Introduction
Hypertonicity and/or spasm of the constrictor pharyngeus muscles in the pharyngoesophageal (PE) segment are the main causes for failure to acquire fluent tracheoesophageal speech. If patients are suspected to be troubled by this problem, it is important to confirm this diagnosis. Insufflation through the voice prosthesis into the PE segment using a catheter can give the clinician already a good idea about the too high resistance of the PE segment. Insufflation could also be done directly through the fistula after removal of the prosthesis to make sure that the problem is not related to the voice prosthesis itself. The too high resistance can be objectified further by trachea pressure measurement during voicing at a comfortable loudness level. A pressure above 0.4 kPa at a comfortable loudness level (approximately 65 dB at 30 cm mouth to microphone distance) indicates hypertonicity. The next diagnostic procedure should be videofluoroscopy (see chapter on videofluoroscopy), which can differentiate between hypertonicity, stricture, and recurrence.1 Finally, a diagnostic plexus pharyngeus blockade with 1% lidocain can be carried out, to establish whether a short-term pharmacological denervation of the constrictor pharyngeus muscles solves the problem temporarily.
The primary mode of treatment of hypertonicity of the PE segment is intensified speech therapy (see chapter on speech therapy), where the addition of relaxation exercises sometimes can be helpful. Once patients get the feeling for fluency of the air and realize that they should press less strong instead of harder during voicing, conservative speech therapy training might overcome this problem. We reserve the invasive methods, i.e. chemical denervation with Botulinum toxin as the first choice and constrictor pharyngeus myotomy as the second choice, for failures of speech therapy only.
The primary mode of treatment of hypertonicity of the PE segment is intensified speech therapy (see chapter on speech therapy), where the addition of relaxation exercises sometimes can be helpful. Once patients get the feeling for fluency of the air and realize that they should press less strong instead of harder during voicing, conservative speech therapy training might overcome this problem. We reserve the invasive methods, i.e. chemical denervation with Botulinum toxin as the first choice and constrictor pharyngeus myotomy as the second choice, for failures of speech therapy only.