You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > SPEECH LANGUAGE PATHOLOGY Laryngectomy RehabilitationArticle Last Updated: Mar 18, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Lori E Lombard, PhD, Associate Professor, Department of Special Education and Clinical Services, Indiana University of Pennsylvania Editors: Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Karen Hall Calhoun, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Missouri; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: laryngectomy rehabilitation, alaryngeal voice rehabilitation, esophageal speech, laryngectomy voice restoration, tracheoesophageal punctures, tracheoesophageal speech, total laryngectomy, TL, near-total laryngectomy, NTL, voice restoration, artificial larynx speech, tracheoesophageal speech, electrolarynx, tracheoesophageal puncture, voice therapy, tracheoesophageal prosthesis, speech prosthesis, voice prosthesis, indwelling larynx prosthesis, duckbill prosthesis, duck bill prosthesis INTRODUCTIONSection 2 of 10
  Background Total laryngectomy (TL) significantly alters speech production. For a speech production system to be functional, 3 basic elements are necessary: (1) a power source, (2) a sound source, and (3) a sound modifier. For laryngeal speakers, lung air is the power source, the larynx is the sound source, and the vocal tract (ie, pharynx, oral cavity) is the sound modifier. During TL, the sound source is removed and the lungs are disconnected from the vocal tract. Successful voice restoration following TL requires identification of an alternative sound source with a viable power source. The 3 basic options for voice restoration after TL are (1) artificial larynx speech, (2) esophageal speech, and (3) tracheoesophageal speech. Selection of a method should be based on input from the surgeon, speech pathologist, and patient. The decision is best made keeping in mind the patient's communicative needs, physical and mental status, and personal preference. Esophageal speech
Artificial larynx speech
Tracheoesophageal speech
EVALUATING TRACHEOESOPHAGEAL SPEECHSection 3 of 10
Assessing the integrity of the pharyngoesophageal segment Tracheoesophageal punctures can be created primarily, at the time of TL, or secondarily, days to years after surgery. If the plan is for a secondary puncture, a simple insufflation test can be performed preoperatively by the speech pathologist to assess the integrity of the PE segment and potential voice quality. Results indicate whether further surgical intervention is necessary during the puncture procedure. If the puncture is performed primarily, insufflation testing is not an appropriate preoperative assessment because the cricopharyngeus will be reconstructed during the laryngectomy. Insufflation testing A catheter is placed through the nose and inserted until the end is just below the PE segment, ie, approximately 25 cm of the catheter length. Air is channeled through the catheter to insufflate the esophagus, simulating tracheoesophageal speech. If insufflation is monitored using manometry, the indication for adequate PE segment integrity is a phonation pressure less than 22 mm Hg. For perceptual assessment, the patient performs speech tasks, such as sustained phonation and/or counting for evaluation of phonatory quality and duration. The patient should be able to sustain phonation of /a/ for at least 10 seconds or produce 10-15 syllables per breath. If the insufflation test is performed correctly and phonation is not achieved or is of poor quality and duration, the 4 possible conditions of the PE segment that should be considered are (1) hypotonicity, (2) hypertonicity, (3) spasticity upon egress of airflow, or (4) stricture. If perception is uncertain, the PE segment can be further evaluated using fluoroscopy with barium swallows and repeated insufflations. If insufflation test results indicate failure, several therapies are available. If hypotonicity is present, consider applying digital pressure to the PE segment or an external pressure band around the patient's neck during phonation. If hypertonicity, spasticity, or both is present, consider pharyngeal constrictor myotomy, pharyngeal plexus neurectomy, or botulinum toxin (BOTOX®) injection with electromyographic or radiographic guidance. If stricture is present, dilatation is indicated. TRACHEOESOPHAGEAL SPEECH PROSTHESESSection 4 of 10
Selecting a prosthesisSeveral sizes and styles of tracheoesophageal prostheses are available. Selecting a valve should be a conscientious decision. The following 4 main issues should be considered when selecting a device: Phonatory effort Before any prosthesis is inserted, phonation should be sampled with a patent puncture tract. The perceptual quality and effort of that sample guides decision-making. For example, if the voice quality is effortless, loud, and consistent, then the patient may do well with a higher-resistance device with increased durability. If the voice quality is strained and effortful, a lower-resistance device of greater diameter (20F) may be appropriate. Candidacy for independent insertion If the patient and his or her spouse or caregiver appear able and willing to participate in prosthesis management, a valve with no restrictions on placement procedures