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Total laryngopharyngectomy results in a considerable degree of morbidity. Although many advances have been made over the past 10 years, the restoration of speech remains an unsolved problem. Herein, we present three patients who underwent both neoglottic and neopharyngeal reconstruction using a free vascularized segment of jejunum. All three patients were able to swallow and two were able to speak. We believe that this method of reconstruction restores speech after total laryngopharyngectomy.

The tracheoesophageal (T-E) shunt technique reported by Komorn et al. (1973) was used for vocal rehabilitation in 8 laryngectomized patients including one case of hypopharyngeal cancer. It was proved that this technique was a simple one-stage procedure with a low incidence of complication. Four out of 7 patients, excluding one patient who died of another disease, acquired excellent speech without symptomatic aspiration. Two patients developed fairly good speech. One shunt was closed by aspiration. The shunt constructed by a flap measuring 2 x 4 cm, opened 1 cm below the distal end of the trachea, showed good results. The T-E shunt speech exceeds esophageal speech in duration and intelligibility.

Follow up of 45 patients who had undergone a surgical voice rehabilitation by Asai's or Staffieri's method showed clearly that the main problem of such operations is not the restoration of a good voice but the guarantee of a normal swallow. The low position of the tracheo-pharyngeal fistula in Staffieri's operation is particularly disadvantageous and often requires surgical closure of the neoglottis. A strict pre-operative assessment is indicated before all operative methods for voice rehabilitation. Oesophageal speech remains the best voice after laryngectomy and operative reconstruction is relegated to second place.

Near-total laryngectomy with myo-mucosal valved neoglottis is the most recent of the various surgical procedures for speech rehabilitation. The site and mechanism of phonatory function of the neoglottis has been investigated in eight patients by means of electrolaryngography. Results demonstrate substantial similarity in the nature of function of the neoglottis when compared with the normal human glottis.

Although various methods of alaryngeal communication after laryngectomy have been described, little attention has been given to voice restoration after laryngopharyngoesophagectomy. This article deals with our experience reconstructing the hypopharynx and cervical esophagus in five patients by the use of microvascular free tissue grafts. Voice restoration procedures with use of a Blom-Singer prostheses were used uniformly and resulted in the attainment of functional voice in each patient. It is our feeling that this method should be used equally in patients undergoing both traditional laryngectomy and laryngopharyngoesophagectomy.

In 1982, we published a new technique to create a tracheoesophageal (TE) fistula, using the combination of an endotracheal tube and a flexible fiberoptic nasopharyngolaryngoscope. An even more simple technique using a fenestrated metal Yankauer Tonsillar suction is now introduced. This technique allows for the TE fistula to be made by any level of the tracheo-esophageal junction. It is easily done with topical and local anesthesia with the patient sitting on the otolaryngology examination chair. The method described has been used in 25 consecutive cases with no complications.

Treatment of laryngeal cancer has evolved over nearly 100 years and includes many methods to conserve the function of speech. It was understood from the inception of total laryngectomy that diversion of exhaled pulmonary air into the pharynx or esophagus would produce satisfactory speech. The effect on safe deglutition of the phonatory fistulae limited the wide applicability of these techniques. The introduction of a silicone bivalve device for use in a tracheoesophageal tunnel permits large numbers of laryngectomees to use tracheoesophageal speech. Acoustic, intelligibility, and aerodynamic studies are described for four laryngectomees and reveal that this method more nearly approximates normal laryngeal speech than conventional esophageal speech. The criteria for contemporary treatment of laryngeal carcinoma are not altered by this rehabilitative method, and expected survival rates are not likely to be affected. The findings and analysis of this method of alaryngeal speech rehabilitation may have important implications for future therapy of laryngeal carcinoma.

The quality of voice production after pharyngolaryngoesophagectomy is examined in comparison with the oesophageal speech by speech tests and speech intelligibility tests. The functional effects of the specific anatomic conditions are discussed in consideration of radiological findings.

