THERAPUTIC MANAGEMENT OF LARYNGETOMY / KUNNAMPALLIL GEJO

                     THERAPUTIC  MANAGEMENT OF LARYNGETOMY

Introduction

            The goal of speech therapy for a laryngectomized patient is to find an appropriate source of sound production that can be articulated for communication purposes.  The most efficient and effective type of sound source depends on:

• Degree of tissue loss, the degree of esophageal  stenosis, level of hearing loss, or other physical limitations of the patient.  The noise level of the environment in which the patient needs to communicate.
• The patients level of motivation in learning an alternative method of communication.        
• The personal preference of the patient.

Fortunately, there are a variety of devices and procedures that can provide a new source of sound.  The patient can then use his or her articulators to produce the sounds of speech.

There are two general categories of sound restoration:

• Mechanical speech aids includes the pneumatic and electronic artificial sound sources.
• Alternative natural sound sources include esophageal tracheoesophageal  speech, other surgically implanted prostheses and surgically created structures.

The various mechanical speech aids and voice prostheses are discussed in the following sections

MECHANICAL SPEECH AIDS

I. PNEUMATIC DEVICES

A. Description

            Pneumatic speech devices were among the first to be used as replacements for voice production and are still in use today.  They usually consist of a piece that fits over the stoma, a small unit with a reed inside to provide sound, and tubing that carries the sound to the mouth.  The patient places the tube in the corner of his or her mouth as exhalatory air from the lungs drives the reed to produce sound that is resonated in the usual way in the patient’s oral cavity and shaped into words by the action of the articulators.  Hand held models do not require valving mechanisms since they can be lifted from the stoma to allow the patient to breathe.

B. Specific Types

1. Dutch speech DSPB speech aid

            In this device, the vibrator is housed within the tubing.  It is rather inexpensive (about $ 90 US).

2. Tokyo artificial larynx

            This has been described by Bloom & Mowrer & Case.  This device is an inexpensive unit (about $ 50.00) and is supplied with an additional oral tube, stoma cushion, and training tape.  It has been demonstrated that patient using this device under optimal condition can achieve a 95% intelligibility level.  The modified version consists of swivel-joint connector on the tracheostoma cover and a mouth tube constructed of curved stainless steel tubing capped by a plastic mouth piece.

3. Osaka artificial larynx:

            It is very similar to Tokyo artificial larynx.  It consists of a tracheostoma cover, a vibrating reed and a mouth piece.  It differs from Tokyo artificial larynx in that it is made up of light weight plastic.

C. Advantages

            The two major advantages of a pneumatic device are that it does not have a buzzing electronic sound and it uses the patient’s own pulmonary air supply.  Phonation can be easily coordinated with respiration and loud voice can be produced.  The patient can use his or her normal phrasing and flow of speech without the need to turn an oscillator on and off.

D. Disadvantages

            There are several problems with the pneumatic devices.  First, they require access to the stoma for placement of the instrument.  Most patients typically wear some kind of covering over the stoma, making access to it awkward.  Second, they require the use of one hand thus limiting the patient’s ability to perform tasks requiring the use of both hands.  Third, they are visually distracting to the listener.  Some believe that they are a sign of patients’ disabilities rather than their abilities.  Other problems include the lack of pitch control and the low fundamental frequency which may be a problem for a female user.

II. Electronic Devices

A. Description

            These devices use electric power to drive a vibrator that provides the sound source.  Two versions of these devices are available.

• Tube-in-the-mouth-type instruments: Consists of a tube attached to the electrically powered hand held transducer.  The tube fits inside the mouth in much the same way as the pneumatic devices.  Electronically generated sound is delivered to the oral cavity via the tube which is articulated in the normal way.
• Handheld type instrument consists of a hand held vibrator that is designed to deliver the sound through the skin when placed on the neck.

There are numerous manufacturers who produce electronic speech aids powered by batteries.  The differences among the aids are  appearance, size, quality of sound, ability to change pitch and loudness characteristics and the types of batteries required.

B. Specific types

1. Tube-in-the-mouth-type instruments:

a. Cooper-Rand Electronic Speech Aid

            This device is a battery powered sound source that directs the sound into the oral cavity via a small tube placed in the mouth.  It is the only instrument that is designed to be used exclusively as an oral device.  Oral placement may be advantageous immediately after surgery because the patient can use it without interfering with neck healing or causing discomfort.  The unit is lightweight (about 7 oz) and can be carried in a shirt or blouse pocket.  An extra long cord (40 in) permits placing the device in other locations as well, such as on a table or a bed.  The unit is controlled from the push button on the tone generator to which the oral tube is attached.

b. Ticchioni pipe artificial larynx:

            Looks like a smoker’s pipe with the battery attached to the base of the pipe bowl.  The tone is generated in the pipe bowl and conducted to the patient’s mouth via the pipe stem.

II. Hand held type instrument

a. Jedcom electrolarynx

            This device is a neck held electric sound source with a built in pitch and volume control and a convenient on-off switch and safety cord.  It is powered by a rechargeable battery.

b. Neovox

            This device is a neck held electro larynx with a single button control for volume and contains a safety strap.  It uses a rechargeable battery.

c. Romet speech aid

            This device is a small, lightweight (5 oz), neck held electronic sound source that uses rechargeable batteries.  The unit is held against the neck, a button is depressed to turn it on, and the sound is articulated by the patient.  The unit is equipped with a volume control as well as a pitch control.

d. Servox Intonation Control

            This device is an electronic, neck held sound source.  The unit is tubular and sealed in a scratch resistant case.  It has an electronic volume control that reduces power consumption and has rechargeable batteries. “intonation control” that varies the pitch and sound of the unit during speech to permit some type of inflection control.  An intraoral connector is also available to permit the use of the instrument immediately after surgery or if the patient prefers to use it in this manner. 

e. SPKR

            This device is another electronic, hand held sound source that is placed against the neck to direct sound through the skin into the vocal tract.  It features a dual tone rocker switch to volume control, an external pitch adjustment and an oral adaptor.  It uses rechargeable batteries and has a safety strap. 

f. Western Electric Artificial Larynx

            It is the most popular one and is available in models that are pitched differently for males (model 5B) and females (5A).  This device is a neck held, 9 volt battery powered device.  It is lightweight, can be carried on a pocket or purse, or hung around the neck.  The unit is activated by a single switch controlled by the patient’s thumb.  This is probably the lowest priced unit available (under $300), and it offers pitch and volume controls. 

