Total Laryngectomy

Question 1

Early symptoms of laryngeal cancer are similar to the common cold they include:

Answer 1

• lump in the throat feeling
• persistent throat clearing
• persistent coughing
• sense of discomfort in the throat
• persistent sore throat
• difficulty breathing
• burning sensation when swallowing
• difficulty or pain in swallowing
• referred pain in ear
• unexplained weight loss

Question 2

Describe a total laryngectomy:

Answer 2

The larynx is removed including the hyoid bone and first tracheal rings. Usually to get a lymph nodes. The neck tissue is brought to the midline to seal the oral cavity from the trachea. The trachea is bent forward.

Question 3

T or F: You can aspirate with a total laryngectomy.

Answer 3

False

Question 4

T or F: If someone has a total laryngectomy, you should breath into their mouth during CPR

Answer 4

False - that would just put air in the stomach

Question 5

T or F: People with a total laryngectomy have no problem swallowing.

Answer 5

False- no aspiration but still can have difficulty especially with bolus entering UES b/c nothing to raise and open it.

Question 6

What is an issue with breathing through a stoma? How is it resolved?

Answer 6

No oral cavity for moisture. Lungs lose heat and moisture. Can use a heat and moisture exchanger or a sponge to protect them.

Question 7

Describe the pneumatic artificial larynx (tokyo larynx) and who uses it:

Answer 7

A hose is put on top of the stoma and air causes a flat noise to be transmitted through catheter into oral cavity where articulators can be used. Not common in canada but popular in tonal languages.

Question 8

Describe the transcervical electrolarynx and who uses it:

Answer 8

Most common in Canada. Batteries are hard to get. Use residual air in the oral cavity to produce sounds.

Question 9

Describe the Servox transcervical electrolarynx:

Answer 9

Difficult to use when there is lots of scar tissue. Usually produces a low freq. Even if not primary mode, most people have as a backup.

Question 10

Describe the cooper-rand intraoral electrolarynx:

Answer 10

similar to Tokyo larynx but sound comes from the machine through a tube into the mouth. Tube interferes with articulation more. May use this is scar tissue prevents use of the electrolarynx

Question 11

List 5 treatment considerations for SLP to use with patients with artificial larynges:

Answer 11

• overarticulation without visible over-exaggerating movements
• identification of best coupling spot
• larynx to skin seal
• develop conversational speech (phrasing, pauses, normal rate, coordination of e-larynx and artic)
• Pragmatic use of the larynx (use it to indicate turn-taking)

Question 12

List 5 possible goals for a patient with an artificial larynges:

Answer 12

1) Optimal placement
2) Coordination of the “on” control with speaking
3) Articulatory precision
4) Appropriate rate and phrasing
5) Attention to nonverbal behaviours

Question 13

Describe esophageal speech:

Answer 13

Uses the UES to produce sound. Air is pumped into upper 3rd of the esophagus. Least freq. method in canada but most freq. around the world.

Question 14

What are the 2 ways of insufflation in esophageal speech:

Answer 14

1) Injection method
2) Inhalation method
* usually pple use both methods

Question 15

Describe the injection method of insufflating the esophagus:

Answer 15

Sends positive pressure into the esophagus. Plosive consonant injection, glossal compression injection, glossopharyngeal compression injection, “modified swallow”.

Question 16

Describe the inhalation method of insufflating the esophagus:

Answer 16

Inhale the air and relax the UES a bit and the neg. air pressure will pull the air into the UES.

Question 17

List Doyle’s 5 steps on the way to esophageal sound production:

Answer 17

1) Train insufflation (injection or inhalation)
2) Voice production on demand following insufflation
3) Repeated production of voice following insufflation
4) Monitor devleopment of detrmimental behaviours
5) Reduce the degree of articulatory contact associated with insufflation and voice production

Question 18

Describe the stages of esophageal speech development (Snidecor):

Answer 18

• Get air in and out
• Produce plosive consonants, vowels and diphtongs
• Simple useful monosyllabic words
• Voice 2-syllable words with first 2 than 1 insufflation
• Voice phrases
• precise articulation and connected speech
• achieve stress
• Use active conversation
• Conversational speech rate

Question 19

List 5 advanced goals of esophageal speech (Doyle):

Answer 19

1) prolongation of voicing
2) Increased intelligibility
3) Minimize associated noises or behaviours which have a neg. impact
4) Maintain adequate speech rate
5) Improve prosodic features

Question 20

List 2 related problems with esophageal speech:

Answer 20

Klunking and Respiratory noise/ stoma blast

Question 21

Describe Klunking:

Answer 21

Klunking is a squeaky sound during insufflation (audible charging of the esophagus).

Question 22

Describe respiratory noise/ stoma blast:

Answer 22

The patient needs to learn to uncouple speech and breathing.

Question 23

Describe Tracheo-esophageal speech:

Answer 23

Esophageal speech driven by airflow from the lungs. A one-way valve attaches trachea and esophagus. Just enough air is needed to push air through when they want to but not all the time.

Question 24

List some criteria to be a TEP candidate:

Answer 24

• motivation
• understanding of anatomy
• understanding of prosthesis
• adequate manual dexterity
• adequate visual acuity
• ability to care for prosthesis
• No sig. hypophayrngeal stenosis
• Positive air insufflation test
• adequate pulmonary function
• adequate stoma
• mental stability

Question 25

Describe the Primary TEP timeline:

Answer 25

TEP is inserted at the time of the laryngectomy. Prosthesis is fit after 8-10 days when patient resumes and oral diet. No speaking until 3-4 days later to avoid formation of a fistula.

Question 26

Describe the secondary TEP timeline:

Answer 26

After the recovery from the laryngectomy. The Prosthesis is inserted on the fourth postoperative day and the patient speaks immediately.

Question 27

Who manages a TEP:

Answer 27

Insertion and maintenance is a delegated act for SLPs

Question 28

T or F: The tracheo-esophageal puncture will close if something isn’t inserted into it.

Answer 28

True

Question 29

List the steps of inserting the Blom-Singer prosthesis:

Answer 29

1) Puncture dilation
2) Puncture Measure
3) Insertion of gel capped prosthesis
4) Cutting or taping of insertion strap

Question 30

List 5 goals for using TEP speech:

Answer 30

1) Valving (teach when to cover and when not to)
2) Articulation
3) Phrasing
4) Rate
5) Attention to nonverbal behaviours

Question 31

What is insufflation testing:

Answer 31

Determining if the UES is a good sphincter for voicing. The Blom-Singer insufflation test involves a tube that goes from the stoma through the oral cavity to the esophagus.

Question 32

What are the four possible outcomes of esophageal insufflation testing:

Answer 32

• Normal tone - good voice production and candidate
• Spasm with complete aphonia (UES is too tight)
• Hypertonicity (reduced voicing) working too hard
• Hypotonicity (reduced voicing) not loud enough

Question 33

List possible complications of TEP voice rehabilitation:

Answer 33

• leaking TEP valve
• esophageal leaking through TEP fistula into airway
• Opening resistance of the TEP valve (too hard/easy)
• Candida biofilm (due to dry mouth)
• Persistent spasm of the PE segment
• Granuloma, scarring, infection, edema of TEP fisutla
• Disappearance of TEP valve under granuloma tissue
• Swallowing of Prosthesis
• Aspiration of prosthesis