Okay, hi everyone. We are going to wrap up our discussion of special problems by talking about laryngeal cancer and laryngectomy.
So some things to keep in mind are that the SLP does not make recommendations about medical aspects of treatment for cancer. We can counsel our patients on what various treatment options are and their consequences, but we can’t say that a patient should or should not have radiation, or chemotherapy, or surgery. Instead we take a monitoring role, and can help ENTs and other medical personnel counsel and treat patients with laryngeal cancer. I will point out that all treatments for cancer have some side effects. For patients who undergo radiation therapy, the vocal folds may become stiff or rough, and may atrophy, or lose muscle mass. All of these things will have an effect on the voice, even if the patient does not undergo a laryngectomy.
And sometimes patients have laryngeal cancer but a laryngectomy, or the complete or partial removal of the larynx, is not warranted. So for these types of patients the role of the SLP is particularly important. There aren’t specialized techniques to help these patients regain a stronger voice. Instead, we simply apply techniques that you are familiar with from our chapter on voice therapy, such as inhalation phonation, nasal glides, glottal fry, and tongue protrusion /i/. Clients may also get a better voice if they experiment with different pitches and loudness levels. We also want to consider our patients from a holistic perspective, and realize that if vocal fold scaring due to surgery or radiation is present, there is a dysphagia risk. I’ve also worked with patients whose experiences with radiation have resulted in changes to the sensation of taste. Many patients will not have a good appetite, as food no longer tastes the same.
So while not all people with laryngeal cancer need a laryngectomy, a great many do. People who experience physical trauma to the larynx, like a car accident or gunshot wound, may also need a laryngectomy. So here we will talk about what happens in the case of a total laryngectomy, where the whole larynx, including the hyoid bone and some of the strap muscles in the neck are removed. There are obviously lots of consequences of having a laryngectomy. One of the most noticeable changes is the creation of a stoma, or whole in the neck. The uppermost tracheal ring is rerouted to the neck, preserving the separation of the esophagus and the airway. Otherwise, if the larynx was removed, there would no longer be two separate tubes for eating and drinking, and all food and drink would go right into the lungs. So the stoma is really important, and air is filtered through the stoma instead of through the nose and mouth. I’ve given you a diagram of the larynx before and after laryngectomy in the hyperlink in the PowerPoint so you can see for yourself.
I also want to note that there are many changes that go beyond voice and dysphagia concerns for patients with a laryngectomy. For example, when we try to bear down or lift something heavy, we valve off the vocal folds. People with a laryngectomy no longer have vocal folds, so they lose these abilities. Sense of smell may go away completely, though there are some techniques that can help with this. And I think most importantly is the ability of people with a laryngectomy to express themselves through the vocalization that comes with laughter and crying. Of course, the reactions of significant others and the general public may also be negative, especially with the changes to communication and the physical change in appearance that accompanies laryngectomy.
So let’s move on now to a discussion of how people with a laryngectomy can communicate after the removal of their larynx. Note: laryngectomy=surgical procedure; laryngectomee=person who has had their larynx surgically removed. There are three methods. The first is the electro larynx, or artificial larynx. This is a device which can be held in one’s hand and placed on the throat or cheek, or there are newer devices now that are hands-free. These devices replicate the buzzing of the vocal folds, and then the person’s articulators shape this sound into speech as usual. We have an artificial larynx from the 1950s in the department, but it doesn’t work so well anymore. To see one in action, you can watch the hyperlinked video clip of a person with a laryngectomy using a hands-free electrolarynx. Virtually everyone will use an electrolarynx after their laryngectomy, until they can learn a more advanced and natural form of speaking. Some people though, may opt to use an electrolarynx permanently. Esophageal speech used to be one of the only options people with a laryngectomy had to communicate besides an electrolarynx. In this method, PWL inject or inhale air and speak while, essentially, burping. If you or anyone you know has ever drank a lot of a carbonated beverage and spoken on an extended belch, this is much like esophageal speech. But this method is hard to teach and hard to learn for clients. Check out the page on esophageal speech from the WebWhispers online support group, including samples of esophageal speech and a good description of how to learn esophageal speech. Esophageal speech may be more common in developing countries rather than the US. Finally, tracheoesophageal speech, or TE speech, is the most popular form of alaryngeal communication. A TE puncture, known as a TEP, is a surgical procedure in which a fistula or opening is created between the trachea and the esophagus. This puncture can be primary, or done at the time of the laryngectomy, or secondary, which means that it is done at a later date after the laryngectomy. Once this puncture heals, a plastic prosthesis is fitted and inserted into the opening. To speak, a person occludes (or covers) the stoma with a thumb or finger and forces air through the prosthesis into the esophagus. This air movement vibrates the walls of the esophagus and the PWL can create sounds and words normally by using the articulators. The prosthesis has a one-way valve in it to prevent swallowed food and liquids from entering the stoma. Additionally, the stoma can be covered with a special valve, called a Hands-Free valve) that closes when the person wishes to speak, thus forcing air into the prosthesis. With this valve in place, the person with a laryngectomy no longer needs to occlude the stoma, and speech is hands-free.
