**4.3. Prerequisites for successful tracheoesophageal voice and speech**

The basic requirement for tracheoesophageal prosthesis is the absence of distant metastases or local recurrence [22]. The ability to produce tracheoesophageal voice implies the formation of tracheoesophageal fistula and the insertion of the prosthesis within the tracheoesophageal fistula, which is the surgical method of voice rehabilitation [5].

Andrews, according to Kazi, provides the following indicative criteria of patient's status for inserting the tracheoesophageal prosthesis: motivation, mental stability, sufficient level of comprehension and understanding of the changes in anatomy and functional mechanism of prosthesis and its use, appropriate manual and motor skills, the adequate vision status necessary for the maintenance of the prosthesis, the adequate tonus of hypopharynx, i.e., the absence of stenosis of the hypopharynx, the positive insufflation Taub's test, the tracheostoma of a neat appearance, i.e., the appropriate shape (minimum diameter of 15 mm) and depth, and sufficient lung capacity [32].

trachea and the esophagus into the oral cavity, thereby creating vibration of the pharyngoesophageal segment and the production of tracheoesophageal speech, while simultaneously preventing undesirable tracheal noise. Rehabilitation begins with rehabilitation-methodical operators of relaxation of the whole body, especially the neck and head, and operators of proper, relaxed, alaryngeal phonation. Once a satisfactory tracheoesophageal phonation is established, the production of this voice articulates the syllables in a combination of silent guttural occlusive and a vocal and then all other sounds. When the patient successfully uses tracheoesophageal voice and speech on a daily basis as the only mean of communication, attention is paid to the details. In order to fix the lack of a free hand, an automatic speech valve is used. The automatic speech valve consists of a plastic casing inside which is located the membrane for controlling the flow of the economical amount of air and the filter for maintain-

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Rehabilitation ends when a patient can produce spontaneous speech without significant difficulties, that is, when tracheostoma is well-occluded, a voice of satisfactory quality, speech is intelligible, and when the patient uses tracheoesophageal speech as the main mean of com-

The assessment of the performance of voice-speech rehabilitation is performed using the Harrison and Robillard-Schultz scales for assessing tracheoesophageal voice and speech, including a sub-scale for assessing the maintenance of tracheoesophageal prosthesis [35].

Complications may occur in the early or late postoperative period in 10–60% of patients [34,

munication. **Figure 4** shows the scheme of tracheoesophageal voice production.

**4.6. Tracheoesophageal puncture and tracheoesophageal prosthesis complications**

ing the temperature and humidity of the air [34].

**Figure 4.** Tracheoesophageal voice production.

**1.** Complications of tracheoesophageal puncture.

**3.** Complications of tracheoesophageal prosthesis.

**2.** Complications of tracheoesophageal fistula.

36, 37] and may be divided into:

### **4.4. Functional characteristics of tracheoesophageal speech**

The tracheoesophageal fistula allows communication between the trachea and esophagus, which is important for the speech because the patient uses the lungs as the air reservoir required for the phonation, which makes the speech more fluent [33], of more appropriate melody and pace with better achieved stresses and fewer respiratory pauses. Although, by acoustic measurements, the fundamental frequency is lowered, and the values of the parameters that determine the timbre are elevated, unlike the esophageal voice, the intensity or volume is greater, and the maximum time of the phonation is longer [5, 24]. If a tracheostoma is occluded manually, patient's hand will be occupied, but this is not necessary because an automatic speech valve can be used for occlusion. The advantage of this method is the duration of rehabilitation, which is considerably shorter than the esophageal speech learning process. The greatest disadvantages of the method are the need to replace prosthesis over a certain period of time and the possibility of developing various speech prosthesis complications or tracheoesophageal fistulas. The average life of the prosthesis is 3–6 months [34].

#### **4.5. Rehabilitation: educational process of learning the tracheoesophageal speech**

The rehabilitation process varies depending on the type of prosthesis insertion, whether it is primary, primary postponed or secondary, but the overall process lasts shorter than the esophageal speech learning process. During the tracheoesophageal voice production, it is necessary to occlude the tracheostoma. At the beginning of the rehabilitation, the tracheostoma is occluded with a non-dominant hand, usually by a thumb, to achieve the best occlusion. The complete occlusion of tracheostoma allows the air from the lungs to be directed through the The Role of Esophagus in Voice Rehabilitation of Laryngectomees http://dx.doi.org/10.5772/intechopen.78594 77

**Figure 4.** Tracheoesophageal voice production.

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.

