Pre- & Post-Operative Counseling Post-Laryngectomy-Test 2 Flashcards by britt w

After a Laryngectomy, things will be different:

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.

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Pre-Operative Counseling

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

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Salvage Laryngectomies

Useless now after cancer treatment

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Jejunal graft

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

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Rehabilitation of laryngectomized Pt should start ____

Before surgery

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

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

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3 ways to produce voice post-laryngectomy

artificial larynx
esophageal speech
voice prosthesis

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Several methods of post-operative communication

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

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Things to cover in post-op counseling:

Safety & hygiene issues

Mouth to neck resuscitation

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Post-Op Evaluation

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

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Social Questions to Consider

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?

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Medical Background Questions to Consider

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?

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Assessment of Speech Production Post-Op

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

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Oral Mech Exam

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?

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

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

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Therapy Post-Op

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

Why an artificial larynx?

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

Best to introduce Artificial Larynx ____

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?

1st goal of Artificial Larynx Tx:

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

2nd goal of Artificial Larynx Tx:

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

3rd goal of Artificial Larynx Tx:

Develop speed of accurate placement

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

4th goal of Artificial Larynx Tx:

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

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

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

Stoma Blast

Air escape & acts like static on radio

6th Goal of Artificial Larynx Tx:

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

7th Goal of Artificial Larynx Tx

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

8th goal of Artificial Larynx Tx

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

9th Goal of Artificial Larynx Tx

Develop Inflection & Stress | Pt taught to manipulate pitch button on device at ends of sentences to reflect questions or to convey emotion

Therapy for Teaching Esophageal Speech

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

Hardest part of esophageal tx:

Accomplishing sound production | Trying to get air in or to swallow air to produce voice

Hierarchy of Acquisition of Esophageal Speech

``` 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 ```

Problems with Learning Esophageal Speech

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

Problems with Learning Esophageal Speech

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

Reasons for Failure to Produce Esophageal Speech

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

Rating Scales:

Useful in providing objective measurements

Therapy for Tracheoesophageal Speech

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

Therapy for Tracheoesophageal Speech

Steps for Teaching Pt to use prosthesis in Tracheoesophageal speech

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