Relation between dimensions and intraluminal pressure of pharyngoesophageal transition and vocal and speech tracheoesophageal proficiency in total laryngectomized subjects

O propósito deste estudo foi relacionar as dimensões e a pressão intraluminal da transição faringoesofágica e a caracterização da proficiência de voz e de fala de laringectomizados totais com prótese traqueoesofágica. Participaram do estudo 20 laringectomizados totais com inserção secundária da prótese traqueoesofágica (Provox®, Atos Medical AB), sendo 17 homens e três mulheres, com idade média de 61 anos e sete meses, submetidos à laringectomia total clássica, com fechamento das camadas mucosa, submucosa e muscular para reconstrução da faringe. Todos os pacientes foram submetidos à coleta e registro do material de voz e de fala utilizando-se uma câmera de vídeo em sala silente. A avaliação da proficiência de voz e de fala foi realizada por quatro expertos, por meio de um protocolo de avaliação da comunicação traqueoesofágica. Em seguida, realizou-se a manometria esofágica para avaliação da pressão intraluminal da transição faringoesofágica no repouso e durante a emissão prolongada da vogal \"a\". Por fim, foi realizada a videofluoroscopia, sendo primeiramente orientado o paciente que deglutisse 20ml de sulfato de bário visando a identificação das estruturas anatômicas, para em seguida emitir por três vezes a vogal prolongada \"a\". Selecionaram-se dois quadros do exame videofluoroscópico, no repouso e durante a fonação, cujas dimensões foram avaliadas por três expertos, por meio de um programa computadorizado. Como resultados, 65% dos laringectomizados totais com prótese traqueoesofágica foram caracterizados como falantes moderados. Durante a fonação, a pressão intraluminal obtida foi de 38,1mmHg, e de 13,83mmHg no repouso. Dimensões de PTFE-PAF e de PTFE-PPF foram respectivamente, 4,73mm e 14,31mm (repouso) e 5,22mm e 18,56mm (fonação). No repouso, CLTFE foi de 12,55mm e 10,46mm durante a fonação. Durante a fonação, houve correlação positiva entre PTFE-PAF e amplitude de pressão intraluminal (0,41) da transição faringoesofágica. Correlações inversas foram constatadas entre CLTFE e amplitude de pressão (-0,27) no repouso, e entre PTFE-PPF e amplitude de pressão, durante a fonação (-0,24). No repouso, os bons falantes apresentaram valor de pressão de 13,1mmHg, e durante a fonação de 25,5mmHg. Quanto às dimensões da transição faringoesofágica, os bons falantes apresentaram maior PTFE-PAF (5,39mm) e menor PTFE-PPF (13,07mm) no repouso. Já na fonação, PTFE-PAF tornou-se menor (3,86mm) e PTFE-PPF maior (24,3mm). CLTFE permaneceu com valor intermediário entre os moderados e ruins falantes com PTE no repouso (16,31mm) e durante a fonação (12,36mm). Concluiu-se que a proficiência de voz e de fala da maioria dos falantes traqueoesofágicos foi categorizada como moderada. As amplitudes de pressão e as dimensões PTFE-PPF e CLTFE da transição faringoesofágica apresentaram diferença significante, considerando-se as condições de repouso e de fonação. Quando comparados aos falantes moderados e ruins, os bons falantes apresentaram valor intermediário de amplitude de pressão intraluminal na condição de repouso e menor valor durante a fonação; PTFE-PAF maior e PTFE-PPF menor, no repouso, e durante a fonação, a primeira dimensão tornou-se menor e a segunda maior. Apenas CLTFE se manteve com valores intermediários nas duas condições avaliadas para os bons falantes traqueoesofágicos.The objective of this study was to relate the dimensions and the intraluminal pressure of the pharyngoesophageal transition and the voice and speech proficiency characterization of individuals with tracheoesophageal prosthesis. The participants of the study were 20 total laryngectomized people with secondary insertion of tracheoesophageal prosthesis (Provox®, Atos Medical AB), characterized by 17 men and three women, with average age of 61 years and seven months, submitted to classic total laryngectomy, with closing of layers mucous, submucous and muscular for reconstruction of pharynx. All the patients had been submitted to collection and register of the voice and speech material with the use of video camera in a silent room. The