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Best Practice for Communication and Swallowing: Hope for Head and Neck Cancer Survivors

Laryngectomee Rehabilitation Across the ContinuumWYOMING SPEECH-LANGUAGE-HEARING ASSOCIATION CONVENTIONOCTOBER 11, 2019BRIDGET GUENTHER, MS, CCC-SLP, BCS-S

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Disclosures Financial Disclosure: ◦ Ms. Guenther is employed by Atos Medical, Inc. and Atos

Medical paid for her travel to present at the conference

Non Financial Disclosure: ◦ Ms. Guenther is a member of the following organizations: ◦ American Speech Language and Hearing Association (ASHA)◦ American Board of Swallowing and Swallowing Disorders (AB-

SSD))◦ Dysphagia Research Society (DRS)◦ New Mexico Speech Language and Hearing Association

(NMSHA)

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MAINTAINRECOVERYTREATMENTDIAGNOSIS 

GI

Consistent/clear communication, navigation & planning between patient and HCPs

Access to supplies

Psychosocial support

Home support

Insurance support

Medical 

Support

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PATIENT

ENT

SLP

RAD ONC

MED ONC

DENTAL

RTDC 

PLANNING 

T

PT

RT

GI

Home Care

Primary Care MD

Supplies

Reality: Inconsistent and Disconnected Care

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CONNECTING THE DOTS:  BEST PRACTICE

Pulmonary

Communication

Quality of Life

Nutrition EDUCATION

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CONNECTING THE DOTS

ENT SLPPatient

Support

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So How Do We Get People From Here…

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Ultimate Goals for Every Patient

Cancer Free

Independent

Able to safely swallow a normal diet

Able to functionally communicate in way that they are most comfortable

Healthy pulmonary function and tracheal climate

Full acceptance of their new way of communication as well as having a permanent stoma

Functioning at the same level or higher than prior to surgery

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Voice Restoration Options Post Laryngectomy

Esophageal speech– PE segment as sound source– Injection of air from oral cavity

Electrolarynx– Sound source is device– Oral/Neck– Interdental

Tracheoesophageal speech– PE segment as sound source– Pulmonary air– One-way valve TE prosthesis

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Artificial Larynx (Electrolarynx))

Types – neck or intraoral Better sound quality Options – pitch and

intonation, volume, and size

Analog and digital Battery operated Affordable, durable Extended warranties Treatment has not

changed. Challenge: “woody

necks”

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Artificial Larynx TrainingRationale

Finding the right device for the patient: You have choices!

How does it work?

Placement – finding the “sweet spot”

Articulation

Pitch and Loudness

Eliminate distracting behaviors

The key to success is minimizing frustration!

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Artificial LarynxBasics

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How does an Electrolarynx (EL) work?

When the head of the device is held against the

tissues of the neck or cheek,

this tone is transmitted into the oropharynx

Sound is shaped into meaningful

speech by movements of the lips, teeth,

tongue and jaw

Tone can also be transmitted via an oral adapter

into the oral cavity

Electrolarynx (EL): An electromechanical device that moves a plastic or metal head, which generates a sound or tone and serves as an external sound source to replace vocal fold vibration

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Intraoral Adaptor vs. Neck Placement

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Does pitch matter?

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(Watson & Schlauch, 2009) Results: Percent words transcribed correctlyListener Group

List A Variable f0

List BVariable f0flattened

List C Single f0

1 89% 78.7% 78.5%

2 92% 81.18% 74.14%

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Styles of ELs with pitch variabilityTruTone Plus ◦ Adjustable pitch

range. Up to ~1.5 octaves

TrueTone Emote – 6 modes◦ 1: monotone◦ 2: ½ octave◦ 3: 1 octave◦ 4: 2 octaves

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TruTonePlus

TruToneEmote

Electrolarynx Training

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Instructional Method for Teaching Use of an Artificial Larynx: IPATPAL METHOD(S. J. Salmon, Ph.D., 1983)