Advantages

            The major advantages of the electric powered speech aids (and to some degree the pneumatic devices) is the ability to offer a rapidly learned means of communication.  The devices can be demonstrated prior to surgery and require little effort to use immediately after surgery.  They are easily portable.  Some permit a limited ability to vary the fundamental frequency (FF) of the voice during speech to achieve some measure of pitch inflection.  Many are available with an intraoral adapter.  The adapter fits over the membrane or vibrator and usually uses a small plastic tube to direct the sound into the vocal tract.  This adapter permits the use of the instrument immediately after surgery when the neck wound is healing.  Patients experience an immediate restoration of their ability to communicate.  After wound healing is complete, patients may use the device in either manner, for example, against the skin of the neck or as an oral unit.

D. Disadvantages

            All  of these devices tend to produce a mechanical sound that may be distracting to a listener and may interfere with communication.  Most require the use of one hand, limiting the ability of the patient to use both hands when talking.  Most have very limited control of fundamental frequency which limits normal pitch inflection of the patient’s speech.  In addition, it may be cumbersome to use the pitch altering mechanisms that are available.  There are some operating expenses, because the batteries wear out, and mechanical devices may need occasional repair.

 Indications for use

1) An oral type of instrument can be used effectively soon after surgery, regardless of the type of alaryngeal speech the patient will choose to pursue.

2) An electronic speech aid may be a preferred primary means of communication for some persons.  Patients who are elderly and infirm and whose life style involves minimal communication may choose an instrument.

3) A person who is very eager to speak and cannot tolerate the frustration or demands for practicing of esophageal speech may be happy with an instrument.

4) The person who cannot master esophageal speech and does not wish to undergo further surgery may choose to use an electronic instrument.

5) All laryngectomees should have an instrument and know how to use it as a backup or insurance policy in case of emergency.

ALTERNATIVE NATURAL SOURCES

I. ESOPHAGEAL SPEECH

A. Description

            Esophageal speech involves the production of a voice source within the esophagus using air supplied by the patient.  The esophagus is a muscular tube that begins just behind the larynx.  The most inferior portion of the inferior constrictor muscle, called the cricopharyngeus, extends from the cricoid cartilage to insert on portions of the pharynx posteriorly and into the esophagus.  Surgeons attempt to leave this muscle intact during laryngectomy so it can be used to constrict the esophagus and permit the trapping of air inferiorly.  When the air is expelled through a narrow constriction in the esophagus created by the cricopharyngeus muscle, the narrowed segment (the pharyngeal esophageal or PE segment) will vibrate, producing sound.  The patient has the capability of producing periodic sound at the beginning of the vocal tract similar to that produced in normal speech.

B. Anatomy of esophageal speech

Surgical alterations

            Surgery for laryngeal carcinoma may involve only the larynx itself (and associated extrinsic muscles), or it may require the extirpation of other structures and muscles in the neck.  In the simplest case, the patient may have lost only the larynx.  This means, of course, that the source of sound for speech is missing.  The larynx and the hyoid bone are typically removed during a routine laryngectomy.  The trachea is sutured to the front of the neck where a permanent opening called the tracheostoma is created.  On the left are the normal anatomical relationships among the larynx, esophagus, pharynx and oral and nasal cavities.  On the right are the surgical alterations to this anatomy.  There are, of course, little or no surgical changes to the esophagus during the procedure.  However, esophageal speech depends on the ability of the esophagus to constrict at a region.  This region is known as the pharyngeal esophageal segment (or simply the PE segment).

PE Segment

            This refers  to that portion of the pharynx and esophagus where muscle fibers fro the inferior constrictor, cricopharyngeus (or the lower portion of the inferior constrictor), and the esophagus blend together.  This creates a potential sphincter that can decrease the cross sectional area of the esophagus.  Although most of the esophagus is composed of muscle fibers not under voluntary control, the muscle fibers in the upper portion of the esophagus are under voluntary control. Thus, an individual can exert conscious control of the upper esophagus.  The cricopharyngeus muscle extends posteriorly from the cricoid cartilage of the larynx and blends with the muscle fibers of the esophagus.  During surgery for a laryngectomy, the anterior fibers of the cricopharyngeus are sutured together, creating a complete muscle sphincter around the esophagus.  The shape and length of the PE segment varies depending on the exact surgical alterations to the anatomy of the region.  However, shape or size of the PE segment does not appear to be factors in predicting successful acquisition of esophageal speech.  Of even greater importance is the degree of tonicity of the segment.  If the resistance of the PE segment to dilation or oscillation is high, it may be difficult for the patient to insufflate the esophagus to produce good esophageal vibrations.

Air Supply

            Esophageal speakers have a much lower air reservoir (less than 100 cc) than is available to laryngeal speakers from the lungs (>5 liters).  However, efficient esophageal as well as laryngeal speakers typically require a very small amount of air to produce vibration.  The small air supply will limit the esophageal speaker’s ability to produce long utterances on a single charge of air.

            Air flow rates are also somewhat variable in esophageal speakers and depend on:

·         the volume of air in the esophagus

·         the pressure within the esophagus, and

·         the resistance of the PE segment (Diedrich, 1991)

Air discharge

            Air is thought to be expelled from the esophagus as a result of mechanisms similar to exhalation of air from the lungs.  That is, increased thoracic pressure creates a force on the esophagus (which passes through the thorax on its way to the stomach).  The esophageal walls within the thorax are constricted forcing the air within to move up the esophagus and out them out.  Interestingly, there is evidence (Kahrilas et al. 1986) that in laryngeal speakers, during a belch, the pressure in the upper portion of the esophagus is lower than in the lower portion of the esophagus.  This suggests that the resistance to opening the upper portion of the esophagus is less than the lower portion, permitting easier release of air upward into the pharynx rather than downward into the stomach.

C. Techniques for obtaining an air supply

1) Injection

            In this method, air injected from mouth into esophagus via the tongue and pharynx.  The tongue acts like a piston to force air back into pharynx and esophagus.  There are 2 stages in this sequence.

            First, the tongue pushes the air into in the mouth back to the pharynx (the so called glosso press).

