Botulinum toxin injection for failed tracheo-oesophageal voice in laryngectomees: the Sunderland experience

Abstract

Spasm of the pharyngo-oesophageal segment is one of the important causes of tracheo-oesophageal voice failure. Traditionally it has been managed by either prolonged speech therapy, surgical pharyngeal myotomy or pharyngeal plexus neurectomy with varying degrees of success. Botulinum neurotoxin has been found to be effective in relieving pharyngo-oesophageal segment spasm. Since 1995, we have used botulinum toxin injection on 10 laryngectomees with either aphonia or hypertonicity due to pharyngo-oesophageal segment spasm. Early results were analysed by the Sunderland Surgical Voice Restoration Rating scale. Seven of the 10 patients, who were previously completely aphonic, developed voice following this therapy and are using their valve choice as their only method of communication. Out of the three patients who were treated for hypertonic voice, two did derive some benefit from the procedure. One patient developed a hypotonic voice, which lasted for a few months.

Use of botulinum toxin in voice restoration after laryngectomy

“…A total of nine published studies were identified from the literature review, dating from between 1995 and 2008 3 , 14 – 21 . The majority of authors were from North American institutions, with only one paper originating from a UK institution.…”

“…As expected from the total number of patients treated, we identified no randomised, controlled trials. Six of the nine studies were prospective 3 , 15 , 17 – 19 , 21 and three were retrospective 14 , 16 , 20 …”

“…There is wide variation in the reported incidence of tracheoesophageal voice failure due to pharyngoesophageal spasm. Singer and Blom described an incidence of 12 per cent, while others have reported figures of between 7.3 and 79 per cent 1 , 3 , 4 . It is thought that airflow-induced spasm is the primary cause of sustained hypertonicity in this segment, preventing adequate airflow through the pharynx and hence causing poor voice 1 , 5 …”

Injection of botulinum toxin for the treatment of post-laryngectomy pharyngoesophageal spasm-related disorders

“…8,9 However, comparison between studies is impeded by the considerable variation in outcome measurements. 14,15 The largest study to dateby Hamaker and Blom 16 used intra-tracheal phonation pressures in a similar manner to our study to assess outcomes in 62 patients. Tracheal APMs are considered to correlate closely with the effort required to produce trans-oesophageal speech.…”

Tracheostomy cannulas and voice prosthesis

“…The diagnosis is made by esophagoscopy or insufflation trial via the voice prosthesis. Granulations are removed; in cases of too high pressure with spasm in the pharyngo-esophageal segment it may be helpful to inject botulinum [160], [161], [162], [163], [164], [165]. Moricz et al refer to endoscopy-based balloon dilation as a non-traumatic method that can be easily performed [166].…”