Problems with tracheoesophageal fistula voice restoration in totally laryngectomized patients. A review of 95 cases.

OBJECTIVES

Tracheoesophageal fistula (TEF) construction, performed during or after total laryngectomy, is used for voice and speech restoration but has been associated with mild to severe complications. Our goal was to study the successes and complications in the application of this technique to restore voice function after laryngectomy in 95 consecutive patients.

RESEARCH

DESIGN

Retrospective cohort study with a mean follow-up time of 3.5 years.

SETTING

Five medical facilities in northern California: the Veterans Affairs Medical Centers in San Francisco and Martinez, the Kaiser Permanente Medical Center in Oakland, and private practice offices in San Francisco and Pinole.

PATIENTS: Ninety-five patients (90 men and five women) who had undergone total laryngectomy with subsequent or primary TEF construction. Patients' ages ranged from 35 to 80 years.

INTERVENTIONS: Three- or two-layer closure was used, depending on whether TEF construction was done as a secondary or a primary procedure. Most patients underwent radiation therapy, and most used surface or intraoral electrolarynx devices before TEF construction. Insufflation tests were performed by clinicians, or self-insufflation tests were performed by the patient. Patients' voices were recorded and analyzed. In many cases, respiratory and pulmonary function studies were performed before and after total laryngectomy or TEF. Blom-Singer and Groningen voice prostheses were used.

MAIN OUTCOME MEASURES: Voice restoration was considered successful when the patient was able to communicate effectively via the TEF.

RESULTS

Approximately 92% of patients who underwent TEF construction and had voice prostheses placed were considered to be successfully rehabilitated. Complications ranged from mild to severe and included problems with predictive values obtained during insufflation, fistula retention, TEF angulation shifts, fungal colonization of the prosthesis, valve retention problems, difficulty with digital occlusion, pressure necrosis, postradiation necrosis, dysphagia, phonatory gagging, emesis, gastric distention, pouching, stenosis, infection, hypertrophy, shunt insufficiency, persistent spasm, myotomy, inadvertent fistula closure, and aspiration of the prosthesis.

CONCLUSIONS

Acoustic measures indicate that speech produced with the TEF compares better with normal laryngeal speech than does esophageal or electronic speech. Thus, TEF should remain the preferred procedure to rehabilitate patients undergoing total laryngectomy.