Twelve male and 12 female total laryngectomy patients who received the tracheoesophageal puncture (TEP) as a means of vocal rehabilitation served as subjects for this investigation. Recordings were made of these subjects' speech produced with four prosthetic/occlusion conditions: (1) duckbill prosthesis with tracheostoma valve; (2) duckbill prosthesis with digital occlusion of the tracheostoma; (3) low pressure prosthesis with tracheostoma valve; and (4) low pressure prosthesis with digital occlusion. Speech tasks consisted of three trials of maximum phonation time on /a/ and reading of a 98-word standard passage. Acoustic analysis of the recorded speech samples included a total of 34 frequency, intensity, temporal, and noise measures. Eight acoustic measures (words per minute, harmonics-to-noise ratio, percent jitter, intensity range during vowel phonation, percent periodic phonation, mean intensity during reading, directional jitter, and directional jitter, and directional shimmer) were chosen as dependent variables for a repeated measures MANOVA. The overall repeated measures MANOVA, a set of complex contrasts, and paired t tests revealed that TEP speech produced with the low pressure prosthesis was significantly different from that produced with the duckbill prosthesis on a weighted linear combination of the eight acoustic variables. Tracheoesophageal voice produced with a low pressure prosthesis had greater amounts of periodic phonation than tracheoesophageal voice produced with a duckbill prosthesis. The use of a tracheostoma valve did not have a significant impact on the subset of acoustic measures used in the repeated measures MANOVA.

The data presented examine the relationship between postlaryngectomy communication method, and the extent of total laryngectomy and the use of radiation therapy. The expectations of speech therapy providers were also examined. The author interviewed 60 laryngectomy patients who were six months to 3 1/2 years postsurgery. Surgeries were grouped into four categories and correlated with communication method. The relationship was statistically significant with the most apparent deterrent effect exhibited only for the most extreme surgical excisions. There was no relationship with the use of radiation therapy. In many cases speech therapy providers' expectations were not supported by the data.

The Staffieri technique was used in 24 patients, but abandoned due to aspiration. The Blom-Singer or other prostheses were used in 40 cases, 50% achieved fluent speech, 15% spoke partially and 35% were not able to use the prostheses at all. Some complications are always met with in these cases: Dysphagia, leakage around the prostheses and difficulties with the function of the prostheses. The selection of suitable cases is important. Their cooperation and motivation must be ensured preoperatively, and in many cases like those living under poor social conditions or in older patients, this procedure should not be tried.

Voice samples of 15 laryngeal, esophageal, and tracheoesophageal speakers using the Blom-Singer voice prosthesis were analyzed for intensity, frequency, and rate. Results indicate that characteristic values for tracheoesophageal speech are more similar to laryngeal speech than esophageal speech, demonstrating the powerful advantage of this pulmonary-supported method of alaryngeal voice.

Our long-term experience with Staffieri's procedure in 42 patients is presented. Our results were evaluated regarding voice production, aspiration problems, and pharyngocutaneous fistula formation. Approximately 50% of the patients were successfully rehabilitated. Twenty-five percent of the patients did not use the neoglottis for speech production, mostly because of stenosis of the neoglottis. The remaining 25% had serious aspiration problems that needed treatment. It was striking that half of these patients initially benefitted from the Staffieri procedure and had no aspiration problems. These 42 patients were compared with a group of 43 patients who underwent conventional total laryngectomy in the same period. After total laryngectomy and Staffieri's procedure, greater than 35% of the patients had a pharyngocutaneous fistula, while after conventional total laryngectomy the fistula rate was less than 20%. The average postoperative stay in the hospital was longer in the Staffieri group. In the long run, the results of this surgical technique do not justify its further use, especially after previous radiotherapy.

A simple operative technique is presented which restores speech without any later risk of aspiration in a one-stage operation performed together with the laryngectomy. 4 types can be distinguished depending on the extent of the resection and the amount of reconstruction necessary. The surgical technique is described. Resection of the tumour is not restricted. Our results on 85 patients are presented. Attention is drawn to mistakes and dangers.

In-depth interviews were conducted with 60 laryngectomy patients. Data were collected on postsurgical rehabilitation in terms of employment, speech, and social functioning. Analysis of the data indicated that only one-third of the respondents were working fulltime or parttime. Twenty-six (43%) of the respondents were retired or not working, due to their health. Employment after surgery was not statistically related to the other measures of rehabilitation success that indicated levels of social functioning in general. In addition, most of the respondents did not cite employer discrimination as their reason for not working. Failure to work after surgery appeared in most cases to be initiated by the respondent, and did not indicate a failure to achieve a high level of rehabilitation in other areas of functioning.

