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The Stout prosthesis: an alternate means of restoring speech in selected laryngectomy patients. (Original Article).

Abstract

We discuss the effectiveness of the Stout prosthesis, a device that was developed more than 30 years ago to restore speech in postlaryngectomy patients. This prosthesis has not been previously described in the literature. The placement of this device entails the creation of a pharyngeal cutaneous fistula that extends to the musculature at the base of the tongue. The prosthesis is then used to connect the fistula and the stoma. Central to this discussion was our evaluation of a patient who had used the Stout prosthesis for 30 years. In this patient, the prosthesis produced excellent long-term voice production with minimal leakage of saliva or other liquids. We conclude that in light of the device's simplicity, low cost, and minimal maintenance requirements with regard to the fistula site, the Stout prosthesis should be considered as an alternative to the standard tracheoesophageal puncture method for patients who are unable to comply with the latter's maintenance requirements and for those in poorly developed countries where costs and hygiene are paramount considerations. Moreover, because the Stout technique does not involve the esophagus and does not require invasive procedures around the stoma, it is also practical for patients who have esophageal rigidity or stomal problems.

Introduction

More than 30 years ago, Stout developed a unique prosthesis that could be used by postlaryngectomy patients who were unable to develop esophageal speech and unwilling to use an electrolarynx. Stout had determined that such a prosthesis needed to be inexpensive, reliable, and easy to manufacture. He also developed a simple onestage surgical procedure to create a fistula to accommodate the prosthesis; this procedure could be performed either during the laryngectomy or at any time thereafter. In time, however, Stout concluded that the subsequent development of the Blom-Singer (1) tracheoesophageal fistula prosthesis and surgical technique essentially eliminated the demand for his device and, until now, his procedure has not been described in the literature.

Two of the authors of this article (A.I.K. and J.K.A.) recently had the opportunity to investigate the voice of the one surviving laryngectomy patient who had undergone the Stout procedure. Our evaluation led us to conclude that the Stout prosthesis still has a definite application for patients who are unable to comply with the postoperative care necessary following placement of a tracheoesophageal prosthesis and for patients in developing countries where medical resources are scarce. The Stout prosthesis can also be useful for patients whose stoma will not tolerate a tracheoesophageal fistula and for those who have a nonvibratory segment of the esophagus or hypopharynx.

The Stout technique

The Stout prosthesis was designed to fit over the stoma and into a pharyngeal cutaneous fistula (figure 1). The site of the fistula is determined by placing a hemostat at the midline of the base of the tongue behind the circumvallate papillae and palpating it through the skin surface of the neck. The skin is marked at that point, and an inferiorly based skin flap of approximately 2 cm is raised; the flap is wide enough to be sewn around a 14 French red rubber catheter. The skin flap must be long enough to extend through the base of the tongue. A tubed flap is then created by sewing it around the red rubber catheter with absorbable suture. The tube is then removed, and the hemostat is pushed through the base of the tongue and opened to widen the fistula tract. Next, the tubed skin flap is grasped and pulled through the base of the tongue (figure 2). The 14 French catheter is then placed through the fistula and into the esophagus to hold the flap in place. The catheter is left in place for 1 week and then remov ed.

In manufacturing the prosthesis, a length of Puritan Bennett 5 1/4-inch flex tubing is shortened so that it extends from the stoma to the fistula site (figure 3). The tapered end of the tube is trimmed back so that a 6-mm, 90[degrees] endotracheal tube connector will fit into the end. A 2- to 3-cm segment of a 14 French Levine tube is placed into the end of the anesthesia connector, with the rounded end distal. The patient is told to make sure that the end of the prosthesis fits entirely through the fistula tract until it can be felt in the throat. Because the patient is able to speak only when the prosthesis is partially placed into the tract, the fit should be checked several times daily to keep the tract dilated.

Case report

Two of us (A.I.K. and J.K.A.) examined a man who had used the Stout prosthesis for 30 years. Our aim was to determine his speech clarity and maximum phonation times and to make an acoustical analysis of his speech signal and a fiberoptic analysis of the method of speech production. We inspected the fistula site for leakage of saliva and other liquids, and we evaluated the patient's ability to forcibly exhale through the mouth and inhale through the nose. Finally, we examined the prosthesis itself for evidence of deterioration.

