Difficulties in the fixation of prostheses for voice rehabilitation after laryngectomy

Abstract

In most patients with advanced or recurrent laryngeal or hypopharyngeal cancer, total laryngectomy is indicated. This means the loss of three main functions: phonation; respiration; and the prevention of aspiration during deglutition. Laryngectomy patients have various options to restore phonation: an oesophageal voice; an electrolaryngeal voice; or a tracheo-oesophageal voice. In the last case a silicone rubber shunt valve is placed in the tracheo-oesophageal wall and phonation is generated when exhaled air is forced through the oesophagus and neopharynx. This method is widely applied in Western Europe. In this paper we review the literature on fixation problems with shunt valves, tracheostoma valves and heat and moisture exchange (HME) filters. Tracheo-oesophageal speech without a valve is not considered. Despite 22 years of experience with the implantation of tracheo-esophageal shunt valves and many improvements in the design, problems still remain, such as biofilm formation with subsequent leakage through the valve, the need for frequent and inconvenient replacements, fistula enlargement leading to leakage around the device and reduced fixation, and infections. The high cost of shunt valves is a drawback to their use worldwide. To enable hands-free speech, different types of tracheostoma valve have been developed. These valves are fixed to the skin or to the tracheostoma by means of an intra-tracheal device. An HME filter is used to protect the airway and maintain physiological balance. Such devices are only suitable for a selected group of patients as fixation to the skin or trachea can be a major problem. Speaking and coughing cause pressure increases, which often result in mucous leakage and disconnection of the valve and/or HME filter. Recommendations are made for future improvements in fixation techniques.

3D stereophotogrammetry for the assessment of tracheostoma anatomy

“…Air leakage has a negative effect on speech quality. Some patients use stronger glue to prevent the adhesive from loosening; however, this can lead to irritation of the peristomal skin [6].…”

“…Additional silicone glue is often needed to fixate properly. Removal of the adhesive disc causes skin irritation and is not infrequently reported as painful [6]. Intratracheal fixation with a button can sometimes overcome the peristomal attachment problems, but still leaves a considerable percentage of patients who are not able to achieve hands-free speech [8Á10].…”

Experimental results of the tracheoesophageal tissue connector for improved fixation of shunt valves in laryngectomized patients

“…[1][2][3] Concerning the shunt valve, however, many laryngectomized patients suffer from valve-related complications such as leakage. 4 This results in coughing and in some cases in recurrent pneumonias. Frequent valve replacement has a negative influence on patients' quality of life.…”

“…Leakage through the shunt valve and leakage around the shunt valve. 4,5 The first type of leakage is generated by valve dysfunction mainly caused by bio-film formation. This process and its solution has been and is still being studied extensively.…”

In vitro Experiments with the Triangular Flap Cutter Applied to Functional Tracheoesophageal Shunt for Voice Rehabilitation after Total Laryngectomy

“…Based on experience with previous and current surgical procedures for vocal restoration, surgeons have not successfully solved the distressing problems of aspiration and fistula tract stenosis and have spent a long time on surgical field exposure [5]. With this situation in mind, we developed a new technique – using a triangular flap cutter (TFC) to restore laryngeal voicing of sounds.…”