I = Information P = PlacementA = ArticulationT= TimingPAL = Pitch and Loudness

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Esophageal Speech

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Tracheoesophageal (TE) Voice Restoration TRACHEOESOPHAGEAL

SPEECH– Sound source is pharyngoesophageal (PE)

segment or neoglottis NOT the voice prosthesis

– Pulmonary air– One-way valve TE VP– Pts without VP, tend to have less social

contacts (Brook et al, 2013)– Considered the “Gold Standard”

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Tracheoesophageal (TE) Speech

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Primary Puncture and Prosthesis Placement

CE001-05.13.2019

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Pulmonary Changes Post-Laryngectomy

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Post Operative Pulmonary Goals

• Pt. independence with stoma care

• Use of the moist air/suction

• Tracheal climate and pulmonary function

• Some of the lost function of upper airway

REPLACE IMPROVE

ENABLEREDUCE

* Also ENABLE Medical staff to distinguish between a laryngectomy and tracheostomy patient.

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Decrease hypersecretion of mucus associated quality of life issues

Improve overall stoma cleanliness

Improve social acceptance

Improve patient’s overall self acceptance

Provide patient with options for speech

Long Term Goals for Pulmonary Rehabilitation:

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Key Points Regarding Respiratory Function

Trachea, bronchi, nose◦ Lined with cilia that transport mucus

Mucus – NOT abnormal, it’s protective

Mucus Viscosity – dependent on hydration, humidification, warming, infection, obstruction, environmental exposure

Mucus Production - 14ml/day (Widdecombe & Widdecombe, 1995) to 100ml/day (Pride, 1997)

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Normal Physiology of the Respiratory System

At The Nose◦ Air Temp = 720F◦ RH=45%◦ Ambient Dirty

At the Bronchioles◦ Air Temp = 98.6◦ RH = 99%◦ Filtered

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Most Defense Mechanisms Exist in the Upper Respiratory Tract

Cilia trap debris & push them out of the airways Goblet cells produce more mucus in response to airway irritantsMucus attracts & traps smaller microorganisms and particles and keeps tract moistThe reflexes of sneezing and coughing help to expel particles from the respiratory system

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Post-LaryngectomyRespiratory System

Primary defense mechanisms have been disconnectedAt The Trachea◦ Air Temp = 720F◦ RH=45%◦ Ambient Dirty

Impaired ciliary activity due to lack of moisture and heatIncrease in mucus production due to introduction of particles and cold/dry air

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Open Airway Without Defense Mechanisms

Patient can lose up to 1 liter of water/day through open stoma100’s of airborne particles are inhaled every minute

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The Answer: Heat & Moisture Exchangers (HME)

• Closed system• Water vapor condenses during

exhalation & re-humidifies during inspiration

• Pulmonary heat is retained & exchanged

• Heat & humidity consistently maintained

• Logical barrier to gross airborne matter

• Covers the stoma• More hygenic• Helps patient adapt to having a

stoma

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These are NOT HME’s

Pictures are compliments of Fashions for your Neck and Kapitex

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HME Basics:Introduce the HME immediately postopThe transition may be easier the sooner the HME is introducedPatient may require adaptation to HME resistance Amount of mucus/coughing may increase during the first days/weeks of use (thinning effect)Expected improvement in pulmonary function usually takes time (average 2-4 weeks) HMEs cannot be rinsed out and reused HMEs can provide easier and more hygienic stomal occlusion with most users

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Restoration of Some of the Lost Upper Respiratory

Function

• increases RH to 70% which results in active cilia and reduction in mucus production

• increases temperature to 91 degrees which results in active cilia

• logical barrier to gross airborne matter which reduces mucus production

• covers the stoma • provides better stomal hygiene• helps with self acceptance &

adaptation to having a stoma

The HME…

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Post Laryngectomy Effects on Breathing

