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Original Article |

Complications That Affect Postlaryngectomy Voice Restoration Primary Surgery vs Salvage Surgery FREE

Heather M. Starmer, MA; Stacey L. Ishman, MD; Paul W. Flint, MD; Nasir I. Bhatti, MD, MHS; Jeremy Richmon, MD; Wayne Koch, MD; Kimberly Webster, MA; Ralph Tufano, MD; Christine G. Gourin, MD
[+] Author Affiliations

Author Affiliations: Departments of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University, Baltimore, Maryland (Mss Starmer and Webster and Drs Ishman, Flint, Bhatti, Richmon, Koch, Tufano, and Gourin) and Oregon Health and Science University, Portland (Dr Flint).


Arch Otolaryngol Head Neck Surg. 2009;135(11):1165-1169. doi:10.1001/archoto.2009.168.
Text Size: A A A
Published online

Objective  To assess the effect of primary treatment on tracheoesophageal voice prosthesis (TEP) complications.

Design  Retrospective cohort study.

Setting  The Johns Hopkins Medical Institutions, Baltimore, Maryland.

Patients  Patients who underwent total laryngectomy and TEP between January 1, 1998, and December 31, 2008, were divided into 3 subgroups according to primary treatment: surgery (n = 81), radiotherapy (n = 61), and chemoradiotherapy (n = 32).

Main Outcome Measures  Number of weeks before leakage through the TEP, occurrence of leakage around the TEP, TEP dislodgement, and size changes 6 months or longer after laryngectomy.

Results  A total of 174 patients met the study criteria. Of the 81 patients who underwent primary surgery, 81% (n = 66) underwent adjuvant therapy with postoperative radiotherapy or chemoradiotherapy. The incidence of leakage around the prosthesis, prosthesis dislodgement, and size changes 6 months or longer after laryngectomy were significantly higher for patients who required salvage total laryngectomy after chemoradiotherapy or radiotherapy (P < .05). In addition, significantly more patients who underwent salvage total laryngectomy required extended laryngectomy or free tissue reconstruction.

Conclusions  Voice prosthesis complications are more frequently encountered in those who require salvage laryngectomy. Understanding the potential for such complications reinforces the need for close communication and follow-up with these patients by the speech language pathologist.

Figures in this Article

For many years, total laryngectomy (TL) with postoperative radiotherapy has been considered the standard treatment for advanced laryngeal cancer. The substantial functional changes in speech and swallowing that result have made this option less than desirable for many patients. In an attempt to avoid the perceived mutilation of TL and preserve voice function, organ preservation approaches have increasingly been used to treat advanced laryngeal cancer since publication of the Department of Veterans Affairs Laryngeal Cancer Study Group data in 1991.1 This prospective randomized clinical trial revealed that approximately two-thirds of patients in the organ preservation group preserved their larynx, with survival equivalent to that of patients treated by TL up front. Further support for organ preservation approaches, in particular concurrent chemoradiotherapy, came with publication of the Radiation Therapy Oncology Group 91-11 protocol.2 This prospective randomized trial demonstrated improved locoregional control in patients treated with concomitant chemoradiotherapy compared with radiotherapy alone or induction chemoradiotherapy.

Despite these favorable results, a wealth of information regarding the functional affect of chemoradiotherapy is beginning to unfold. The profound negative effect of chemoradiotherapy on the oropharyngeal swallowing mechanism has been well established. Frequent deficits reported include decreased epiglottic tilt, decreased tongue base retraction, impaired bolus propulsion, laryngeal penetration/aspiration, and esophageal stricture.35 In addition, voice complications from organ preservation approaches have been reported, including impaired vocal fold mobility, increased supraglottic constriction, decreased vibratory characteristics of the true vocal folds, and glottic incompetence.6,7 Other functional impairments may include xerostomia8 and trismus.9,10 Studies that evaluate the functional effect of primary organ preservation approaches on voice rehabilitation after salvage TL have been scarce to date. We reviewed our experience with voice prosthesis complications to identify risk factors for tracheoesophageal voice prosthesis (TEP) failure in patients who underwent salvage laryngectomy.