            Second, the back of the tongue and pharynx force the air down into esophagus (glossopharyngeal press).

a) The glossal press is produced by the tongue tip contacting the alveolar ridge.  The midportion of the tongue may elevate to contact the hard palate.  Air is trapped behind the tongue and moved posteriorly by the backward movement of the tongue.  The tongue does not make actual contact with the posterior pharyngeal wall.  However, the soft palate is elevated to prevent escape of the air through the nose.  The lips may or may not be closed because the tongue tip traps the air needed for injection.

b) In the glossopharyngeal press, tongue movement is similar to that seen in the glossal press, but the tongue continues to move backward to contact the pharyngeal wall.  Again, velopharyngeal closure is necessary, but lip closure is not.  Tongue and pharynx force air down into esophagus.

2) Inhalation Method

            It is based on the principle that air will enter the esophagus if the PE segment is sufficiently relaxed when pulmonary inhalation occurs.  To accomplish this, the patient must be able to relax the PE segment; otherwise, air cannot flow downward.  Typically, the intraesophageal pressure is between -4 and -15 mm Hg (Diedrich, 1991) below atmospheric pressure.  When the PE segment opens, air in the mouth and pharynx which is typically at atmospheric pressure (+14 mm Hg) will naturally flow from the region of higher pressure to the region of lower pressure, that is, in the esophagus.  The reduction of pressure within the esophagus is a by-product of the normal inhalation of pulmonary air.  That is, when the speaker inhales air, the pressure within the esophagus becomes even more negative relative to the atmosphere (as much as -15 mm Hg), creating an even greater sucking force to pull the air into the esophagus).

3) Swallowing

            At one time or another, each of us has swallowed air into the stomach and has, at a later time, burped.  But, swallowing air is not advantageous for creating an air supply for esophageal speech for a variety of reasons.

a)      Swallowing is a reflex that requires a bolus of some type to trigger the reflex action.  In the absence of a trigger it is often difficult to initiate a swallow.

b)      It is not possible to dry swallow quickly and repetitively as required for speech.

c)      Voluntary control of the air supply from the stomach may be very difficult to achieve, if not impossible.

4) Consonantal injection:

            It is an efficient method of getting air into the esophagus as it allows air to be injected in to the esophagus during intra phrase intervals as well as during rest unlike other methods.  Because air can be injected when the tongue is positioned for releasing a consonant of word, air for subsequent esophageal production is usually injected into the esophagus simultaneously with the release of articulator.  Teach the patient to produce intraoral whispers of plosive consonants (p); patient should be able to feel the compressed air inside the mouth moving towards the throat during the production of sound.  Once the patient is able to produce crispy /p/ ask him to produce other plosives, fricative and affricates followed by monosyllables and polysyllables with pressure consonants.

E. Advantages

            Esophageal speech may offer a number of advantages over other forms of communication.

·         There are no external, visually distracting devices necessary.

·         The sound of esophageal speech is more “natural” and nearly like that produced by the vocal folds (although usually of much lower fundamental frequency).

·         The patient is able to achieve some measure of pitch and loudness control and good esophageal speakers are able to vary these dynamically during speech.

·         There are no batteries that run down or devices that break down.

·         Both hands are free during the speech act.

F. Disadvantages

1) Grimacing and excessive body tension: Patients  may clench his lips tightly together, produce unusual facial contortions or bend head during insufflations.

2) Excessive stoma noise due to forceful movement of air through stoma during inhalation of exhalation which competes with the esophageal  speech intensity.

3) Klunking and other extraneous noise when attempting to forceful injection of air using glossopharyngeal press or swallow method.

4) In the course of insufflating the esophagus a certain amount of air is swallowed into the stomach.  Patients will complaint of bloated feeling and frequent burps.

5) Esophageal speech must be learned and may take a long time to master.  Some patients may never learn to produce functional esophageal speech even after much effort.

6) A person’s ability to articulate clearly must be excellent; otherwise the intelligibility of esophageal speech may be poor.  The patient may have difficulty being heard above background noise.  There are speech amplifiers (Voicette, rand Voice Amplifier, or AddVox (Figure 4-7) see Appendix B) that may increase loudness but these must be carried with the patient and may be visually distracting.

I. Indications for use of Esophageal Speech

1) Most patients are potential esophageal speakers.  The exceptions to this might be patients with extensive pharyngeal, esophageal, lingual, and / or mandibular resection; patients whose medical status is otherwise compromised, patients with significant hearing loss patients who have chosen to have a Tracheoesophageal  fistulization and patients who have no desire to learn esophageal speech.

2) Patients can use esophageal speech and electronic speech aids interchangeably, depending on the environmental noise level or situation.

3) Teaching Esophageal Speech

            The teaching of esophageal speech requires skill, understanding of the anatomy and physiology of esophageal sound production, patience, sensitivity to the psychological impact of the process on the patient, and the ability to be supportive.  It is extremely helpful for the clinician to have acquired the ability to produce esophageal sound.  Often demonstration of its production can be more instructive than verbal explanations.

            For the patient, the learning of esophageal speech requires a high degree of motivation, a willingness to learn to produce a sound voluntarily that has always had a negative stigma, patience, the physical integrity necessary to produce esophageal sound, emotional stability, and a host of other factors that are difficult to itemize.

            There are a variety of methods for teaching patients and the following sections are based on clinical experience with methods that have proven effective as well as  discussion of less successful methods.

·         The clinician should listen carefully for any involuntary production of esophageal sound.  Some patients will inflate or charge the esophagus unconsciously as they attempt to produce whispered speech.  Even if the clinician does not hear evidence of such sounds during the first session, patients should be asked if they have made any sounds involuntarily since their surgery, and if so, to describe when it happened.

·         Ask the patient to make a burping sound.  It is always good for the clinician to be able to demonstrate production of a “burp”.  This may make the patient more comfortable about producing a sound that has been considered socially unacceptable.  Some patients will be able to produce such a sound with ease.  The clinician should carefully observe the manner in which the patient attempts to produce the burp, whether successful or not.  It is especially important to note whether the patient is working hard at swallowing during the attempt.  If that is the case, it is a behavior that should not be encouraged or reinforced.  If the patient seems to be injecting air into the esophagus appropriately and producing sound, the clinician should continue with additional trials during which the patient’s attention is directed at determining how the sound is being produced.

