**4.1. Tracheoesophageal puncture and tracheoesophageal prosthesis placement**

Tracheoesophageal puncture is a surgical method of voice restoration after total laryngectomy that implies creation of a fistulous tract in tracheoesophageal wall—the wall that separates the trachea and esophagus, in the level of tracheostomy. This surgically created fistula which may be formed at the time of the total laryngectomy (primary tracheoesophageal puncture) or after the laryngectomized person has healed from surgery (secondary tracheoesophageal puncture). For satisfactory performance of the tracheoesophageal puncture, an adequate tracheostoma is preferable. The location of puncture is positioned in the midline, 5–10 mm below the mucocutaneous junction. A tracheoesophageal prosthesis is inserted into a fistula, as shown in **Figure 2** [4].

by the mucosa and surrounding fibers of the repaired cricopharyngeal, thyropharyngeal and the upper esophageal sphincter muscles is very important in voice production, and because of that it is important to preserve as much pharyngeal mucosa as possible at the time of laryngeal surgery [28]. Sometimes PE segment may be hypertonic, spastic or hypotonic. In case that hypertonicity or spasticity is a problem, cricopharyngeal myotomy, pharyngeal neurectomy,

The Role of Esophagus in Voice Rehabilitation of Laryngectomees

http://dx.doi.org/10.5772/intechopen.78594

75

The first experimental prostheses appeared in the second half of the last century, but due to initial structural defects, they could not be cleansed in detail from the secretion, resulting in an infection of the trachea and esophagus [30]. The first silicone tracheoesophageal prosthesis for commercial use was constructed in 1979 and its creators were Blom and Singer [31]. Due to its specific appearance, the prototype of the prosthesis was named duckbill. At the rounded esophageal end, an opening was located with the aim of one-way airflow from the trachea to the esophagus, and at the tracheal end, there was a rim with the extension and the possibility of sticking to the skin to prevent prosthesis from falling out. The second prototype of the prosthesis was created by introducing a one-way valve with a hinged door shape and reduced air resistance. The prostheses were built in secondarily, anterogradely through tracheostoma under general anesthesia. After this, other types of prostheses are created and developed, such as Hermann's prosthesis, Henley-Cohn's prosthesis, Staffieri's prosthesis, Traissac's prosthesis,

PES dilatation or botulinum toxin injection may be beneficial [29].

**4.2. History of tracheoesophageal speech**

**Figure 3.** Tracheoesophageal prosthesis.

**Figure 2.** Tracheoesophageal fistula with inserted prosthesis.

The prosthesis is an artificial device, mostly made of silicone. The purpose of the prosthesis, which is practically "one-way" valve is to allow air to be delivered from the lungs into the esophagus (**Figure 3**). At the same time, the leak of saliva and food in trachea is undesirable and prevented [27]. For this passage of air, good occlusion of the tracheostoma during phonation is necessary. During phonation, high intrathoracic pressure forces the valve to open and directs the air into the upper part of esophagus. Passing of this air into the pharynx and mouth produces vibrations in the mucosal wall of the pharyngoesophageal segment which generates sound. Resonation of the sound occurs in the pharynx, mouth and nose, with simultaneous articulation using the tongue, lips, and teeth.

The most important anatomical part responsible for alaryngeal voice formation is pharyngoesophageal segment. The vibrating pharyngoesophageal segment is the source of sound production and performs vocal cord function. The state of pharyngoesophageal segment made

**Figure 2.** Tracheoesophageal fistula with inserted prosthesis.

**Figure 3.** Tracheoesophageal prosthesis.

esophagus, and in the articulation of the labial, alveolar and guttural occlusive the air is liberated and affects the achievement of a satisfactory tonus of the pharyngoesophageal segment. In 1966, Diedrich and Youngstrom created a variation of this method by introducing certain

The blocking method was accomplished by performing several procedures of injectable method followed by specific articulator's movements and by changing the head position. The method involves injecting air from the oral cavity to the esophagus by lip occlusion causing anterior blockage with simultaneous posterior repositioning of the base of the tongue and

