Introduction
This paper will discuss the role of Speech-Language Pathologists (SLP) in the Management of Persons with a Laryngectomy both before and after the Laryngectomy. The Alternative possible methods employed to enable a person with a laryngectomy to speak are also discussed, and the Techniques employed by the Speech-Language Pathologist in assisting Persons with a Laryngectomy.
An SLP is professionally trained to help people with various speech problems. Laryngectomy involves the surgical removal of a person’s larynx, which is the ‘voice box’ from the neck. The larynx connects the nose, mouth, and lungs. The vocal folds necessary for speech are also situated in the larynx.
Persons who have had a complete Laryngectomy, with their airway redirected to a stoma (a hole in the neck) from the lungs have to breathe differently, and also require a new source of sound than they had before they had their larynx removed. Thus, there will be many changes after a person has undergone a Laryngectomy
Alternatives
The most important change for most Laryngectomees is the communication challenges posed by an inability to speak.
“There are 3 possibilities to enable a person with a laryngectomy to speak. The first and easiest to use is an artificial larynx (AL). The AL is an electronic device held with one hand and is placed directly on the neck or a tube is placed in the mouth. The person pushes a button and articulates speech as before surgery. It is the easiest and quickest to learn and is most often used directly following surgery. The drawback is that it has a robotic sound and runs on battery.” (Frowen, J., & Perry, A. p.394)
Another possibility is for the person to start using esophageal speech. The third alternative for voice restoration is by creating a tracheoesophageal puncture (TEP) Although there are some Speech-Language Pathologists who have little or no experience in assisting people who have had a Laryngectomy, there are some with special training in assisting Laryngectomees and as such, are proficient at assisting Laryngectomees. Most Speech pathologists do not get enough academic exposure to Laryngectomy and people with a Laryngectomy during their university education.
“A survey carried out by Melvin, Frank, and Robinson suggested that many speech pathologists indicated they felt unprepared to work in the area of Laryngectomy and required further training, clinical exposure, and coursework to improve their skills in this area. It is suggested that speech pathologists dealing with a Laryngectomy client should be appropriately trained, or should consult colleagues with more experience in this specialist area.” (Melvin, Frank, and Robinson p.9)
In persons with a laryngectomy, it becomes necessary to breathe and speak in a new way. Thus, alaryngeal speech, which entails speaking without a voice box is employed. In persons with a laryngectomy, the air coming from the hugs will not pass through the nose and the mouth anymore, as the air will now be directed through a new channel, created by surgical means. This new channel or hole in the neck is called a stoma, and the Speech-Language Pathologists is responsible for guiding the laryngectomee through the process of speaking through a new channel. The Speech-Language Pathologists also guide persons with a laryngectomy on the usage of speech devices like the electrolarynx which produces an electromagnetic vibration that sounds like a tone.
Whatever method is chosen for speech, the Speech-Language Pathologists primary objective is to ensure that persons with a laryngectomy find a new sound source for speaking. Before the surgery, the Speech-Language Pathologists meets with the family of the patient and will evaluate some factors including pitch range, vocal quality, any accounts, or regional speech variations. This will enable the Speech-Language Pathologists to gain an understanding of the patient’s voice and speech abilities, which will then enable the Speech-Language Pathologists to plan a suitable course of voice treatment after the larynx is removed. The Speech-Language Pathologists also explain the physiology and anatomy of the larynx to the patient and the patient’s family and describe to them the charges that might come about as a result of the surgery. “The impact of a total laryngectomy on an individual’s life has primarily been measured from a male viewpoint reflecting the demographics of a diagnosis of laryngeal cancer. A small number of studies have looked specifically at females, but very few are comparison studies. Consequently, there is little consistent research regarding any potential gender differences.” (The American Speech-Language-Hearing Association) A study aimed at investigating any possible gender differences in the perception of health-related life quality and the ability to function after a total laryngectomy was carried out among 21 female and 22 male participants, who had previously undergone a total laryngectomy at least 1 year in the past. The procedure and method involved the completion of a questionnaire by the 43 participants. From the results it can be deduced that there were no really significant differences between female and male participants on disease-related or demographic variables, except for those highlighted below:
“Significantly more females lived alone and changed their employment status following surgery. Males had a significantly higher global health status/quality of life than females (p < 0.05) and significantly higher levels of physical (p = 0.01), emotional (p < 0.01), cognitive (p < 0.05) and social functioning (p < 0.05). After adjusting for differences in living arrangements and changes in employment status, differences in emotional and social functioning remained significant. There was a general trend for females to have higher symptom/impairment levels and to report more treatment-related problems, but the majority of these differences were not significant.” (The American Speech-Language-Hearing Association)
Implications: it would seem that total laryngectomy does affect females more in the aspects of quality of life, as they may be particularly vulnerable socially and emotionally. The findings of the study imply that there is a need for laryngectomees’ rehabilitation programs to address specific areas so as to improve the quality of life and the long-term outcomes reported by patients.
