Page 36 - Prosthetic voice rehabilitation-5th edition

3.2 Secondaryprostheticvoicerehabilitation 3.2.1 Indications Failure to obtain useful esophageal, and/or electrolarynx speech, or dissatisfaction with the results of either of the two, is the main indications for a secondary prosthetic voice rehabilitation procedure. The percentage of successful secondary prosthetic voice rehabilitations seems to be somewhat lower, compared with primary rehabilitation, probably due to the fact that the patient has not been using pulmonary driven speech for some time. Furthermore, there might be a negative selection aspect, because failed esophageal speakers might have more problems with hypertonicity of the PE-segment. Nevertheless, with proper training, and if necessary, medical or surgical treatment of hypertonicity of the PE segment, many secondary patients should be able to regain a useful prosthetic voice. In fact, we think that, as is the case for the primary prosthetic procedure, there are no real medical contraindications to this technique, with the exception of radiotherapy doses well exceeding 70 Gy in 7 weeks or the equivalent, especially when combined with chemotherapy. As a matter of caution, it should be mentioned, that secondary punctures should not be performed within 6 weeks after completion of the radiation. Severe pharyngeal or stoma stenosis form relative contraindications, but in most patients these problems should be correctable. Also in patients in whom the pharynx and/or esophagus are reconstructed with a gastric pull-up procedure, the colon, a free tubed-radial forearm flap, or a free re- vascularized jejunum graft, the method is applicable. If the patient is motivated enough, the method is worthwhile trying. 3.2.2 Preoperative screening Apart from a regular ENT examination, including inspection of the pharynx for the presence of a stenosis or web formation at the base of the tongue and checking the stoma size, a barium swallow should be performed to check the size and mobility of the pharyngoesophageal (PE) segment. This is done to anticipate possible problems with the introduction of the rigid endoscope and to see whether dilation of the PE-segment is needed. Often an insufflation test is advocated in order to predict the outcome of secondary prosthetic voice rehabilitation. The test can performed through a 12-14 Fr nasogastric catheter introduced into the PE segment. Subsequently, the examiner can blow air into the pharynx to produce speech, or the catheter is connected to the stoma and the patient him/her self can try to speak by blowing air through the catheter. However, the results of this test are not very reliable and a negative result should not be interpreted as a contraindication for secondary prosthetic voice rehabilitation. A negative result could be indicative of a hypertonicity of the constrictor pharyngeus muscles, which can be corrected surgically with a myotomy or chemically with Botox. In general, however, we are not in favor of combining secondary TEP with a myotomy of the constrictor pharyngeus muscle. It is advisable to wait for the results of the speech therapy. Only if hypertonicity of the constrictor pharyngeus muscle becomes apparent, and results do not improve after proper training, a chemical neurectomy with Botox or a surgical myotomy of this muscle could be considered. In the Netherlands Cancer Institute very few hypertonicity treatments have to be performed, as this problem appears to be quite rare after introduction upper esophageal sphincter myotomy. If needed, however, results of voice rehabilitation can be expected to improve considerably. For the technique of secondary myotomy and/or chemical denervation with Botox, see paragraph 3.3 below. 36