Alaryngeal speech rehabilitation

INTRODUCTION — Patients with head and neck cancer face multiple psychological and functional problems associated with the diagnosis and treatment of their disease. Although cure remains a primary goal, functional restoration is an important secondary goal of therapy that influences treatment for many patients with head and neck cancer. (See "Locally advanced squamous cell carcinoma of the head and neck: Approaches combining chemotherapy and radiation therapy".)

The options for alaryngeal voice rehabilitation in the patient with total laryngectomy will be reviewed here. This discussion is geared toward practicing head and neck clinicians and all other caregivers who are involved in the care of the head and neck cancer patient. However, this topic does not go into detail regarding specific surgical techniques, and the interested reader should consult a surgical atlas and other technique articles for further information.

General issues related to speech and swallowing rehabilitation are discussed separately. (See "Speech and swallowing rehabilitation of the patient with head and neck cancer".)

GENERAL PRINCIPLES — A goal of rehabilitation following total laryngectomy is restoration of voice and speech production. Most patients achieve this goal, but not all are capable due to anatomic constraints (eg, persistent stricture), mental and physical handicap, lack of rehabilitative access and support, or financial constraints for prosthetic replacement and management.

There are three major approaches used to restore oral communication, and many patients learn to use all three methods:

●The artificial larynx (electrolarynx)

●Tracheoesophageal voice restoration

●Esophageal speech

The different approaches are not applicable to all laryngectomized individuals. Selection of the mode of alaryngeal communication should be based on an individual's specific needs, personality, physical capabilities, level of independent functioning, caregiver support, and motivation.

Despite significant improvements in alaryngeal speech production using other methods, the electrolarynx remains a commonly used method for communication following total laryngectomy [1-3]. In a report of 166 laryngectomized patients who participated in the Veterans Administration Cooperative Study, artificial electrolarynx (55 percent) and tracheoesophageal speech (31 percent) were the primary methods of speech production [2]. Only a few patients developed usable esophageal speech (6 percent) or remained nonvocal (8 percent).

Overall, patients' speech intelligibility increases dramatically over the first year after a total laryngectomy [4]. Patients should be encouraged that improvements are realized with progressive speech therapy and work. Those who attended speech therapy clinics achieved greater objective speech intelligibility at one year.

Total laryngectomy has diminished in frequency due to both an increased use of nonsurgical therapy and an overall decrease in the number of laryngeal cancers as tobacco use has decreased. In most cases, laryngectomized patients make up a very small percentage of speech pathologists' caseloads when compared with other more common rehabilitative populations, such as stroke and traumatic brain injury, thus many speech pathologists have general familiarity with alaryngeal speech rehabilitation but may not have the expertise in tracheoesophageal voice restoration to thoroughly manage the often complex rehabilitative and prosthetic needs of the tracheoesophageal speaker.

ARTIFICIAL LARYNX — The electrolarynx remains the most commonly used artificial device for alaryngeal speech production. It is an electronic, battery-powered device that produces vibrations that are transmitted through the external tissues of the neck or cheek or delivered intraorally via a plastic tube into the oral cavity for speech production. The patient shapes the sound for word production via movements of the tongue, jaw, lips, and pharynx. The electrolarynx has almost completely replaced other types of mechanical or pneumatic devices and can be used immediately after surgery.

There are numerous manufacturers of electrolarynges. Some newer devices include mechanisms for pitch variation for more natural and melodious speech [5]. Selection of the appropriate device depends on a variety of factors, including adequate sound transmission for optimal speech intelligibility and patient preference.

Advantages — The electrolarynx has the advantage of providing immediate postoperative verbal communication with relative ease. The electrolarynx is equal in intelligibility to esophageal speech [6] and is better discriminated in noise than esophageal speech, resulting in improved communication in noisy environments [7]. Additionally, in the United States, the electrolarynx has become more readily available to many patients who have undergone total laryngectomy.

Use of the electrolarynx does not affect the acquisition of either esophageal or tracheoesophageal speech. It can therefore be used as an interim means of communication while the patient is learning esophageal speech production or during the immediate postoperative healing period prior to placement of a voice prosthesis. It can serve as a backup to the other alaryngeal speech alternatives in case of an emergency, should esophageal or tracheoesophageal speech production become effortful or fail due to fatigue, upper respiratory tract infection, cancer recurrence, or problems associated with the tracheoesophageal prosthesis.

Therefore, all patients who have undergone total laryngectomy should receive and be conversant using an electrolarynx even if it is not used as the primary method for communication.

