Pre- & Post-Operative Counseling Post-Laryngectomy-Test 2

Question 1

After a Laryngectomy, things will be different:

Answer 1

Anatomy will be different
Coughing, volume control, daily activity (hobbies—at pool, lake, etc.—inhaling water), food tasting different (smell), sneezing, can’t sniff, can’t blow nose
Nose hairs & mucus humidify and warm air, trap bad particles, etc.

Question 2

Pre-Operative Counseling

Answer 2

Prior to surgery, Pt should have this
This way, Pt can meet in a professional setting & it allows therapist to prepare pt prior to hospitalization
SLP should know extent of planned surgery prior to counseling session: how large is tumor, is there metastases, is a jejunal graft planned
Lymph nodes not considered metastasis (often go to lungs)
Dry erase board before going into hospital

Question 3

Salvage Laryngectomies

Answer 3

Useless now after cancer treatment

Question 4

Jejunal graft

Answer 4

aka jejunal pull-up
take part of jejunum and use it in larynx/upper esophagus (skeletal muscles)—putting smooth muscle up at this point, but now there is more mucus, so voice will be easier but voice will be lower and deeper with lots of secretions

Question 5

Rehabilitation of laryngectomized Pt should start ____

Answer 5

Before surgery

Question 6

In the initial counseling session, we want to inform Pt ____

Answer 6

of surgical procedure by showing diagrams of laryngeal structures before & after surgery
Creation of the permanent stoma created
Make sure to let Pt know that there’s no chance of choking/aspirating after surgery since there will be no connection b/t airway & esophagus
We inform of 3 ways to produce voice post-laryngectomy
Only basic info pamphlet given before surgery; detailed info about first aid procedures & hygiene shouldn’t be given now
Include pt’s family in all aspects of counseling w/ emphasis on return to normal lifestyle
Visitation by a laryngectomized esophageal speaker or voice prosthesis user

Question 7

3 ways to produce voice post-laryngectomy

Answer 7

artificial larynx
esophageal speech
voice prosthesis

Question 8

Several methods of post-operative communication

Answer 8

1. writing slate/white board useful since it’s easily erased
2. Use of Manual Communication for the Laryngectomized
3. Stenographic book
4. Eye blinks
5. Hand signals
   Method should be agreed upon & practiced by pt, family, and hospital staff pre-operatively

Question 9

Things to cover in post-op counseling:

Answer 9

Safety & hygiene issues

Mouth to neck resuscitation

Question 10

Post-Op Evaluation

Answer 10

Following discharge, laryngectomee usually goes for a 2 wk follow-up w/ ENT
Physician checks surgical site to see if healing is completed & pt is ready for post-op vocal rehab
Physician will then recommend that the pt is ready to start OP voice Tx

Question 11

Social Questions to Consider

Answer 11

What is occupation in order to assess immediate importance for speech?
Education-assess Pt’s ability to read, write
What is pt’s current attitude?
What is degree of dependency on spouse or family?
How was person prior to surgery?
Have things changed w/ family/friends since surgery?
Has pt continued to use tobacco/alcohol post-laryngectomy?

Question 12

Medical Background Questions to Consider

Answer 12

Obtain staging of tumor & site of lesion
Has pt had a radical neck dissction, unilateral/bilateral?
Has there been any reconstructive surgery?
Were there any post-op complications?
Did pt have pharyngectomy or esophagectomy?
Has pt undergone radiation or chemotherapy or planning to in future?
Is esophagus stiff or stenosed following surgery or radiation?
Does pt have swallowing problems? What is current diet?

