 |
|
Fiberoptic Examination of the Pharyngoesophageal Segment in Tracheoesophageal Speakers
Charles K. Oh, MD;
Robert J. Meleca, MD;
Mark L. Simpson, PhD;
James P. Dworkin, PhD
Arch Otolaryngol Head Neck Surg. 2002;128:692-697.
ABSTRACT
Objective To describe a novel use of flexible fiberoptic endoscopy to examine
the pharyngoesophageal segment, upper esophagus, and distal end of the tracheoesophageal
prosthesis in patients who have undergone a total laryngectomy and a tracheoesophageal
puncture.
Methods Five patients with poor-quality or no tracheoesophageal voice were evaluated
by a speech pathologist and an otolaryngologist. A flexible endoscope interfaced
with a video monitoring device was introduced transnasally and passed through
the pharyngoesophageal segment. Examination of the anatomical relationship
between the prosthesis and the esophageal mucosa was conducted while the subjects
attempted to phonate. Treatments were then initiated based on the endoscopic
findings.
Conclusion Flexible endoscopy is a safe, cost-effective, diagnostic tool for evaluating
laryngectomees suffering from poor-quality tracheoesophageal voice.
INTRODUCTION
TRACHEOESOPHAGEAL puncture (TEP) has been used for more than 20 years
as an effective surgical voice restoration technique after total laryngectomy.
After a fistula tract is created between the esophagus and trachea, a 1-way
prosthetic valve is placed into the tract that enables pulmonary airflow from
the trachea to enter the esophagus, while preventing the backflow of food
and fluids from the esophagus into the trachea.1
It is a relatively simple procedure to perform, and in most cases patients
achieve good to excellent voice quality and speech production after appropriate
instruction on the use of the prosthesis.2-3
In a small percentage of cases, effective tracheoesophageal voicing is not
achieved. Often, the problem results from spasm of the pharyngoesophageal
segment (PES), with a resultant inability to initiate and/or sustain airflow
for voicing. Occasionally, poor voice outcomes may result from improper fit
of the prosthesis or from the erosive effects of Candida colonization,4 which may stiffen the
valve of the prosthesis and inhibit the airflow dynamics that are required
for voice production. Redundant esophageal mucosa and unusually narrow luminal
dimensions may also be culpable in patients who fail to produce acceptable
tracheoesophageal voice, and in some cases these tissue abnormalities may
encroach on the prosthesis valve itself and restrict airflow. It has been
suggested that the use of endoscopy to visualize the tracheoesophageal prosthesis
can help verify the correct placement of the prosthesis within the esophagus.5 We have discovered that visualization of this valve
within the esophagus can help in the differential diagnosis of prosthesis-related
tracheoesophageal voicing difficulties. Such findings have prompted a variety
of minor prosthesis modifications, which in turn have resulted in improved
tracheoesophageal voice quality. We describe 5 patients who underwent TEP
but who were unable to produce effective voice despite proper prosthesis fitting
and adequate training. The unique method of evaluation and treatment is detailed
in each case.
SUBJECTS AND METHODS
Five patients with poor-quality or no tracheoesophageal voice served
as subjects for this study: 4 underwent secondary TEP, and 1 underwent a TEP
procedure at the time of laryngectomy. Routine clinical evaluations were performed
by a speech pathologist (M.L.S.) with more than 20 years of experience in
such cases to assess the site and size of the TEP, fit of the prosthesis,
and probability of PES spasm, as well as to find out whether each patient
was using proper technique to generate tracheoesophageal voice. If no obvious
abnormalities were identified, flexible endoscopy was performed.
To evaluate the status of the tracheoesophageal prosthesis within the
esophageal lumen, a flexible fiberoptic scope (Rhino-Laryngofiberscope Type
P3; Olympus America Inc, Melville, NY) interfaced with a videocassette recorder
(Diamond Pro Professional Video Cassette Recorder BV2000; Mitsubishi Electronics
America Inc, Torrance, Calif) and camera (Mitsubishi Electronics America Inc)
was introduced transnasally and passed through the PES. The anatomical relationship
between the distal end of the prosthesis and the walls of the esophagus was
then examined. After the examination, the patient was instructed to phonate
by occluding the tracheostoma with a finger to shunt pulmonary air through
the prosthesis and into the esophagus. Valve activity and prosthesis function
were evaluated and photodocumented to determine the extent to which the prosthesis
itself might be responsible for the faulty voice output. Treatments were then
initiated based on the results of the investigation. The problems encountered
and the management techniques used for our patients are described below.