The role of the Speech-Language Pathologist after surgery
The Speech-Language Pathologist also gives to the intensive care unit immediately after surgery to provide information on the charges expected. “Since the laryngectomee will not have his or her voice in the period following surgery, the Speech-Language Pathologists provides the patient with writing devices like pen and writing pads so that he can be able to express basic needs to the doctor, the nurses and family and friends immediately after surgery” (The American Speech-Language-Hearing Association) According to the American speech-language-hearing association, the duties of the Speech-Language Pathologists includes “working with and communicating with a multidisciplinary team to ensure optimum and individualized care for the client; Presenting post-Laryngectomy voice restoration options in an unbiased manner; Selecting appropriate candidates for receiving a tracheoesophageal puncture (TEP) and voice prosthesis; Determining an appropriate voice prosthesis for a client, and inserting the prosthesis; Teaching the client how to insert the prosthesis and produce voice; Teaching the client and their family or carers how to clean and care for the external stoma and TEP site; Helping the client trial different voice prostheses, and problem-solve to achieve optimum effectiveness.” (The American Speech-Language-Hearing Association).
The Speech-Language Pathologist conducts a clinical evaluation of the patient in order to assess suggest and develop proper therapeutic goals and follow the progress of the patient. The Speech-Language Pathologist also communicates with the moves to ascertain if there are any changes in the status of the patient in order to make necessary recommendations and adjustments. The Speech-Language Pathologist also assesses the laryngectomee’s candidacy for the use of a speaking valve. If the patient is placed on mechanical ventilation, the Speech-Language Pathologist connects the respiratory therapist to schedule a coordinated assessment session. During an evaluation, the role of the Speech-Language Pathologist is to explain how the speaking value is used and its purpose. The Speech-Language Pathologist will be directly involved in efforts to resolve these problems and minimize aspiration risk. The Speech-Language Pathologist also endeavors to maintain the comfort and safety of the patient as much as possible during oral intake
Although the role of Speech-Language Pathologists in palliative laryngectomy mostly has to do with the assessment of communication, the eating and swallowing difficulties posed by the laryngectomy also have to be addressed. The Speech-Language Pathologists also has the duty of “supporting and counseling the client and family, Reviewing/assessing swallowing as appropriate, solving Problems regarding issues with a client’s TEP valve, such as leaking due to radiation and/or cancer recurrence, Ensuring the client has an effective means of communication towards the end of life, Providing alternative means of communication (e.g. an electrolarynx) if a client’s tracheoesophageal prosthesis is removed due to complications or illness (e.g. following palliative chemotherapy), Cleaning the stoma site, although this has been described as primarily the role of nursing staff” (Haynes, p. 96). As Eadie and Doyle noted, “changes in a person’s ability to eat and swallow after Laryngectomy directly affects their overall quality of life” (Eadie & Doyle, p. 13)
Conclusion
Effectively, the Speech-Language Pathologist assists persons with a Laryngectomy by helping the patient to achieve good body and head positioning and posture during recovery, helping to improve dentition and swallowing oral-peripheral examination, helping to improve primitive oral reflexes, describing the necessary Laryngeal functions (i.e. cough, throat clearing, MPT, sound quality, sound volume, and the ability to impound air) to persons with a laryngectomy, helping the patient to improve his speech articulation, helping the laryngectomee to synchronize the flow of air through the speech tube by folds adduction, assisting in the elimination of anxiety, and proving daily voice therapy to the laryngectomee
The Techniques employed by the Speech-Language Pathologist include a throat clearing/ coughing maneuver, which is used to stimulate fold adduction. Using this technique, the laryngectomee is able to shape reflexive sounds into vowels, and then the vowels are gradually connected to form full speech patterns. The Speech-Language Pathologist may also place a finger lightly on the ventilator hose of the tracheotomy tube, in order to position the tube optimally and prevent air from leaking through the interface between the skin and the tracheotomy tube. An SLP also plays the role of training the laryngectomees in the occlusion of the line for airflow, and also shows the patient how he or she can speak during the expiration phase of ventilation
The ability of persons with a laryngectomy to communicate effectively does have a direct impact on the quantity of life. It is therefore of great essence for the Speech-Language Pathologist to strive to ensure that persons with a langugecfomy active and maintain an effective method of communication. The Speech-Language Pathologist should also ensure that the patient and the family of the patient are properly educated on maintenance issues like value remedial and placement in cases where speech aid is used.
References
Eadie, T., & Doyle, P. (2005) “Quality of life in male tracheoesophageal (TE) speakers Journal of Rehabilitation Research and Development”, 42(1), 115-124.
Frowen, J., & Perry, A. (2001) “Reasons for success or failure in surgical voice restoration after total Laryngectomy: An Australian study”. The Journal of Laryngology and Otology, 115(5).
Haynes, V. (1996) “Caring for the Laryngectomy patient”. American Journal of Nursing, 96(5).
Melvin, C., Frank, E., & Robinson, S.(2001). “Speech-language pathologist preparation for evaluation and treatment of patients with tracheosphageal puncture”. Journal of Medical Speech Language Pathology.
The American Speech-Language-Hearing Association www.asha.org.(2009) “Roles and responsibilities of Speech-language pathologists with respect to evaluation and treatment for tracheoesophageal puncture and prosthesis.”