 |
|
Tracheoesophageal Speech in a Developing World Community
Johannes J. Fagan, MD, FCS(SA), MMed(Otol);
Roslyn Lentin, BSc(Log);
Manuel F. Oyarzabal, MD, FRCS;
Sedick Isaacs, PhD, FSS, MBCS;
Sean L. Sellars, MD, FRCS
Arch Otolaryngol Head Neck Surg. 2002;128:50-53.
ABSTRACT
| |
Objectives To determine the tracheoesophageal speech results in a Third World medical
practice; to examine the impact of socioeconomic status, literacy, and proximity
to specialist services on tracheoesophageal speech; to assess whether these
factors should affect patient selection for fistula speech; and to determine
guidelines for voice prosthesis selection.
Design Retrospective analysis.
Setting Groote Schuur Hospital, Cape Town, South Africa, which serves a Third
World community.
Patients Ninety-seven consecutive patients who underwent total laryngectomy between
January 1, 1996, and October 1, 1998. Patients who undergo total laryngectomy
routinely have a primary tracheoesophageal fistula created for speech.
Main Outcome Measures Speech outcomes after total laryngectomy; tracheoesophageal speech in
relation to social class, literacy, and proximity to specialist services;
and experience with removable and indwelling valves.
Results Fifty-nine (81%) of 73 patients acquired useful speech. Speech outcome
was not affected by employment status or proximity to specialist services.
Although speech was affected by literacy and housing, several illiterate shack
dwellers acquired good speech. Average device life of removable prostheses
was 16 weeks (>4 months in 35% [64/183]). Indwelling prostheses had an average
life of 28 weeks.
Conclusions Tracheoesophageal speech results in a Third World community equate with
those in the Developed World. All patients who undergo laryngectomy and have
adequate manual dexterity and cognitive function should be given a trial of
fistula speech. Removable voice prostheses can successfully be used as indwelling
prostheses.
INTRODUCTION
THE OTOLARYNGOLOGY Unit at Groote Schuur Hospital in Cape Town, South
Africa, serves a predominantly lower socioeconomic and Third World population.
It has a catchment area extending 800 km from Cape Town. Many patients are
poverty stricken, are illiterate, and cannot communicate in English or Afrikaans,
the languages used by most health professionals. Many patients live in unserviced
shacks (no running water, flush toilets, electricity, or telephones) (Figure 1A) and reside a long distance from
specialist services.
|
|
|
|
Figure 1. A, Typical unserviced shack. B,
Typical low-income houses.
|
|
|
Our speech rehabilitation program for patients who undergo total laryngectomy
for cancer of the larynx comprises preoperative speech counseling, primary
tracheoesophageal puncture, and pharyngoesophageal myotomy. Open-tract voicing
is attempted approximately 10 days after surgery. If voicing is successful,
then a prosthesis is inserted. Antifungal prophylaxis is not administered.
The study objectives were to determine the tracheoesophageal speech
results in a Third World medical practice; to examine the impact of literacy,
socioeconomic status, and proximity to specialist services on speech outcome;
to determine whether these factors should affect patient selection for fistula
speech; and to assess our choice of voice prosthesis and establish guidelines
for prosthesis selection.
PATIENTS, MATERIALS, AND METHODS
A retrospective analysis was performed of the tracheoesophageal speech
results of 97 patients who underwent total laryngectomy at Groote Schuur Hospital
between January 1, 1996, and October 1, 1998. Data were obtained from hospital
medical records and speech therapists' records. Speech therapists responsible
for patient rehabilitation subjectively assessed tracheoesophageal speech
at the time of the initial fitting of the prosthesis, at 3 months, and at
the last follow-up visit. Speech was considered "good" if tracheoesophageal
speech was intelligible, fluent, and used daily as the primary means of communication.
The Bartholomew test was used to determine significance.1
RESULTS
Ninety-seven patients who underwent total laryngectomy between January
1, 1996, and October 1, 1998, were available for analysis (80 men and 17 women;
age range, 24-78 years). Eighty-four patients had been irradiated before (n
= 18) or subsequent to (n = 66) surgery. In addition to total laryngectomy,
9 patients underwent partial pharyngectomy and 2 underwent total glossectomy.
Eight patients underwent total pharyngolaryngoesophagectomy. Sixty-eight patients
underwent neck dissection. Nineteen patients underwent pharyngeal reconstructive
procedures by means of pedicled or free flaps or grafts (Table 1).
|
|
|
|
Table 1. Surgical Details of 97 Patients Who Underwent Total Laryngectomy
(TL)
|
|
|
Voice prostheses were inserted into 87 patients (90%). Eighty-eight
patients (91%) had primary punctures. Some patients with gastric pull-ups
and jejunal interpositions underwent secondary punctures. Eight patients (8%)
required repeated tracheoesophageal puncture for poorly placed fistulae or
closure of the fistula due to loss of the voice prosthesis. One patient who
initially had no voice because of spasm of the pharyngoesophageal segment
gained excellent speech following pharyngeal myotomy 5 months after laryngectomy.