·         The clinician should demonstrate injection of air in an audible manner and ask the patient to produce a similar sound.  The sound is typically referred to as a “klunk”, and should be audible but not excessively loud.

·         Try to trigger esophageal sound production using plosive consonants.

·         The patient can learn to manipulate the air trapped in the mouth by puffing the cheeks out and by moving the air around in the mouth from side to side and forward.

·         In addition to using the voiceless stop plosive/vowel combinations noted above to trigger esophageal sound production, there are a number of words that often trigger sound production.

·         As a last resort, after having tried and retried all of the above methods to teach injection, the “idea” of swallowing in a controlled way may be introduced.

·         Extending sound production into speech early in the process is helpful to patients, but should not be rushed.

II. GASTRIC SPEECH:

            A successful pharyngolaryngoesophagectomy with pharyngogastric anastomosis – the so-called gastric pull-up-surgery-involves a variety of postoperative functional alterations, including alimentation and speech.

Surgical procedure

            Under general anesthesia, a secondary TG fistula was created, using a Groningen tracheal puncture forcep.  With the patient in a supine position, a rigid esophagoscope was placed into the cervical stomach via the oral cavity.  The esophagoscope was turned 180 degrees to expose the beveled edge toward the penetration site, which was within the visible lumen of the stoma.  Considerable force was required to puncture through the gastric wall.  Immediately following the puncture, the voice prosthesis was inserted.  The fistula site was placed at the level of the inferior margin of the stoma.

Disadvantages:  

            Although the problems involved in solving the postoperative difficulties of swallowing and digestive processes have been discussed extensively restoration of voice and speech in these patients has been largely unsuccessful.  For example, of the 136 cases of gastric pull-up performed at the Queen Mary Hospital in Hong Kong, speech rehabilitation was highly unsatisfactory, with only 9 patients (6.6 percent) able to produce audible whisper, and 6 patients (4.4 percent) able to use an electro larynx.  This occurred despite the fact that 87 percent of patients satisfactory alimentary. 

            Functions, Nonetheless, speech restoration for all types of pharyngeoesophageal  reconstruction was not considered to be satisfactory, and involved single word utterances or was achieved only with the aid of an electronic device.  Although better speech quality

Was obtained for the gastric pull-up group than for the other categories, since these patients were able to inject air transorally and generate neoesophageal  sound, the functional scores for speech were still poor.  Of the 101 gastric pull-up surgeries performed in England by Harrison and his colleagues, acquisition an adequate voice was possible only in a small number of patients, in contrast to the number who regained trouble-free eating ability.  Patients who were able to produce voice did so  by manual compression of the cervical stomach, or when experiencing pharyngogastric fistulas.

III. VOICE USING SURGICALLY CREATED STRUCTURE OR SURGICALLY CREATED PROSTHESIS

A. Description

            The rationale of these approaches has been that a patient who is given replacement of excised vocal folds would then be able to use pulmonary air to speak effortlessly soon after surgery without the necessity for extensive speech training.

B. Types:

1) Tracheoesophageal  air shunt approaches:

            Modern interest in surgical reconstruction of laryngectomized patient began in the late 1950s for shunting air to the esophagus for the production of voice.  Although these techniques resulted in the production of a satisfactory voice, the procedures were discontinued because patients frequently experienced a leakage of fluids of esophagus into the trachea via the shunt during swallowing and because it was difficult to maintain the airway due to stenosis.

2) Asai Technique:

            It is an early attempt to surgically create a tracheoesophageal  air shunt and a vibratory source for voicing purpose.  The multi-staged surgical procedure consisted of connecting the trachea with the hypo pharynx with  a dermal tube.  To phonate, the patient  would occlude the stoma with a finger and pulmonary air would force through the dermal tube and into the hypo pharynx, causing the pharyngeal end of the tube to vibrate.  Although the voice produced was adequate, many patients experienced problems like tube stenosis and air growth on dermal tube.

3) Air bypass approaches:

            Here surgery  is done to design a method by which pulmonary air from the tracheostoma can be diverted via a chest-mounted or neck-mounted air shunt into the esophagostoma that has been surgically created specifically for this type of prosthesis.  The method by which voice produced would on which type of air bypass prosthesis is used.

4) The staffieri approach:

            Developed by Staffieri, this  approach consists of creating a muscle and mucosal neoglottis between the trachea ands the esophagus.  This procedure needs frequent surgical revisions to prevent closure of the neoglottis.

5) Tracheoesophageal  fistulization / puncture:

            Tracheoesophageal  fistulization / puncture is a surgical procedure in which a small puncture (fistula) is made through the tracheal wall into the esophagus.  The surgery may be performed at the time of the laryngectomy, or it may be performed at  a later date.  It is a relatively simple procedure and is relatively free of any major complications.  The opening allows the insertion of a prosthesis that acts as a conduit, or shunt to direct the air into the esophagus.  This air moves up through the PE segment and in so doing creates sound.  The sound in the esophagus travels into the pharynx and oral and nasal cavities where it is resonated and articulated  to produce speech.

a) Description of Surgical Procedure

            Tracheoesophageal  fistulization puncture may be performed under general or local anesthesia, and a puncture or fistula of the Tracheoesophageal  wall is surgically created.  Maintaining this surgically created fistula until it has healed is accomplished by placing a catheter through the puncture site.  The catheter is subsequently removed by the surgeon or speech-language pathologist at the time of the fitting of the voice prosthesis.

b) Voice Prosthesis

            The voice prosthesis is a short length (1.8 – 3.6 cm) of medically sage material (usually silicone) with a valve (slit or hinge type) at the distal end.  The anterior or front and has an opening through which pulmonary air enters, and a small collar separates that part which is inserted into the esophagus from that which is in the trachea.

            Air pressures required to force open the slit range between 2 and 25 cm H2O and depend on the rate of airflow from the lungs and the type of device used (Weinberg & Moon, 1984).  Some patients may have considerable difficulty producing these pressures.  In these cases, lower resistance prosthesis may be suitable, allowing for greater ease of sound production.

c) Mechanisms of TEF/TEP Sound Production

·         To produce sound with the voice prosthesis in place, the patient uses his or her own air supply from the lungs.  To do so, the patient occludes the stoma, usually with a finger or thumb, and inhales.  Air from the lungs enters the prosthesis and is released into the esophagus through the slit.  This air passes through the PE segment where sound is produced.

