THE ROLE OF PHARYNGEAL REPAIR IN PRIMARY SURGICAL VOICE RESTORATION AFTER TOTAL LARYNGECTOMY

Abstract

Total laryngectomy is a functionally destructive procedure followed by altered respiration, voice, and swallowing. Rapid reestablishment of an acceptable voice and fluent, intelligible speech is critical successful psychosocial adjustment.

Historically, alaryngeal esophageal voice has been the method of choice. However, only a small percentage of laryngectomees acquired esophageal voice that resembles presurgical communication parameters despite months of therapy and practice. The electrolarynx devices subsequently used provide a relatively intelligible communication. However, the drawbacks include the mechanical quality of unnatural voice, the need for good dexterity, the ongoing costs, and user self consciousness. The planned surgical shunts or fistulae through which pulmonary airflow could be directed to the cervical esophagus or pharynx failed over time because the communication either became too patent to allow aspiration or stenotic resulting in effortful phonation.

Initially secondary endoscopic tracheoesophageal puncture (TEP) was used for laryngectomized individuals who failed or did not choose to develop esophageal speech or use of an artificial larynx. The investigators further advanced this method by incorporating TEP at the time of laryngectomy, a method widely named primary TEP.

The pulmonary air injected via the TEP elevates the tone of the pharyngoesophageal segment as a reflex action. This hypertonicity varies with operative techniques and pharyngeal reconstruction. Pharyngoesophageal myotomy and plexus neurectomy have been the gold standard for surgical management of the hypopharynx. Other methods as non-muscle and transverse repairs have been used effectively.

The prosthetic voice rehabilitation is not only limited to standard laryngectomy, but also should be offered to patients who undergo pharyngolaryngectomy. In these patients the goal is for more than simply creating an intact neopharynx that does not leak. The luminal diameter of this neopharynx should be sufficient to allow for the passage of food bolus, but not so flaccid to an extent that may adversely affect postoperative voice quality and should allow for either primary or secondary TE voice restoration.