Our initial examination of the patient revealed a small midline fistula opening that was located 8 cm above a well-healed stoma (figure 4, A). Thanks to the pliability of the Puritan Bennett tube, he was able to manipulate the prosthesis to easily connect the stoma and the fistula in almost any head position (figure 4, B).

The patient was evaluated while he swallowed water and a number of other liquids. He showed no evidence of any leakage of saliva or liquids, apparently because the base of the tongue acted as a sphincter each time the patient swallowed. The patient's speech production was evaluated by several observers, who found his voice quality and the intelligibility of his articulation in Spanish to be acceptable. Maximum phonation times were recorded at 9 and 12 seconds. Findings on acoustical analysis were rather typical of a good tracheoesophageal fistula voice. (2) The patient's pitch ranged from 82 to 90Hz (mean: 84). The loudness of his voice averaged 87 dB during conversation, with inflectional variations of up to 8 dB. The quality of the patient's voice production and articulation was not as good to the ear as it had been 30 years earlier (as determined by voice recordings). We attribute this decline to the development of some stenosis in the fistula tract at the tongue level, to the patient's increased age, and to the possibility that a recent stroke had left him with some residual damage. His voice improved when the fistula tract was dilated; dilation was achieved by having the patient push the Levine tube completely into the oropharynx. The patient was instructed to regularly repeat this procedure because the prosthesis is placed only part way into the fistula tract during speech.

When the patient was asked to forcibly inhale and exhale through the prosthesis, he was able to generate enough air pressure to produce a whistle, blow out a match, and blow his nose. He also demonstrated the ability to sniff and smell with forced inhalation while the prosthesis was in place. Apparently, the size of the fistula tract and its placement close to the oral cavity allowed for some large movement of air under pressure through this area.

Fiberoptic laryngoscopy showed that the fistula site had been placed in the midline, posterior to the circumvallate papillae. When the patient produced a voice, the tip of the prosthesis did not protrude from the base of the tongue, but it still allowed air to escape through the fistula tract. From this observation, we concluded that the vibrating segment that produced the fundamental voice frequency was the fistula tract.

Examination of the prosthesis revealed some loss of flexibility in both the Levine and Puritan Bennett tubes. Nevertheless, their function was still adequate, even though the patient had been using his current prosthesis for approximately 10 years. The patient had made one modification of the prosthesis; he added a small plastic ring to mark how far he should place the tube into the fistula tract.

Discussion

The ability to speak is the foundation of human communication. The absence of voice following laryngectomy in cancer survivors was recognized early on to be a severe handicap. (3) As the number of laryngectomy patients has increased, various attempts have been made to provide a means to restore their voices. In the 1920s, the Western Electric pneumatic mechanical larynx became popular. The design of this artificial larynx (which did not operate on electricity) featured a cap that fit over the stoma and shunted air up a tube (figure 5). The tube was equipped with a metal or rubber-band reed that supplied a sound source for speech production. Two problems were associated with this device: It was difficult to securely fit the cap over the stoma, and the voice that it produced was weak and sounded artificial.

Electric devices were introduced during the 1940s. Among them was the hand-held electrolarynx, which when placed under the mandible provided a sound that resonated through the pharynx. (4) The electrolarynx was sometimes used with the Cooper-Rand reed, a tube that was inserted into the mouth to transmit sound. All these instruments produced a weak and artificial-sounding voice.

At that time, esophageal voice production was being heavily promoted as the ultimate means by which postlaryngectomy patients could achieve a functional voice. (5) However, most patients were unable to master the techniques required to produce an esophageal voice. (3)

In succeeding decades, new surgical procedures were developed by Conley et al, (6) Asai, (7) Montgomery, (8) and others who discovered means of shunting air from the stoma to different areas of the hypopharynx, base of the tongue, or esophagus. However, these operations were all plagued with problems requiring extensive or multiple surgeries and frequent leakage around the fistula tracts. In 1974, Komorn reported his attempt to simplify surgery by using a one-stage procedure to create a more direct tracheoesophageal fistula, but he still faced problems with leakage. (9) In 1975, Taub described his rather complex airbypass prosthesis, which extended from the stoma to the esophagus, but his procedure required a bulky prosthesis and significant surgery. (10) Finally, Singer and Blom described their rather simple technique for introducing a prosthesis in 1980. (1)