·         The sound produced enters the oral cavity where it is articulated and shaped into words.  With practice, the patient learns to produce complete sentences with normal rate and phrasing.  Special valves are available to eliminate the need to occlude the stoma manually.  These valves close automatically when greater than normal thoracic pressures are present as when, for example, the patient wishes to produce speech.

C) Advantages

            This technique can provide the most rapid restoration of near normal speech for most laryngectomized patients.  After normal healing has been complete, the prosthesis can be fitted easily by the physician / speech pathologist team.  After appropriate instruction, the patient should be able to remove and reinsert the device.  The prosthesis is inexpensive (less than $ 20.00) and is available in a variety of sizes to accommodate variations in stoma size ands fistulae size.

            The other major advantage is that normal pulmonary air is used t drive the PE segment, freeing the patient’s hands and permitting near-normal speech production.  Experience with surgical prosthetic voice restoration has demonstrated a very high success rate in the acquisition of functional  speech.

D. Disadvantages

1) As with any surgery, there are risks.  The possibility of complications that may compromise the airway or the fistula is present.

2) Occasionally, the fistula may stenose, preventing the insertion of the device.  This usually occurs if the fistula has been allowed to remain totally unstinted or if the prosthesis has been improperly fitted.

3) There is a slight risk of aspiration of the prosthesis if it becomes dislodged from its placement.

4) Other complications include stoma stenosis, infection due to poor hygiene, radiation-induced fistula closure, granulation buildup, prolapse, or leakage around the prosthesis with subsequent aspiration.

E) Teaching Tracheoesophageal  Speech:

a) Patient Selection

            Patient selection for primary fistulization is often determined by the surgeon, who is primarily concerned with the success of the surgery and the fewest complications.  The speech-language pathologist should ideally be involved in selecting.  TEF patients and should consider the factors discussed below (with the exception of esophageal insufflation testing).

·         Healing from previous surgery should be complete.

·         Radiation treatment or other forms of treatment should have been completed.

·         The patient should have had an adequate interval of being free of disease.

·         The patient should be medically stable in areas other than the laryngectomy.  Patients with major respiratory problems must be carefully assessed to ensure they will have adequate air volume and adequate ability to generate air pressures required to move the air through the prosthesis and generate sound.

·         The tracheostoma must be of adequate size (1.5 cm minimum) to house the prosthesis, and it must be above the jugular notch at the manubrium.  If the stoma has a tendency to close, the patient may need to be fitted with a prosthesis that is built into a  tracheostoma  tube.  An excessively large stoma may be difficult for the patient to occlude with the thumb.

·         There must be a healthy common wall between the trachea and the esophagus.

·         The patient should display emotional stability sufficient to undergo another surgical procedure followed by fitting of a device and training in its use.

·         Dependence on drugs or alcohol would serve to eliminate the patient from consideration.

·         The patient’s should display a degree of motivation sufficient to follow through with the full program of voice restoration.

·         The patient’s  eyesight, manual dexterity and control, habits of general hygiene and general alertness must be considered.

·         The prospective candidate for TEF, having passed all of the above tests, should then have insufflation testing.  This procedure is within the scope of practice of the speech-language pathologist who has the appropriates competencies.  This involves the transnasal insertion of a rubber catheter into the esophagus, introduction of air through that catheter, and production of sound.  A judgement of the adequacy and quality of the sound that is elicited must be made.

b) The Blom-Singer Insufflation Test Kit is available and includes complete instructions for its use.  The test kit contains a measured section of 14 Fr. (French) red rubber catheter attached to a tracheostoma adapter and housing.  This is affixed to the stomal area of the neck.  The catheter must be passed transnasally as far as the marker at the 25 cm point, which should rest at the nasal tip.  If the catheter is not inserted up to this marker, the test may be invalid.  With the catheter and the stomal housing in place in patient is instructed to inhale, to cover the stoma adapter with his or her finger, and thus, to self-insufflates the esophagus.  The patient should be able to produce sound easily.  Ideally, production of a vowel should be sustained for 8 sec. or longer, and the patient should be able to count to 15.  The patient must attempt easy sound production without excessive strain and tension.  He or she should neither swallow air nor attempt to pump air in.  Either maneuver will not allow the pulmonary air to be released.  When the initial test is unsuccessful, repeated trials may be needed.

            Unsuccessful insufflation testing should lead to referral for further exploration of the cause for failure.  This may involve a videoradiographic study and / or injection of lidocaine to produce a pharyngeal plexus nerve block that induces relaxation of the PE segment.

            Preoperative recording of intraesophageal peak pressure levels have been proposed by Lewin, Baugh, and Baker (1987) as a procedure that can predict the success of fistulization more objectively.  It reported to be more than 90% accurate.  Patients found to have intermediate or high intraesophageal pressures required myotomy to become fluent tracheoesophageal  speakers.

c) Fitting of the Voice Prosthesis

·         The timing for fitting the voice prosthesis may be different for each patient.  For the patient with primary TEF (at the time of surgery) fitting of the prosthesis may be delayed for as long as 3 weeks or until surgical sites show adequate healing.  Fitting of the prosthesis for the patient with secondary fistulization (after the primary surgery) may take place anywhere from 36 hours to 1 week or more after the procedure.  The fistula must be healed well prior to the fitting.

·         To remove the red rubber catheter, it may be necessary to remove the sutures that were put in at the time of surgery.  The area must then be carefully cleaned, and a clean catheter is reinserted and may be held in place by tape.  Whenever a catheter or prosthesis is not in place, the patient is cautioned not be swallow.  This should not occur for more than seconds at a time.

·         To test the phonatory mechanism with the least possible resistance, ask the patient to inhale, occlude the stoma, and exhale.  This should result in sound production.  A few trials may be necessary.  If no sound is produced after several trials, the catheter should be replaced, or a dummy prosthesis may be used, and the fitting should be postponed for a few days to allow more time for healing and reduction of swelling.

