SPEECH PATHOLOGIST ROLE IN BREATHING AND

COMMUNICATION CHANGES FOLLOWING A TOTAL

LARYNGECTOMY

MID KANSAS EAR, NOSE & THROAT ASSOCIATES

RENEE’ L EDIGER, MA, CCC-SLP

Disclosure

• The presenter wishes to acknowledge that she has no proprietary interest in any products mentioned; she nor members of her family do not have any equity interest in any of the products covered; and she has not and does not receive payments either formal or any kind for any product discussed.

RESPIRATORY TRACT BEFORE LARYNGECTOMY

• Upper Respiratory Tract--Nose--Nasal Cavity--Pharynx

• Lower Respiratory Tract--Larynx--Trachea--Bronchi--Lungs

Breathing with Normal AnatomyInhaled air passes through the nose, nasal cavities, pharynx, and the larynx where it is:

•Filtered- Airways have cilia that trap foreign particles (bacteria, dust, etc.)and sweep the particles up to the mouth or nose where they are swallowed, coughed, or sneezed out of the body.•Warmed-inhaled air is warmed to 97⁰F•Humidified to 98⁰F by the time it reaches trachea•Meets resistance which causes deeper breathing compared to mouth or stoma breathing-results in complete expansion of lungs

Breathing after a Laryngectomy• The upper respiratory tract and larynx are

bypassed after a laryngectomy and inhalation begins at the trachea

• Breathing air that is cold, dry and unfiltered of dust and other particulate matter will cause the lungs to produce more mucous.

• Mucous is intended to moisten the mucosa and provide a medium in which to cough out the particulate matter.

• An open stoma provides little breathing resistance and results in shallow breaths.

Factors Affecting Mucus Production in the Laryngectomee Patient

• Normal age-related decline in overall pulmonary function• COPD is common due to smoking history• Progressive impairment of bronchial obstruction and tracheal

infection during the first year post laryngectomy• Significant increase in mucous for 2 months post laryngectomy

during the hypersecretory phase Todisco, et al., Laryngeal cancer: Long term follow-up of respiratory functions after laryngectomy. Respiration 1984.

Pulmonary rehabilitation of the laryngectomee patient involves heat, humidity, filtration, and

resistance to their respiration

Stoma Covers

• Effective for covering the stoma visibly

• Do not provide any heat or moisture to the inhaled air

• Minimal filtering• Do not provide much

resistance to breathing

Heat and Moisture Exchange Device (HME)

– Nasal Breathing• Air of 72⁰ F and 40%

Relative Humidity is Conditioned to 90⁰ F and 99% RH at the trachea

– Laryngectomee with HME• Air of 72⁰ F and 40%

Relative Humidity is Conditioned to 81⁰ F and 50% RH

Keck et. Al. Laryngoscope 2005

Different types of HME’s

External Housings

• Disks that adhere to the peristomal area and provide a housing for the HME device.

Intra-luminal Housings

Housing Seal

–The key to maximizing effectiveness of any HME is the airtight SEAL of the housing around the stoma. Inhaled and exhaled air MUST pass through the HME.

Suggestions for obtaining a good adhesive seal

• Start with a CLEAN peri-stomal area

• Use Skin-Prep

• Use Skin Tac (some patients use Silicon Glue for a better seal)

• Allow time for the adhesive to set before using HME for Tracheoesophageal speech (particularly with the hands free)

Troubleshooting• Many choices of HME housings, HME’s, Accessories, Voice

Prostheses and hands free devices.• Communicate with sales representatives for information

regarding new products or to ask questions about current products

• Try different products….what works best for one patient may not work for another

• Continuing Education courses• Consult with other SLP’s• Some patients may choose not to use HME due to cost,

personal choice, etc.

Rescue Breathing—Total Neck Breather

• Important to carry a card, wear a bracelet, make family members and local EMS people aware that person is now a total neck breather and would need CPR through stoma in an emergency situation

TOTAL LARYNGECTOMY

COMMUNICATION OPTIONS FOLLOWING

OPTIONS FOR COMMUNICATION FOLLOWING A TOTAL LARYNGECTOMY

1. Artificial Laryngeal Devices• Transcervical (Neck Type)• Intraoral (Mouth Type)• Pneumatic methods exist (i.e. Tokyo device), but are

infrequently used2. Esophageal Speech• Costs less because no equipment • Takes several hours of practice with low success

rate (20-60%)3. Tracheoesophageal Speech (TEP)• Not everyone is a candidate• Can be expensive depending on insurance

