Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento.
JAMA Otolaryngol Head Neck Surg. 2021 Dec 1;147(12):1065-1070. doi: 10.1001/jamaoto.2021.2409.
Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures.
To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019.
Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed.
Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type.
This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.
重要性：气管食管语音假体（TEP）是全喉切除术后用于发声的常用设备。TEP 语音和言语产生的差异可能反映在气管内压力的差异上。
目的：检查 TEP 患者的气管内压力（IMP）、言语功能和近端食管异常之间的关系。
设计、地点和参与者：这是一项回顾性队列研究，在一个单一的学术机构进行，纳入了所有全喉切除术和 TEP 病史的患者，他们在 2019 年 9 月 9 日至 2019 年 12 月 4 日之间完成了放射食管造影和气管内压力测量。
主要结果和措施：对 22 名患者进行了持续发声、会话语音和最大音量任务期间的气管内压力测量。在有吞咽困难和无吞咽困难抱怨的患者之间比较了压力指标、发声持续时间和言语产生的流畅性。还评估了压力与言语指标之间的关系。
结果：22 名患者中，17 名（77.2%）为男性，5 名（22.7%）为女性，平均（SD）年龄为 66.6（8.8）岁。平均（SD）持续发声持续时间为 9.3（5.2）秒，持续发声时的平均（SD）IMP 为 50.5（21.4）cm H20。持续发声时的 IMP 与会话语音强烈相关（r=0.712；95%CI，0.384-1.039），与最大音量任务中度相关（r=0.524；95%CI，0.127-0.921）。会话语音期间的 IMP 与最大音量任务中度相关（r=0.538；95%CI，0.145-0.931）。持续发声时的 IMP 增加与持续发声持续时间减少中度相关（r=-0.450；95%CI，-0.867 至-0.034），会话语音与持续发声持续时间减少中度相关（r=-0.524；95%CI，-0.921 至-0.127）。有主观吞咽困难和近端食管异常的患者最大发音时间（均值[标准差]，7.08[5.03]秒）明显短于无主观吞咽困难抱怨的患者（均值[标准差]，11.95[4.40]秒），差异有统计学意义（Cohen d=1.031；95%CI，0.141-1.92）。所有 TEP 言语不流畅的患者均存在近端食管结构异常。原发性闭合与重建瓣型之间的压力或言语指标无差异。
结论和相关性：这项队列研究发现，增加的 IMP 和近端食管异常与 TEP 语音质量较差有关。在 TEP 发声有困难的患者中，应考虑对食管进行评估。需要进一步研究气管内压力作为改善 TEP 发声的生物反馈工具。
