Definition & Overview
The construction of tracheoesophageal fistula and the subsequent insertion of laryngeal prosthesis is a combined medical procedure used for voice and speech restoration. It is usually performed during or after a total laryngectomy, or the removal of the voice box. The voice box sometimes has to be removed due to disease or injury. Unfortunately, this procedure can result in permanent voice loss. Because of this, some patients seek voice and speech restoration after the procedure. The construction of tracheoesophageal fistula (TEF) combined with laryngeal prosthesis is one technique of doing so.
Who Should Undergo and Expected Results
The construction of tracheoesophageal fistula and the subsequent insertion of laryngeal prosthesis is beneficial for patients who have had their larynx completely removed. One of the major effects of a total laryngectomy is voice and speech loss. However, it is possible for patients to have their voice and speech restored through various techniques, including:
- The use of electrolarynx, a battery-operated medical device that makes a humming sound
- Oesophageal speech, a method that involves the oscillation of the oesophagus
- Tracheoesophageal voice restoration
While the use of electrolarynx and oesophageal speech is non-surgical, tracheoesophageal voice restoration requires surgery. The procedure connects the trachea and the oesophagus to create a passageway for air, allowing the patient to produce sound.
In a study performed on 95 patients who underwent a tracheoesophageal fistula construction and had prosthesis placed to try and restore voice and speech after laryngectomy, as many as 92% were able to communicate effectively after the procedure. The procedure was considered successful if the patient was able to communicate through the fistula. This shows that the procedure is indeed an effective way to restore voice and speech even after the complete removal of the larynx.
Moreover, acoustic measurements also showed that the procedure is capable of producing speech that is closer to normal than electronic speech. Tracheoesophageal speech is also louder. Thus, the procedure is the preferred choice for speech rehabilitation following a laryngectomy.
Additionally, the insertion of laryngeal prosthesis after a tracheoesophageal fistula is constructed saves patients from frequent prosthesis changes.
How is the Procedure Performed?
The oesophagus and the trachea are two distinct tubes that are not normally connected. If they are connected at birth or become connected due to disease, it is considered as a serious medical condition. However, a TEF may also be deliberately constructed through surgery. Doctors do so for the purpose of voice and speech rehabilitation. The TEF is constructed to accommodate the laryngeal prosthesis and to create a one-way valve system to divert airflow from the trachea into the oesophagus when the patient exhales. Once the airflow enters the oesophagus, the procedure then works the same way as oesophageal speech. The airflow causes vibrations in the oesophagus, producing sound in the process. The sound is then filtered through the mouth to form speech.
During the procedure, the surgeon creates a small puncture between the trachea and the oesophagus, and the two are connected through a fistula.
Once the fistula is constructed, the doctor will insert the laryngeal prosthesis. The prosthesis needs to be inserted carefully at the puncture point to prevent leakage of food and saliva when the patient swallows.
However, a large part of the success of the procedure depends on the type of prosthesis used. Some examples include the Blom-Singer and Groningen voice prostheses, which come in various sizes and may work in different ways. Some prostheses require manual intervention. The patient has to hold a finger onto the oesophageal stoma to make sure air is successfully redirected onto the oesophagus.
Doctors and patients usually select the right prosthesis to use based on a number of factors, such as:
- Phonatory effort and resulting voice quality
If the patient decides to undergo tracheoesophageal fistula construction and to have laryngeal prosthesis placed even before a laryngectomy, the doctor will create the puncture and fistula during the laryngectomy. This way, the patient can begin speech rehabilitation right after the surgery. This also saves the patient from undergoing two different surgeries.
Most patients who undergo the combined procedure undergo radiation therapy after.
Possible Risks and Complications
Some patients who underwent the construction of tracheoesophageal fistula with subsequent insertion of laryngeal prosthesis experienced the following complications:
- Fistula retention
- Tracheoesophageal fistula angulation shifts
- Valve retention
- Fungal colonisation of the prosthesis
- Pressure necrosis
- Post-radiation necrosis
- Phonatory gagging
- Gastric distention
- Persistent spasm
- Shunt insufficiency
- Inadvertent closure of the fistula
The use of laryngeal prosthesis also comes with its own disadvantages. For one, prostheses need maintenance. They need to be taken out for cleaning then placed back in. Patients also face the risk of:
- Aspiration of the prosthesis
- Leakage through or around the prosthesis
- Dislodgement of the prosthesis
If the prosthesis falls out within 24 hours of the surgery, the puncture wound might seal itself. When this happens, the patient will need another surgery to have it reinserted.
Some of these disadvantages discourage patients from choosing the tracheoesophageal method and instead opt for the electrolarynx method.
Izdebski K, Reed CG, Ross JC, Hilsinger RL Jr. “Problems with tracheosophageal fistula voice restoration in totally laryngectomized patients. A review of 95 cases.” Arch Otolaryngol Head Neck Surg. 1994 Aug; 120(8): 840-5. http://www.ncbi.nlm.nih.gov/pubmed/8049046
Graville D, Gross N, Andersen P, Everts E, Cohen J. ‘The long-term indwelling tracheosophageal prosthesis for alaryngeal voice rehabilitation.” Arch Otolaryngol Head Neck Surg. 1999 Mar;125(3):288-92. http://www.ncbi.nlm.nih.gov/pubmed/10190800