The medical records of all patients who underwent TL at The Johns Hopkins Medical Institutions, Baltimore, Maryland, between January 1, 1998, and December 31, 2008, were reviewed in compliance with the Health Insurance Portability and Accountability Act and in accord with previous approval by the Johns Hopkins institutional review board. Patients who did not undergo TEP, who did not complete treatment, or who did not receive follow-up TEP care at The Johns Hopkins Medical Institutions were excluded from analysis. Patients were divided into 3 treatment groups: primary surgery, primary radiotherapy, and primary chemoradiotherapy. Patient demographic factors and clinical outcomes were analyzed. Voice prosthesis–related outcomes of interest were time to leakage through the prosthesis, episodes of leakage around the prosthesis, episodes of spontaneous prosthesis dislodgment, and occurrence of prosthesis size changes after the first 6 months. These variables were chosen for their clinical relevance as the most frequent complications addressed by the speech language pathologist.

Standard statistical analyses, including χ2 analysis and the Fisher exact test, were used to evaluate patient variables (GraphPad InStat; GraphPad Software, San Diego, California). Because categorical variables were not normally distributed, comparison of means was performed using the Kruskal-Wallis test. Analysis of differences in TEP outcomes between treatment groups was performed using simple and multivariable linear regression models. Kruskal-Wallis and regression analyses were performed using Stata 10 (StataCorp, College Station, Texas). Statistical significance was attributed at P < .05.

A total of 174 patients met the inclusion criteria for analysis (Table 1). Mean follow-up was 5.67 years and did not differ significantly among treatment groups. Primary TL was performed in 46.6% of patients, whereas salvage laryngectomy was performed after primary chemoradiotherapy failure in 18.4% and after primary radiotherapy failure in 35.1%. Adjuvant postoperative therapy (radiotherapy or chemoradiotherapy) was used in 81% (n = 66) of 81 patients who underwent primary surgery. The mean patient age was 62 years (age range, 32-87 years). No significant differences were found between treatment groups for age, sex, or duration of follow-up. Most patients (68.4%) had advanced-stage cancer (stage III/IV), with the glottic larynx being the most common primary site (54.6%). Extended laryngectomy, free tissue reconstruction, or both were performed in 20% of patients. Most of this group had primary sites outside of the larynx (58%), and 50% were treated initially with chemoradiotherapy. Primary TEP was performed in 80.5% of patients and was equally distributed among treatment groups. Decisions regarding the timing of TEP were made by preference of the surgeon or speech language pathologist. The primary site differed significantly between treatment groups, with significantly more glottic cancers treated initially with primary radiotherapy (P < .001) compared with supraglottic tumors. Primary TL was performed significantly more often for advanced-stage disease, whereas nonoperative treatment was the most common initial procedure for early-stage disease (Figure 1).

Place holder to copy figure label and caption
Figure 1.

Tumor stage by treatment group.

Graphic Jump Location

Regression models demonstrated significant differences among treatment groups regarding the need for extended TL and free tissue reconstruction. Simple linear regression models demonstrated that significantly more patients required extended laryngectomy procedures for surgical salvage after chemoradiotherapy failure (56%) compared with radiotherapy failure (8%) and with those who underwent primary TL (15%; P < .001) (Figure 2). Similarly, significantly more patients required free tissue reconstruction for surgical salvage after chemoradiotherapy failure (56%) compared with radiotherapy failure (10%) and with those who underwent primary TL (12%; P < .001) (Figure 3). There was overlap between these groups, with 89% of those requiring extended laryngectomy undergoing reconstruction and 89% of those requiring reconstruction undergoing extended laryngectomy. Despite the higher incidence of extended TL and reconstruction in the chemoradiotherapy group, Kruskal-Wallis analysis showed no difference between those who required extended surgery and reconstruction and those who did not regarding measured voice prosthesis complications.

Place holder to copy figure label and caption
Figure 2.

Extended laryngectomy by treatment group. Primary surgery was less likely to require extended laryngectomy than was salvage surgery (P < .001).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Free tissue reconstruction by treatment group. Primary surgery was less likely to require reconstruction than was salvage surgery (P < .001).

Graphic Jump Location

Significant differences existed among treatment groups during analysis of voice prosthesis complications (Table 2). Using simple linear regression models, the mean frequency of leakage around the prosthesis (P = .04), frequency of prosthesis dislodgement (P = .02), and number of size changes in the first 6 months after laryngectomy (P = .006) were significantly higher for patients who required salvage TL after chemoradiotherapy or radiotherapy compared with patients who underwent primary TL (P < .001) (Table 2). There were no differences among treatment groups when comparing the number of weeks to leakage through the prosthesis (P = .42).