·         A sizing device, available from the manufacturers, is used to measure the length of the prosthesis required.  The catheter is removed and the measuring probe is inserted.  It is possible to feel when that probe impinges on the posterior pharyngeal wall.  The clinician should gently retract the probe until the flange is at the anterior esophageal wall and  resistance to further movement is felt.  At that point where the sizing device is comfortably within the esophageal lumen, neither abutting against the posterior esophageal wall nor too snugly pulled against the anterior esophageal wall, the measurement should be taken.  It is better to measure too long than too short in this early stage of sizing.  If it is too short, the surgically produced track may begin to close.  It is sometimes helpful to leave the instrument in place for a minute or two to see what happens to the position of the prosthesis when the patient swallows.  On occasion, the probe will be pushed forward slightly by the swallow.  It may be more comfortable for the patient to fit the prosthesis allowing for the adjustment as long as the prosthesis is in the esophagus and is sufficiently long to maintain an open tract.  The anterior end of the prosthesis should lie fairly flush against the puncture aperture.

·         If the prosthesis cannot be inserted easily, the lumen of the fistula may be tight and require easy dilation.  Catheters of increasing dimension may be used to dilate the fistula.  This should be done gradually and carefully to allow for ease of insertion as well as a well fitting seal around the prosthesis.

·         Insert the prosthesis using the insertion tool to demonstrate the process to the patient.  The patient is instructed to attend to the sensation when the collar flange is released in the esophagus.  The outer flange or strap is released from the insertion too, and the tool itself is gently rotated as it is pulled forward and removed.  Tape the outer strap to the neck.

·         With the prosthesis in place, check for any signs of leakage around the fistula by having the patient swallows small amounts of water or other liquid.  Observing the swallow with a light directed into the stoma should make it possible to detect leakage.  If it is noted, the patient will need to allow further time for the puncture to close down around a 14 Fr catheter.  If leakage occurs through the prosthesis itself, a new prosthesis should be inserted.

·         The patient should then be instructed to inhale and attempt to phonate while the clinician occludes the stoma.  It is important that the entire stoma be occluded but that the pressure against it is gentle.  On these initial trials, it is not unusual for the patient to inhale too deeply thereby over inflating the esophagus, or not activate the airflow correctly due to excess tension.  Either of these will inhibit the production of sound.

·         The patient should then be taught to occlude the stoma.  If the stoma is too large for the patient to be able to occlude digitally, creative ingenuity must be used to solve this problem.  For example, the housing and the stoma adapter that come with the insufflation kit can be used to removing the catheter and plugging the attachment port.  The housing is affixed to the peristomal area as it would be for the insufflation test.

·         The patient is now ready to attempt speech by inhaling, occluding the stoma, and producing either a sustained sound or words, such as counting.  When patients are successful in this, they are instructed to practice frequently throughout the day.  As the patient becomes comfortable with the device and proficient in the act of occluding the stoma, the speech usually becomes increasingly fluent and effortless.

·         Removal and reinsertion of the prosthesis must be learned properly.  Although it may not be necessary for the patient to remove the prosthesis until a return visit to the speech language pathologist or doctor, he or she should know how to remove, clean, and reinsert the prosthesis or a dummy prosthesis or the red catheter, should it become necessary to do so.  This should be taught in a slow, step-by-step process.

1)      Arrange a clean, well lit area with a mirror and the equipment required.

2)      The patient is instructed to remove the prosthesis by firmly pulling it forward by the outer flange or strap.  It must be remembered that, if the prosthesis is to be out for any period of time, the catheter or a dummy prosthesis must be inserted.  The patient is shown how to do this and given the opportunity to practice.

3)      The prosthesis is cleaned according to manufacturer instructions.

4)      The patient is then shown how to place the prosthesis on the insertion tool and is given the opportunity to do this.

·         Patients undergoing radiation therapy after being fitted with prosthesis may find a temporary disruption in their ability to speak during the course of the radiation treatments because of swelling and inflammation of the tissues.  Speech should return naturally as those problems resolve.

·         Candida deposits on or in the prosthesis may interfere with sound production.  A solution for this involves having more than one prosthesis, changing prostheses every day or two, and soaking one prosthesis in hydrogen peroxide.

·         Granulation tissue formation may occur as a result of inflammation associated with infrequent prosthesis removal.  The obvious solution to this problem is more frequent removal and cleaning of the prosthesis.

·         Difficulty in producing voice that occurs after a time of initial success may have a number of causes.  The prosthesis valve should be checked to make sure that it is not stuck.  If the prosthesis was incorrectly fitted and is too short, or if it was not fully inserted, secondary tract closure may have occurred.  This will require dilation of the tract and reinsertion of a longer prosthesis.

d) The Tracheostoma Valve

            The tracheostoma valve eliminates the need for digital occlusion of the stoma for speech production.  Patients must be selected and fitted appropriately with the valve.  The design of the valve allows quiet breathing to be unimpeded.  A thin diaphragm responds to the natural increase in air pressure for speech by closing.   There is a flexible housing or collar (similar to that used in the insufflation test) which must be sealed on the peristomal skin.  This is done with the use of double-faced tape  and a liquid adhesive.  A tight seal is essential for the valve to function.  The valve is inserted into the housing and can be quickly removed.  If necessary, leaving the housing in place.  Patients with significant respiratory problems may not be good candidates for use of the valve.  Similarly, patients who experience excessive mucous discharge and secretions find the valve problematic.  All other patients should be given a trial with the valve to determine its efficacy for them.

1)      Patients should be speaking effectively using digital stoma occlusion before the valve is attempted.

2)      The peristomal area should be clean and dry.  The prosthesis should be place.  The outer strap of the prosthesis should be shortened by approximately ¼ in. prior to its insertion.

3)      The double-sided tape or a foam disc is affixed to the housing.  The liquid adhesive is spread thinly around the stoma and allowed to dry before affixing the housing.  This is often the most troublesome part of valve fitting.  Unless the neck around the stoma is flat and smooth which is rarely the case, an attempt must be made to fit the flexible housing so that it fits the neck contour.  Because of the frequency of this problem, foam discs are now available that can be helpful in counteracting the irregularity of the neck anatomy (See Appendix C for a list of suppliers).  The opening of the housing should ideally be slightly below the lower edge of the stoma.  It is necessary to seal the contact between housing and skin manually, or with the use of a blunt ended instrument, rubbing firmly around the housing.  All air bubbles must be pressed out.

4)      The valve is inserted into the housing.  Valves with three different weights have been available.  Each required slightly greater air pressure to close.  More recently, a single variable weight valve has been designed that can replace the previous individually weighted valves.  When the valve is in place, the patient should be allowed to sit quietly briefly to be reassured that breathing is unimpaired.

