Surgical Prosthetics-Test 2

Question 1

Ways to produce speech post-laryngectomy

Answer 1

Artificial larynx
Esophageal speech
Voice prosthesis

Question 2

Extra Artificial Larynx Info

Answer 2

Intelligibility on the ultra-voice is not very good.
One button with a trutone. Can have a range for emphasis; several pitches.
Cervox will last a couple years.
Trutone has a standard 9-volt battery that you can buy in a store.
Goal for SLP would be how to use this and maintain it.
Cooper-Rand is another brand that is just an intraoral device.
Intraoral piece would go half inch to an inch inside the mouth; not as intelligible as on the neck.
May have trouble hearing yourself or someone else bc sound will be distorted. Don’t turn it up to adjust bc the feedback gets louder still.
“I didn’t catch those last few words. Could you repeat that?”—communication is the reason for the therapy

Question 3

The Artificial Larynx

Answer 3

Typically introduced post-laryngectomy

Takes quite a bit of tx sessions to teach a pt to use

Question 4

2 modes of use with artificial larynx

Answer 4

Intra-oral & neck vibrating

Question 5

Artificial Larynx requires ____

Answer 5

Functional articulatory skills

Pt must move the tongue & lips clearly to articulate words

Question 6

What are 2 types of artificial larynx power

Answer 6

Battery powered
Pulmonary powered (own lung air)
Both with neck & intraoral vibratory sources

Question 7

Battery Powered Artificial Larynx

Answer 7

Requires recharging the batteries for device to remain operable (expense of batteries?)

Question 8

Pulmonary Powered Artificial Larynx

Answer 8

Attached to the stoma & is powered by the lungs

Not an option for patients with a history of COPD

Question 9

Pulmonary Devices

Answer 9

External Pneumatic Larynges/Pneumatic Larynx

Question 10

Types of Battery-Powered Devices

Answer 10

Western Electric
Cooper Rand
Servox

Question 11

Western Electric Battery-Powered Device

Answer 11

Neck vibrating, battery powered
Can be purchased from the phone company
Has a large head or diaphragm & can only be used with patients who have a soft neck

Question 12

Cooper Rand Battery-Powered Device

Answer 12

Intra-oral, battery powered
Pt places a tube in the mouth, presses a button, & begins to speak
Pt must have good articulatory skills
Pt must have good motoric & coordination skills
Device has volume & pitch controls
Usually used right after surgery (don’t want neck vibrating right after surgery)

Question 13

The Servox

Answer 13

Similar to Western Electric but higher quality & smaller head
Requires less soft tissue for vibration

Servox: high and low tone
Griffin labs: 1 button with all tones whole pitch range: True Tone

Question 14

Advantages of Artificial Larynx

Answer 14

Way to talk if Pt can’t use esophageal speech or a voice prosthesis
Permits prompt speech anytime
Quick & easy to learn
Can be used when esophageal speech can’t be heard due to low volume
Permits communication early
Prevents depression, by giving pt an early form of communication

Question 15

Disadvantages of Artificial Larynx

Answer 15

Very few are satisfied with sound of mechanical voice
Some feel it inhibits future learning of esophageal speech
Physical reminder of disability
Attracts attention
Requires use of 1 hand
Pt rendered speechless while batteries are recharging
Sounds computerized
Some feel it’s a sign of defeat

Question 16

Esophageal Speech

Answer 16

Intake of air through the mouth & 1/2 swallow into esophagus
Sound is produced on release of air by exciting upper esophageal tract into vibration at P-E segment (pseudoglottis)-use amount of air in oral cavity (blow up cheeks–amt of residual air you have)
Only 1 tbsp. of air is needed to speak

Question 17

Where sound is made in esophageal speech

Answer 17

At the level of the cervical esophagus at C5-C6

Question 18

2 methods to producing esophageal speech:

Answer 18

Inhalation method

Injection method

Question 19

Inhalation method of esophageal speech

Answer 19

Pt sniffs air through nose & mouth & allows bolus of air to fall into the P-E segment

Question 20

Injection method of esophageal speech

Answer 20

3 ways to produce:

• Glossal press (pressing air back with tongue)
• Glossopharyngeal press (pressing air up against pharynx with tongue)
• Plosive injection (p-t-k): put lips together, push it back, swallow

Question 21

Characteristics of a good esophageal speaker

Answer 21

Pt can speak up to 113 words per minute
Pt can produce 6-8 words per air charge (before swallowing again)
Length of esophageal sound should be 1.5 to 2 seconds duration
Time b/t injection of air & voice production should be approximately 1/2 second
Intensity of voice should be approximately 75 dB with a range of about 11 dB
Pitch level should be about 65 Hz for males & females

Question 22

Normal vowel prolongation:

Answer 22

15-20 seconds

Question 23

What is a Tracheal Esophageal Puncture (TEP)

Answer 23

Surgical prosthetic procedure
Created by placing a small surgical passage in stoma from back wall of the trachea into the esophageal wall
Prosthesis is a 1” (can be other sizes) tube placed in the passage to enable tracheoesophageal speech
Speech is produced by covering stoma with finger to direct air from the lungs through the prosthesis into esophagus
Primary vs. Secondary placement
Shunts air from lungs into esophagus

Question 24

TEP Voice

Answer 24

Produced at the same location as classic esophageal speech

Question 25

Criteria for success with prosthesis

Answer 25

Can't be alcoholic or use drugs (poor judgement, may not take care of it, may not know he's aspirating) Good pulmonary support Good hand eye coordination Good motoric skills Be able to follow instructions Adequate stoma size (at least large enough to place equipment; 1st finger past 1st knuckle) Good vibration of esophageal walls

Question 26

Is TEP appropriate?