Artificial Larynx: Neck and intra-oral

Artificial Laryngeal Devices--Examples

Basic Introduction to Artificial Laryngeal Device

• How does the device work?• Basic placement goals---get a good seal and find “sweet spot”• Rate and --speak slow and overaticulate• Basic on-off control---timing of device• Nonverbal factors---head position, facial hair, etc• Have patient try and learn use of device with non-dominant

hand

Primary Goals of TreatmentPlacement of device

• Proper placement neck type—help patient find the “sweet spot” With both neck and intraoral type this will be the spot with the best

transmissionSometimes difficult due to neck tissue, surgery and/or radiotherapyAvoid fibrotic tissue and facial hairDemonstrate placement, pressure, and a good seal with the palm of

your hand and then on neck (too little pressure will cause external noise and too much pressure will cause a weaken signal)

May be too tender for neck placement when early post-op

Primary Goals of TreatmentPlacement of device

Proper placement of intraoral typeTypically 1-2 inches in mouthTrial and error works best to find the “sweet spot”Slight adjustments make a huge difference (tip up,

middle, or down)Side of the mouth is best if possibleBe aware of saliva and hygiene issues

Primary Goals of TreatmentRate and Overarticulation of Speech

• Work on Slow rate with over emphasized speech• Start with common words or phrases and

gradually progress to longer phrases and sentences• Practice, practice, practice!!!!• Begin and end treatment sessions with success

Primary Goals of TreatmentOn/Off timing of Device

• Is best learned with practice• Sometimes a difficult skill to acquire• Opt for “on” too soon and “off” too late•Must have good dexterity and finger

control

Anatomy of Esophageal Speech•Air in the mouth and throat (A) is passed into the P-E segment (B) and immediately returned causing vibration of the air in the mouth & throat(C) which is shaped into speech by the lips, tongue and teeth (D)

ESOPHAGEAL SPEECH

• AdvantagesNo cost associated with devices or batteries….nothing can “break down”Hands freeSpeech quality sounds more natural to listenersCan modulate pitch and rate when proficient

• DisadvantagesSignificant investment of time and effort with high failure rate (only 20-60%

success rate for those that try and learn)Not everyone is a good candidate for esophageal speechLoudness can be an issue

What interferes with Esophageal Speech?

• Oral problems—limited mobility of tongue/jaw or absent dentition• Pharyngeal/esophageal problems—trouble

swallowing due to extensive surgery or presence of a stricture• Hearing impairment• Lack of motivation and/or poor health• Lack of access to good resources for training

Pharyngoesophageal (P-E) Segment

• Area where muscle fibers from inferior pharyngeal constrictor, cricopharyngeus and cervical esophagus blend together• Shape and length vary• Usually located at level of C4-C7• Tonicity (amount of tone) is very important

Methods of Getting Air into P-E segment

• Injection methods--Push air down into the P-E segment using the tongue.Teaching the Injection Method (Build up intra-oral pressure to push

air into P-E segment) Tongue pump—push whole of tongue up against roof of mouth Tongue sweep—compress air from front to back in sweeping

motion Both can be done with or without lip seal

Facilitators—puffing cheeks, blowing balloons, lowering/turning head, starting swallow, using air from deflating balloon

Methods of Getting Air into P-E segment

• Inhalation method--Suck air down into the P-E segment by taking a quick breathCreate negative pressure in esophagus to “suck” air down

With mouth open, take a sudden breath as if surprisedTake a long breath in until lungs half full then “sniff”

suddenlyFacilitators—Stretching/relaxation, yawning, sighing,

sucking/sipping air, and raising, turning or jerking head back

Returning the air for phonation

• Listen for “click” as air passes through P-E segment or ask patient to monitor the feeling of air “going down”

• Use gentle abdominal pressure to return• Do not exhale forcefully or push too hard as this will produce noisy

exhalation from the stoma (stoma blast) which interferes with communication

• Start with sustained phonation “ah” (once patient is consistent…i.e. five successful attempts consecutively)

• Progress to single syllable words• PRACTICE, PRACTICE, PRACTICE + MOTIVATION

Tracheoesophageal Voice:How does it work?

