Preoperative screening
Apart from a regular ENT examination, including inspection of the pharynx for the presence of a stenosis or web formation at the base of the tongue and checking the stoma size, a barium swallow should be performed to check the size and mobility of the pharyngoesophageal (PE) segment. This to anticipate on possible problems with the introduction of the rigid endoscope and to see whether dilation of the PE segment is needed. Insufflation test: Often this test is advocated in order to predict the outcome of secondary prosthetic voice rehabilitation. The test is performed by introducing a 12-14 Fr nasogastric catheter into the PE segment. Either the examiner blows air into the pharynx in order to obtain speech, or the catheter is connected to the stoma and the patient tries to speak blowing air through the catheter himself.
However, the results of this test are not very reliable and a negative result should not be interpreted as a contraindication against secondary prosthetic voice rehabilitation. A negative result could be indicative of a hypertonicity of the constrictor pharyngeus muscles, which can be corrected surgically with a myotomy or chemically with Botox.
In general, however, we are not in favor of combining the secondary introduction of the voice prosthesis with a myotomy of the constrictor pharyngeus muscle. It is advisable to wait for the results of the speech therapy. Only if hypertonicity of the constrictor pharyngeus muscle becomes apparent, and results do not improve after proper training, a chemical neurectomy with Botox or a surgical myotomy of this muscle could be considered. In the Netherlands Cancer Institute very few hypertonicity treatments have to be performed, as this problem appears to be quite rare after introduction of primary plexus pharyngeus neurectomy and upper esophageal sphincter myotomy. If needed, however, results of voice rehabilitation can be expected to be improved considerably. For the technique of secondary myotomy, see page 25.
However, the results of this test are not very reliable and a negative result should not be interpreted as a contraindication against secondary prosthetic voice rehabilitation. A negative result could be indicative of a hypertonicity of the constrictor pharyngeus muscles, which can be corrected surgically with a myotomy or chemically with Botox.
In general, however, we are not in favor of combining the secondary introduction of the voice prosthesis with a myotomy of the constrictor pharyngeus muscle. It is advisable to wait for the results of the speech therapy. Only if hypertonicity of the constrictor pharyngeus muscle becomes apparent, and results do not improve after proper training, a chemical neurectomy with Botox or a surgical myotomy of this muscle could be considered. In the Netherlands Cancer Institute very few hypertonicity treatments have to be performed, as this problem appears to be quite rare after introduction of primary plexus pharyngeus neurectomy and upper esophageal sphincter myotomy. If needed, however, results of voice rehabilitation can be expected to be improved considerably. For the technique of secondary myotomy, see page 25.