Details about speech fluency and intelligibility were available for analysis
in 84 patients.
TRACHEOESOPHAGEAL SPEECH RESULTS
Follow-up ranged from 4 to 38 months (mean, 12.5 months). Decline in
good speech at 3 months correlates with the time when many patients would
have been undergoing postoperative radiation therapy (Figure 2).
|
|
|
|
Figure 2. Speech fluency and intelligibility
in 84 patients.
|
|
|
Twenty-five (30%) of the 84 patients available for analysis did not
acquire fistula speech. Speech therapists attributed failure to acquire speech
to impaired cognitive function, poor motivation, and limited learning ability
(n = 14); extrusion of the prosthesis with fistula closure (n = 8); poor articulation
(total glossectomy) (n = 2); and inadequate pulmonary function (n = 1). If
patients who lost prostheses, had poor articulation, or had inadequate pulmonary
function are excluded from the analysis, then 59 (81%) of 73 patients acquired
useful speech.
IMPACT OF LITERACY ON SPEECH
Of 84 patients assessed for speech fluency and intelligibility, 17 were
illiterate and 12 were partially literate. Literacy was not associated with
speech outcome at the initial fitting of the prosthesis (P>.05). Although there was a significant association between literacy
and speech failure at final follow-up (P<.002),
8 of 17 illiterate patients had good speech.
IMPACT OF SOCIOECONOMIC STATUS ON SPEECH
Housing was classified into unserviced shacks in squatter camps (Figure 1A), low-income houses (Figure 1B), and serviced homes. There was no association between
housing and speech at the initial fitting of the voice prosthesis (P>.05). Although there was a significant association between quality
of housing and speech at last follow-up (P<.002),
all 3 shack dwellers had good speech. Only 22 patients had regular employment
before surgery. There was no association between regular employment and speech
(P>.05).
IMPACT OF PROXIMITY TO SPECIALIST SERVICES ON SPEECH
Twenty patients lived more than 250 km and 6 patients lived 50 to 250
km from Groote Schuur Hospital. There was no association between distance
from specialist services and speech outcome (P>.05).
VOICE PROSTHESES
We used Blom-Singer prostheses (InHealth Technologies, Carpinteria,
Calif), principally because of cost. Device life could be calculated for 187
prostheses. Thirty-seven percent of voice prostheses were removable duckbill
and 61% were removable low-pressure prostheses. Indwelling prostheses were
inserted in only 2% of patients because indwelling prostheses are more expensive
and patients living far from the hospital need to be able to replace prostheses
by themselves should they malfunction or extrude. The average device life
for removable valves was 4 months (range, 1-15 months); 35% lasted more than
4 months (Figure 3). The average
device life for indwelling valves was 7 months (range, 5-15 months).
|
|
|
|
Figure 3. Device life of removable voice
prostheses.
|
|
|
COMMENT
Our tracheoesophageal speech results compare favorably with those of
studies from developed countries (Table
2).2-6
This demonstrates that successful speech can be achieved in a Third World
medical practice. Only 5% to 30% of patients acquire esophageal voice.2, 7 Our results, therefore, support use
of tracheoesophageal speech in a Third World setting. We attribute our favorable
results to attention to surgical technique and a committed speech therapy
service.
|
|
|
|
Table 2. Published Tracheoesophageal Speech Results
|
|
|
Our surgical technique comprises the following. A horizontal or T-shaped
pharyngeal closure is used to ensure maximal capacity of the pharyngoesophageal
segment. Should the pharyngeal mucosal remnant be deemed insufficient, a pectoralis
major flap is used to increase the capacity of the pharyngoesophageal segment.
A myotomy is performed to the level of the tracheoesophageal fistula. A size
12 Foley catheter is inserted through the fistula by which the patient is
initially fed. When oral feeding is established and the tracheotomy stoma
has healed (day 7-10), the Foley catheter is removed and open-tract voicing
is assessed. The fistula tract is measured, and an appropriate Blom-Singer
voice prosthesis is inserted by the speech therapist. Patients who do not
achieve voicing are subsequently assessed by videofluoroscopy to exclude the
presence of a pharyngoesophageal segment stricture or spasm. Patients with
spasm undergo pharyngeal myotomy from the level of the fistula to the base
of the tongue. In the event of a stricture, widening of the pharyngoesophageal
segment by means of a free or pedicled flap is considered.
Voice prosthesis selection, placement, and maintenance are performed
by the speech pathologist. The choice of removable duckbill and low-pressure
Blom-Singer prostheses has been determined by budgetary constraints. Despite
the benefits of indwelling prostheses, such as reduced extrusion, the cost
of indwelling prostheses has precluded its routine use. However, we use removable
prostheses as "indwelling" prostheses. The prosthesis is not removed for cleaning,
and patients clean the prosthesis in situ with a cytobrush and tweezers. The
prosthesis is removed only when it malfunctions (ie, when it leaks or fails
to provide adequate voice for speech).
