食道音声を早期に獲得させる手術法

A NEW SURGICAL TECHNIQUE FOR THE VOCAL REHABILITATION OF THE LARYNGECTOMIZED PATIENTS

　Ⅰ．緒言

　喉頭全摘出術後の発声法には，食道音声と人工喉頭声とがある。最近ではその他に喉頭造設術laryngoplastyによる発声も試みられつつある。食道音声と人工喉頭声とでは，食道音声の方が発語明瞭度もよく，また特殊な器械を必要としないのですぐれている。しかし，人工喉頭による発声法の獲得はきわめて容易であるのに，食道音声の習得は困難であることに難点があり，現状では，食道音声に習熟している無喉頭者は全例の約60％あるいはそれ以下と考えられている^2）。

　食道音声の獲得は生理学的因子によるだけでなく，患者の性格，意志など心理学的因子に左右されることが多いので，これに関する基礎的研究の多くは単に現象の解析に止まつて，臨床面で実際に利用されているものは少ない。術者は癌の根治のみを考えて手術し，術後の発声機能に関してはすべてspeech therapistに委せているというのが各国共通の現状である。この論文では，食道音声に関して解明されている生理学的成果について，手術の面より，食道音声を獲得し易くさせる基本条件を検討してみた。

　For 22 cases of total laryngectomy, Conley's surgical method was carried out. An esophageal fistula was created after laryngectomy and the patient spoke in a way similar to the esophageal speech with the exhaled pulmonary air directed into the esophagus through the fistula. Eleven cases of them came to speak without special cannulas after speech training.

　From these experiences and some physiological findings about the esophageal phonation, a new surgical technique was devised by modifying Conley's method. The larynx was dissected just beneath the third tracheal cartilage. After the pharyngeal opening was closed, the thyropharyngeal muscle was tightly sutured together, while the cricopharyngeal muscle was not sutured. The muscle layer of the anterior wall of the cervical esophagus was separated 1.5cm below the pharyngoesophageal junction, and the mucous membrane was drawn up and sutured at the small opening of the skin above the tracheal stoma, similar to the procedure of colostomy. The fistula was created without any difficulty by a small incision on the exposed mucous membrane a few days later.

　The patient soon spoke in the Conley's way and was trained to intake air into the esophagus and force it out through the pharynx.

　This new surgical procedure has been administered to 10 cases of total laryngectomy. Six cases of them obtained excellent esophageal speech and the fistula was closed, three of themcould speak without special cannulas; i. e., ninety per cent attained proficiency in esophageal voice.