Introduction
Following a total laryngectomy, speech rehabilitation generally includes three modalities: electrolarynx, oesophageal speech and tracheo-oesophageal (TEP) voice prosthesis. Tracheo-oesophageal voice prosthesis is particularly effective, offering fluent, intelligible and natural-sounding alaryngeal speech.Reference Doyle, Swift and Haaf1
Following total laryngectomy, the neopharynx, including the pharyngo-oesophageal (PE) segment, is crucial for successful tracheo-oesophageal (TE) speech. The tone of the vibrating PE segment is an important factor for optimum voice production. Pathological PE segments include: hypotonic segment, hypertonic segment and stricture.Reference Stell and Maran9
Abnormal tone of the PE segment, thus, hinders the initiation and maintenance of TEP speech.Reference Spector, Callaway, McKean and Prince2
Once a hypertonic PE segment is diagnosed, cricopharyngeal myotomy (CPM) is recommended. Cricopharyngeal myotomy can be accomplished by surgical means under direct laryngoscopic guidance.Reference Horowitz and Sasaki6
Injection of botulinum toxin into the hypertonic segment offers a relatively non-invasive alternative to relax the spasmodic segment.Reference Lightbody, Wilkie, Kinshuck, Gilmartin, Lewis-Jones and Jones5 However, the success of botulinum toxin injection is largely dependent on the accurate localisation of the hypertonic segment. In this article, we describe the utility of high-resolution ultrasound for precise localisation of the hypertonic segment.
Methods and materials
Description of the technique
A fifty-eight-year-old male patient was diagnosed with carcinoma supraglottis cT4aN0M0. He underwent total laryngectomy (bilateral level II, III, IV lymph nodal clearance), total thyroidectomy, CPM, primary TEP insertion and neopharynx formation by primary closure under general anaesthesia.
The patient subsequently underwent post-operative adjuvant radiation therapy of 60 Gy/30 fractions.
Speech rehabilitation began one month post-surgery, with barely any successful outcomes. The primary TEP insertion site was examined, and no features suggestive of peri-prosthetic leak /blockade of the prosthesis were noted.
The patient underwent modified barium swallow examination, and cricopharyngeal bar was noted as shown in Figures 1a and 1b.
Modified barium swallow (1a: anteroposterior, 1b: lateral view) showing the short-segment pharyngo-oesophageal spasm and cricopharyngeal bar (arrow).
Informed written consent was obtained from the patient. For botulinum toxin injection preparation, 50 mouse units (MU) of lyophilised botulinum toxin powder is reconstituted with 10 ml of normal saline (NS). The solution is then drawn into an insulin syringe equipped with a 26-gauge needle. Typically, 0.6 ml of the reconstituted botulinum toxin is loaded into two to four syringes. It is important to note that the reconstituted botulinum toxin should be used within 24 hr to ensure efficacy and sterility.
Using a linear array probe of 6 to 13 MHz (Philips Innosight, Amsterdam, The Netherlands), the cricopharyngeal segment is identified as a concentric muscular zone with a central air-filled lumen (Figures 2 and 3).
Botulinum toxin injection under ultrasound guidance.
Ultrasound localisation of the hypertonic segment (double arrow) and adjacent great vessel (single arrow).
The hypertonic segment can be confirmed by identifying the narrowest zone (Supplementary Video 1). During the procedure, the patient should be asked to attempt phonation and to swallow. During this manoeuvre, the tonic segment can be seen to contract transiently, thereby confirming the site for botulinum toxin injection. The diluted botulinum toxin is injected at three sites of the hypertonic segment. The patient received 2 injections, each of 40 MU of botulinum toxin A (BTA), 24 hr apart.
One week post-injection, the patient reported minimal subjective improvement in voice quality. Speech therapy was continued for the patient with the guidance of the trained speech therapist. (Supplementary Video 2).
With continued efforts made by the patient with the help of a speech therapist, the patient’s voice quality improved drastically.
Discussion
Introduced by Blom and Singer in 1979, tracheo-oesophageal puncture (TEP) is a procedure used to restore speech in patients who have undergone a total laryngectomy. Tracheo-oesophageal puncture can be done either at the time of the laryngectomy (primary TEP) or six weeks afterwards (secondary TEP). Radiotherapy does not interfere with the success of the procedure. While TEP was initially used for patients unable to achieve oesophageal speech or unsatisfied with an artificial larynx, it has now become a preferred method, with primary TEP increasingly used as the first choice for voice restoration.Reference Doyle, Swift and Haaf1
Tracheo-oesophageal prosthetic speech utilises a one-dimensional valve mechanism, which allows air from the lungs to enter the oesophagus for phonation, while preventing aspiration of the contents of the oesophagus to the airway. Failure of TEP speech can be categorised as prosthesis-related, puncture site-related and those associated with pathologies of the PE segment.Reference Dev and Saha3, Reference Kim, Lewin, Knott, Hutcheson and Dekovich4
After eliminating device-related and puncture site anomalies, one must evaluate the PE segment for its vibrating properties. Videofluoroscopy or modified barium swallow allows a dynamic assessment of the PE segment. Most of the techniques involve electromyographic guidance (EMG) along with the videofluoroscopic technique, as demonstrated by Spector et al.Reference Spector, Callaway, McKean and Prince2
Cricopharyngeal myotomy reduces the resting pressure of the upper oesophageal sphincter, thereby alleviating cricopharyngeal spasm and decreasing tension on the pharyngeal suture line.Reference Horowitz and Sasaki6
Research into the neural pathways controlling the pharyngeal musculature has led to the development of a novel technique called pharyngeal plexus neurectomy (PPN), designed to regulate pharyngeal tone without requiring a myotomy.Reference Singer, Blom and Hamaker7
Botulinum toxin A, derived from clostridium BTA, acts on pre-synaptic cholinergic muscle fibres to prevent the release of acetylcholine at the neuromuscular junction. It is commonly used as a percutaneous injection to relieve PE spasm, facilitating speech fluency.Reference Spector, Callaway, McKean and Prince2, Reference Lightbody, Wilkie, Kinshuck, Gilmartin, Lewis-Jones and Jones5
A simple clinical bedside method has been developed to identify the hypertonic PE segment in patients with PE spasm for botulinum toxin injections. The patient phonates while blocking the stoma, and the air column is traced upward until it disappears, marking the spasmodic segment’s lower boundary. Botulinum toxin A is injected into this segment. The best method for localising the PE segment for injecting BTA remains videofluoroscopy.Reference Vishal, D’Cruz, Deshpande, Chaukar and Pai8
Our technique differs from the traditional technique of BTA injection, as it involves an ultrasound-guided injection technique, which is relatively easier to master and employ in routine practice. The use of bedside ultrasound does not expose the patient or the clinician to radiation. It has additional advantages in the form that it can be repeated without additional radiation exposure and does not require the setup for fluoroscopy.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0022215125104027.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical statement and informed consent
The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the All India Institute of Medical Sciences. Informed consent was obtained from the patient.