An original technique of voice rehabilitation following total laryngectomy based on the concept of a myomuscosal unit was originally described by Strome. Thirty-one cases of myomucosal shunts (MMS) are analyzed in the present report. The 14 initial cases failed because of a lack clinical and surgical experience and insufficient selection of the patients. Among the last 17 cases, 1 was lost to follow-up, 1 had an insufficient follow-up, and 2 patients refused to speak with the MMS instead of a patent shunt; 5 of the remaining patients had voices evaluated as excellent, 7 had voices interpreted as good and only 1 patient had a voice evaluated as poor. Aspiration was not a problem. Eleven patients were found to stenose their shunt, but fistula were recalibrated successfully. The MMs can be used safely in oncological surgery and only 1 of 31 deaths in our total experience was due to a local recurrence. These findings show that the MMS is a reliable procedure for voice restoration following total laryngectomy; a prosthesis is not required and there are currently no oncological limits to the procedure. However, a very close follow-up of the patients is required after surgery.

A protocol was established at our institution to compare a series of primary and secondary tracheoesophageal punctures using the Singer-Blom voice prosthesis. Over a 24-month period, 20 primary and 18 secondary punctures were performed. Voice production, fluency of voice, and functional use were graded. Our data support the use of both primary and secondary voice restoration following laryngectomy.

After laryngopharyngectomy and reconstruction of the upper digestive tract, a free jejunal graft can be anastomosed in an isoperistaltic direction end-to-end to the trachea and the hypopharynx in order to form a shunt for vocal rehabilitation. Following placement of the shunt, no special care is required nor does any patient show any aspiration. Because of a low-flow resistance of the shunt, patients so treated possess long-lasting phonation with loud and modulated voices.

A number of studies over the last decade have reported on a viability of the primary neoglottis reconstruction after total laryngectomy. Early results have been encouraging, although operative and perioperative complications are higher than with a classic laryngectomy. This article reports on a series of 13 neoglottis reconstructions performed at Emory University Medical School using the techniques developed by Mario Staffieri, MD. During the course of the study, the overall success rate has fallen from 80% at three years to 54% at five years. With each succeeding year there has been an increasing need for revision surgery. The series emphasizes the need for long-term follow-up in any vocal rehabilitation procedure.

An air bypass voice prosthesis and the refinement of a surgical technique has been developed. It involves a one-stage, low retrograde cervical esophagostomy that is functionally and cosmetically feasible since it permits hidden use of the device and eliminates fistula tract stenosis; and the problem of aspiration is eliminated. Most importantly, it provides a natural speech mechanism without any training period. Patients can regain immediate speech following installation of a voice prosthesis with a minimum of maintenance required. Ultimately, they have demonstrated greater self-reliance and developed a high degree of self-esteem which has enabled them to resume a normal way of life.

A new one-stage surgical technique for postlaryngectomy speech was applied to 30 patients and its results are described. The essential part of this technique consists of the construction of a tracheoesophageal shunt using the posterior part of the trachea exposed at the time of the laryngectomy to reestablish an air communication between the trachea and the esophagus. Twenty-three of the 30 patients operated on developed conversational ability equivalent to that of a normal subject, except that they had to use a finger during speaking for the occlusion of the tracheal opening. The duration of phonation averaged 15 seconds. Speech developed in an average of 20 days after the operation was performed. Aspiration of liquids during deglutition was recognized in 9 patients. This was effectively controlled by digital pressure on the shunt during deglutition. The technique as described is applicable to nearly all candidates for total laryngectomy, with radical neck dissection and preoperative irradiation therapy.

The acquisition and acceptability of esophageal speech were evaluated relative to a number of variables in 188 laryngectomees. Of the population studied, 63% were rated as having socially acceptable esophageal speech (SAES) according to a rating scale developed by the author. Advanced age, persistent swallowing difficulties, and small stomas or dependency on a cannula resulted in reduced capability for acquiring SAES. As well, the ratings of premorbid adjustment patterns and personality traits were found to predict success in esophageal speech acquisition better than any social or situational factor.