Chapter 27: Living with and beyond cancer
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Related theory
Once the vocal cords have been removed, another vibrating source needs to be created. There are a variety of communication options post laryngectomy, including oesophageal speech, artificial larynx and surgical voice restoration.
Box 27.12 lists the variety of ways in which communication is restored post laryngectomy.
Box 27.12
Ways in which communication is restored after laryngectomy
- Oesophageal voice involves moving air into the oesophagus (Searl and Reeves [253]) either by inhaling or injecting air into the back of the mouth. Instead of the vocal cords vibrating, the walls of the pharynx vibrate. Sound then moves into the mouth where recognizable speech is produced by the articulators, tongue, lips and palate. Patients are asked to imagine gulping air into their mouths, begin to swallow but return it to their mouth in a controlled manner. It has previously been described as ‘burped speech’ and usually the patient can achieve a small number of words on one breath.
- An artificial larynx involves using a battery‐powered device that is placed against the neck or cheek or intraorally (Searl and Reeves [253]). When the button is pushed, a vibration occurs in the head of the device and it is this vibration through the tissues that creates sound as the patient mouthes the words.
- Surgical voice restoration (SVR) allows communication to be restored by use of a voice prosthesis which may also be referred to as a valve. See Figure 27.36 for the operative site for surgical voice restoration.
Figure 27.36 Operative site for surgical voice restoration. Source: Dougherty and Lister ([90]). Image courtesy of InHealth Technologies.
SVR has become the most popular form of restoring communication, with success rates of up to 90% reported (Op de Coul et al. [215]). SVR entails creating a fistula between the posterior wall of the trachea and the anterior wall of the oesophagus, into which a one‐way voice prosthesis is placed. By closing off the tracheostoma, pulmonary air is diverted through the prosthesis into the oesophagus where the walls vibrate to make sound (van As‐Brooks and Fuller [278]).
The prosthesis is a silicone device that fits into the TEP and acts as a one‐way valve, preventing food and drink from entering the trachea from the oesophagus (Figure 27.37). Patients can have the puncture created during their laryngectomy operation, which is called a primary puncture. Post‐operatively, patients with a primary puncture are fed via a stoma gastric tube, which enables the puncture to remain patent, avoids food contamination around the healing pharynx and decreases the risk of fistula formation (Karlen and Maisel [136], Rhys‐Evans et al. [237]). Once healing has occurred, the stoma gastric tube is removed and the prosthesis can be placed into the TEP.
Figure 27.37 Voice prosthesis in situ. Source: Dougherty and Lister ([90]). Image courtesy of InHealth Technologies.
If patients are required to wait for their puncture following the laryngectomy surgery, for example due to an extended laryngectomy, they are likely to have a secondary puncture. Another option involves patients having their voice prosthesis placed into the TEP during the laryngectomy surgery; this is known as primary placement.
Voice prostheses
Voice prostheses have been available in Britain for over 25 years (Singer [257]) and there are several devices on the market, mainly Blom‐Singer (InHealth Technologies, Carpinteria, California, USA) and Provox (Atos Medical, Malmo, Sweden) products. All work according to the same principle with a one‐way valve, two flanges (one anterior and one posterior) to secure the prosthesis in situ in the TEP, and a strap to attach to the neck (Figure 27.38). The prostheses come in a variety of diameters and lengths and it is the role of the specialist speech and language therapist to choose the most appropriate model for the patient, taking into account the patient's requirements. Prostheses can be either exdwelling, meaning the patient can be taught to self‐change, or indwelling, requiring the input of a specialist clinician, including a specialist speech and language therapist, Ear, Nose and Throat (ENT) doctor or a nurse experienced in fitting and managing voice prostheses.
Figure 27.38 (a) Duckbill Blom‐Singer voice prosthesis. (b) Low‐pressure ex dwelling Blom‐Singer voice prosthesis. (c) Indwelling Blom‐Singer voice prosthesis. (d) Non‐indwelling (NID) voice prosthesis. Photo courtesy of Atos Medical, www.atosmedical.com. (e) Vega voice prosthesis, indwelling. Photo courtesy of Atos Medical, www.atosmedical.com.
Voice prostheses are usually kept in Speech and Language Therapy or Ear, Nose and Throat Departments. Patients are provided with all the items that are needed for cleaning their voice prosthesis (see Procedure guideline 27.22), usually by the speech and language therapist or an appropriately trained specialist nurse. Patients need to store the items securely but they do not need to be kept in a sterile environment. Frequently patients receive a sealable bag to store their equipment.
Humidification
All laryngectomy patients need to wear a heat–moisture exchange system (HME) for humidification. As the patient no longer breathes through the nose there is a reduction in filtration, humidification, heat exchange and resistance. Studies have shown that people with laryngectomies have increased mucus production, dryness, crusting, coughing, shortness of breath and increased risk of chest infections (Jones et al, [134], Zurr et al. [295]) Use of an HME will:
- trap moisture on expiration to warm air on inspiration
- filter inhaled air
- provide air stream resistance to encourage lung expansion.
Post‐operatively, patients may wear a hypoallergenic baseplate, and a filter cassette will fit into this device (Figure 27.39).
Figure 27.39 (a) Provox laryngectomy tube, (b) Provox laryngectomy tube with HME filter, (c) Provox HME baseplate, (d) Provox HME baseplate with filter in situ.