Disadvantages — The primary disadvantage of the electrolarynx is the mechanical sound quality, which some patients find unacceptable. In addition, the devices generally require the use of one hand, a problem for some patients interested in returning to work and for those who want to be able to speak without the use of their hands. Although newer devices offer adaptations for hands-free use, the modified devices are often bulky and are not easily adapted or preferred by all individuals.

The electrolarynx also may draw unwanted attention to the laryngectomized speaker, a disadvantage that prompts many to seek an alternative form of alaryngeal speech.

TRACHEOESOPHAGEAL VOICE RESTORATION — Tracheoesophageal (TE) voice restoration offers the laryngectomized individual the potential for spontaneous, effortless speech production.

TE voice restoration has often been cited as the alaryngeal speech alternative most comparable to normal laryngeal speech in quality, fluency, and ease of production [8-11]. TE speech is superior to esophageal speech in terms of speech quality, longer phonatory duration, and higher maximal vocal intensity (movie 1 and movie 2) [12-15].

Furthermore, TE speakers are generally more satisfied with their speech, perceive their speech to be of better quality, have improved ability to communicate over the telephone, and have fewer limitations in their interactions with others compared with those using the electrolarynx or esophageal speech [16].

Tracheoesophageal puncture (TEP) may be performed as a primary procedure at the time of total laryngectomy; in other cases, TEP may be carried out as a secondary procedure at a subsequent time point. Although debate persists regarding the optimal timing for creation of the fistula and outfitting with the prosthesis, ultimate success often depends on patient motivation and clinician expertise.

Advantages of primary TEP include earlier use of the voice prosthesis for voice rehabilitation. The procedure may be carried out at the same time as the total laryngectomy procedure, adds minimal time to that procedure, and does not require a separate procedure at a later date. It is logical to expect more healing problems with the creation of a fistula (TEP) at the time of laryngectomy in a patient previously treated with chemoradiation. However, a review of all total laryngectomy procedures in a large national database did not find an increased number of infections in patients undergoing primary TEP versus no TEP, and it found only a small increase in the overall complication rate [17]. Other retrospective studies have found that the rate of complications in patients undergoing primary versus secondary TEP is similar [18]. The rates of successful TE voice restoration are similar with either primary or secondary TEP placement [19].

The traditional placement of TEP involves insertion of a temporary catheter or stent, which is exchanged for a prosthesis after the tract matures. More contemporary practitioners have reported success with placement of a voice prosthesis when the TEP is initially created. A prospective study reported that placing a voice prosthesis at the time of TEP includes fewer early device changes, less need to resize the device, a longer interval to first device change, and earlier commencement of voicing [20].

Patient selection — The goal of patient selection for TE speech is to identify those individuals who will achieve useful sound production, who can access rehabilitative services from centers with expertise, and who can maintain and replace necessary prostheses over the course of their lifetime.

Potential contraindications to TE voice restoration include impaired cognitive-mental functioning, severe psychosocial dysfunction, or continued substance abuse (alcohol, pharmaceuticals), as these conditions prevent reliable, precise, and consistent management of the TE voice prosthesis. When patients present with significant and multiple comorbidities or postoperative anatomical changes, or have limited psychological readiness for TE voice restoration, it is prudent to consider TEP as a secondary procedure to allow for postoperative recovery and adaptation to new anatomic and physiologic changes.

Access to comprehensive rehabilitative services that include clinicians experienced in airway management and care of the wide variety of prosthetic options is important to optimally manage patients employing TE voicing. In a review of experience with 390 alaryngeal patients with TEP, the median device life was 61 days before needing to be replaced, most often due to leakage around the prosthesis [21]. The frequency of device replacement may necessitate visits with a qualified speech pathologist approximately every two months. Despite otherwise appropriate TE voicing candidacy, the inability to access expert help or necessary prosthetic equipment remains a contraindication to TE voice restoration.

When TEP is recommended as a secondary procedure following total laryngectomy, proper preoperative evaluation will help determine appropriate candidacy. Preoperative esophageal insufflation testing is not used as commonly to predict postoperative TE speech production but, in many cases, may have a purpose to allow the patient to hear his or her new voice. In addition, it provides a preoperative functional baseline for postoperative comparison.

Preoperative counselling is important to ensure realistic expectations and commitment to prosthetic management. A study showed that durability of the prosthesis is a key limiting factor to successful TE voice restoration, patient satisfaction, and overall quality of life [21].

