Outline 12 Alyrangeal speech

Question 1

What is insufflation testing?

Answer 1

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

Question 2

In an insufflation test what are looking to see?

Answer 2

If the upper esopagus can vibrate

Question 3

The patient occludes the housing and blows air into the hose into the esophagus. How long should the hose go down?

Answer 3

25 cm

The patient occludes the housing and blows air into the hose into the esophagus

Question 4

Once you get the hose in what will you ask your patient to do?

Answer 4

The patient occludes the housing and blows air into the hose into the esophagus

Question 5

What is the passing criteria for an inflation test?

Answer 5

1. 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

Question 6

T/F Up to half of laryngectomees may benefit from PE segment relaxing procedures

Answer 6

True

like botox injections or surgery.

Question 7

Why do you want relaxing procedures?

Answer 7

Because the upper esophageal sphincter may be too tight to allow air to come through

Question 8

What are the two types of surgery?

Answer 8

1. Neurectomy
   - Nerve is cut on one side –vagus CN X to make it more relaxed
   - Problem? They are now allowing acid to come up
2. Myotemy
   - Slice the muscle on one side
   - But surgery is intended damage

Question 9

What kind of things can you recommend or do in therapy to relax the UES or PE segment?

Answer 9

Hypotonicity

Hypertonicity

Question 10

Explain hypotonicity

Answer 10

1. Possible to have a breathy esophageal speech
2. This will result in a consistent continous voice but will be very weak and breathy
3. If you put pressure on the esophagus
4. Wear a chocker or a really tight collar
5. Should never EVER have relaxing surgery (neuretomy or myotemy)
6. There is a strong correlation between cancer and acid reflux

Question 11

Explain hypertonicity

Answer 11

1. Tight spinchter
2. Interrupted phonatation in the insufflation test
3. Intermittent voice

Question 12

T/F UES speech may not be possible from insufflation testing

Answer 12

true

Question 13

What happens to the esophageal structure after attempt to repair the pharynx?

Answer 13

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

Question 14

How do you measure the TE prosthesis?

Answer 14

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

Question 15

1 Fr = _______ mm

Answer 15

.33

Question 16

T/F The collar is smaller than the diameter?

Answer 16

False it is bigger than the diameter
** remember this is the middle barrel

depends on the incision diameter

Question 17

After you measure them what can you do to make sure you sized it right?

Answer 17

Give them a glass of water and if they cough go up in size

The Fr (diameter) should have a good snug fit

Question 18

If the prosthesis is too long, it will _____

Answer 18

piston

Question 19

If the prosthesis pistons what does that mean?

Answer 19

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

Question 20

Why should we change low pressure prosthesis often?

Answer 20

1. Acid reflux

2. Yeast

Question 21

T/F It’s not unusual for a prosthesis to change in size

Answer 21

True

Question 22

Creating a TE (tracheal esophageal) hole is an office procedure, how do you make a hole?

Answer 22

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

Question 23

How do you place a prothesis?

Answer 23

First, the catheter needs to be removed

1. If the patient is sitting up when you pull out the catheter it’s likely that you’ll get saliva and mucous as well
2. 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

Question 24

Before you put in the cathetor have them occlude the stoma and have them voice

Answer 24

1. This is the you can see if the puncture works
2. 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

Question 25

How do you place the first prosethesis?

Answer 25

1. sizing device - Measure diameter and length 2. Load the prosthesis 3. Insert the prosthesis using the insertion stick 4. Once the prosthesis is inserted, turn the insertion stick to see if it spins easily 5. Tape the tail in place 6. Removing the prosthesis and the next insertion may be done by the patient

Question 26

When inserting the prosthesis using the insertion stick what are some things you can do make sure it’s sitting right ?

Answer 26

ii. Give them a cup of water so the gel dissolves and turn it iii. If the prosthesis turns it’s seated well 1. If it DOES NOT turn the collar has opened inside the puncture 2. Either it’s against the posterior esophageal wall 3. Have them voice to see if they can voice

Question 27

What is the difference between low pressure and high pressure prosthesis ?

Answer 27

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!

Question 28

Explain how you will tell people to clean and care for their prosthesis at home

Answer 28

They can be cleaned in situ (in place) with a tiny brush and/or flushed with water. 1. You can put nistatan and flush the prosethsis itself 2. It’s not a bad idea to swallow or garggle nistanan in the pharynx on top of the esophagus

Question 29

What is candida?

Answer 29

a type of yeast that likes to develop 1. Once yeast begins to colonize it needs to be changed 2. Thus, cleaning needs to be done to stop it from growing on the prosthesis-- tell them to use nystatin and to gargle it regularly 3. They no longer have the adequate airflow between mouth and nose so they’re at a high risk of having it

Question 30

What are the signs of prosthesis failure?

Answer 30

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

Question 31

Counsel the patient about accidents they can make---for example, dropping the prosthesis.

Answer 31

Tell them not to panic unless you drop a perfect shape!!! air will still go around the object just go to the hospital

Question 32

7. Voiced-voiceless issues with esophageal and TE speakers

Answer 32

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

Question 33

Esophageal speech requires air injectors. List them

Answer 33

Compression Inhalation Constant Injection

Question 34

Explain how they use compression as an air injector

Answer 34

This is essentially swallowing Compressing the air by closing the lips and the velum and pushing the air backwards

Question 35

Explain how they use inhalation as an air injector

Answer 35

1. Putting air into the esophagus 2. 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

Question 36

Explain how they use Constant injection as an air injector

Answer 36

1. Similar to compression but they do that as they’re speaking 2. 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

Question 37

T/F Compression is easier to learn but inhalation is probably better

Answer 37

true

Question 38

What do you do in alaryngeal speech therapy?

Answer 38

1. get air in, get air out 2. CV and CVC syllables are the best to start with 3. short phrases to long phrase 4. Articulation practice 5. Normal speech rate

Question 39

What types of phonemes do you start with in CV and CVC syllables?

Answer 39

1. 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 2. Then liquids and glides

Question 40

What is the normal speech rate for a TEP speaker vs normal speaker?

Answer 40

``` Normal = 150 WPM TEP = 60-70 WPM ```

Question 41

What are some challenges for alyrngeal speakers?

Answer 41

TEP speakers have similar difficulties as electrolarynx Specifically, inflection and volume are problematic why? they no longer have the same vibratory force

Question 42

TEP speech therapy overall what things should you do? (this is a review of everything)

Answer 42

- 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