evaluation of the voice and speech proficiency was performed by four experts, by means of an evaluation protocol of the tracheoesophageal communication. After that, esophageal manometry was carried out to evaluate the intraluminal pressure of the pharyngoesophageal transition during the drawn out emission of the vowel \"a\" and during rest. Finally, the videofluoroscopy was performed. At first the patient was oriented to swallow 20ml of barium sulphate aiming the identification of the anatomical structures; afterwards the patient was oriented to emit three times the drawn out vowel \"a\". Two pictures of the videofluoroscopy examination during phonation and rest were selected, and their dimensions were evaluated by three experts by means of computer software. Such results, 65% of the total laryngectomized with tracheoesophageal prosthesis were characterized as moderate speakers. The intraluminal pressure obtained during the phonation was 38,1mmHg, and 13,83mmHg during rest. PTFE-PAF and PTFE-PPF dimensions were respectively 4,73mm and 14,31mm (rest); and 5,22mm and 18,56mm (phonation). CLTFE was 12,55mm during rest and 10,55mm during phonation. During phonation, there was positive correlation between PTFE-PAF and the TFE intraluminal pressure amplitude (0,41). Inverse correlations were evidenced between CLTFE and the pressure amplitude (-0,27) during rest, and between PTFE-PPF and pressure amplitude during phonation (-0,24). The good speakers presented pressure values of 13,1mmHg during rest and 25,5mmHg during phonation. Considering the pharyngoesophageal transition, good speakers presented a bigger PTFE-PAF (5,39mm) and a smaller PTFE-PPF (13,07mm) during rest, when compared to moderate and bad ones. However an opposite situation occurred during phonation, and PTFE-PAF was about 3,86mm and PTFE-PPF about 24,3mm. CLTFE had an intermediate value during rest (16,31mm) and during phonation (12,36mm) among the moderate and bad speakers with tracheoesophageal prosthesis. A conclusion was that the voice and speech proficiency of majority of the tracheoesophageal speakers was characterized as moderate. The pressure amplitudes and the PTFE-PPF and CLTFE dimensions of pharyngoesophageal transition presented significant differences, when considering rest and phonation conditions. When compared to moderate and bad speakers with tracheoesophageal prosthesis, the good ones presented intermediate value of intraluminal pressure during rest and a smaller value during phonation. The good speakers presented a bigger PTFE-PAF and a smaller PTFE-PPF during rest, and a bigger PTFE-PPF and a smaller PTFE-PPF during phonation, when compared to moderate and bad speakers. Only CLTFE had intermediate values during the two evaluated conditions for the good tracheoesophageal speakers

Effect of singing training on total laryngectomees wearing a tracheoesophageal voice prosthesis

PURPOSE: To assess the effect of a program of singing training on the voice of total laryngectomees wearing tracheoesophageal voice prosthesis, considering the quality of alaryngeal phonation, vocal extension and the musical elements of tunning and legato. METHODS: Five laryngectomees wearing tracheoesophageal voice prosthesis completed the singing training program over a period of three months, with exploration of the strengthening of the respiratory muscles and vocalization and with evaluation of perceptive-auditory and singing voice being performed before and after 12 sessions of singing therapy. RESULTS: After the program of singing voice training, the quality of tracheoesophageal voice showed improvement or the persistence of the general degree of dysphonia for the emitted vowels and for the parameters of roughness and breathiness. For the vowel "a", the pitch was displaced to grave in two participants and to acute in one, and remained adequate in the others. A similar situation was observed also for the vowel "i". After the singing program, all participants presented tunning and most of them showed a greater presence of legato. The vocal extension improved in all participants. CONCLUSION: Singing training seems to have a favorable effect on the quality of tracheoesophageal phonation and on singing voice