Technique — A small, surgically controlled fistula is created in the TE wall. The opening is maintained by a unidirectional valved prosthesis that protects the airway during swallowing and opens to divert pulmonary air across the pharyngoesophageal mucosa for phonation when the tracheostoma is occluded. TE speakers can shunt air from the trachea into the pharyngoesophagus either by manual occlusion of the stoma with a digit or by the use of a tracheostoma breathing valve. The movement of the structures of the oral cavity then shapes the sound into words for speech production (picture 1 and picture 2 and picture 3).

The tracheostoma breathing valve attaches to the neck via peristomal or intraluminal attachments. It remains open during quiet breathing and automatically closes in response to an increase in expiratory air flow to allow speech production. The device permits hands-free speech that eliminates the inconvenience, unwanted attention, and lack of hygiene associated with digital stomal occlusion.

When a tracheostoma valve is used in lieu of digital occlusion of the stoma, the most common problem is maintaining the seal between the valve attachment and the skin. This is particularly true for patients who use the peristomal type of attachment, whether it is a standard, commercially available device or it has been customized to the patient's individual neck contour. Nonsignificant benefit in the duration of seal attachment has been reported when peristomal attachments are customized [22]. A similar problem occurs when the valve cannot be adequately retained in the trachea using the intraluminal attachment. In either case, air leakage and eventual detachment of the valve occur, which is often distracting to the listener and frustrating to the TE speaker.

A customized intraluminal attachment may offer some patients who are unable to wear a peristomal or standard intraluminal attachment an additional alternative for attachment of the hands-free tracheostoma valve [23-25]. One study reported a significantly higher success rate with hands-free TE speech using custom Barton buttons as compared with standard Barton buttons and peristomal attachments (85 versus 57 and 9 percent, respectively) [22]. A step-by-step approach for customizing another type of laryngectomy button, the LaryButton, has been described to provide assistance to clinicians attempting to modify this device for intraluminal attachment of breathing valves for hands-free speech production [25]. Surgical release of the sternocleidomastoid muscles at the time of laryngectomy frequently provides a flatter, more even peristomal surface that facilitates attachment of hands-free devices. When peristomal or intraluminal attachments fail, digital occlusion of the stoma for TE speech production is often preferred [23,24].

Despite the attraction of hands-free speech production, the ability to successfully maintain peristomal or intraluminal attachments for use of a tracheostoma breathing valve continues to be limited by irregular stomal contours and increased pulmonary backpressure against the device during TE speech production. Attention to modifying the anterior neck to flatten the region around the stoma by transection of the sternal head of the sternocleidomastoid muscle may help avoid anatomic irregularities around the stoma. It is therefore prudent to carefully assess candidacy for hands-free TE speech production prior to investing in alternatives that are costly and ultimately unsuccessful.

Since its introduction in 1980, the surgical method has become simpler and the occurrence of complications rare. In some instances, TEP can be performed as an outpatient procedure using local anesthesia, with high rates of reported success [26].

Definition of success — Various definitions of success in evaluating TE voice restoration have been used in the past, complicating analysis of the literature. A scale to evaluate outcomes, the Harrison-Robillard-Shultz Tracheoesophageal Puncture Rating Scale (HRS rating scale), was described in 1992 [27]. The HRS rating scale incorporates assessment of prosthesis use, quality of communication, and ability to provide independent care of the prosthesis [27]. However, this scale is not widely used in outcome studies of TE rehabilitation, although no other standard assessment instrument is used instead. In most cases, the ability to produce 10 to 15 syllables on a single breath without hesitation has been used as the indicator of successful TE speech production [28].

Factors influencing tracheoesophageal puncture success — A number of factors influence the likelihood of success with TE voice restoration, including the experience of the managing team as well as patient age, history of prior irradiation, and timing of placement [29,30]. Selecting appropriate candidates for TE puncture maximizes the chances of achieving useful and fluent TE speech production and minimizes known postoperative complications. (See 'Patient selection' above.)

Surgical factors — Success using TE voice restoration is more complicated when performed following complex pharyngeal reconstructions that require the use of fasciocutaneous free flaps or visceral transpositions. Successful speech and swallowing outcomes have been reported following fasciocutaneous free flap reconstructions, such as those that use the anterior thigh or radial forearm free flap, compared with those following visceral transpositions using the jejunum [31]. As a result, visceral transposition as a reconstructive alternative for circumferential defects of the pharynx has become less popular.