• TE puncture between trachea and esophagus

• Prosthesis stents tract, one way valve to shunt air and prevent aspiration

• Stomal occlusion• Diverts pulmonary airflow into

esophagus for vibration• Sound to mouth and articulators

shape sound

Tracheoesophageal Voice Restoration

• State-of-the-art method of voice restoration• Most comparable to the laryngeal (someone with normal

larynx) speaker in quality, fluency, and ease of production• Maintains pulmonary airflow

Louder voice with better qualityLonger phonatory durationNOT synthesized speechSound generator = esophageal walls

Who is a candidate for TE Speech

• Not every patient is a candidate for a TEP• Success depends on the patient and the expertise of the medical staff

working with he or she (SLP, ENT, etc)• Comprehensive Pre-Operative Evaluation

Surgery and reconstructionRadiation therapyPatient’s reliability and commitment (Independence, support, etc)CognitionSubstance abuseManual dexterity and visionInsurance

Primary vs Secondary TEP

• Primary TEPPerformed at time of the total laryngectomy

• Secondary TEPPerformed after the total laryngectomyInvolved another procedure in operating room or outpatient procedure room

• For either Primary or Secondary puncture a red rubber catheter or a TEP is placed at the time of the procedure

• SLP evaluates patient approximately 7-10 days after puncture for TEP placement or assessment for proper size and fit

Selection of the Voice Prosthesis

• Standard Voice Prosthesis (price approximately $57-$97 depending on brand and style)Diameter (16, 17, or 20FR) Length (4mm-28mm)Cheaper than indwellingManaged by patient/caregiverstrap stays onmore frequent replacements (approximately 2-3

months)Insertion methods—Gel caps or loading sticks

Selection of the Voice Prosthesis• Indwelling Voice Prosthesis (price $218-$1896 depending

on brand and style)

– Diameter (16, 20, or 22.5FR)

– managed by healthcare professional

– strap optional

– usually longer duration (approximately 3-5 months) Insertion Methods

Inserters/sticks Gel caps Loading tubes

RadiopaqueCandida-resistantSilicone, Titanium, Magnets, Silver Oxide

Sizing of the Voice Prosthesis

• Proper FitCollars should be flush with mucosal wallsNo pistoningNo leakageNo tissue induration

• Improper FitToo longToo short

Post Placement Assessment and Instruction

• Assessment Assess vocal quality with prosthesis in placeAssess fluency and effortAssess for leakage (through and around prosthesis)

• Speech TrainingStomal occlusion, breath support, timing, and phrasing

• CleaningFlushing (pipette vs syringe)BrushingTweezers

• Troubleshooting• Need for Hands Free TE Speech Devices• Emergency catheter kit

Troubleshooting• Leakage through the prosthesis

Prosthesis too old—replace prosthesisCandida—replace prosthesis and patient use anti-fungal or use anti-fungal TEP Increased Intraesophageal pressure—increased resistance TEP, Duckbill, Activalve, NID

• Leakage around the prosthesisProsthesis too long—remove TEP and resizeEnlarged TEP—will require enlarged anterior or retention collar….do not place bigger

prosthesis• Post fitting Aphonia

Mucous/food obstructing TEP—Clean prosthesis Prosthesis not fully inserted—remove TEP and resize Posterior TE tract stenosis or closure—remove TEP, dilate, resize and replace or

repuncture Hypertonicity or PE spasm—Insufflation testing, botox injections

Insufflation Testing

Issues with using a TEP

• Involved medical history• Younger population who demand premorbid abilities• Unrealistic patient expectations• Advanced technology and more options, but less access

(clinician and resources)• Rising costs of prostheses (supplies); healthcare in general• Troubleshooting—sometimes you just can’t make it work

Take Home Messages

• Patients are younger, more demanding, and more medically complex• Successful TE speech is more than just placing the prosthesis• Know when to step away from the patient• Know limitations• Ask questions• Know products• Mentoring with experienced clinicians• Etiology is not always obvious and may be a combination of problems

that require multiple interventions

Wichita Support Group for Laryngectomees

• Place: Chisholm Trail New Voice Club• Meeting time: 11:00AM 3rd Wednesday of each month• Meeting Place: Via Christi Cancer Resource Room

• 817 N Emporia• Wichita, KS

• Contacts: Renee’ L Ediger, MA, CCC-SLP• (316)928-4950• Susan Kennedy, MS, CCC-SLP• (316)573-6802

RESOURCES

• Cavanagh (2011)• Doyle (1994)• Doyle & Keith (2005)

• Keck et. Al. Laryngoscope (2005)• Palmer , A.D. & Graham, M.S. (2004)• (Rohe 1986; Shanks, 1995)• Todisco, et al., (1984)