Chapter 12: Respiratory care, CPR and blood transfusion
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Laryngectomy: communication
Evidence‐based approaches
The following options are available (Everitt [77], NTSP [206], Zenga et al. [294]):
- Surgical voice restoration (SVR) allows communication to be restored via the use of a voice prosthesis, which may also be referred to as a valve. See below for further information.
- Oesophageal voice involves moving air into the oesophagus either by inhaling or injecting air into the back of the mouth. Instead of the vocal cords vibrating, the walls of the pharynx vibrate. Sound then moves into the mouth, where recognizable speech is produced by the articulators (i.e. the tongue, lips and palate). Patients are asked to imagine gulping air into their mouth, beginning to swallow but returning the air to their mouth in a controlled manner. Oesophageal voice has previously been described as ‘burped speech’ and usually the patient can achieve a small number of words in one breath.
- An artificial larynx involves using a battery‐powered device that is placed against the neck or cheek, or intraorally. When a button is pushed, a vibration occurs in the head of the device and it is this vibration through the tissues that creates sound as the patient mouths words.
SVR has become the most popular means of restoring communication, with success rates of up to 90% reported (Zenga et al. [294]). SVR entails creating a puncture between the posterior wall of the trachea and the anterior wall of the oesophagus, into which a one‐way voice prosthesis is placed. By occluding the stoma, pulmonary air is diverted through the prosthesis into the oesophagus, where the walls vibrate to make sound (Ward and Van As‐Brooks [280]).
The prosthesis is a silicone device that fits into the tracheo‐oesophageal puncture (TEP) and acts as a one‐way valve, preventing food and drink from entering the trachea from the oesophagus (Zenga et al. [294]). Patients can have the puncture created during their laryngectomy operation, in which case it is called a ‘primary puncture’. Post‐operatively, patients with a primary puncture may have a catheter or a stoma gastric tube in place in the TEP, which enables the puncture to remain patent. Once healing has occurred, the stoma gastric tube is removed and the prosthesis can be placed into the TEP (secondary voice prosthesis placement). Alternatively, a voice prosthesis may be placed at the time of TEP creation; however, it will not be used for a period of time, until adequate healing has occurred (primary voice prosthesis placement).
If patients are required to wait for their puncture following the laryngectomy surgery – for example, due to an extended laryngectomy – they are likely to have a ‘secondary puncture’. A secondary puncture may involve primary or secondary placement and can be done in the operating theatre under general anaesthetic or in the outpatient setting under local anaesthetic (Noel et al. [199]).