REPORT OF CASES
CASE 1
A 76-year-old man who underwent a total laryngectomy and primary TEP
at an outside institution presented to our voice center 2 months after surgery.
His chief complaint was that he had difficulty initiating and sustaining sufficient
airflow to produce voice. He also complained of intermittent leakage of esophageal
contents through the prosthesis into the trachea, which caused episodic coughing
spells during meals and occasionally at rest. He was examined and found to
have a 2.6-cm, 16F, low-pressure Blom-Singer voice prosthesis (InHealth Technologies,
Carpinteria, Calif). The TEP tract was measured, and it was determined that
the existing prosthesis was too long. The patient was subsequently fitted
with a smaller, appropriately sized 2.2-cm, 20F, indwelling Blom-Singer prosthesis.
Despite refitting of the prosthesis, the patient continued to have difficulty
generating a fluent tracheoesophageal voice. He also continued to struggle
with transient aspiration symptoms. At this point, the decision was made to
try to visualize the prosthesis within the esophagus using the previously
described flexible endoscopy technique. This examination revealed the prosthesis
to be entering the esophagus at an awkward angle within the esophageal lumen,
perhaps as a sequela to the unusual direction of the TEP tract. Such positioning
caused the valve of the device to be partially impacted against the esophageal
wall (Figure 1). Examination of
good tracheoesophageal speakers has shown us that speech and voice performance
are most proficient when the distal end of the prosthesis rests, without obstruction,
perpendicular to the anterior esophageal wall (Figure 2). The unusual angle of the prosthesis in the current case
resulted in at least intermittent lateral pressure on the esophageal retention
collar and valve mechanism. This pinching effect caused transient resistance
to airflow during speech efforts, as well as incomplete closure of the valve
during swallowing. To correct these problems, an additional Silastic collar
was molded to the original esophageal retention collar of the prosthesis to
provide an improved and more stable platform within the esophagus. Improved
stability was accomplished using nonreinforced silicone sheeting (Pharm Elast
20-20 Silicone Sheeting; SF Medical, Hudson, Mass) and adhesive silicone (Type
1A, MED 1137; Nusil Technologies, Carpinteria, Calif) (Figure 3). The desired result was to stiffen and expand the existing
collar and to prevent it from becoming embedded in the esophageal wall. Consequently,
the angle of the prosthesis within the esophagus more closely resembled the
aforementioned benchmark for proficient speech production and airway protection.
After reinsertion of this modified device, the patient was able to generate
more fluent tracheoesophageal voice and speech. He also exhibited no further
esophageal leakage through the tracheoesophageal prosthesis.
|
|
|
|
Figure 1. The tracheoesophageal prosthesis
is seen positioned at an unusual angle within the esophageal lumen and partially
impacted against the esophageal wall.
|
|
|
|
|
|
|
Figure 2. Fiberoptic view showing the proper
position of the tracheoesophageal prosthesis within the esophagus in an excellent
tracheoesophageal speaker. Note how the prosthesis sits flush against the
anterior (A), posterior (P), and lateral (L) esophageal walls.
|
|
|
|
|
|
|
Figure 3. An additional Silastic collar
(arrows) is added to the original retention collar of the prosthesis using
silicone sheeting.
|
|
|
CASE 2
A 64-year-old man underwent a total laryngectomy and right radical neck
dissection. A TEP was performed 2 years after surgery, and the patient was
fitted with a 2.2-cm, 20F, low-pressure Blom-Singer prosthesis. His initial
voice production was of good overall quality; however, he experienced difficulties
with aspiration through the prosthesis. The leakage persisted despite replacement
of the prosthesis with a second device of the same size. Fiberoptic endoscopy
revealed that the prosthesis was entering the esophagus at the junction of
the anterior and posterior walls (Figure 4). This caused the retention collar of the prosthesis to become
crimped by the surrounding esophageal mucosa, resulting in inadvertent opening
of the prosthetic valve, with leakage into the trachea. To prevent crimping
of the voice prosthesis, a larger Silastic collar was attached to the anterior
side of the esophageal retention collar with materials that were similar to
those described in case 1. This augmentation served to both stiffen the retention
collar and flatten out the esophageal wall, thus stopping further leakage
and aspiration (Figure 5).