should be considered. Indwelling devices, although touted for their advanced design, must be inserted by a trained professional. This stipulation creates a situation of patient dependency on the health care professional. Autonomy offered by devices that can be changed without restriction is appealing to many patients. Conversely, if the patient is unable or unwilling to change the valve independently, an indwelling style device offers more security from dislodgement. Durability Occasionally, the device that provides the least phonatory effort also has a patient-specific tendency to malfunction rapidly. If the device recurrently leaks in less than a couple of months with no treatable cause (eg, candidal infection), a device with higher resistance and durability should be considered. Cost Prices for valves vary from $28 (Inhealth 16F duckbill) to $199 (Provox 2 indwelling, Atos Medical). See Prosthetic Supply Vendors for vendor information. Cost issues should be considered when devices are comparable in style and performance. Certain health insurance policies do not cover prosthetic supplies. Patients without prosthesis coverage should be provided cost options when selecting a device. Prosthesis choicesDuckbill
Low resistance/pressure
Indwelling
Steps for fitting a prosthesis
Hands-free tracheostoma valves Tracheostoma valves provide 2 primary functions: hands-free speech and housing for heat and moisture filters. These external valves are adhered to the neck, with a valve housing directly over the stoma. For speech, the air pressure generated during increased exhalatory effort closes the tracheostoma valve and directs air back through the tracheoesophageal prosthesis. An adequate adhesive seal is essential to generate hands-free speech. Without a tight external seal, stomal air escape reduces the amount of airflow available for speech. Heat-and-moisture–exchange filters are also available to place over, or in lieu of, the tracheostoma valve. These filters modify the inhaled environmental air. Benefits of the filters include decreased airway irritation and maintenance of airway humidification, which may reduce tracheal secretions. TROUBLESHOOTING TRACHEOESOPHAGEAL PUNCTURESSection 5 of 10
Problems related to tracheoesophageal punctures and prosthetic devices are mentioned, along with typical causes and corresponding solutions. Leaking through the prosthesis
Leaking around the prosthesis
Difficult or no phonation
Dislodgement of prosthesis
Granulation tissue
EMERGENT PROCEDURESSection 6 of 10
When a prosthesis is dislodged, patients are instructed to insert a catheter into the puncture tract as soon as possible to maintain patency and prevent aspiration. If they are unable to place the catheter, they may come to the emergency department for puncture tract stenting. Patients are sometimes unaware that they can phonate without the prosthesis. As long as the puncture tract is patent, phonation is possible. Encouraging tracheoesophageal speech to explain their situation may ease patient anxiety. If the patient cannot speak, have them drink a sip of water, preferably with blue dye. If the water leaks through the puncture tract into the airway, the tract is patent. The role of the emergency department staff is to stent the puncture tract with a catheter (8-20F). If no catheters are readily available, a Duo Tube or nasogastric tube works. The next step is to dilate the puncture tract. Progressively increase the size of the catheter until a 16F or 20F catheter passes through the tract, depending on the size of the prosthesis. At this point, the prosthesis can be reinserted. If the patient did not recover the prosthesis, the device may have been aspirated. Some patients report violent coughing after aspirating a valve; however, many patients are asymptomatic. Therefore, diagnostic imaging should be performed. Most prostheses manufactured by InHealth are radiopaque. The indwelling device has only a ring of radiopacity. A chest radiograph should be the first test, followed by a CT scan if a prothesis that is not radiopaque is missing. The final approach should be bronchoscopy. Typically, a prosthesis lodges in the right mainstem bronchi and can be easily retrieved by an otolaryngologist or pulmonologist. CONCLUSIONSection 7 of 10
Successful voice restoration for alaryngeal speakers can be attained with any of the 3 speech options. Although, no single method is considered best for every patient, the tracheoesophageal puncture has become the preferred method in the past decade. Perceptual studies have demonstrated listener and speaker advantages of tracheoesophageal speech. Despite the potential facility of voice production with the tracheoesophageal puncture, careful attention must be directed to PE segment integrity, valve selection, and troubleshooting. Voice restoration is a process, not a prosthesis. PROSTHETIC SUPPLY VENDORSSection 8 of 10
InHealth Technologies - 1110 Mark Avenue, Carpenteria, CA 93013; Phone (800) 477-5969, Fax (805) 684-8594 Atos Medical - 2202 North Bartlett Avenue, Milwaukee, WI 53202; Phone (800) 227-0025, Fax (414) 227-9033 MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Laryngectomy Rehabilitation excerpt Article Last Updated: Mar 18, 2006 | ||||||||||||||||||||||||||||||||||||||