A series summarizing results with TE voice restoration from the past decade reported an overall success rate of 72 percent at two years [18]. Older series from prior decades reported success rates ranging from 80 to 96 percent [32,33]. This difference suggests a changing population of patients who need alaryngeal speech rehabilitation following total laryngectomy, including those who are more likely to have been treated for recurrent tumors following nonsurgical treatments and thus are less likely to have undergone a primary laryngectomy.

Other factors — Multiple other factors that impact successful use of TE voicing include the following:

●Age – Some series suggest that age is an important determinant of success with TE voice restoration, with older patients having reduced likelihood of success [27,34,35]. In contrast, other retrospective series have demonstrated equivalent outcomes, with the suggestion that careful patient selection can optimize success even among older patient populations undergoing TE rehabilitation [33,36].

●Gastroesophageal reflux – Gastroesophageal reflux disease (GERD) has been identified as an important factor leading to TEP complications [37,38]. Patients with severe reflux had a 10 times higher risk of developing TEP complications [38]. The association of prosthesis failure with GERD was strongly associated with postoperative radiation treatment [39].

A prospective study demonstrated that treatment with a proton pump inhibitor could objectively reduce reflux to the level of the prosthesis and neopharynx to decrease problems with periprosthetic leakage [40]. Another study evaluating a group with objectively diagnosed GERD demonstrated that treatment with a proton pump inhibitor led to improvements in prosthesis function [37].

●Tracheoesophageal puncture diameter – Anecdotal reports have suggested a positive relationship between increased diameter of the TE voice prosthesis and problems developing from leakage around an enlarging fistula site [41,42]. However, a systematic review and multivariable analysis of 194 patients failed to identify a statistically significant association between use of a large-diameter prosthesis and subsequent enlargement of the fistula [43]. Factors correlating enlarging fistula with leakage included radiation therapy, advanced nodal disease, recurrent cancer after laryngectomy, postoperative stricture, extended resection/reconstruction, and nutritional deficiencies.

Access to rehabilitative services that include expert clinicians as well as a variety of prosthetic options is critically important to ensuring successful TE voice restoration in patients who live far away from large centers of excellence so that serious prosthetic complications are avoided and TE voice production is maintained. Despite excellent TE voice restoration candidacy, the inability to access expert help or necessary prostheses remains a contraindication to TE voice restoration.

Problems — Specific problems associated with the production of TE speech can be subdivided into two groups: physiologic-anatomic variations in structure and function, and mechanical problems. In a review of experience with 390 alaryngeal patients with TEP, the median device life was 61 days before needing to be replaced, most often due to leakage around the prosthesis [21]. The frequency of device replacement may necessitate visits with a qualified speech-language pathologist approximately every two months.

Physiologic-anatomic variations — Physiologic-anatomic variations may be directly related to the laryngectomy itself, including the following:

●Pharyngeal constrictor hypertonicity or "spasm"

●Hypopharyngeal stricture

●Flaccidity of the neoglottic segment

●Stomal stenosis and irregularity

●Enlargement of the TEP

Some of these problems may be aggravated following laryngectomy, especially in patients with gastroesophageal reflux and Candida colonization within the oropharynx. Some of these problems may be worse in patients who have received radiation therapy, either definitively for cure or in combination with surgery.

Treatment strategies for some of these physiologic-anatomic variations are discussed below:

●Pharyngeal constrictor hypertonicity – Initial results with pharyngeal myotomy, performed primarily or secondarily, significantly reduced the occurrence of pharyngeal constrictor hypertonicity and facilitated vocal rehabilitation [44,45].

The use of botulinum toxin injection to the pharyngeal constrictors, a noninvasive treatment for the relief of constrictor hypertonicity, has been equally successful and is preferred by many over surgical alternatives [46]. This intervention can successfully address postoperative failures in TE speech production caused by pharyngeal constrictor spasm. Prior to botulinum toxin injection, it is useful to confirm that a fixed obstruction, such as a stricture, is not present. This assessment is often done by in-office flexible transnasal endoscopy or radiographically with barium ingestion. At many institutions, trials of air insufflation as well as lidocaine injections [45,47] are no longer used prior to botulinum toxin injection to determine its potential for success.

●Stomal stenosis and irregularity – Treatment with irradiation may create problems for patients who have had a TEP placed prior to radiation therapy. Common issues may include difficulty with stomal occlusion and tenderness or pain when removing, cleaning, or replacing the voice prosthesis. Placement of a "dummy" prosthesis during the course of radiation therapy ensures patency of the fistula and prevents spontaneous closure of the TEP tract. Although short-term use of a catheter to stent the TEP tract is often helpful in maintaining patency of the TEP, extended catheter placement may be contraindicated in some patients, particularly those who have been irradiated. When the catheter remains in place for extended periods of time, the weight of the catheter against the fragile TEP mucosa may cause erosion and enlargement of the puncture site, resulting in leakage and aspiration around the catheter, and later around the TEP prosthesis, that is often difficult to manage and frequently intractable.