Question 13

Assessment of Speech Production Post-Op

Answer 13

Approach every person same: take everything into perspective: hx, all of modalities, etc.
Does pt have hearing problems?
Does the spouse have hearing problems?
Make an assessment of Pt’s articulation & intelligibility; can be done with an artificial larynx
Conduct an oral mech exam

Question 14

Oral Mech Exam

Answer 14

Look at lips: can they say /p/ in isolation & w/ repetitive productions
Is pt able to get sufficient intraoral air pressure in order to use plosive injection method or glossal press & glossopharyngeal press methods?
Was there any involvement w/ lips, tongue, hard/soft palate, pharynx, or esophagus during surgery?
Can pt say /t/ & /k/ in isolation/ w/ repetitive productions?
Is pt able to produce buckle speech? intra-oral whispered speech
Has BOT been resected interfering w/ good elevation of posterior tongue?
What is teeth status? Dentures/do they fit properly? May be necessary for referral to dentist to create new set of dentures
Have gums reduced in size after radiation?
Have teeth been removed prior to radiation?

Question 15

After the oral mech, the rest of the eval session consists of ____

Answer 15

Trying different types of artificial devices to see which works best & to instruct Pt in air injection techniques to produce esophageal speech

Question 16

Therapy Post-Op

Answer 16

Following eval
SLP needs to see the pt for 2 to 3 times/week for vocal rehab
Pt may be seen for a few weeks to 3-4 months

Question 17

Why an artificial larynx?

Answer 17

Provides immediate communication following surgery
Helps w/ psych issues like isolation/depression
Useful for those that can’t learn esophageal speech/use voice prosthesis
Covered under most insurances
Reimbursement on this stuff is low
May do tx for several months or a few weeks

Question 18

Best to introduce Artificial Larynx ____

Answer 18

ASAP
We select it
Is neck soft enough to accommodate vibrating surface of neck vibrating artificial larynx?
Can pt tolerate intraoral device? Can pt tolerate intraoral device that attaches to teeth?
What is stoma size?
What is price?

Question 19

1st goal of Artificial Larynx Tx:

Answer 19

Placement
Identifying best locations on neck or oral cavity
If intraoral device is selected, it’s placed to left or right of midline w/in oral cavity w/ tube angled upward & away from tongue
If neck vibrator is selected, it’s placed on a soft spot on neck, which can be very small

Question 20

2nd goal of Artificial Larynx Tx:

Answer 20

Develop consistent accuracy of placement
Using mirror, instruct pt to place device on spot either on neck or w/in oral cavity then put it down
Pt doesn’t turn on device but just becomes consistent w/ same placement every time
Next step is then to remove mirror

Question 21

3rd goal of Artificial Larynx Tx:

Answer 21

Develop speed of accurate placement

Pt required to pick up device & place it on correct spot in accurate & timely fashion

Question 22

4th goal of Artificial Larynx Tx:

Answer 22

Develop accurate timing of voice activation & termination
Pt is taught to turn on device only when it is placed on neck or w/in oral cavity when voicing is initiated
Turn the device off with the last sound produced

Question 23

Artificial Larynx Tx: Modification of Breathing & Stoma Noise-5th Goal

Answer 23

Laryngectomees tend to blow air through stoma when speaking
This is only natural since when we speak with a larynx, we exhale to activate the VCs
Air escape & acts like static on radio
W/ this goal, we teach pt to breath & speak independently
Pt can speak continuously w/ artificial larynx w/o a need to inhale or replenish air supply

Question 24

Stoma Blast

Answer 24

Air escape & acts like static on radio

Question 25

6th Goal of Artificial Larynx Tx:

Answer 25

Improve Artic Skills
Use artificial device to listen to artic skills
Pt taught to over articulate & to place specific emphasis on articulating final consonants, since they tend to omit final consonant & turn off device too quickly

Question 26

7th Goal of Artificial Larynx Tx

Answer 26

Develop Natural Pausing & Phrasing
Instruct pt not to turn device on/off w/ each word
Work on sentence production immediately rather than individual words & phonemes since we’re trying to obtain natural phrasing
Emphasize that @ a natural break in sentence, device is turned off then reactivated w/ next phrase
Don’t want pt to turn it off & on w/ excessive frequency