Table Graphic Jump LocationTable 2. Simple Linear Regression Results for Prosthesis-Related Complications

Multivariable linear regression was used to evaluate the primary outcomes of extended laryngectomy, free tissue reconstruction, and primary or secondary TEP placement based on the results of simple linear regression analysis. Salvage laryngectomy was associated with an increased incidence of TEP dislodgement (Table 3). Tracheoesophageal prosthesis size changes were significantly more common for extended laryngectomy and salvage laryngectomy. There was also a trend toward an association between leakage around the prosthesis and extended laryngectomy; however, this trend did not reach statistical significance (Table 3).

Table Graphic Jump LocationTable 3. Multivariable Linear Regression of Voice Prosthesis Complications by Patient Variables

Kruskal-Wallis analysis did not reveal significant differences among groups for time to leakage through the prosthesis (P = .30) or number of leaks around the prosthesis (P = .27). Increases in prosthesis dislodgements and number of size changes after 6 months were observed in the chemoradiotherapy and radiotherapy groups (P = .11) compared with the primary TL group (P = .09), but this difference was not significant.

The effect of TL on communicative functioning and quality of life cannot be disputed. In 1981, McNeil et al11 administered a questionnaire to healthy individuals that explored quality of life vs quantity of life. Twenty percent of participants indicated a preference for radiotherapy over TL, even when this choice reduced the potential for survival. These early findings highlighted the magnitude of impact that quality of life issues may have in medical decision making. Disturbance of normal laryngeal voice production can be catastrophic for some individuals. Restoration of verbal communication must be considered paramount in rehabilitating patients after laryngectomy. Although esophageal and electrolaryngeal speech are viable options for the restoration of communication, TEP has become the primary rehabilitation tool owing to improved quality of life,12 improved speech intelligibility and quality,13,14 and improved patient satisfaction.15 Known factors that may affect the successful establishment of tracheoesophageal speech include difficulty in establishing voice due to cricopharyngeal spasm or stricture,16,17 granulation tissue formation,18,19 premature leakage through the voice prosthesis,20,21 and leakage around the voice prosthesis.21 Less common reasons for failure to maintain tracheoesophageal speech include prosthesis dislodgement, hypertrophic scarring, and infection.22 It is logical to postulate that as a result of the toxic effects associated with chemotherapy and radiotherapy, some of these complications may occur more frequently in patients who require laryngectomy after primary organ preservation treatment in contrast to those who have had primary surgical treatment.

The results of this analysis demonstrate that patients who undergo salvage TL after chemoradiotherapy and radiotherapy have a higher incidence of prosthesis-related complications, such as leakage around the prosthesis, prosthesis dislodgement, and multiple size changes, compared with patients who undergo primary surgery. The greatest variance was seen between primary radiotherapy and primary TL in these measures. Although one might postulate that a greater difference would be seen in the chemoradiotherapy group given the additive effects of chemotherapy, this was not demonstrated in this data set, perhaps owing, in part, to the smaller sample size and the shorter mean follow-up for this group. In addition to increases in prosthesis-related complication rates, salvage laryngectomy due to chemoradiotherapy failure was more likely to require extended laryngectomy procedures and free tissue reconstruction, suggesting that organ preservation strategies have multiple soft-tissue effects that can affect voice rehabilitation efforts after salvage TL.

Although the number of patients who never received chemoradiotherapy or radiotherapy was too low to include in statistical analysis (n = 14), there were some interesting findings regarding their TEP success. In these individuals, the longevity of prosthesis life before leakage through the center was longer than that in the primary surgery group at large (22.8 vs 15.2 weeks). A slight advantage was also seen regarding leakage around the prosthesis, with a mean occurrence of 0.33 in the pure surgical group compared with 0.56 in the TL group receiving postoperative radiotherapy or chemoradiotherapy. The remaining TEP variables, however, were similar to the primary surgery group at large. Specifically, the mean number of dislodgements was 0.33 (compared with 0.28), and the mean number of size changes was 1.33 (compared with 1.20).

The present findings are consistent with those of Kummer et al,23 who demonstrated an increased incidence of leakage around the prosthesis, dilatation of the puncture, and spontaneous dislocation of the voice prosthesis in patients who underwent salvage laryngectomy after primary radiotherapy. Although these findings do not establish clear causation, the relationships suggest the need to consider rehabilitative treatment approaches that will minimize the potential for development of these complications in the salvage laryngectomy population. This is particularly true given the paradigm shift toward nonoperative laryngeal cancer therapy reflected in the National Cancer Database24,25 and the likelihood of continued increases in salvage surgical procedures. Such treatments may require novel intraoperative and postoperative considerations, long-term patient management strategies, or prosthesis-specific intervention strategies. Although specific treatment modalities have not been validated for this population to date, to our knowledge, there is a clear role for patient education regarding potential prosthesis-related complications and close communication with and follow-up by the speech language pathologist.