|
|
|
|
Figure 4. Poorly situated tracheoesophageal
prosthesis is seen entering the esophagus at the junction of the anterior
(A) and lateral (L) esophageal walls. P indicates posterior esophageal wall.
|
|
|
|
|
|
|
Figure 5. View of the prosthesis introducer
(A), standard tracheoesophageal prosthesis (B), and indwelling prosthesis
(C). The arrows indicate the added Silastic collar modifications.
|
|
|
CASE 3
A 50-year-old man who underwent a total laryngectomy followed by a TEP
1 month later was fitted with a 1.4-cm, 20F, low-pressure Blom-Singer voice
prosthesis. The TEP tract was located near the mucocutaneous junction of the
tracheostoma, which made it difficult for the patient to avoid digital occlusion
of the airflow port during voicing. He was ultimately able to manage this
problem. He next presented 3 years after surgery with complaints of progressive
difficulties in voicing. Granulation tissue had developed around the tracheostoma,
near the unusually high-placed tracheoesophageal prosthesis. When the patient
attempted to speak, he was intentionally tipping the voice prosthesis superiorly
to achieve the airflow necessary to generate voice, while trying to avoid
occluding the airflow port. The constant manipulation of the prosthesis and
the subsequent irritation of the surrounding mucosa most likely led to the
development of granulation tissue. To improve the high TEP position, a decision
was made to remove the prosthesis and to have the patient undergo a second
TEP procedure. A second TEP was performed, and fitting was accomplished using
a 1.8-cm, 20F, low-pressure Blom-Singer prosthesis. However, after the fitting,
the patient had difficulty initiating and sustaining airflow and voice. Attempts
with open-tract voicing (removing the prosthesis) resulted in a substantial
improvement in voice production, which indicated that the problems were prosthesis
related. Measurement of the TEP tract revealed that the tracheoesophageal
prosthesis was coming into contact with the posterior esophageal wall during
voicing attempts. Further investigation using a flexible endoscope confirmed
our initial suspicions; direct contact of the prosthesis against the posterior
esophageal wall prevented the valve of the prosthesis from opening and obstructed
airflow (Figure 6). Also, endoscopy
revealed an abnormally small anterior to posterior diameter of the esophageal
lumen. To solve this problem, the patient was fitted with a 1.8-cm, 20F, ultra–low-pressure
prosthesis (Bivona Medical Technologies, Gary, Ind) (Figure 7). This device is specially designed with a hood over the
distal esophageal end of the prosthesis, with a side-located airflow passage
into the esophagus. The valve door is contained within the barrel of the prosthesis
and opens into a side area where contact with the posterior esophageal wall
will not obstruct airflow. The patient now has good-quality tracheoesophageal
voicing.
|
|
|
|
Figure 6. Fiberoptic view showing the distal
end of the prosthesis (arrow) abutting the posterior esophageal wall (P),
preventing valve opening and obstructing airflow. The patient had an unusually
narrow anterior-posterior dimension of the esophageal lumen.
|
|
|
|
|
|
|
Figure 7. Picture of prosthesis introducer
(A) and ultra–low-pressure prosthesis (B), which is designed so that
the valve door is located within the barrel of the prosthesis and is not affected
by contact with the posterior esophageal wall.
|
|
|
CASE 4
A 76-year-old man underwent a total laryngectomy and secondary TEP with
postoperative voice therapy at an outside institution. He subsequently presented
to our center and was found to have a 2.2-cm, 16F, duckbill Blom-Singer prosthesis
in place. The TEP tract was noted to be located at the mucocutaneous junction,
with the prosthesis projecting abnormally into the tracheal airway. The patient
also complained that there was leakage of esophageal contents around the prosthesis
when he was drinking liquids. Measurement of the TEP tract indicated the correct
fit to be 1.8 cm; however, this fitting resulted in digital occlusion of the
airflow port during phonation attempts owing to the unusual location of the
original TEP site. The patient was advised to allow the present tract to close
and then to have a second TEP to create a more optimally positioned tract.