Lost functions of the upper airway◦Heating◦ Filtering◦Humidity◦Pulmonary resistance

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•References:•Hilgers, Ackerstaff, Aaronson, Schouwenburg, van Zandwijk. Clin Otolaryngol1990;15:421-5•Ackerstaff, Souren, van Zandwijk, Balm, Hilgers. Laryngoscope 1993;103;1391-4•Ackerstaff, Hilgers, Balm, van Zandwijk. Clin Otolaryngol 1995;20:547-51•Ackerstaff, Hilgers, Meeuwis, Knegt, Weenink. Clin Otolaryngol 1999;24:491-4.

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Level 1 Evidence: Randomized controlled trial on postoperative pulmonary humidification after total laryngectomy: External Humidifier versus Heat and Moisture Exchanger (Provox)Mérol J, Charpiot A, Langagne T, Hémar P, Ackerstaff A, Hilgers F. The Laryngoscope 2011

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Euros Dollars

11.54

16.50

3.57

5.00

Cost Comparison External Humidification versus Heat Moisture Exchanger (per day)

External Humidifier HME System

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Reducing Inpatient Complications

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Total # AdverseEvents

ExternalHumidification

HME

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Immediate Post‐Operative ComplicationsAdverse event defined as a mucus plug

“The ultimate saving is in patient overall morbidity following TL“ Foreman

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Immediate Postoperative Use of an HME Results in…

Easy adaptation & compliance

Decreased need for suctioning (Chapman et al, 2014; Icuspit et al, 2014)

↓ suctioning & nursing care

Cost-effective

Eliminate noisy moist air

Immediate HME benefits

Avoid mucus plugging

Early familiarization, confidence & competence with stomal care and management (Chapman et al, 2014)

Preparation for ambulatory care

Easier to differentiate trach vs. laryngectomee

Reduced stomal crusting and better handling of secretions (Icuspit et al, 2014)

Easier discharge planning

May decrease need for other medical supplies (i.e. moist air) and actually result in lower medical expenses (Brook et al, 2013)

Icuspit, P, Yarlagadda, B., Garg, S, Johnson, T & Deschler, D. (2014).  Heat and Moisture Exchange Devices for Patients Undergoing Total Laryngectomy.  ORL‐ Head & Neck Nursing 32(1):  20‐23.  Chapman P, Lyons, B Dickinson G, McKinley K, Brinkmann S, West T. Heat Moisture Exchanger (HME) equipment provision to patients Iimmediately post laryngectomy‐Does it make a difference with the tracheostomamanagement outcomes?  Poster at IFHNOS 2014, New York, USA

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HME Attachments in the Early Postoperative Phase

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Provox Laryngectomy Pulmonary system

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Patients Undergoing Total Laryngectomy: An At-Risk Population

for 30-Day Unplanned ReadmissionGraboyes, E.M, Yang, Z, Kallogjeri, D., Diaz, J.A. & Nussenbaum, B. JAMA Otolaryngology Head Neck Surgery (2014),

Retrospective review of 155 TLs◦ Primary objective: to calculate 30-day unplanned

readmission rates for TL◦ Secondary objectives: reasons for readmission,

and possible risk factors (comorbidities, demographics, stage, etc)

Results:◦ 26.5% readmission rate for TL◦ Twice the risk of 6 other major surgeries (CABG, lobectomy,

open and endovascular AAA repair, hip replacement and colectomy)a

◦ Most common diagnoses:◦ Pharyngocutaneous Fistula (27%)◦ Stomal Cellulitis (16%)

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Coming Home Kit: Transition to Home

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HME BenefitsShort Term Benefits• Discrete• Improved Hygiene• Improved Voice (including

increased Maximum Phonation Duration and more dynamic range.

• Easier Stoma Occlusion for TE Speech

Long Term Benefits• Decreased sputum

production• Improved ciliary function=

improved pulmonary function

• More forceful cough• Improved Quality of Life

HMEs are of high importance for ALL types of neck breathers!!

