postoperative period, patients could only succeed in speech production when myotomy was carried out. The results of our study correlate with those of Callaway et al's study.…”

“…To achieve low PES pressure for successful voice restoration, pharyngeal constrictor myotomy,2, 7, 8–11 nonmuscular pharyngeal closure,12–14 pharyngeal plexus neurectomy,15 botulinum toxin injection,16 and laser‐assisted endoscopic transmucosal pharyngeal myotomy17 were proposed.…”

“…There are studies that indicate a positive effect of primary or secondary pharyngeal myotomy in the success of esophageal or shunt voice 2, 7, 8–11. Complications like hypotonic PES, residual spasm, reapproximation of the transected muscle fibers, infection, hemorrhage, gastroesophageal reflux, stomal stenosis, and pharyngocutaneous fistula have been reported after myotomy 2, 10, 11, 18, 25.…”

“…For a successful voice restoration, this spasm and hypertonicity should either be prevented or abolished. Methods like botulinum toxin injection, laser‐assisted myotomy, nonmuscular pharyngeal closure, pharyngeal constrictor myotomy, and pharyngeal plexus neurectomy have been recommended to prevent this hypertonicity 7–17. For voice restoration to be successful, the PES pressure level should be less than the critical level of 20 mmHg, which was demonstrated with manometric measurements 18–20.…”