Despite this recommendation, he refused to undergo another operation and requested
some type of alternative treatment. He was therefore fitted with a 1.8-cm,
20F, low-pressure Blom-Singer prosthesis to further decrease expiratory pressures
needed to initiate and sustain airflow for voicing. To prevent digital occlusion
of the airflow tract, a tracheostoma valve housing was fashioned with a digital
occlusion reducer and positioned over the stoma site. These adjustments enabled
him to achieve good-quality tracheoesophageal voice.
Several years later, the patient presented with complaints of increased
difficulty in initiating and sustaining airflow for voice production. Examination
revealed that the prosthesis was the appropriate size. Flexible endoscopy
showed that the distal end of the prosthesis was buried in a mound of granulation
tissue on the anterior esophageal wall (Figure
8). To stabilize the prosthesis within the esophagus, an additional
larger Silastic collar was attached to the existing esophageal retention collar.
Stability was accomplished using nonreinforced silicone sheeting (Pharm Elast
20), as described previously. This modification created a stiffer and larger
retention collar, allowing the prosthesis to be stabilized (Figure 9). It also resulted in reduction of expiratory pressures
during phonatory efforts, providing an improved platform for the prosthesis.
The results were excellent.
|
|
|
|
Figure 8. Tracheoesophageal prosthesis (arrow)
is seen buried in a mound of granulation tissue.
|
|
|
|
|
|
|
Figure 9. A larger Silastic collar is seen
attached to existing retention collar, allowing prosthesis to sit above the
bed of granulation tissue. A indicates anterior esophageal wall; P, posterior
esophageal wall.
|
|
|
CASE 5
A 79-year-old man underwent a total laryngectomy with a secondary TEP.
He was fitted with a 1.8-cm, 20F, low-pressure, indwelling Blom-Singer voice
prosthesis and was able to produce reasonably good voice with this device.
One year after surgery, he presented with complaints of difficulties in initiating
and sustaining airflow for voicing. Measurement of the TEP tract verified
that the prosthesis was the proper length. When the prosthesis was removed,
the patient generated significantly improved voicing through the open tract,
which indicated that the problem was prosthesis related. Fiberoptic endoscopy
revealed that the esophageal retention collar was seated within a craterlike
defect in the anterior esophageal wall (Figure 10). Although the patient was refitted with a larger prosthesis,
the distal portion of the prosthesis continued to retract into the defect.
To solve this problem, an additional Silastic collar was attached to the existing
esophageal retention collar, as previously described. The additional width
of the retention collar prevented the indwelling prosthesis from being displaced
into the depression in the anterior esophageal wall. After a 6-month period,
the mucosal crater healed around the prosthesis barrel, and the patient was
able to return to a standard 2.2-cm, 20F, indwelling Blom-Singer voice prosthesis.
|
|
|
|
Figure 10. Prosthesis is seen buried in
a craterlike defect on the anterior esophageal wall.
|
|
|
COMMENT
Preservation of voice and swallowing function after total laryngectomy
is a vital concern of the patient and a challenge for the rehabilitation team.
In the distant past, total laryngectomees had 2 choices for voice rehabilitation.
They either learned how to develop esophageal voice skills that often required
extensive speech therapy or used an artificial larynx, which resulted in functional
but poorer-quality voice and speech characteristics. The TEP surgical voice
restoration technique developed by Singer and Blom1
dramatically improved functional voice and speech outcomes for total laryngectomees.
This procedure can be performed primarily at the time of the laryngectomy,
or at a later date as a secondary approach. To date, the TEP alternative has
been widely accepted internationally, and it may be considered the "gold standard"
for speech rehabilitation, particularly for those laryngectomees who are reluctant
to use an artificial larynx or to learn esophageal speech to communicate verbally.
