Speech pathologists are an integral part of a larger team of professionals who are concerned with the assessment and treatment of speech and swallowing disorders associated with head and neck cancer. The conditions associated with head and neck cancer can create disorders of speech and swallowing as well as psychological well being. First and foremost, assessments and treatments for various head and neck cancers are designed to save the life of the individual. A secondary but crucial part of head and neck treatment is overseen by the speech pathologist in fulfillment of a directive provided by the ENT/head and neck surgeon. It is the role of the speech pathologist to follow this physician directive helping the patient to re-establish communication or swallowing lost or adversely affected by surgical ablation.
Speech pathology services in head and neck cancer are located on the ground floor of the neuroscience building in clinic with otolaryngology. The close proximity of ENT and speech pathology together in the same clinic helps to provide head and neck cancer patients with a team aspect to their medical and functional assessments and rehabilitation.
Here at UNC, all head and neck cancer patients with potential post-op speech and swallowing problems are referred for a pre-op work-up.
Removal of the larynx is of course a very traumatic and life changing event. Laryngectomy patients report a variety of thoughts and feelings associated with the prospect of loss of voice. Patients often experience stages of grief just as someone who has lost a loved one. Depression can become a factor to consider in a patient's coping with the loss. Outcomes can be adversely affected by lack of coping on the part of the patient. Often, the patient finds their own way of dealing with the loss, or they simply come out of the grief stronger on the other side. Psychological counseling can be very beneficial for those who fail to develop adequate coping strategies with development of acceptance of loss.
Tracheoesophageal Puncture (TEP)
TEP is the formation of a small fistula or hole leading from the rear wall of the trachea through the front wall of the esophagus. The puncture is generally placed at a level just above the middle portion of the patient's stoma and is visible if viewing the patient's stoma from directly in front or slightly to the side. The purpose of the fistula is to allow airflow from the lungs to be shunted into the upper esophagus for voice production via the pseudoglottis that was either created during the total laryngectomy procedure (primary) or weeks or months after surgery (secondary). This pseudoglottis, which is made up of muscles, takes the place of the vocal cords as the vibrating source for speech with the airflow continuing from the upper esophagus into the nose and mouth for intelligible speech production.
Directing Airflow in TEP
In order to voice with TEP, airflow must be directed into the upper esophagus. To do this, the laryngectomy places a thumb or finger over the stoma and applies gentle pressure, just enough to force the pulmonary air into the fistula. The patient then simply speaks as before removal of the larynx. Often, it is necessary for the laryngectomy to practice occluding the stoma with the right amount of force so as not to occlude the prosthesis within the fistula or compress the esophagus. In addition, air leaks around the stoma must be closed before adequate air is directed into the esophagus via the fistula.
The Voice Prosthesis
In order to keep the fistula between the trachea and esophagus patent, a prosthetic device is placed into the hole. The prosthesis is also designed to keep food or liquid from penetrating the trachea which would potential for aspiration pneumonia. The typical prosthesis is a small silicone cylinder that contains a small flapper on the side of the esophagus that remains closed during swallowing but is pushed open for entrance of pulmonary air into the upper esophagus for phonation (voicing) and speech. The prosthesis is also designed with widened edges on both ends for the purpose of holding the valve in place against the rear wall of the trachea and the front wall of the esophagus. With the prosthesis effectively held in place in this manner, the chances of dislodgment are reduced even with high-pressure events such as coughing, swallowing, or speech. This is the basic design of the voice prosthesis, which leads to a discussion of the different types of prostheses most often used in the UNC Head and Neck Clinic. Click the link above for illustration of prostheses.
Hospital Course Post Operation
After the head and neck surgeon has completed removal of the larynx and a fistula created, a 12 or 14 FR. rubber catheter is pulled through the fistula to provide closure between the larynx and esophagus as well as serving as a feeding tube. The tube remains in place post-operatively while sutures and tissues heal in the pharyngeal and upper esophageal areas. Once healing has taken place in these areas, a leak test is performed under fluoroscopy to determine if there are any leaks into the patient's tissues. Once the patient is determined safe to swallow, food and liquid may be consumed. However, the rubber catheter is capped and remains in place to keep the fistula closed. Voicing is not possible at this time, as air is not shunted in the manner previously outlined. Typically, the patient uses a Cooper-Rand intra-oral electrolarynx to communicate. The rubber catheter is sutured to the skin lateral to the stoma. Barring complications, the patient is usually ready for discharge from the hospital 4-7 days following surgery.
