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Flashcards in Surgical Prosthetics-Test 2 Deck (45):

Ways to produce speech post-laryngectomy

Artificial larynx
Esophageal speech
Voice prosthesis


Extra Artificial Larynx Info

Intelligibility on the ultra-voice is not very good.
One button with a trutone. Can have a range for emphasis; several pitches.
Cervox will last a couple years.
Trutone has a standard 9-volt battery that you can buy in a store.
Goal for SLP would be how to use this and maintain it.
Cooper-Rand is another brand that is just an intraoral device.
Intraoral piece would go half inch to an inch inside the mouth; not as intelligible as on the neck.
May have trouble hearing yourself or someone else bc sound will be distorted. Don’t turn it up to adjust bc the feedback gets louder still.
“I didn’t catch those last few words. Could you repeat that?”---communication is the reason for the therapy


The Artificial Larynx

Typically introduced post-laryngectomy
Takes quite a bit of tx sessions to teach a pt to use


2 modes of use with artificial larynx

Intra-oral & neck vibrating


Artificial Larynx requires ____

Functional articulatory skills
Pt must move the tongue & lips clearly to articulate words


What are 2 types of artificial larynx power

Battery powered
Pulmonary powered (own lung air)
Both with neck & intraoral vibratory sources


Battery Powered Artificial Larynx

Requires recharging the batteries for device to remain operable (expense of batteries?)


Pulmonary Powered Artificial Larynx

Attached to the stoma & is powered by the lungs
Not an option for patients with a history of COPD


Pulmonary Devices

External Pneumatic Larynges/Pneumatic Larynx


Types of Battery-Powered Devices

Western Electric
Cooper Rand


Western Electric Battery-Powered Device

Neck vibrating, battery powered
Can be purchased from the phone company
Has a large head or diaphragm & can only be used with patients who have a soft neck


Cooper Rand Battery-Powered Device

Intra-oral, battery powered
Pt places a tube in the mouth, presses a button, & begins to speak
Pt must have good articulatory skills
Pt must have good motoric & coordination skills
Device has volume & pitch controls
Usually used right after surgery (don't want neck vibrating right after surgery)


The Servox

Similar to Western Electric but higher quality & smaller head
Requires less soft tissue for vibration

Servox: high and low tone
Griffin labs: 1 button with all tones whole pitch range: True Tone


Advantages of Artificial Larynx

Way to talk if Pt can't use esophageal speech or a voice prosthesis
Permits prompt speech anytime
Quick & easy to learn
Can be used when esophageal speech can't be heard due to low volume
Permits communication early
Prevents depression, by giving pt an early form of communication


Disadvantages of Artificial Larynx

Very few are satisfied with sound of mechanical voice
Some feel it inhibits future learning of esophageal speech
Physical reminder of disability
Attracts attention
Requires use of 1 hand
Pt rendered speechless while batteries are recharging
Sounds computerized
Some feel it's a sign of defeat


Esophageal Speech

Intake of air through the mouth & 1/2 swallow into esophagus
Sound is produced on release of air by exciting upper esophageal tract into vibration at P-E segment (pseudoglottis)-use amount of air in oral cavity (blow up cheeks--amt of residual air you have)
Only 1 tbsp. of air is needed to speak


Where sound is made in esophageal speech

At the level of the cervical esophagus at C5-C6


2 methods to producing esophageal speech:

Inhalation method
Injection method


Inhalation method of esophageal speech

Pt sniffs air through nose & mouth & allows bolus of air to fall into the P-E segment


Injection method of esophageal speech

3 ways to produce:
-Glossal press (pressing air back with tongue)
-Glossopharyngeal press (pressing air up against pharynx with tongue)
-Plosive injection (p-t-k): put lips together, push it back, swallow


Characteristics of a good esophageal speaker

Pt can speak up to 113 words per minute
Pt can produce 6-8 words per air charge (before swallowing again)
Length of esophageal sound should be 1.5 to 2 seconds duration
Time b/t injection of air & voice production should be approximately 1/2 second
Intensity of voice should be approximately 75 dB with a range of about 11 dB
Pitch level should be about 65 Hz for males & females


Normal vowel prolongation:

15-20 seconds


What is a Tracheal Esophageal Puncture (TEP)

Surgical prosthetic procedure
Created by placing a small surgical passage in stoma from back wall of the trachea into the esophageal wall
Prosthesis is a 1" (can be other sizes) tube placed in the passage to enable tracheoesophageal speech
Speech is produced by covering stoma with finger to direct air from the lungs through the prosthesis into esophagus
Primary vs. Secondary placement
Shunts air from lungs into esophagus


TEP Voice

Produced at the same location as classic esophageal speech


Criteria for success with prosthesis

Can't be alcoholic or use drugs (poor judgement, may not take care of it, may not know he's aspirating)
Good pulmonary support
Good hand eye coordination
Good motoric skills
Be able to follow instructions
Adequate stoma size (at least large enough to place equipment; 1st finger past 1st knuckle)
Good vibration of esophageal walls


Is TEP appropriate?