Although the TEP technique provides good to excellent voice quality
in the majority of cases, speech pathologists and otolaryngologists are sometimes
confronted with patients who struggle with poor voice output and control;
in some cases, little or no usable voice is obtained. This group of patients
poses a therapeutic challenge for even the most experienced speech pathologist
because of the complexity of problems that may be responsible for the voicing
difficulty. The lack of a clear understanding of the cause of poor voice production
can lead to an incorrect diagnosis, resulting in unnecessary, costly, and
unsuccessful treatments. At our institution, an algorithm has been developed
to help guide the speech pathologist and otolaryngologist during the diagnostic
evaluation of such patients (Figure 11).
|
|
|
|
Figure 11. Algorithm used to aid in diagnostic
evaluation. TE indicates tracheoesophageal; PES, pharyngoesophageal segment.
|
|
|
Common causes of poor tracheoesophageal voicing include: (1) problems
related to the proximal (tracheal) or distal (esophageal lumen) ends of the
tracheoesophageal prosthesis and/or (2) abnormalities associated with the
PES and upper esophagus, such as spasm, stenosis, mucosal irregularities,
and persistent or recurrent carcinoma. Time since the onset of voice difficulties
after the TEP procedure and the rate of progression of voice dysfunction can
aid in developing a differential diagnosis. Those patients who fail to produce
good quality voice after being initially fitted with a prosthesis will usually
demonstrate problems related to (1) the technique being used to produce voice,
(2) the size or fit of the prosthesis, or (3) spasm, stenosis, or mucosal
abnormalities of the PES and upper esophagus. Patients who have enjoyed good
quality voicing but who eventually develop phonatory difficulties will commonly
have obstruction of the proximal or distal ends of the prosthesis as a result
of crusting, mucous collection, or Candida colonization.
Less commonly, they may demonstrate abnormalities associated with the PES
and upper esophagus, such as stenosis, mucosal irregularities, or recurrent
carcinoma.
A thorough history and complete physical examination are vital in the
initial workup, because the findings will establish the diagnosis in the majority
of cases. The initial examination should assess whether the patient is using
proper technique for voice production. Next, the tracheoesophageal prosthesis
should be inspected in situ for (1) collection of mucus or crusts within its
lumen that may result in airflow obstruction (for patients with an established
TEP tract and prosthesis), (2) abnormal TEP tract angulations that may lead
to dysfunction of the prosthesis, or (3) unusual position of the prosthesis
within the tracheostoma owing to irregular size or shape of the stoma. If
no abnormalities are noted, or if voice fails to improve after cleaning of
the device, the prosthesis should be removed to assess the integrity of the
valve mechanism, to see if there is Candida colonization,
to measure the length of the TEP tract to verify proper prosthesis size and
fit, and to replace the prosthesis if necessary. If no improvement in voicing
is obtained after these maneuvers, the prosthesis should again be removed
and the patient should be taught how to voice through the open TEP tract using
the usual finger-to-stoma valving technique. To facilitate this effort, the
examiner can position a catheter through the open tract and blow air through
the tube to insufflate the esophagus to induce passive PES vibrations and
vocalization. The patient can then convert these sounds into speech activity.
Improvement in voice quality with open-tract voicing, or with the trans-tracheoesophageal
tract insufflation technique, is suggestive of a prosthesis-related problem,
likely at its proximal or distal end. If no improvement is noted with the
open-tract voicing or insufflation techniques, other causes for poor tracheoesophageal
speech ability related to the PES and upper esophagus should be entertained.
Ancillary tests such as the modified barium swallow study, esophagram, or
esophagoscopy with the patient under general anesthesia can aid in providing
a diagnosis. Similarly, in-office fiberoptic endoscopy with the patient performing
phonatory tasks can provide excellent visualization of the PES and upper esophagus
to help differentiate these disorders, as well as provide a dynamic evaluation
of the distal end of the prosthesis and its relationship to surrounding soft
tissue structures.