Future investigations will be valuable in defining and investigating strategies that may reduce complications in the salvage laryngectomy population. It is postulated that treatments designed to minimize traction and trauma to the delicate tissues of the party wall may show promise for improving patient outcomes. Patient education regarding independent monitoring for early signs of complications and ways to address these complications show additional promise. A role for smaller-diameter voice prostheses in this population has also been proposed,23,26 although a formal investigation of this interventional strategy has not been published to date.

The results of this analysis demonstrate that the incidence of prosthesis-related complications is increased when laryngectomy is performed for salvage after organ preservation therapy compared with primary laryngectomy for the treatment of laryngeal cancer. Tracheoesophageal voice prosthesis dislodgement and multiple size changes within the first 6 months after laryngectomy were seen more frequently in the salvage laryngectomy population than in the primary surgery group. In addition, extended laryngectomy and free tissue reconstruction were more often required in patients who underwent salvage laryngectomy after chemoradiotherapy failure, suggesting that organ preservation strategies have multiple soft effects that can affect voice rehabilitation efforts after salvage laryngectomy. These data suggest the need for adjustment of clinical practice patterns in the salvage laryngectomy setting and further investigation into strategies that may reduce such risks.

Correspondence: Heather M. Starmer, MA, Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University, 601 N Caroline St, Ste 6260, Baltimore, MD 21287 (hstarme1@jhmi.edu).

Submitted for Publication: May 5, 2009; final revision received June 3, 2009; accepted June 25, 2009.

Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Starmer. Acquisition of data: Starmer, Koch, Webster, and Tufano. Analysis and interpretation of data: Starmer, Ishman, Flint, Bhatti, Richmon, Koch, and Gourin. Drafting of the manuscript: Starmer. Critical revision of the manuscript for important intellectual content: Starmer, Ishman, Flint, Bhatti, Richmon, Koch, Webster, Tufano, and Gourin. Statistical analysis: Starmer, Ishman, and Gourin. Administrative, technical, and material support: Starmer, Flint, and Koch. Study supervision: Bhatti and Tufano.

Financial Disclosure: None reported.

Previous Presentation: This study was presented at the American Head and Neck Society 2009 Annual Meeting; May 30, 2009; Phoenix, Arizona.