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Tracheoesophageal Voice Prosthesis

Types of Voice Prostheses

INDWELLING: PLACED BY A PROFESSIONAL ONLY NON-INDWELLING: PATIENT

AND/OR PROFESSIONALLY MANAGED

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Voice Prothesis Types and Management

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Indwelling Voice Prosthesis

• Clinician managed

• Can be placed intraoperatively

• Can be cleaned in situ

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Non-Indwelling Voice Prosthesis

• Patient can be taught to change/manage prosthesis

• Can be cleaned and replaced

• Less upfront cost than Indwelling style

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Prosthesis Selection: Considerations

Diameter of the TEPClinical indicatorsPatient independenceQuality of voicingEase of use and cleaningProsthetic design to accommodate pt’s anatomic configurationsCost-effective prosthesis◦ Cheaper upfront cost ≠ cost effective

Mean device lifetime

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VP Device Lifetime

Patient DependentPresence of GERD/GPRBiofilm formationOral floraXRT vs. no XRTCare and maintenance of deviceDietPressure in pharynxValve opening during inhalation

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Checking the Fit of the Current Prosthesis

Courtesy of Saint Louis University Cancer Center – Dennis Fuller

*Using actual sizing device provides optimal results*

The novice clinician should always resize and not guess

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Voice Prosthesis Care/Cleaning“Brush and Flush”

Courtesy of Saint Louis University Cancer Center – Dennis Fuller, PhD

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Outpatient Pulmonary Follow-Up

HME Introduced in Hospital◦ Confirm patient use

practice◦ Assess peristomal

healing◦ Determine best

attachment for voicing◦ F/U in 5-7 days

No Immediate HME Introduction◦ Educate on benefits of

HME◦ Assess peristomal

healing◦ Determine best

attachment for voicing◦ Introduce HME◦ F/U in 7 days or less

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HME Success = Good Stomal Attachment

Peristomal Attachments ◦ Attachment to skin around stoma◦ Base plates, valve housings, custom housings, tapes,

glues/adhesives

Intraluminal Attachments◦ Attachment within the stoma◦ Provox® LaryButton™, Provox® LaryTube™, Barton-

Mayo™ (BM) button

Intraluminal + Peristomal Attachments◦ Provox® LaryTube™ with Blue Ring◦ Kapi-Gel™ washer with button/tube

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Peristomal Attachments

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Provox® Adhesive BasePlates

Five different types◦ FlexiDerm™ ◦ XtraBase™◦ Stabilibase™ (reg or OptiDerm™)◦ OptiDerm™◦ Luna

Three different shapes ◦ Oval, round and “plus” size options (except for

XtraBase, Luna & Stabilibase)

Life: dependent on the patient

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InHealth® AdhesiveBase Plates/Housings

Types of base plates/housings- Truseal• Countor and Contour Low Profile

- Reusable Valve Housing• Silicone or PVC

Various Types of Adhesives- Tape discs- Foam Discs

Life: dependent on the patient

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Intraluminal Attachments

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Provox® LaryButton™Soft, silicone material◦ Easy to fold & insert◦ Comfortable for pt

Available in 4 diameters & 2 lengthsIdeal stoma:◦ Symmetric, round◦ Contiguous stomal lip ◦ TEP position 7-15mm from tracheocutaneous juncture (TCJ)

Retains all Provox® HMEs and hands-free valvesMaintains stomal patencyCan use w/ or w/o Provox ® TubeHolder™ or Provox ® LaryClips™

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Provox® LaryTube™

Standard◦ Maintains tracheostomal patency◦ Houses HME◦ Allows for customized fenestration to allow TE

speech

Fenestrated◦ Used in combination with voice prosthesis

Blue Ring◦ Worn with adhesive base plate◦ Supports stomal seal with Provox® FreeHands™

HME◦ Used in acute post-op phase to avoid ties

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