PROBLEMS WITH TRACHEOESOPHAGEAL FISTULA VOICE RESTORATION IN TOTALLY LARYNGECTOMIZED PATIENTS - A REVIEW OF 95 CASES

Objectives: Tracheoesophageal fistula (TEF) construction, performed du ring or after total laryngectomy, is used for voice and speech restora tion but has been associated with mild to severe complications. Our go al was to study the successes and complications in the application of this technique to restore voice function after laryngectomy in 95 cons ecutive patients. Research Design: Retrospective cohort study with a m ean follow-up time of 3.5 years. Setting: Five medical facilities in n orthern California: the Veterans Affairs Medical Centers in San Franci sco and Martinez, the Kaiser Permanente Medical Center in Oakland, and private practice offices in San Francisco and Pinole. Patients: Ninet y-five patients (90 men and five women) who had undergone total laryng ectomy with subsequent or primary TEF construction. Patients' ages ran ged from 35 to 80 years. Interventions: Three- or two-layer closure wa s 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 const ruction. Insufflation tests were performed by clinicians, or self-insu fflation tests were performed by the patient. Patients' voices were re corded and analyzed. In many cases, respiratory and pulmonary function studies were performed before and after total laryngectomy or TEF. Bl om-Singer and Groningen voice prostheses were used. Male Outcome Measu res: 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 valu es obtained during insufflation, fistula retention, TEF angulation shi fts, fungal colonization of the prosthesis, valve retention problems, difficulty with digital occlusion, pressure necrosis, postradiation ne crosis, dysphagia, phonatory gagging, emesis, gastric distention, pouc hing, stenosis, infection, hypertrophy, shunt insufficiency, persisten t spasm, myotomy, inadvertent fistula closure, and aspiration of the p rosthesis. Conclusions: Acoustic measures indicate that speech produce d 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.