The basic requirement for tracheoesophageal prosthesis is the absence of distant metastases or local recurrence [22]. The ability to produce tracheoesophageal voice implies the formation of tracheoesophageal fistula and the insertion of the prosthesis within the tracheoesophageal

Andrews, according to Kazi, provides the following indicative criteria of patient's status for inserting the tracheoesophageal prosthesis: motivation, mental stability, sufficient level of comprehension and understanding of the changes in anatomy and functional mechanism of prosthesis and its use, appropriate manual and motor skills, the adequate vision status necessary for the maintenance of the prosthesis, the adequate tonus of hypopharynx, i.e., the absence of stenosis of the hypopharynx, the positive insufflation Taub's test, the tracheostoma of a neat appearance, i.e., the appropriate shape (minimum diameter of 15 mm) and depth,

The tracheoesophageal fistula allows communication between the trachea and esophagus, which is important for the speech because the patient uses the lungs as the air reservoir required for the phonation, which makes the speech more fluent [33], of more appropriate melody and pace with better achieved stresses and fewer respiratory pauses. Although, by acoustic measurements, the fundamental frequency is lowered, and the values of the parameters that determine the timbre are elevated, unlike the esophageal voice, the intensity or volume is greater, and the maximum time of the phonation is longer [5, 24]. If a tracheostoma is occluded manually, patient's hand will be occupied, but this is not necessary because an automatic speech valve can be used for occlusion. The advantage of this method is the duration of rehabilitation, which is considerably shorter than the esophageal speech learning process. The greatest disadvantages of the method are the need to replace prosthesis over a certain period of time and the possibility of developing various speech prosthesis complications or tracheoesophageal fistulas. The average life of the prosthesis is 3–6 months [34].

**4.5. Rehabilitation: educational process of learning the tracheoesophageal speech**

The rehabilitation process varies depending on the type of prosthesis insertion, whether it is primary, primary postponed or secondary, but the overall process lasts shorter than the esophageal speech learning process. During the tracheoesophageal voice production, it is necessary to occlude the tracheostoma. At the beginning of the rehabilitation, the tracheostoma is occluded with a non-dominant hand, usually by a thumb, to achieve the best occlusion. The complete occlusion of tracheostoma allows the air from the lungs to be directed through the

**4.3. Prerequisites for successful tracheoesophageal voice and speech**

fistula, which is the surgical method of voice rehabilitation [5].

**4.4. Functional characteristics of tracheoesophageal speech**

and sufficient lung capacity [32].

76 Esophageal Cancer and Beyond

trachea and the esophagus into the oral cavity, thereby creating vibration of the pharyngoesophageal segment and the production of tracheoesophageal speech, while simultaneously preventing undesirable tracheal noise. Rehabilitation begins with rehabilitation-methodical operators of relaxation of the whole body, especially the neck and head, and operators of proper, relaxed, alaryngeal phonation. Once a satisfactory tracheoesophageal phonation is established, the production of this voice articulates the syllables in a combination of silent guttural occlusive and a vocal and then all other sounds. When the patient successfully uses tracheoesophageal voice and speech on a daily basis as the only mean of communication, attention is paid to the details. In order to fix the lack of a free hand, an automatic speech valve is used. The automatic speech valve consists of a plastic casing inside which is located the membrane for controlling the flow of the economical amount of air and the filter for maintaining the temperature and humidity of the air [34].

Rehabilitation ends when a patient can produce spontaneous speech without significant difficulties, that is, when tracheostoma is well-occluded, a voice of satisfactory quality, speech is intelligible, and when the patient uses tracheoesophageal speech as the main mean of communication. **Figure 4** shows the scheme of tracheoesophageal voice production.

The assessment of the performance of voice-speech rehabilitation is performed using the Harrison and Robillard-Schultz scales for assessing tracheoesophageal voice and speech, including a sub-scale for assessing the maintenance of tracheoesophageal prosthesis [35].