Fistula Dilation for Placement of Indwelling Prosthesis
Eric Blom and Marc Singer developed the low pressure indwelling prosthesis to provide TEP speech for long periods of time without the necessity to remove the prosthesis for cleaning and re-insertion. This is the method most often opted at the UNC Head and Neck Clinic. It also provided the laryngectomy with the possibility of speaking hands-free. Additionally, indwelling prostheses do not protrude significantly into the upper esophagus reducing the possibility of occluding the prosthesis against the posterior wall of the esophagus creating loss of airflow into the upper esophagus. The indwelling may also be worn for up to 6 months without removal. Cleaning can be done simply by placing a small saline bullet into the prosthesis bore and squeezing. This has the effect of cleaning the inside bore of the prosthesis as well as creating greater patency of the inner flange.
The placement of the Blom-Singer indwelling prosthesis is similar to that of the low-pressure prosthesis mentioned previously. The outer cylinder measurement of the indwelling device is 20 mm. This requires that the fistula be dilated ideally to a level just above 20 mm. 22 mm is the best dilation size to pursue for eventual placement of the indwelling device. Once the patient has been wearing a 16 Fr. low-pressure prosthesis or has had a 16 or 18 Fr. coude-tipped catheter in for 1-2 weeks, dilation is typically simpler to perform. The process consists of the SLP inserting gradually larger dilators into the fistula to affect the increase in bore to accommodate the indwelling prosthesis. Following dilation with 18 Fr. dilator, an 18 Fr. catheter is placed, the catheter size is then increased to 20 Fr., then the fistula is dilated with the specially designed dilators up to 22 mm. The 22 dilator is replaced with a 22 Fr. rubber capped catheter and left until it is determined that the 20 Fr. indwelling prosthesis may be inserted without significant resistance.
The prosthesis is prepared with gel cap and lubricated. With the clinician's non-dominant hand, the rubber catheter is gently removed and the prosthesis inserted through the fistula with the aid of the inserter stick. The prosthesis is held in place by the clinician for approximately 2-4 minutes while the gel cap dissolves on the side of the esophagus and is thus ingested by the patient. To test to see if the gel cap is dissolved and the prosthesis flattened against the anterior esophageal wall, the prosthesis remains attached to the inserted stick as the clinician rotates the stick. If the prosthesis turns freely, this is an indication that the prosthesis is freed of the gel cap.
After insertion, the clinician occludes the patient's stoma (or the patient does this, depending on whether he/she is used to this aspect) to see is voicing is achieved. If voicing is not achieved immediately, the clinician usually tests to determine if the flange within the prosthesis is opening without resistance. To do this, the wooden end of a cotton swab is very gently inserted into the bore of the prosthesis until opening of the flange is felt. This should correct the problem. The clinician may also apply the leak test for two reasons, 1) to determine if green water flows through the prosthesis revealing a leak and 2) to more fully seat the prosthesis on the non-visible esophageal side. For further possible explanations regarding lack of voicing or leak with new prosthesis click here: problems and solutions.
Candidacy for TEP
Candidacy for the tracheoesophageal puncture is assessed by the speech pathologist in collaboration with the ENT doctor. The criteria, while somewhat variable based on the circumstances at hand, are generally the same for all patients. These criteria consist of 1) ability to fully understand the anatomy of TEP, 2) good function of the pulmonary (lungs) system, 3) ability to occlude (cover) the stoma without excessive difficulty of movement, 4) the ability to diligently care for the TEP site.
This makes the pre-operative orientation a critical feature for treatment of the laryngectomy. Typically, the patient is brought to a quiet room where distractions are minimized. The clinician then presents information to the patient regarding change of anatomy using diagrams, models, verbal and written information. It is critical for the patient to recognize the difference in anatomy pre and post operation for mental preparation as well as the recognition of options. As with all medical conditions and procedures, more is better. The clinician explains and illustrates the patient's current and normal anatomy, then demonstrates via model what will be removed and why it constitutes a loss of voice i.e. the voice box will be removed.
Many patients are treated surgically with the supraglottic laryngectomy procedure. This procedure refers to the technique of removing the anatomical structures from the base of the tongue, sometimes including the hyoid bone, inferior to the epiglottis, ventricular folds as well as a part of the thyroid cartilage. The true vocal cords (those used in production of voice) remain intact. Typically, the tumors are located above the level of the true vocal cords and do not invade the tongue base. Thus, the patient is able to maintain communication through use of his or her own voice.