5)      The patient is then instructed to produce easy speech using a quick exhalation to close the valve.  If the housing seal is firm, the valve diaphragm should be head to close and speech should be produced.  If the diaphragm does not close, make certain that air is not leaking around the housing.  Allow the patient several trials.  It may be necessary and advisable to use a low pressure  prosthesis when using a valve.  The valve must shut easily for speech yet be sufficiently resistant to remain open during increased physical exertion.

6)      As with the prosthesis, the patient must be instructed in affixing the housing and inserting the valve.  The latter is particularly.

7)      Important because of the need to remove the valve during or after coughing, or at any other time that it may need cleaning.  It is important that patients grasp the outer edge of the valve to remove it and not the bar that may go across the top.  The function of that bar is simply to keep clothing away from the valve.

8)      Patients may need short-term therapy to lean to use the valve effectively.  Attention should be given to easy speech production with minimal strain, length of utterances consistent with pulmonary air supply, appropriate phrasing, and good coordination of exhalation and speech.

Advantages and disadvantages of each form of alaryngeal speech are presented in Table.  The various mechanical speech aids and voice prostheses are discussed in the following sections

Table: Comparison of alaryngeal speech modes

Type of speech	Advantages	Disadvantages
Pneumatic speech aid	Natural non electronic sound, easy to learn, intelligible speech inexpensive operating cost (no batteries)	Bulky size, requires access to stoma, sometimes difficult to maintain seal at stoma
Electronic speech and (neck type)	Easy to learn, fits in pocket or purse, volume and pitch controls for individual preference.  Adequate volume to be heard in noisy places, intelligible speech when used well.	Noisy electronics sound, cannot be used with heavily scanned or erythematous neck, moderate initial cost, low operating cost for renewed batteries, occasional extra cost for repair, requires very clear articulation skills.

Type of speech	Advantages	Disadvantages
Electronic speech aid (oral type)	Easy to learn to use, fits in pocket or purse but may be larger than neck type, volume and pitch controls for individual preference.  Adequate volume to be heard in noisy places, may be less noisy than neck types, can be used soon after surgery evening presence of much scar tissue, intelligible when used well.	Electronic sound very obvious to all observers “clumsy” feeling initially to talk with tube in mouth, moderate initial purchase cost, occasional additional cost or repairs, requires very clear articulation for easy intelligibility.
Esophageal speech	Natural non-electronic sound, requires no dependence on mechanical instrument or other device, sound of the voice does not call attention to itself (may be perceived as having a child)	A period of therapy required for most people, may be difficult for one third or more of patients to learn well enough to be easily intelligible, difficult to hear in noisy environments, requires excellent articulation skills, and may exacerbate symptoms of hiatal hemia condition.

Type of speech	Advantages	Disadvantages
Tracheoesophageal  speech	Natural non-electronic sound requires short learning period, smooth, fluent speech using long sentences because of availability of pulmonary air, smooth, clear sound for most patients, flexibility of loudness and pitch variations, and sound of voice does not call attention to itself.	If not done as primary procedure, requires another surgical procedure, requires maximum manual dexterity, visual activity and levels of alertness to care for, requires use of finger to occlude stoma or daily affixing of valve to peristomal area, occasional aspiration due to poorly seated prosthesis, or poorly functioning prosthesis, buildup of Candida deposits requiring frequent cleaning may need to remove valve when coughing or to clean after coughing.

THERAPY:

General Considerations:

            A few broad areas apply to all alaryngeal speech modes; however, some are most relevant to the learning to esophageal speech.  These include initiation of therapy, group versus individual therapy, frequency of therapy, involvement of family and / or friends in the therapy session, practice and pace of therapy, prognostic factors, and when to terminate therapy.  Issues of reimbursement are too complex and changeable to be discussed here.

A. Timing of Speech Therapy

1) We advocate the earliest possible initiation of speech therapy.  Patients are strongly encouraged to begin speech therapy as soon after discharge from the hospital as possible.  It is important for them to begin the rehabilitation process promptly because the longer the time between the surgery and the beginning of therapy, the poorer are the prospects for a good result.  Many patients will have to undergo a course of radiation therapy, a difficult period often lasting 5 to 6 weeks.  Many have physical reactions to the radiation treatment that may retard or interrupt the process of speech therapy during that time.  It is important for them to have acquired some form of communication (other than writing) prior to radiation.  Furthermore, lack of involvement in the rehabilitation process for a period of 1 to 2 months (or more), particularly in the absence of a viable means of communication, can lead to feelings of isolation, depression, and frustration.

a) Patients are usually ready to begin esophageal speech training shortly after they begin to take food by mouth.  The beginning of oral feeding suggests that wound healing has progressed to the point where attempts to produce sound will not jeopardize further recovery.

b) Use of an oral type of electronic speech aid can often begin within days after laryngectomy surgery assuming the patient’s progress is without complications.  The extent of the lesion and of the surgery must be considered when judging the patient’s readiness for using an electronic speech aid.

c) Use of a   neck-held electronic speech aid can begin as soon as healing of the surgical suture lines is complete and swelling has resolved sufficiently to obtain good transcutaneous transmission of sound.

d) In the case of TEF, readiness for initiation of speech with a prosthesis depends on the healing of the puncture site.

2) Early use of speech aid can decrease feelings of isolation, depression, and frustration.  In uncomplicated cases, an oral type of electronic speech aid can be introduced on the fourth to seventh post surgical day along with instruction in its use.

B. Group Versus Individual Therapy

            Each approach has its advantages and disadvantages and may be determined by the type of alaryngeal speech to be pursued, patient preference, clinician style, and scheduling constraints.  The fitting of prosthesis is best done individually, as is the initial instruction in producing tracheoesophageal  speech.  For those patients who will pursue either esophageal speech training or the use of an electronic speech aid, or both, the choice of group versus individual therapy can be considered.

1)      Individual therapy of course, provides the patient with the full and undivided attention of the speech-language pathologist.  The amount of time given directly to the individual patient is greater than can be provided to any  one individual in a group setting.  Some patients become anxious and self-conscious in the pressure of a group and may not learn as fast or as well as when alone.

2)      Group therapy on the other hand, exposes the individual to others who “are in the same boat” thus lessening the feelings of isolation.  It allows for interchange among group members about shared concerns other than speech.  Newly laryngectomized persons benefit from the models presented by others in the group who are further along in the process.