Department of Veterans Affairs Laryngeal Cancer Study Group, Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324 (24) 1685- 1690
PubMed Link to Article
Forastiere  AAGoepfert  HMaor  M  et al.  Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349 (22) 2091- 2098
PubMed Link to Article
Goguen  LAPosner  MNorris  C  et al.  Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer. Otolaryngol Head Neck Surg 2006;134 (6) 916- 922
PubMed Link to Article
Dworkin  JPHill  SStachler  RMeleca  RJKewson  D Swallowing function outcomes following nonsurgical therapy for advanced-stage laryngeal carcinoma. Dysphagia 2006;21 (1) 66- 74
PubMed Link to Article
Logemann  JARademaker  APauloski  B  et al.  Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head Neck 2006;28 (1) 64- 73
PubMed Link to Article
Fung  KYoo  JLeeper  HA  et al.  Effects of head and neck radiation therapy on vocal function. J Otolaryngol 2001;30 (3) 133- 139
PubMed Link to Article
Meleca  RJDworkin  JPKewson  DTStachler  RJHill  SL Functional outcomes following nonsurgical treatment for advanced-stage laryngeal carcinoma. Laryngoscope 2003;113 (4) 720- 728
PubMed Link to Article
Roh  JLKim  AYCho  MJ Xerostomia following radiotherapy of the head and neck affects vocal function. J Clin Oncol 2005;23 (13) 3016- 3023
PubMed Link to Article
Louise Kent  MBrennan  MNoll  J  et al.  Radiation-induced trismus in head and neck cancer patients. Support Care Cancer 2008;16 (3) 305- 309
PubMed Link to Article
Wang  CJHuang  EYHsu  HCChen  HCFang  FMHsiung  CY The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer. Laryngoscope 2005;115 (8) 1458- 1460
PubMed Link to Article
McNeil  BJWeichselbaum  RPauker  SG Speech and survival: tradeoffs between quality and quantity of life in laryngeal cancer. N Engl J Med 1981;305 (17) 982- 987
PubMed Link to Article
Finizia  CBergman  B Health-related quality of life in patients with laryngeal cancer: a post-treatment comparison of different modes of communication. Laryngoscope 2001;111 (5) 918- 923
PubMed Link to Article
Williams  SEWatson  JB Speaking proficiency variations according to method of laryngeal voicing. Laryngoscope 1987;97 (6) 737- 739
PubMed
Robbins  J Acoustic differentiation of laryngeal, esophageal, and tracheoesophageal speech. J Speech Hear Res 1984;27 (4) 577- 585
PubMed
Clements  KSRassekh  CHSeikaly  HHokanson  JACalhoun  KH Communication after laryngectomy: an assessment of patient satisfaction. Arch Otolaryngol Head Neck Surg 1997;123 (5) 493- 496
PubMed Link to Article
Blitzer  AKomisar  ABaredes  SBrin  MFStewart  C Voice failure after tracheoesophageal puncture: management with botulinum toxin. Otolaryngol Head Neck Surg 1995;113 (6) 668- 670
PubMed Link to Article
Henley  JSouliere  C  Jr Tracheoesophageal speech failure in the laryngectomee: the role of constrictor myotomy. Laryngoscope 1986;96 (9, pt 1) 1016- 1020
PubMed Link to Article
Pattani  KMMorgan  MNathan  CA Reflux as a cause of tracheoesophageal puncture failure. Laryngoscope 2009;119 (1) 121- 125
PubMed Link to Article
Calder  NMacAndie  CMacGregor  F Tracheoesophageal voice prostheses complications in north Glasgow. J Laryngol Otol 2006;120 (6) 487- 491
PubMed Link to Article
Mäkitie  AANiemensivu  RJuvas  AAaltonen  LMBäck  LLehtonen  H Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience. Ann Otol Rhinol Laryngol 2003;112 (12) 1007- 1010
PubMed
Op de Coul  BMHilgers  FJBalm  AJTan  IBvan den Hoogen  FJvan Tinteren  H A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution's experience with consistent application of Provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 2000;126 (11) 1320- 1328
PubMed Link to Article
Acton  LMRoss  DASasaki  CTLeder  SB Investigation of tracheoesophageal voice prosthesis leakage patterns: patients self-report versus clinician's confirmation [published correction appears in Head Neck. 2008;30(12):1663]. Head Neck 2008;30 (5) 618- 621
PubMed Link to Article
Kummer  PChahoud  MSchuster  MEysholdt  URosanowski  F Prosthetic voice rehabilitation after laryngectomy: failures and complications after previous radiation therapy [in German]. HNO 2006;54 (4) 315- 322
PubMed Link to Article
Chen  AYSchrag  NHao  Y  et al.  Changes in treatment of advanced laryngeal cancer 1985-2001. Otolaryngol Head Neck Surg 2006;135 (6) 831- 837
PubMed Link to Article
Hoffman  HTPorter  KKarnell  LH  et al.  Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope 2006;116 (9, pt 2) ((suppl 111)) 1- 13
PubMed Link to Article
Blom  ED Some comments on the escalation of tracheoesophageal voice prosthesis dimensions. Arch Otolaryngol Head Neck Surg 2003;129 (4) 500- 502
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Tumor stage by treatment group.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Extended laryngectomy by treatment group. Primary surgery was less likely to require extended laryngectomy than was salvage surgery (P < .001).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Free tissue reconstruction by treatment group. Primary surgery was less likely to require reconstruction than was salvage surgery (P < .001).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Simple Linear Regression Results for Prosthesis-Related Complications
Table Graphic Jump LocationTable 3. Multivariable Linear Regression of Voice Prosthesis Complications by Patient Variables

