Outline 12 Alyrangeal speech Flashcards
What is insufflation testing?
i. The SLP can blow the air or the patient can
ii. Gasket needs to be placed on the neck
iii. Put the air hose down the nose
1. Stick the tube on the housing before you put on the neck
2. Ask the patient to pretend to breathe and they swallow it down the velopharyngeal port
In an insufflation test what are looking to see?
If the upper esopagus can vibrate
The patient occludes the housing and blows air into the hose into the esophagus. How long should the hose go down?
25 cm
The patient occludes the housing and blows air into the hose into the esophagus
Once you get the hose in what will you ask your patient to do?
The patient occludes the housing and blows air into the hose into the esophagus
What is the passing criteria for an inflation test?
- Continuous – continuous phonation of about 8 seconds on ‘ah’ and/or the patient being able to count from 1-15 on one breath
a. Proof that this is usable and work
2.Consistent – being able to do it repeatedly
T/F Up to half of laryngectomees may benefit from PE segment relaxing procedures
True
like botox injections or surgery.
Why do you want relaxing procedures?
Because the upper esophageal sphincter may be too tight to allow air to come through
What are the two types of surgery?
- Neurectomy
- Nerve is cut on one side –vagus CN X to make it more relaxed
- Problem? They are now allowing acid to come up - Myotemy
- Slice the muscle on one side
- But surgery is intended damage
What kind of things can you recommend or do in therapy to relax the UES or PE segment?
Hypotonicity
Hypertonicity
Explain hypotonicity
- Possible to have a breathy esophageal speech
- This will result in a consistent continous voice but will be very weak and breathy
- If you put pressure on the esophagus
- Wear a chocker or a really tight collar
- Should never EVER have relaxing surgery (neuretomy or myotemy)
- There is a strong correlation between cancer and acid reflux
Explain hypertonicity
- Tight spinchter
- Interrupted phonatation in the insufflation test
- Intermittent voice
T/F UES speech may not be possible from insufflation testing
true
What happens to the esophageal structure after attempt to repair the pharynx?
i. The laryngectomy may scar that esophagus
ii. Tissue changes are possible from radiation
iii. The esophagus may be shortened by the surgery
iv. Esophagus may not be working for mechanical reasons
v. Some reason for a small rigid PE segment
How do you measure the TE prosthesis?
a. Length is measured in mm
b. Diameter is measured in French (Fr.)
i. Ex. 4 french
iii. Common size for TEP diameter is 15 Fr.
iv. Is around the middle of the prosthsesis
1 Fr = _______ mm
.33
T/F The collar is smaller than the diameter?
False it is bigger than the diameter
** remember this is the middle barrel
depends on the incision diameter
After you measure them what can you do to make sure you sized it right?
Give them a glass of water and if they cough go up in size
The Fr (diameter) should have a good snug fit
If the prosthesis is too long, it will _____
piston
If the prosthesis pistons what does that mean?
i. The collar in the trachea is going to move forward and back
ii. This is bad it will wear out tissue
iii. If the prosthesis is too short the collar is going to inflate inside the tissue between trachea and esophagus
1. Resulting in a terrible infection
2. Once you mess up the puncture hole the odds it will work correctly now are low
Why should we change low pressure prosthesis often?
- Acid reflux
2. Yeast
T/F It’s not unusual for a prosthesis to change in size
True
Creating a TE (tracheal esophageal) hole is an office procedure, how do you make a hole?
A hole is made by a punch
ii. Hold it open with a dilator and the cathetor stays in place until it heals
1. You don’t know the size the hole is going to be after it heals so you cannot put the prosthesis
2. To keep acid coming out of the catheter stick a golf t and the acid will not spill over
a. Or tie it off if there is enough length and tape it down
How do you place a prothesis?
First, the catheter needs to be removed
- If the patient is sitting up when you pull out the catheter it’s likely that you’ll get saliva and mucous as well
- If the patient is lying backwards your less likely to get saliva and mucous coming out
iv. Once the catheter is out, put the dilator INSTANTLY!
2. Have the patient push the dialter as far as they can comfortably put
a. They’ll have much better control
3. Let the dialator sit for a minute as soon as they’ve pushed it as far as they can comfortably put it
Before you put in the cathetor have them occlude the stoma and have them voice
- This is the you can see if the puncture works
- The reason that you’re doing this with the puncture itself without the prosethesis—you need to see if the puncture works!
a. You know if it’s the prothesis or the puncture not working
How do you place the first prosethesis?
