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Total laryngectomy, with its complete loss of voice, has stimulated the imagination of laryngologists and speech therapists to develop methods of voice production.

The are numerous techniques now available, some of which involve the use of technical equipment of varying complexity. They can be broadly subdivided under three headings:
1. Esophageal Speech
2. Surgical Methods

• (a) External method / external fistulae 
• (b) Internal method / internal fistulae
• (c) Functional or reconstructive techniques

Of the second group of surgical techniques, the more popular are the more recent development of a tracheo-esophageal fistula by direct puncture, either at the time of or some time after a laryngectomy. The patient wears a voice prosthesis in the fistula , with insertion of voice prosthesis; the most widely used having been described by Bloom and Singer and Gronigen. By virtue of their relative simplicity, and the ease with which they can be carried out, these techniques are now in the process of replacing those previously used. 


The fitting of the prosthesis can be carried out as a secondary procedure - as originally described by Bloom and Singer - or during the course of a total laryngectomy. After laryngectomy it is advisable to wait three weeks before making initial attempts at phonation, so that the recently sutured pharynx is not submitted to a high intraluminal pressure. This delay, and the use of postoperative radiotherapy, has led in some cases to postponing the fitting of the prosthesis until later. Wetmore recommended that the prosthesis should be inserted one month after the laryngectomy, or one month after the completion of postoperative radiotherapy. Rehan's group also believe that patients over the age of 70 years were unsuitable candidates for a prosthesis.


For several years the Bloom - Singer type of prosthesis was though to have provided the definitive solution to the problem of speech rehabilitation by returning voice to almost all laryngectomees, carrying a very low complication rate, and allowing patients a speedy return to a normal social and professional life, without them having to pay too high a price. Since the publication of the long - term results and complications of this technique, it has been necessary to temper the initial enthusiasm a little, although in experienced hands this certainly remains the best of the prosthetic techniques. 


Acquiring a voice using this technique requires close cooperation among the patient, the surgeon, and the speech therapist. A good result (a sufficiently powerful distinct and well - sustained voice) is achieved in about 60 to 70 percent of patients, but this varies significantly with patient selection. The effects of using the prosthesis long - term remains unknown. Even so, there are many patients who achieve a good initial result but do not continue to do so. The fact that the "ideal" prosthesis, if it exists, has yet to be found is reflected by the great number of different voice prostheses currently available. Whatever method is chosen to rehabilitate the laryngectomee, it is important that he be motivated and encouraged by a team comprising the surgeon, the speech therapist, and someone from the local laryngectomee association. The team itself must be equally well motivated. Occasionally the help of a psychologist may be useful for very difficult cases. 


Unfortunately, and in spire of all efforts, between 10 and 15 percent laryngectomees fail to acquire any form of vocal communication. For them, the solution still remains to be found.