By combining several specific procedures from the deglutition and inhalation method, a new method was created by Portman, and was named after him as Portman's method. It requires a few fast-paced air inspirations that are followed by "edacious" deglutition of the air bolus

In addition, there is Tartapan's method, which is seldom used in clinical speech therapy practice, as well as other possible combinations of existing standard methods that are not

Tracheoesophageal puncture is a surgical method of voice restoration after total laryngectomy that implies creation of a fistulous tract in tracheoesophageal wall—the wall that separates the trachea and esophagus, in the level of tracheostomy. This surgically created fistula which may be formed at the time of the total laryngectomy (primary tracheoesophageal puncture) or after the laryngectomized person has healed from surgery (secondary tracheoesophageal puncture). For satisfactory performance of the tracheoesophageal puncture, an adequate tracheostoma is preferable. The location of puncture is positioned in the midline, 5–10 mm below the mucocutaneous junction. A tracheoesophageal prosthesis is inserted into a fistula,

The prosthesis is an artificial device, mostly made of silicone. The purpose of the prosthesis, which is practically "one-way" valve is to allow air to be delivered from the lungs into the esophagus (**Figure 3**). At the same time, the leak of saliva and food in trachea is undesirable and prevented [27]. For this passage of air, good occlusion of the tracheostoma during phonation is necessary. During phonation, high intrathoracic pressure forces the valve to open and directs the air into the upper part of esophagus. Passing of this air into the pharynx and mouth produces vibrations in the mucosal wall of the pharyngoesophageal segment which generates sound. Resonation of the sound occurs in the pharynx, mouth and nose, with simultaneous

The most important anatomical part responsible for alaryngeal voice formation is pharyngoesophageal segment. The vibrating pharyngoesophageal segment is the source of sound production and performs vocal cord function. The state of pharyngoesophageal segment made

**4.1. Tracheoesophageal puncture and tracheoesophageal prosthesis placement**

modifications [17].

74 Esophageal Cancer and Beyond

specifically described.

as shown in **Figure 2** [4].

articulation using the tongue, lips, and teeth.

inferior mandibular repositioning.

to make speech air flow into the esophagus [22].

**4. Esophagus and tracheoesophageal speech**

by the mucosa and surrounding fibers of the repaired cricopharyngeal, thyropharyngeal and the upper esophageal sphincter muscles is very important in voice production, and because of that it is important to preserve as much pharyngeal mucosa as possible at the time of laryngeal surgery [28]. Sometimes PE segment may be hypertonic, spastic or hypotonic. In case that hypertonicity or spasticity is a problem, cricopharyngeal myotomy, pharyngeal neurectomy, PES dilatation or botulinum toxin injection may be beneficial [29].

## **4.2. History of tracheoesophageal speech**

The first experimental prostheses appeared in the second half of the last century, but due to initial structural defects, they could not be cleansed in detail from the secretion, resulting in an infection of the trachea and esophagus [30]. The first silicone tracheoesophageal prosthesis for commercial use was constructed in 1979 and its creators were Blom and Singer [31]. Due to its specific appearance, the prototype of the prosthesis was named duckbill. At the rounded esophageal end, an opening was located with the aim of one-way airflow from the trachea to the esophagus, and at the tracheal end, there was a rim with the extension and the possibility of sticking to the skin to prevent prosthesis from falling out. The second prototype of the prosthesis was created by introducing a one-way valve with a hinged door shape and reduced air resistance. The prostheses were built in secondarily, anterogradely through tracheostoma under general anesthesia. After this, other types of prostheses are created and developed, such as Hermann's prosthesis, Henley-Cohn's prosthesis, Staffieri's prosthesis, Traissac's prosthesis, Nijdam's prosthesis, Ultra Voice prosthesis, Algaba prosthesis, and Provox prostheses [22]. The primary goal of the prosthesis development was to improve its structural and construction properties with the aim of achieving proper, safe and reliable use, adequate fixation of prosthesis within tracheoesophageal fistula, better prosthesis functionality in terms of low air resistance and greater resistance to fungal and bacterial infections. To date, different manufacturers' tracheoesophageal prostheses of perfected construction and design are available.