The speech pathologist replaces all prostheses except for those in patients
who live far from the hospital. Should the voice prosthesis become dislodged,
patients are taught to maintain patency of the fistula tract by inserting
a Foley catheter into the tract. Antifungal prophylaxis is not used because
of the expense.
Our prosthesis policy has been successful, with many removable voice
prostheses lasting longer than 6 months (Figure 3). The average device life of removable prostheses (4 months)
is similar to that reported for indwelling Blom-Singer and Provox (ATOS Medical
AB, Milwaukee, Wis) prostheses.8 Although the
number of indwelling valves used was small, the lifespan (7 months) is similar
to that reported by Leder and Erskine.9 We
rarely encounter problems of inadvertent fistula closure or granuloma formation,
which may suggest that granuloma formation is a consequence of frequent or
traumatic prosthesis replacement.
Jacobson et al3 reported poor speech
outcome in a cross-cultural situation in which the patient could not converse
in the language of the therapist. We use interpreters (including family members)
and nonverbal demonstration to communicate with patients and do not consider
this to be a contraindication to using tracheoesophageal speech.
CONCLUSIONS
Based on the results of our study, we conclude the following:
1. Tracheoesophageal speech results in a Third World medical practice
are comparable to those of First World centers of excellence.
2. Tracheoesophageal speech results are unaffected by employment status
or proximity to specialist services.
3. Although literacy and quality of housing may affect speech outcome,
many illiterate patients and patients living in squalor acquire good speech.
4. Traditional duckbill and low-pressure voice prostheses can successfully
be used as indwelling voice prostheses.
RECOMMENDATIONS
To remove a patient's larynx without providing an opportunity to acquire
speech is unacceptable practice. Tracheoesophageal speech is currently the
best method of alaryngeal communication.10
All patients who undergo laryngectomy and have adequate dexterity and insight,
regardless of social and educational status and proximity to specialist care,
should be afforded a trial of tracheoesophageal speech.
AUTHOR INFORMATION
Accepted for publication August 24, 2001.
Corresponding author and reprints: Johannes J. Fagan, MD, Department
of Otolaryngology, University of Cape Town School of Medicine, Groote Schuur
Hospital, Observatory, Cape Town 7925, South Africa (e-mail: fagan{at}iafrica.com).
From the Departments of Otolaryngology (Drs Fagan, Oyarzabal, and Sellars)
and Logopedics (Ms Lentin), University of Cape Town School of Medicine, Groote
Schuur Hospital, and Medical Informatics (Dr Isaacs), Groote Schuur Hospital,
Cape Town, South Africa.
REFERENCES
| |
1. Fleiss J. The comparisons of proportions from many samples. In: Statistical Methods for Rates and Proportions. New York, NY: John Wiley & Sons Inc; 1973:96.
2. Guily JL, Angelard B, El-Bez M, et al. Postlaryngectomy voice restoration: a prospective study in 83 patients. Arch Otolaryngol Head Neck Surg. 1992;118:252-255.
ABSTRACT
3. Jacobson MC, Franssen E, Birt BD, Davidson MJ, Gilbert RW. Predicting postlaryngectomy voice outcome in an era of primary tracheoesophageal
fistulization: a retrospective evaluation. J Otolaryngol. 1997;26:171-179.
PUBMED
4. Kerr AIG, Denholm S, Sanderson RJ, Anderson SJ. Blom-Singer prostheses: an 11 year experience of primary and secondary
procedures. Clin Otolaryngol. 1993;18:184-187.
PUBMED
5. Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol Head Neck Surg. 1985;111:182-186.
ABSTRACT
6. Singer MI, Hamaker RC, Blom ED, Yoshida GY. Applications of the voice prosthesis during laryngectomy. Ann Otol Rhinol Laryngol. 1989;98:921-925.
PUBMED
7. Perry A. The role of the speech and language therapist in voice restoration
after laryngectomy. J Laryngol Otol. 1997;111:4-7.
PUBMED
8. Delsupehe K, Zink I, Lejaegere M, Delaere P. Prospective randomized comparative study of tracheoesophageal voice
prosthesis: Blom-Singer versus Provox. Laryngoscope. 1998;108:1561-1665.
PUBMED
9. Leder SB, Erskine MC. Voice restoration after laryngectomy: experience with the Blom-Singer
extended-wear indwelling tracheoesophageal voice prosthesis. Head Neck. 1997;19:487-493.
FULL TEXT
|
ISI
| PUBMED
10. Clements KS, Rassekh CH, Seikaly H, Hokanson JA, Calhoun KH. Communication after laryngectomy: an assessment of patient satisfaction. Arch Otolaryngol Head Neck Surg. 1997;123:493-496.
ABSTRACT
RELATED ARTICLE
Archives of Otolaryngology–Head & Neck Surgery Reader's Choice: Continuing Medical Education
Arch Otolaryngol Head Neck Surg. 2002;128(1):95-96.
FULL TEXT
|