- sizing device
- Measure diameter and length
- Load the prosthesis
- Insert the prosthesis using the insertion stick
- Once the prosthesis is inserted, turn the insertion stick to see if it spins easily
- Tape the tail in place
- Removing the prosthesis and the next insertion may be done by the patient
When inserting the prosthesis using the insertion stick what are some things you can do make sure it’s sitting right ?
ii. Give them a cup of water so the gel dissolves and turn it
iii. If the prosthesis turns it’s seated well
- If it DOES NOT turn the collar has opened inside the puncture
- Either it’s against the posterior esophageal wall
- Have them voice to see if they can voice
What is the difference between low pressure and high pressure prosthesis ?
i.When changing the high pressure prosthesis without a tail is hard! You have to go in and get them with locking forceps and you just pull
ii. The Low pressure prosethesis must have the tail (the individual does it themselves)
1. The first two or three are done by us so teach them because they will have to do it
2. Or train the caregiver
REMEMBER: Stick the dialator immediately!
Explain how you will tell people to clean and care for their prosthesis at home
They can be cleaned in situ (in place) with a tiny brush and/or flushed with water.
- You can put nistatan and flush the prosethsis itself
- It’s not a bad idea to swallow or garggle nistanan in the pharynx on top of the esophagus
What is candida?
a type of yeast that likes to develop
- Once yeast begins to colonize it needs to be changed
- Thus, cleaning needs to be done to stop it from growing on the prosthesis– tell them to use nystatin and to gargle it regularly
- They no longer have the adequate airflow between mouth and nose so they’re at a high risk of having it
What are the signs of prosthesis failure?
i. Leakage through the prosthesis
1. Liquids will leak first
ii. Air will not pass through as easily
1. So they will find that they press really hard to speak
Counsel the patient about accidents they can make—for example, dropping the prosthesis.
Tell them not to panic unless you drop a perfect shape!!! air will still go around the object just go to the hospital
- Voiced-voiceless issues with esophageal and TE speakers
Voice onset time is the biggest clue for any human to identify any phoneme
i.The contrast and voiceless-voiced for TEP speakers is quite diminished issue
For electrolarynx speakers have them over exaggerate artic
i.Very strong tongue movement
For TEP speakers they need to push harder
i. Take a breathe and push the air
ii. Take the air and squeeze the ribcage and push air through PE segment
Relax the PE segment but still push more air pressure through!
They need some sort of respiratory drive
Esophageal speech requires air injectors. List them
Compression
Inhalation
Constant Injection
Explain how they use compression as an air injector
This is essentially swallowing
Compressing the air by closing the lips and the velum and pushing the air backwards
Explain how they use inhalation as an air injector
- Putting air into the esophagus
- They inhale which lowers the air pressure in the esophagus, and they open the top of the top of the esophagus and then air leaks in
Explain how they use Constant injection as an air injector
- Similar to compression but they do that as they’re speaking
- Can be done on stops specifically /k,g/ because the tongue is pushing air into the back
a. If the tongue is anterior it’s a littler harder
T/F Compression is easier to learn but inhalation is probably better
true
What do you do in alaryngeal speech therapy?
- get air in, get air out
- CV and CVC syllables are the best to start with
- short phrases to long phrase
- Articulation practice
- Normal speech rate
What types of phonemes do you start with in CV and CVC syllables?
- Use stops/affricatives first
- Why? It builds up air pressure and the release is very satisfying
- But if you’re a TEP the stops build up air pressure and push through because they can use their breath - Then liquids and glides
What is the normal speech rate for a TEP speaker vs normal speaker?
Normal = 150 WPM TEP = 60-70 WPM
What are some challenges for alyrngeal speakers?
TEP speakers have similar difficulties as electrolarynx
Specifically, inflection and volume are problematic
why? they no longer have the same vibratory force
TEP speech therapy overall what things should you do? (this is a review of everything)
- Talk about exaggerated artic
- Care and cleaning of the prosthesis
- Prosthesis management, occlusion
- Occlusion takes practice of when to put it on and off
- formants and freq are not that big of a deal