●Enlargement of the tracheoesophageal puncture – Enlargement of the TEP may occur in up to 20 percent of patients and has been postulated to be associated with a variety of etiologies, including tumor recurrence, fibrosis, malnourishment, uncontrolled diabetes, and smoking [34,48]. A multivariate analysis in a retrospective cohort found that advanced nodal disease, postoperative stricture, and locoregional recurrence/distant metastasis were the most significant risk factors for enlargement of the TEP. Additionally, preoperative nutritional status and extended resection were also found to be associated with greater risk of enlargement of the TEP [48].

The complications associated with an enlarged TEP can be life threatening [34,43,49]. Investigators have previously reported a 39 percent risk of pneumonia and a 14 percent rate of chronic feeding tube dependence in patients with intractable leakage resulting from an enlarged TEP that is inadequately managed [49]. Radiation therapy affects tissue elasticity. This tissue change may predispose to leakage of saliva or food around the TE prosthesis due to an enlarged or irregular TEP.

Conservative treatment options to relieve the leakage, prevent complications such as aspiration, and avoid permanent closure of the TEP have been proposed for management of leakage around the prosthesis, but most have failed to provide long-term resolution of the problem. In some instances, removing the prosthesis and inserting a catheter with a smaller diameter than the prosthesis temporarily alleviates the problem. More often, patients will require modification of the TE voice prosthesis that enlarges the posterior retention flange to provide adequate surface coverage of the fistula within the esophageal lumen.

A contemporary study found that 80 percent of patients with enlarged TEPs had been successfully managed at last follow-up with a customized voice prosthesis and avoided permanent gastrostomy, aspiration pneumonia, and surgical TEP closure, regardless of the extent of prior surgery or radiation. Customization of both the esophageal and tracheal collars has been successful in preventing long-term leakage around the voice prosthesis. The strategy to achieve surface coverage of the esophageal mucosa may be challenging because of movement of the prosthesis during speech production, swallowing, and breathing [50]. One study reported elimination of aspiration around the prosthesis after placement of a customized TE prosthesis in 99 percent of cases [51].

A variety of surgical techniques have been proposed to facilitate narrowing and even closure of the enlarged TEP [34]. Injections of various materials into the TEP wall have been reported to facilitate stenosis of the enlarged puncture [34,52-56]. In severe cases, intractable leakage may require surgical closure and repuncture [34]. However, a systematic review found that less than 20 percent of patients with an enlarged TEP require complete closure of the puncture site [43].

Both TE voice production and swallowing are intimately related after total laryngectomy; thus, any intervention that affects one will most certainly affect the other. A thorough examination by a knowledgeable and experienced clinician who can carefully weigh the functional benefits against the potential risks associated with the proposed intervention is extremely important. This will minimize the potential for deterioration or permanent loss of either speech or swallowing.

Mechanical problems — Mechanical problems incurred in the management of the TE prosthesis include challenges experienced during sizing, fitting, removing, and replacing the TE voice prosthesis within the puncture tract. Improvements in prosthetic designs, which have now extended to include a large variety of products as well as better professional training, have helped address these types of complications [57].

Despite improvements in prosthetic design, voice prosthesis device life remains a limiting factor of TE voice restoration that drives patient satisfaction, health care costs, and overall burden. Historic data suggest that TE voice prostheses have an average device life of three to six months, but these data are typically derived from small samples using only one or two devices. One study that reexamined device life in a large United States hospital showed that voice prosthesis duration demonstrates overall a lower durability than historically reported. A 2016 study reported that the median device life associated with leakage was 61 days for all prostheses, median 70 days for indwelling types, and 38 days for non-indwelling voice prostheses. In this study, no significant difference in device life between specialty prostheses and standard devices was found. Neither radiation therapy nor extent of surgery was found to have a meaningful impact on device life (p >0.05) [58].

In addition, TE speakers typically will need up to six prosthesis replacements each year. When patients experience problems associated with the prosthesis, the number of prosthetic replacements can be expected to increase. Thus, the ability to manage and replace prosthetic devices may be a costly necessity that many alaryngeal speakers cannot afford. It is therefore important that patients are counselled preoperatively to ensure understanding of the lifetime commitment to prosthetic management and ability to return for care to a treating institution that may be geographically distant [21].