C) Involvement of Family and / or Friends in Therapy Sessions

            Involvement of significant others is always encouraged.  It is especially important during the initial session, at the very least, so that family and / or friends can gain a basic understanding of the rehabilitation process, and specifically speech rehabilitation.  Of course, the amount of involvement must always be tempered by sensitivity to the relationship between the persons involved.  Supportive family members or close friends can be a major source of help for the patient and can be more effective when they understand the process.

D) Prognostic Factors

             There is no clear way to determine how quickly or how well functional alaryngeal communication will be acquired.  A statement of prognosis is a well educated guess.

1)      The prognosis for Tracheoesophageal  speech following fistulization in probably most easily and reliably determined.  Because the learning time for that type of speech is very short it is possible to judge relatively quickly how well the patient will do.  However, caution must be exercised in making the judgment too soon because the healing process may result in stricture or stenosis that may have a negative effect on speech production even after an initially positive outcome.  If this is suspected, the patient should be encouraged to see the surgeon.  Furthermore, a small percentage of patients have difficulty in producing speech following fistulization and may require additional workup and treatment.

2)      Prognosis for the patient who chooses to use an electronic speech aid for purposes of communication can also be assessed with fairly good accuracy.  As a person begins to use the instrument, the ability to articulate clearly and place the instrument appropriately in quite obvious.

3)      Prognosis for the acquisition of functional esophageal speech is problematic because it involves the learning of new skills that are more difficult to acquire than for either of the other two methods.  Factors such as viability of the pharyngeoesophageal  segment, time elapsed since surgery, age, extent of surgery, hearing acuity, and personality must be considered.  Even taking all those factors into account, the most skilled and experienced clinician can still make incorrect judgements.  It may be best to err on the side of giving the patient the benefit of the doubt as long as he or she is motivated and making the effort to learn.

 

1)     J Voice. 2004 Dec;18(4):567-77

Aerodynamic characteristics of laryngectomees breathing quietly and speaking with the electrolarynx.

Liu H, Wan M, Wang S, Niu H.

The primary purpose of this study was to investigate the aerodynamic characteristics of laryngectomees under two conditions: breathing quietly and speaking with electrolarynx. Twenty male adult subjects, 8 normal speakers, and 12 laryngectomees participated the experiment. Airflow, pressure, and speech data were obtained simultaneously. The acceptability of electrolarynx speech under different conditions was also evaluated by 20 listeners (14 men, 6 women). Results indicated a higher peak expiration airflow and pressure among the laryngectomees as compared with the normal during breathing. Three different breathing patterns appeared among the laryngectomees when speaking with the electrolarynx: holding breath, exhaling, and breathing. Four long-time electrolarynx users held breath during speaking. Seven of 12 laryngectomees kept exhaling, whereas only 1 could breathe during speech production. In addition, (1) the acceptability of electrolarynx speech was the highest when speaking breathlessly; (2) no significant difference was found in the acceptability between the patterns of exhaling and breathing smoothly; and (3) the acceptability decreased if breathing quickly during phonation with the electrolarynx. It also suggests that the laryngectomees who can breathe during speaking may be more appropriate to use the new electrolarynx controlling the pitch by expiration pressure.

2) IEEE Trans Biomed Eng. 2004 Feb;51(2):325-32

Design and implementation of a hands-free electrolarynx device controlled by neck strap muscle electromyographic activity.

Goldstein EA, Heaton JT, Kobler JB, Stanley GB, Hillman RE.

The electrolarynx (EL) voice prosthesis is widely used, but suffers from the inconvenience of requiring manual control. Therefore, a hands-free EL triggered by neck muscle electromyographic (EMG) activity was developed (EMG-EL). Signal processing circuitry in a belt-mounted control unit transforms EMG activity into control signals for initiation and termination of voicing. These control signals are then fed to an EL held against the neck by an inconspicuous brace. Performance of the EMG-EL was evaluated by comparison to normal voice, manual EL voice, and tracheo-esophageal (TE) voice in a series of reaction time experiments in seven normal subjects and one laryngectomy patient. The normal subjects produced voice initiation with the EMG-EL that was as fast as both normal voice and the manual EL. The laryngectomy subject produced voice initiation that was slower than with the manual EL, but faster than with TE voice. Voice termination with the EMG-EL was slower than normal voice for the normal subjects, but not significantly different than with the manual EL. The laryngectomy subject produced voice termination with the EMG-EL that was slower than with TE or manual EL. The EMG-EL threshold was set at 10% of the range of vocal-related EMG activity above baseline. Simulations of EMG-EL behavior showed that the 10% threshold was not significantly different from the optimum threshold produced through the process of error minimization. The EMG-EL voice reaction time appears to be adequate for use in a day-to-day

    

       3)    J Voice. 2001 Dec;15(4):592-9

Functional characteristics of a new electrolarynx "Evada" having a force sensing resistor sensor.

Choi HS, Park YJ, Lee SM, Kim KM.

Electrolarynxes have been used as one of the rehabilitation methods for laryngectomees. Earlier electrolarynxes could not alter frequency and intensity simultaneously during conversation. Recently, we developed an electrolarynx named "Evada" (prototype so far) using a force sensing resistor (FSR) sensor that can control both frequency and intensity simultaneously during conversation. Employing three types of electrolarynxes (Evada, Servox-inton, Nu-vois), this study was undertaken to examine the functional characteristics of Evada for the normal control group and for laryngectomess. Five laryngectomees and five normal adults were asked to express three sentences (declarative sentence, "You stay here.", interrogative sentence, "You stay here?", and imperative sentence, "You! Stay here.") using three types of electrolarynxes. Frequency and intensity changes between the first and last vowels in the three sentences were calculated and analyzed statistically by paired t test. The frequency changes in the interrogative and imperative sentences were more prominent in Evada than in Servox-inton and Nu-vois. The intensity changes in the interrogative and imperative sentences were also more prominent in Evada than in Servox-inton and Nu-vois. Evada controls frequency and/or intensity by having the subject press the control button(s). Therefore, Evada appears to be better at producing intonation and contrastive stress than Nu-vois and Servox-inton.

      

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KUNNAMPALLIL GEJO JOHN,BASLP, MASLP