References

Department of Veterans Affairs Laryngeal Cancer Study Group, Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324 (24) 1685- 1690
PubMed Link to Article
Forastiere  AAGoepfert  HMaor  M  et al.  Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349 (22) 2091- 2098
PubMed Link to Article
Goguen  LAPosner  MNorris  C  et al.  Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer. Otolaryngol Head Neck Surg 2006;134 (6) 916- 922
PubMed Link to Article
Dworkin  JPHill  SStachler  RMeleca  RJKewson  D Swallowing function outcomes following nonsurgical therapy for advanced-stage laryngeal carcinoma. Dysphagia 2006;21 (1) 66- 74
PubMed Link to Article
Logemann  JARademaker  APauloski  B  et al.  Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head Neck 2006;28 (1) 64- 73
PubMed Link to Article
Fung  KYoo  JLeeper  HA  et al.  Effects of head and neck radiation therapy on vocal function. J Otolaryngol 2001;30 (3) 133- 139
PubMed Link to Article
Meleca  RJDworkin  JPKewson  DTStachler  RJHill  SL Functional outcomes following nonsurgical treatment for advanced-stage laryngeal carcinoma. Laryngoscope 2003;113 (4) 720- 728
PubMed Link to Article
Roh  JLKim  AYCho  MJ Xerostomia following radiotherapy of the head and neck affects vocal function. J Clin Oncol 2005;23 (13) 3016- 3023
PubMed Link to Article
Louise Kent  MBrennan  MNoll  J  et al.  Radiation-induced trismus in head and neck cancer patients. Support Care Cancer 2008;16 (3) 305- 309
PubMed Link to Article
Wang  CJHuang  EYHsu  HCChen  HCFang  FMHsiung  CY The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer. Laryngoscope 2005;115 (8) 1458- 1460
PubMed Link to Article
McNeil  BJWeichselbaum  RPauker  SG Speech and survival: tradeoffs between quality and quantity of life in laryngeal cancer. N Engl J Med 1981;305 (17) 982- 987
PubMed Link to Article
Finizia  CBergman  B Health-related quality of life in patients with laryngeal cancer: a post-treatment comparison of different modes of communication. Laryngoscope 2001;111 (5) 918- 923
PubMed Link to Article
Williams  SEWatson  JB Speaking proficiency variations according to method of laryngeal voicing. Laryngoscope 1987;97 (6) 737- 739
PubMed
Robbins  J Acoustic differentiation of laryngeal, esophageal, and tracheoesophageal speech. J Speech Hear Res 1984;27 (4) 577- 585
PubMed
Clements  KSRassekh  CHSeikaly  HHokanson  JACalhoun  KH Communication after laryngectomy: an assessment of patient satisfaction. Arch Otolaryngol Head Neck Surg 1997;123 (5) 493- 496
PubMed Link to Article
Blitzer  AKomisar  ABaredes  SBrin  MFStewart  C Voice failure after tracheoesophageal puncture: management with botulinum toxin. Otolaryngol Head Neck Surg 1995;113 (6) 668- 670
PubMed Link to Article
Henley  JSouliere  C  Jr Tracheoesophageal speech failure in the laryngectomee: the role of constrictor myotomy. Laryngoscope 1986;96 (9, pt 1) 1016- 1020
PubMed Link to Article
Pattani  KMMorgan  MNathan  CA Reflux as a cause of tracheoesophageal puncture failure. Laryngoscope 2009;119 (1) 121- 125
PubMed Link to Article
Calder  NMacAndie  CMacGregor  F Tracheoesophageal voice prostheses complications in north Glasgow. J Laryngol Otol 2006;120 (6) 487- 491
PubMed Link to Article
Mäkitie  AANiemensivu  RJuvas  AAaltonen  LMBäck  LLehtonen  H Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience. Ann Otol Rhinol Laryngol 2003;112 (12) 1007- 1010
PubMed
Op de Coul  BMHilgers  FJBalm  AJTan  IBvan den Hoogen  FJvan Tinteren  H A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution's experience with consistent application of Provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 2000;126 (11) 1320- 1328
PubMed Link to Article
Acton  LMRoss  DASasaki  CTLeder  SB Investigation of tracheoesophageal voice prosthesis leakage patterns: patients self-report versus clinician's confirmation [published correction appears in Head Neck. 2008;30(12):1663]. Head Neck 2008;30 (5) 618- 621
PubMed Link to Article
Kummer  PChahoud  MSchuster  MEysholdt  URosanowski  F Prosthetic voice rehabilitation after laryngectomy: failures and complications after previous radiation therapy [in German]. HNO 2006;54 (4) 315- 322
PubMed Link to Article
Chen  AYSchrag  NHao  Y  et al.  Changes in treatment of advanced laryngeal cancer 1985-2001. Otolaryngol Head Neck Surg 2006;135 (6) 831- 837
PubMed Link to Article
Hoffman  HTPorter  KKarnell  LH  et al.  Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope 2006;116 (9, pt 2) ((suppl 111)) 1- 13
PubMed Link to Article
Blom  ED Some comments on the escalation of tracheoesophageal voice prosthesis dimensions. Arch Otolaryngol Head Neck Surg 2003;129 (4) 500- 502
PubMed Link to Article

Correspondence

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