ESOPHAGEAL SPEECH — Historically, esophageal speech production was the traditional choice for alaryngeal speech rehabilitation. The vibratory source is the pharyngoesophageal segment. Oral air that is introduced into the esophagus and expelled past the pharyngoesophageal segment is the driving force for speech production.

There are several methods used to teach esophageal speech [59]. The goal is for the patient to be able to rapidly impound air into the esophagus and then expel air from the esophagus through the oral cavity in a controlled manner to produce fluent speech.

Advantages — Esophageal speech has the advantage of verbal communication that does not require use of any mechanical or prosthetic device, thereby leaving the hands free while avoiding the maintenance associated with care of a prosthesis. The voice is produced by the patient with his or her own remaining postoperative anatomy and therefore is often viewed as more normal and desirable.

The vibrations of the pharyngoesophageal segment more closely approximate the sound of laryngeal vibrations, even though the pitch (mean 77.1 versus 102.8 Hz) and intensity (median 59.3 versus 69.3 dB) of esophageal voice are lower than that of normal laryngeal speech [8].

Disadvantages — The primary disadvantages of developing esophageal speech are the length of time required to learn the technique and the reduction in quality compared with tracheoesophageal voice restoration and normal laryngeal speech. Conservative estimates suggest that four to six months of daily practice and regular speech therapy sessions may be required to facilitate speech production; for some patients, it may take longer. In addition, although the majority of laryngectomized patients can learn to produce esophageal sound and some phrases, it has been estimated that less than 30 percent of patients are able to develop and use esophageal voice as their primary means of communication [60].

The low number of speech pathologists and fluent esophageal speakers trained to properly teach the method of esophageal speech production further limits its availability. Despite this limitation, esophageal speech production may be the optimal alaryngeal speech alternative for contemporary tracheoesophageal speakers who are at high risk for postoperative complications.

ALARYNGEAL SPEECH DURING THE COVID-19 PANDEMIC — For patients who have undergone permanent laryngectomy, guidelines for reducing infection risk during the COVID-19 pandemic, including mask-wearing and its integration with alaryngeal speech, are discussed separately. (See "COVID-19: Considerations in patients with cancer", section on 'Laryngectomized individuals'.)

SUMMARY

●Goals of rehabilitation - A focus for the speech pathologist in rehabilitation following total laryngectomy is restoration of voice and speech. There are three major approaches used to restore oral communication: the artificial larynx (electrolarynx), tracheoesophageal voice restoration, and esophageal speech. (See 'General principles' above.)

●Artificial larynx – The artificial larynx, or electrolarynx, is a battery-powered device that produces vibrations that are transmitted through the external tissues of the neck or cheek or delivered intraorally via a plastic tube into the oral cavity for speech production. The electrolarynx provides immediate postoperative verbal communication, is equal in intelligibility to esophageal speech, and provides improved communication in noisy environments. (See 'Artificial larynx' above.)

The primary disadvantage of the electrolarynx is the mechanical sound quality, which many patients find unacceptable. In addition, the devices necessitate the use of one hand, a problem for some patients interested in returning to work and for those who want to be able to speak without the use of their hands.

●Tracheoesophageal speech – Tracheoesophageal voice restoration relies on a controlled fistula in the tracheoesophageal wall that diverts pulmonary air across the pharyngoesophageal mucosa for phonation when the tracheostoma is occluded. Tracheoesophageal voice restoration is the alaryngeal speech alternative most comparable to normal laryngeal speech in quality, fluency, and ease of production (movie 1 and movie 2).

Ultimate success with tracheoesophageal voice restoration depends to a large extent on clinician expertise. Most studies report successful tracheoesophageal speech in more than 80 percent of patients who receive primary puncture and more than 70 percent who receive secondary puncture. Despite the simplicity associated with the concept and method of tracheoesophageal voice restoration, the process can be associated with challenging problems that often are best managed in centers of excellence by expert clinicians who have significant experience treating tracheoesophageal speakers. (See 'Tracheoesophageal voice restoration' above.)

●Esophageal speech – Esophageal speech production depends on air that is introduced into the esophagus and is then expelled past the pharyngoesophageal segment, the vibratory source for sound production. The primary disadvantages of developing esophageal speech are the length of time required to learn the technique and the reduction in voice quality compared with tracheoesophageal and normal laryngeal speech, compounded by the lack of availability of trained clinicians who can teach it. (See 'Esophageal speech' above.)