Resultant problems created by the removal of these tissues include, resonance, i.e. vibratory changes during voicing/speech and the even direr consequence of increased aspiration risk due to the anatomical changes made in the swallowing mechanism. Prior to removal, the tissue that is targeted and subsequently removed provides protection from inhalation of food and liquid into the trachea and lungs. With the absence of the protective tissues, swallowing becomes much greater risk given that inhalation of foods and liquids can contribute to the development of pneumonia, reduced lung volume, and a potential for a myriad of additional pulmonary problems.
In the case of the supraglottic laryngectomy, the speech pathologist intervenes to educate the patient regarding anatomical changes and makes assessments regarding the functional decline of the swallowing mechanism via the modified barium swallow study (MBSS). The MBSS is usually pursued within 1-2 weeks following the surgical procedure. The ENT orders the MBSS and the speech pathologist assesses the functional swallowing changes that have taken place in conjunction with a radiologist. During the MBSS, the speech pathologist instructs the patient regarding what possible postures and/or techniques will best facilitate safe swallow. Additionally, different textures of food and liquid are assessed for safety.
A technique to facilitate safe swallow in this population is the supraglottic swallow technique. The technique consists of having the patient hold his or her breath very tightly, move the bolus posteriorly in the oral cavity, initiate pharyngeal swallow while tightly holding breath, swallow effortfully, immediately cough, and swallow again using same technique. This can be tedious for the patient but generally quite effective. This technique is used in combination with posture changes to facilitate bolus (food or liquid that is formed into a ball for swallow) direction and efficiency given anatomical differences. The posture change is usually that of a head back extended neck posture to create a compensation for reduced tongue mobility particularly at the tongue base. The bolus simply falls into the pharynx (lower throat) and is swallowed immediately using the described technique.
Swallowing safely after the supraglottic laryngectomy procedure generally requires experimentation to determine best method and textures for use in nutrition and hydration. At the same time, the patient must learn to exercise diligence and maintenance of swallow safety for the long term.
Initial Prosthesis Placement
The catheter may be removed prior to discharge and a low-pressure voice prosthesis placed by the speech pathologist. The method for placement of the low-pressure voice prosthesis begins with the speech pathologist or otolaryngologist removing the sutures that bind the catheter to the skin. The SLP then uses a 10 mL syringe to remove any remaining air or water from the distal end of the tube. The patient usually takes 2 tablespoons of liquid antacid to keep reflux from being manifested as the catheter is removed. The SLP gently pulls the catheter through the fistula until it is freed. The patient should be encouraged to refrain from swallowing, as the fistula is temporarily open following catheter removal. Some coughing is likely to occur during this phase. Thus a suction catheter is maintained nearby.
Once the rubber catheter is fully removed, an 18 Fr. red rubber coude-tipped capped and lubricated catheter is inserted into the fistula. The 18 Fr. catheter is taped in place on the patient's neck and left for several minutes in order to dilate the fistula to a size that will accept an 18 Fr. low-pressure voice prosthesis. The clinician must then measure the thickness of the party wall, i.e. the thickness of the fistula from back to front using a measurement tool that contains lines with numerical readings. The measurement tool is placed onto another specially designed stick and lubricated. The measuring device is inserted gently into the fistula until the lip of the measuring tool is fully extended downward into the esophagus. The measuring tool is then allowed to retract a small amount until the lip inside the esophagus meets with the anterior esophageal wall. This is determined by placing a small amount of outward force on the inserter stick in order to visualize and feel the resistance against the anterior esophageal wall.
The reading just outside the fistula is the reading that is taken. If the numbers or lines on the measuring device are just barely visible, the next number along the shaft of the measurement tool is taken. This is the size prosthesis that is chosen for insertion. The prosthesis is prepared by placing a gel cap over the large esophageal side of the prosthesis. The prosthesis is then placed on a specially designed inserter stick and lubricated. The 18 Fr. catheter is then removed and the prosthesis inserted into the fistula and held with moderate pressure for 2-3 minutes until the gel cap is dissolved into the esophagus and the flange is opened against the anterior wall of the trachea. The inserter stick is then removed by detaching the prosthesis strap, giving a slight twist and retracting.
The low-pressure prosthesis is now in place with the strap facing upward and taped to the skin. The prosthesis will keep the fistula dilated to a 16-mm size until the next visit to the clinic, usually 1-2 weeks later. The patient uses the electrolarynx until he or she is successful at TEP speech, which is typically when the stoma has healed so that stoma occlusion is possible without irritation or significant bleeding.