The Blom-Singer method and similar procedures soon became the standard means of achieving postlaryngectomy voice restoration because of the simplicity of both the prosthesis and the surgical procedure. Even so, this method is not without its disadvantages. The placement of the prosthesis requires a rather substantial stoma, and a segment of the esophagus and hypopharynx must be supple enough to vibrate. Moreover, patients must learn how to remove, clean, and replace their prostheses, which requires a certain level of sophistication. Finally, patients must bear the ongoing costs of replacement prostheses. As a result, the tracheoesophageal fistula type of prosthesis is unsuitable for patients who have nonvibratory segments of the esophagus or hypopharynx and for those who have stomal problems. Moreover, this type of prosthesis might be impractical in developing countries where the level of medical care, patient sophistication, hygiene, and costs are important concerns.

The Stout prosthesis obviates many of these problems because the fistula tract at the base of the tongue serves as the vibratory segment and the stoma is not violated. Another unique advantage of the Stout prosthesis is that the size of the fistula tract allows for enough of an air exchange that the patient can blow the nose, blow out candles, and sniff enough air to smell. However, this procedure is not without potential problems. For example, if the fistula tract is placed too far forward into the main body of the tongue, it conceivably would be difficult to maintain the tract's patency. Also, if the tract is placed too low into the hypopharynx and not through the tongue muscle, leakage might occur. Finally, the need for a handheld prosthesis does not allow for hands-free speech, which some patients would find cosmetically unacceptable.

In conclusion, the Stout prosthesis remains a viable alternative in the head and neck surgeon's armamentarium for postlaryngectomy voice restoration. The procedure appears to be particularly applicable for patients in developing countries and for patients who have stomal or esophageal problems. Further experience with this method would help to more accurately define its role in future applications.

Acknowledgment

Dr. Stout expresses his thanks to Mr. Frank Weeden for his help and advice in the design of the Stout prosthesis.

References

(1.) Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Am Otol Rhinol Laryngol 1980;89:529-33.

(2.) Robbins J, Fisher HB, Blom EC, Singer MI. A comparative acoustic study of normal, esophageal, and tracheoesophageal speech production. J Speech Hear Disord 1984;49:202-10.

(3.) Gardner W. Harris HE. Aids and devices for laryngectomees. Arch Otolaryngol 1961;73:145-52.

(4.) Lueders OW. Use of the electrolarynx in speech rehabilitation. Arch Otolaryngol 1956;63:133-4.

(5.) Heaver L, White W, Goldstein N. Clinical experience in restoring oral communication to 274 laryngectomized patients by esophageal voice. J Am Geriatr Soc 1955;3:687-90.

(6.) Conley JJ, DeAmesti F, Pierce MK. A new surgical technique for the vocal rehabilitation of the laryngectomized patient. Ann Otol Rhinol Laryngol 1958;67:655-64.

(7.) Miller AH. First experiences with the Asai technique for vocal rehabilitation after total laryngectomy. Ann Otol Rhinol Laryngol 1967;76:829-33.

(8.) Montgomery WW. Postlaryngectomy vocal rehabilitation. Arch Otolaryngol 1972;95:76-83.

(9.) Komorn RM. Vocal rehabilitation in the laryngectomized patient with a tracheoesophageal shunt. Ann Otol Rhinol Laryngol 1974;83:445-51.

(10.) Taub S. Air bypass voice prosthesis for vocal rehabilitation of laryngectomees. Ann Otol Rhinol Laryngol 1975;84:45-8.

From the Voice Institute of West Texas, Abilene Christian University, Abilene, Tex. (Dr. King and Dr. Ashby). Dr. Stout is in private practice in Houston.

Reprint requests: Austin I. King, MD, 2217 Danville Dr., Abilene, TX 79605. Phone: (915) 695-2270; fax: (915) 695-3908; e-mail: Kinga@acu.edu
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Article Details
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Author:Ashby, Jon K.
Publication:Ear, Nose and Throat Journal
Date:Feb 1, 2003
Words:2330
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