Unaided speech in long-term tube-free tracheostomy.

OBJECTIVES/HYPOTHESIS: Objectives of the current study were as follows: 1) to determine whether a self-sustaining, tube-free tracheostomy with unaided speech capability can be achieved, 2) to propose new surgical techniques to enhance voluntary constriction of a tube-free tracheostoma to improve cough and speech production, and 3) to explain the mechanism involved in unaided speech after long-term tracheostomy. The hypotheses were that long-term, tube-free tracheostomy could minimize the unwanted effects of conventional tube-dependent tracheotomy; that surgical shunting of the trachea to the skin surface can be established through a short, skin-lined, self-supporting, nostril-like opening; and that patients could generate speech and cough without the need to occlude the stoma or use stents and/or one-way valves if such a long-term tube-free tracheostoma were established.

STUDY DESIGN: A prospective study of tube-free tracheostomy intended to establish unaided cough and speech.

METHODS: Thirty-five patients who underwent long-term flap tracheostomies between 1992 and 1999 with the prospective intent of establishing a self-sustaining stoma without the need for tubes or stents were reviewed. The patients were trained to intentionally constrict the stoma for production of unaided speech and cough. The pertinent techniques developed for successful achievement of these characteristics are presented and reviewed. A new surgical technique using a local tendinous muscular sling was designed to further improve the efficacy of stomal constriction.

RESULTS: A tube-free stoma was successfully established in all 35 patients. Eighteen patients achieved effective intentional constriction of the stoma and thereby were capable of unaided speech production. Four patients required an additional new surgical sling procedure to optimize unaided cough and speech production. Thirteen patients achieved only limited unaided speech production, but were satisfied to do nothing further.

CONCLUSIONS: New surgical techniques and postoperative management to create a modified tube-free tracheostomy with self-constricting capabilities can enable production of effective cough and near-normal generation of unaided speech. In this manner, the airway can be secured with little or no voice compromise.