Answer 26

Must pass a transnasal air insufflation test first

Question 27

Transnasal Air Insufflation Test

Answer 27

Determines if Pt is a good candidate for TEP Catheter is placed over the stoma & then passed transnasally to esophagus Catheter stops at C5-C6 level, b/c that's where the esophageal wall vibrates for speech SLP covers the stoma to prevent air escape Pt instructed to phonate vowel /e/ Pt should be able to produce voice with normal lung capacity of approximately 15 seconds Pt is instructed to count to 10 three times Good candidates demonstrate uninterrupted fluent speech

Question 28

Purpose of Transnasal Air Insufflation Test

Answer 28

Get someone who has already had a laryngectomy. Get circular double-stick tape (clean around stoma and then place the double-stick on). Fit the plastic piece over the tape and stoma, get a good seal, pop tube on, lube tube, and insert tube into nose and have them swallow it for about 25 mm in (tube is marked). The insufflation test kit redirects the air to see if pt can talk through esophagus.

Question 29

3 Types of Voice Prostheses

Answer 29

``` Low Pressure Duck Bill Indwelling low pressure prosthesis (Shiley makes nonindwelling Blomsinger or Provox) ```

Question 30

Low Pressure Voice Prostheses

Answer 30

Size 16-20 French, can be removed by pt for cleaning or replacement following initial fitting & placement by SLP

Question 31

Duck Bill Voice Prostheses

Answer 31

Size 16 French, removed by pt following initial fitting & placement by SLP

Question 32

Indwelling low pressure Voice Prostheses

Answer 32

Inserted and removed by SLP or doctor Lasts 6 months at a time Cannot be cleaned or recycled

Question 33

Fitting Prosthesis & Insertion

Answer 33

1. Determine size of puncture site using sizer 2. Place a dilator into fistula site to make it a little larger to accept prosthesis 3. Blue loading device is used next to pull prosthesis through in order to place a gel cap over the top of the prosthesis for easier insertion 4. The inserter rod is used to endure the prosthesis isn’t dropped into the lungs 5. The strap of the prosthesis always stays on the outside of the neck and the therapist then makes a full rotational turn of the prosthesis with the insertion rod so that the retention collar is in place and the duck bill will be able to open and enable air flow into the esophagus 6. Strap should be taped on to the neck and the insert rod is slowly removed 7. Have the patient drink a warm glass of water to check for aspiration and to melt the gel cap

Question 34

Using a sizer

Answer 34

The sizer is inserted through the puncture site until you come in contact with the posterior esophageal wall Then pull down until you feel a resistance form the retention collar which gives you the size of the puncture site

Question 35

Notes with Placement:

Answer 35

Sizes Different diameters of prostheses and different lengths. Diameteres range from 16 French to 22 French (1 Fr= 1/3 mm) Non-indwelling prostheses are typically the smaller diameter. The Provox 2 is the larger diameter of 22.5 mm. Length of what? The thickness of the posterior tracheal wall and the anterior wall of the esophagus. The white sizer: lube it up, put all the way in and then fit. The number you can completely see is the sixe you should use. If laryngectomee has breathing problems; give them a card or medical alert bracelet so if in ER, the staff will know what the white circle is in their throat. “I am a neck breather.”

Question 36

Valve is supposed to be one-way so that...

Answer 36

Swallowing is still doable with prosthesis in | Blom-Singer & Provox

Question 37

Chemotherapy & Radiation affect...

Answer 37

use/function/amount of time to wait before making the puncture

Question 38

How is the Puncture made?

Answer 38

With a trocar, scalpel, or needle and dilator | Seems to be the best and less swelling

Question 39

With swelling and prosthesis:

Answer 39

give them 24 hours, reevaluate, no voice?, resize them

Question 40

To fit a Pt with a tracheostoma valve

Answer 40

Clean skin around stoma with alcohol Put cutaneous glue around stoma Place double edged tape on valve and skin Attach valve to skin, diaphragm w/in the valve closes when talking & opens for breathing Remove when coughing Humidifier goes into valve to decrease coughing and phlegm

Question 41

With an insufflation, you want Pt to be able to ____

Answer 41

say 2-3 words | If they can't, may need Botox or dilation

Question 42

Cleaning & Changing Prosthesis

Answer 42

Pt needs to be taught how to clean the prosthesis & detect when a new 1 is necessary Cleaning: Can be done with forceps; Can be done by shooting water through the prosthesis with a pipette Keep in mind that people can change sizes with prostheses

Question 43

TEP Complications

Answer 43

Esophageal perforation during the creation of fistula Severe allergic reactions to prosthesis or the glue from the tracheostoma valve Leakage of saliva & food through the puncture site resulting in aspiration Enlargement of the fistula Pneumonia as a result of recurring aspiration Aspiration of the prosthesis (not common but they are radio-opaque) Tracheal stoma stenosis Esophageal stenosis

Question 44

Voice Prosthesis Advantages

Answer 44

Preservation of speech rate and voice duration Normal prosody as a result of using the pulmonary air stream 10dB louder intensity Voice is usually obtained at a faster rate than learning esophageal voice by classical means Less therapy is needed More natural sounding; easier to understand

Question 45

TEP size

Answer 45

Different lengths & diameters of prostheses