#### **4.6. Tracheoesophageal puncture and tracheoesophageal prosthesis complications**

Complications may occur in the early or late postoperative period in 10–60% of patients [34, 36, 37] and may be divided into:


Complications of tracheoesophageal puncture are complications resulting from the surgical procedure itself, and among them are tracheostoma of inadequate form, size and depth, inadequate tonus of the pharyngoesophageal segment (hypotonicity or hypertonicity) [38] and the formation of pseudoepiglottis or pseudo-vallecula [39].

**Author details**

\*, Marinela Rosso2

2 Polyclinic Rosso, Osijek, Croatia

Medicinski fakultet; 2017

senschaftliche Classe; 1859

Chirurgie. 1874;**17**:343-356

\*Address all correspondence to: ljsiric@gmail.com

University Hospital Centre Osijek, Osijek, Croatia

Philadelphia: Saunders/Elsevier; 2010

Vrije University Medical Center; 2005

1 Department of Otorhinolaryngology and Head and Neck Surgery,

3 Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia

and Aleksandar Včev<sup>3</sup>

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[1] Sabiston DC, Sellke FW, Del NPJ, Swanson SJ. Sabiston & Spencer Surgery of the Chest.

[2] Rice TW. Esophagus. In: Norton JA et al, editors. Surgery. Berlin, Heidelberg: Springer; 2001 [3] Hilgers FJM, Ackerstaff AH. Comprehensive rehabilitation after total laryngectomy is

[4] Shah JP, Patel SG. Head and Neck Surgery and Oncology. Edinburgh: Mosby; 2003

[5] Širić Lj. Utjecaj vrste alaringealne fonacije na akustičke parametre glasa i prozodijske elemente govora. [Doktorska disertacija]. Osijek: Sveučilište J. J. Strossmayera Osijek,

[6] Rosso M. Utjecaj kazeta za održavanje vlažnosti i temperature zraka na morfološki i funkcionalni status donjih dišnih putova laringektomiranih osoba. [Doktorska disert-

[7] Van der Torn M.A sound-producing voice prosthesis [Doctoral dissertation]. Amsterdam:

[8] Hirokazu S, Takahashi H. Voice generation system using an intra-mouth vibrator for the

[9] Czermak J. Uber die Sprache bei luftdichter Verschliessung des Kehlkopfs. Wien: Sitzungsberichte der kaiserlichen Academie der Wissenschafter mathematischnaturwis-

[10] Gussenbauer C. Ueber die erste durch Th. Billroth am Menschen ausgefuerte Kehlkopf – Extirpation und die Anwendung eines Kuenstlichen Kehlkopfes. Archiv Fur Klinische

[12] Struebbing PDL. Pseudostimme nach Ausschaltung des Kehlkopfs, speziell nach

acija]. Osijek: Sveučilište J. J. Strossmayera Osijek, Medicinski fakultet; 2015

laryngectomee [Master's thesis]. Japan: University of Tokyo; 2000

[11] Weir N. Otolaryngology: An Illustrated History London: Butterworths; 1990

Extirpation desselben. Deutsche Medizinische Wochenschrift. 1988;**14**:1061

more than voice alone. Folia Phoniatrica et Logopaedica. 2000;**52**:65-73

Ljiljana Širić<sup>1</sup>

**References**

Complications of tracheoesophageal fistula occur in later postoperative period, most commonly the same patient having several different complications. Among these complications are the atrophy of the tracheoesophageal wall, tracheal mucosa granulation, esophageal mucosa hypertrophy, increase in diameter of tracheoesophageal fistulae, dislocation of the voice prosthesis and leakage of the esophagus from the voice prosthesis into the trachea [40]. Inadequate size of voice prosthesis causes pressure on the esophageal and tracheal mucosa and may result in fibromatous reactions [39]. Several cases of decubitus of the back esophageal wall have been reported due to the incompatibility of the length of the tracheoesophageal fistula with the length of the voice prosthesis.

The complications of the tracheoesophageal prosthesis are the release of one-way prosthesis valves, resulting in leakage of the esophagus through the voice prosthesis into the trachea [41, 42], and the creation of biofilm in the voice prosthesis due to its use during several months [43, 44].
