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 Anatomy
Inhaled 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
COMMUNICATION OPTIONS
FOLLOWING
TOTAL LARYNGECTOMY
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 used
2. 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
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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 Treatment
Placement 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
transmission
Sometimes difficult due to neck tissue, surgery and/or radiotherapy
Avoid fibrotic tissue and facial hair
Demonstrate 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 Treatment
Placement of device
Proper placement of intraoral type
Typically 1-2 inches in mouth
Trial 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 possible
Be aware of saliva and hygiene issues
Primary Goals of Treatment
Rate 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 Treatment
On/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
• Advantages
No cost associated with devices or batteries….nothing can “break down”
Hands free
Speech quality sounds more natural to listeners
Can modulate pitch and rate when proficient
• Disadvantages
Significant 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 speech
Loudness 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 breath
Create negative pressure in esophagus to “suck” air down
 With mouth open, take a sudden breath as if surprised
 Take a long breath in until lungs half full then “sniff”
suddenly
 Facilitators—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 quality
Longer phonatory duration
NOT synthesized speech
Sound 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 reconstruction
Radiation therapy
Patient’s reliability and commitment (Independence, support, etc)
Cognition
Substance abuse
Manual dexterity and vision
Insurance
Primary vs Secondary TEP
• Primary TEP
Performed at time of the total laryngectomy
• Secondary TEP
Performed after the total laryngectomy
Involved 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 indwelling
Managed by patient/caregiver
strap stays on
more 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
 Radiopaque
 Candida-resistant
 Silicone, Titanium, Magnets, Silver Oxide
Sizing of the Voice Prosthesis
• Proper Fit
Collars should be flush with mucosal walls
No pistoning
No leakage
No tissue induration
• Improper Fit
Too long
Too short
Post Placement Assessment and Instruction
• Assessment
 Assess vocal quality with prosthesis in place
 Assess fluency and effort
 Assess for leakage (through and around prosthesis)
• Speech Training
 Stomal occlusion, breath support, timing, and phrasing
• Cleaning
 Flushing (pipette vs syringe)
 Brushing
 Tweezers
• Troubleshooting
• Need for Hands Free TE Speech Devices
• Emergency catheter kit
Troubleshooting
• Leakage through the prosthesis
 Prosthesis too old—replace prosthesis
 Candida—replace prosthesis and patient use anti-fungal or use anti-fungal TEP
 Increased Intraesophageal pressure—increased resistance TEP, Duckbill, Activalve, NID
• Leakage around the prosthesis
 Prosthesis too long—remove TEP and resize
 Enlarged 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
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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:
• Meeting time:
• Meeting Place:
• Contacts:
Chisholm Trail New Voice Club
11:00AM 3rd Wednesday of each month
Via Christi Cancer Resource Room
• 817 N Emporia
• Wichita, KS
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)