In the present investigation, 5 patients presented with poor-quality
tracheoesophageal voice, and 3 of the 5 patients had symptoms of aspiration
through the tracheoesophageal prosthesis. Examination of the TEP tract, tracheoesophageal
prosthesis, and tracheostoma failed to provide an explanation for the voice
or aspiration difficulties, therefore prompting use of fiberoptic videoendoscopy
of the PES, upper esophageal region, and distal end of the tracheoesophageal
prosthesis to help provide a diagnosis. This examination revealed abnormalities
involving the distal aspect of the tracheoesophageal prosthesis and its anatomical
relationship to surrounding soft tissues in all our patients. Fiberoptic observation
was pivotal in determining the cause of the abnormal symptoms, thus allowing
implementation of prompt and effective treatments. None of our patients complained
of discomfort during or suffered complications after the endoscopic examination.
Management required simple modifications in the design of the prosthesis to
overcome valve crimping and prosthesis compression to prevent aspiration and
to improve airflow dynamics for better PES vibration and voice production.
Without the aid of fiberoptic endoscopic visualization, an accurate diagnosis
would not have been made, therefore delaying the necessary prosthesis adjustments
needed to correct the underlying tracheoesophageal speech difficulties.
CONCLUSIONS
During tracheoesophageal voicing, the upper esophagus and PES are insufflated
by pulmonary-driven airflow through the tracheoesophageal prosthesis. This
phenomenon enables use of fiberoptic endoscopy to provide unobstructed visualization
of the luminal side of the prosthesis and its relationship to surrounding
structures. If abnormalities are identified, customized prosthesis alterations
can be performed to improve tracheoesophageal voice quality. Alternative modifications
are addressed in the current case presentations. These individuals benefited
from such intervention in that their speech characteristics markedly improved
and aspiration symptoms subsided after treatment. Importantly, none of the
patients complained of discomfort from the endoscopic technique, and there
were no reported complications.
The present investigation was supported by an algorithm that we routinely
incorporate to assist in the differential diagnosis and treatment of total
laryngectomees suffering from poor-quality tracheoesophageal voice, aspiration
symptoms, and/or dysphagia, notwithstanding adequate speech therapy. Otolaryngologists
in the office setting can easily perform the flexible videoendoscopic procedure.
Combined with a thorough clinical evaluation, this technique is relatively
simple to perform, safe, and cost-effective. The greatest utility of this
evaluation approach is realized when the otolaryngologist and speech pathologist
work closely together to determine when such an appraisal is warranted and
what therapeutic measures can be used to alleviate the underlying problem.
AUTHOR INFORMATION
Accepted for publication November 8, 2001.
This study was presented as a poster at the American Academy of Otolaryngology–Head
and Neck Surgery Annual Meeting, Washington, DC, September 24, 2000.
We thank Eric Blom, PhD, for input and suggestions for prosthesis modifications
using Silastic sheeting and silicone adhesive.
Corresponding author: Robert J. Meleca, MD, Department of Otolaryngology–Head
and Neck Surgery, Wayne State University School of Medicine, 5G UHC, 540 E
Canfield, Detroit, MI 48201.
From the Department of Otolaryngology–Head and Neck Surgery,
Wayne State University School of Medicine, Detroit, Mich.
REFERENCES
1. Singer MI, Blom ED. An endoscopic technique for voice restoration after total laryngectomy. Ann Otol Rhinol Laryngol. 1980;89:529-533.
ISI
| PUBMED
2. Tardy-Mitzell MA, Andrews ML, Bowman SA. Acceptability and intelligibility of tracheoesophageal speech. Arch Otolaryngol. 1985;11:213-215.
3. Pindzola RH, Cain BH. Acceptability ratings of tracheoeosphageal speech. Laryngoscope. 1988;98:394-397.
ISI
| PUBMED
4. Izdebski K, Ross JC, Lee S. Fungal colonization of tracheoesophageal voice prosthesis. Laryngoscope. 1987;97:594-597.
PUBMED
5. Casper JK, Colton RH. Clinical Manual for Laryngectomy and Head/Neck Rehabilitation. 2nd ed. San Diego, Calif: Singular Publishing Corp; 1998.
RELATED ARTICLE
Archives of Otolaryngology–Head & Neck Surgery Reader's Choice: Continuing Medical Education
Arch Otolaryngol Head Neck Surg. 2002;128(6):726-728.
FULL TEXT
|