Question 27

8th goal of Artificial Larynx Tx

Answer 27

Determine Appropriate Rate of Speech
Train pt to slow down & take their time when using device
Best way to practice this is w/ reading paragraphs & then carryover into conversational speech

Question 28

9th Goal of Artificial Larynx Tx

Answer 28

Develop Inflection & Stress

Pt taught to manipulate pitch button on device at ends of sentences to reflect questions or to convey emotion

Question 29

Therapy for Teaching Esophageal Speech

Answer 29

Pt should achieve 90% accuracy on each goal before moving to next goal
Pt needs to swallow air & make sound; sound will probably be /ah/ or /e/ sound
Produce consonants & vowels
Voice simple 1-syllable words: plosives such as cake, cup, scotch or use vowel + plosives such as up, eat, it, at
Voice 2 syllables: cupcake, eat out
Voice 5-8 syllables on 1 air charge: Pt swallows air & is able to produce phrase like “I want a cup of coffee.” on 1 swallow
Refine loudness, pitch, quality, timing: Make esophageal speech as natural & unobtrusive as possible
Final goal is to expand utterance length: Link utterances together so that listener won’t know that pt is reswallowing after every 5-8 syllables

Question 30

Hardest part of esophageal tx:

Answer 30

Accomplishing sound production

Trying to get air in or to swallow air to produce voice

Question 31

Hierarchy of Acquisition of Esophageal Speech

Answer 31

V-less plosive consonants
V-less fricatives
Wh glides
Voiced plosives
Voiced fricatives
/w/
Rest of sounds
Leave /h/ to the very end: since it is a glottal sound it is almost impossible to produce

Question 32

Problems with Learning Esophageal Speech

Answer 32

Common faults are: air swallowing, stoma blast, noisy air intake (klunk), double pump, grimacing, lack of fluency

Question 33

Problems with Learning Esophageal Speech

Answer 33

Common faults are: air swallowing, stoma blast, noisy air intake (klunk), double pump, grimacing, lack of fluency

Question 34

Reasons for Failure to Produce Esophageal Speech

Answer 34

Anatomical, physiological, motivational factors
Scar tissue from radiation inhibits vibration of esophageal walls
Surgical alteration of esophagus
Fistula in esophagus leads to aspiration
Esophagus becomes smaller & stiffer (stenosis) possibly due to radiation
Presence of hiatal hernia (at distal esophagus)
Esophagus is too tight which causes spastic & interrupted voice or it is too loose which causes weak & breathy voice
Pt not motivated to learn esophageal speech

Question 35

Rating Scales:

Answer 35

Useful in providing objective measurements

Question 36

Therapy for Tracheoesophageal Speech

Answer 36

An alternative to esophageal speech
Silicone device inserted surgically created opening between trachea & esophagus to allow air from lungs to reach P-E segments
Tracheoesophageal puncture (TEP) may be quickest way for client to regain near-normal speech after larynx has been removed

Question 37

Therapy for Tracheoesophageal Speech

Answer 37

An alternative to esophageal speech
Silicone device inserted surgically created opening between trachea & esophagus to allow air from lungs to reach P-E segments
Tracheoesophageal puncture (TEP) may be quickest way for client to regain near-normal speech after larynx has been removed

Question 38

Steps for Teaching Pt to use prosthesis in Tracheoesophageal speech

Answer 38

Ask pt to inhale then phonate vowel prolongations on exhalation while SLP uses a finger to occlude stoma; if stoma isn’t covered completely, air will leak out around edges & voice will be unacceptable
Teach pt to digitally occlude stoma during exhalation & attempt to phonate sustained vowels or words: Pt is taught to cover stoma, speak naturally phrased sentences, unocclude stoma for breath, & then occlude stoma for next sentence
Use of tracheostoma valve can eliminate need for manual occlusion of stoma during speech production