Must pass a transnasal air insufflation test first


Transnasal Air Insufflation Test

Determines if Pt is a good candidate for TEP
Catheter is placed over the stoma & then passed transnasally to esophagus
Catheter stops at C5-C6 level, b/c that's where the esophageal wall vibrates for speech
SLP covers the stoma to prevent air escape
Pt instructed to phonate vowel /e/
Pt should be able to produce voice with normal lung capacity of approximately 15 seconds
Pt is instructed to count to 10 three times
Good candidates demonstrate uninterrupted fluent speech


Purpose of Transnasal Air Insufflation Test

Get someone who has already had a laryngectomy. Get circular double-stick tape (clean around stoma and then place the double-stick on). Fit the plastic piece over the tape and stoma, get a good seal, pop tube on, lube tube, and insert tube into nose and have them swallow it for about 25 mm in (tube is marked). The insufflation test kit redirects the air to see if pt can talk through esophagus.


3 Types of Voice Prostheses

Low Pressure
Duck Bill
Indwelling low pressure prosthesis
(Shiley makes nonindwelling
Blomsinger or Provox)


Low Pressure Voice Prostheses

Size 16-20 French, can be removed by pt for cleaning or replacement following initial fitting & placement by SLP


Duck Bill Voice Prostheses

Size 16 French, removed by pt following initial fitting & placement by SLP


Indwelling low pressure Voice Prostheses

Inserted and removed by SLP or doctor
Lasts 6 months at a time
Cannot be cleaned or recycled


Fitting Prosthesis & Insertion

1. Determine size of puncture site using sizer
2. Place a dilator into fistula site to make it a little larger to accept prosthesis
3. Blue loading device is used next to pull prosthesis through in order to place a gel cap over the top of the prosthesis for easier insertion
4. The inserter rod is used to endure the prosthesis isn’t dropped into the lungs
5. The strap of the prosthesis always stays on the outside of the neck and the therapist then makes a full rotational turn of the prosthesis with the insertion rod so that the retention collar is in place and the duck bill will be able to open and enable air flow into the esophagus
6. Strap should be taped on to the neck and the insert rod is slowly removed
7. Have the patient drink a warm glass of water to check for aspiration and to melt the gel cap


Using a sizer

The sizer is inserted through the puncture site until you come in contact with the posterior esophageal wall
Then pull down until you feel a resistance form the retention collar which gives you the size of the puncture site


Notes with Placement:

Different diameters of prostheses and different lengths.
Diameteres range from 16 French to 22 French (1 Fr= 1/3 mm)
Non-indwelling prostheses are typically the smaller diameter. The Provox 2 is the larger diameter of 22.5 mm.
Length of what? The thickness of the posterior tracheal wall and the anterior wall of the esophagus.
The white sizer: lube it up, put all the way in and then fit. The number you can completely see is the sixe you should use.
If laryngectomee has breathing problems; give them a card or medical alert bracelet so if in ER, the staff will know what the white circle is in their throat.
“I am a neck breather.”


Valve is supposed to be one-way so that...

Swallowing is still doable with prosthesis in
Blom-Singer & Provox


Chemotherapy & Radiation affect...

use/function/amount of time to wait before making the puncture


How is the Puncture made?

With a trocar, scalpel, or needle and dilator
Seems to be the best and less swelling


With swelling and prosthesis:

give them 24 hours, reevaluate, no voice?, resize them


To fit a Pt with a tracheostoma valve

Clean skin around stoma with alcohol
Put cutaneous glue around stoma
Place double edged tape on valve and skin
Attach valve to skin, diaphragm w/in the valve closes when talking & opens for breathing
Remove when coughing
Humidifier goes into valve to decrease coughing and phlegm


With an insufflation, you want Pt to be able to ____

say 2-3 words
If they can't, may need Botox or dilation


Cleaning & Changing Prosthesis

Pt needs to be taught how to clean the prosthesis & detect when a new 1 is necessary
Cleaning: Can be done with forceps; Can be done by shooting water through the prosthesis with a pipette
Keep in mind that people can change sizes with prostheses


TEP Complications

Esophageal perforation during the creation of fistula
Severe allergic reactions to prosthesis or the glue from the tracheostoma valve
Leakage of saliva & food through the puncture site resulting in aspiration
Enlargement of the fistula
Pneumonia as a result of recurring aspiration
Aspiration of the prosthesis (not common but they are radio-opaque)
Tracheal stoma stenosis
Esophageal stenosis


Voice Prosthesis Advantages

Preservation of speech rate and voice duration
Normal prosody as a result of using the pulmonary air stream
10dB louder intensity
Voice is usually obtained at a faster rate than learning esophageal voice by classical means
Less therapy is needed
More natural sounding; easier to understand


TEP size

Different lengths & diameters of prostheses