The decision of what type of communication method to use will depend on the client and the ENT, with your input as an SLP. We play a role in counseling patients with a laryngectomy before their laryngectomy surgery. We can explain to them that they will lose their natural voice, and other consequences such as loss of smell, inability to lift heavy objects, etc. I’ve seen interviews with people with a laryngectomy where they claim that they were never told by medical personnel that they would lose their voice after the surgery. Whether they were truly not told this information or whether they were told but were in denial is not certain, but it is especially important that we give patients good pre-and post-operative counseling. I’ve given you a clip of an interview with someone scheduled for a laryngectomy. Pay attention to his concerns and feelings, as these are issues that you may experience if you work with PWL.
Finally, it is important that PWL have support from various sources before and after their laryngectomy. Hospitals may have support groups for PWL, and some SLPs may lead or co-lead these groups. There are also some online resources, such as the webwhispers website. Finally, the International Association of Laryngectomees has a nice site, and also hosts an annual conference. Students and SLPs can attend this conference for more hands-on practice. I just want to add that there are many other resources related to laryngectomy, so I hope you will take the opportunity to seek out these resources in order to learn more about this topic.
Laryngectomy and laryngeal cancer
CDIS 700Voice Therapy Following Laryngeal Cancer
Keep in Mind… The SLP does not make recommendations for medical treatments for cancer. Radiation Chemotherapy Surgery (including a laryngectomy) SLPs can play a monitoring role before and after treatment. Stiffness to the VFs is likely to result from radiation and surgery. The VFs may also lose mass and their smooth shape after surgery in particular.
Non-Laryngectomy Treatment For those clients who have cancer but did not undergo a laryngectomy, there are many therapy approaches: Inhalation phonation, nasal glides, glottal fry Change of pitch or decreased loudness Digital pressure or tongue protrusion /i/ Dysphagia note: If the VFs are too stiff from scaring, patients may be at an increased risk for aspiration. Also, foods can taste different and be less appetizing after radiation and chemotherapy!
Laryngectomy Recall that in a total laryngectomy, the entire larynx, including the hyoid bone and part of the tracheal rings are removed. The remaining portion of the trachea is attached to a new opening (stoma) in the neck. Cancer is the main reason someone might need a laryngectomy, but laryngeal trauma also necessitates removal of the larynx. The appearance of the stoma, the remaining anatomical structures, and the ability of individuals to use alternative verbal communication vary from person to person.
What Changes After Laryngectomy? Sense of smell is often completely nonexistent. The ability to lift heavy objects is lost. Bearing down is no longer feasible. Laughing, crying, and other form of emotional expression that come from the vibrating vocal folds are hard to produce. Feelings of depression are very common. May experience poor reactions from others; could include one’s spouse, children, or friends.
Communicating After Laryngectomy Electrolarynx (Artificial Larynx) Usually only a temporary solution, but can be permanent A hand-held device that replicates the buzzing vocal folds Esophageal Speech (ES) Speak on injected or inhaled air; much like speaking while burping Not an easy technique to teach; may be harder to learn for some clients as well Tracheoesophageal Speech (TE) An opening is created between the trachea and esophagus (TE puncture—TEP); may be primary or secondary. The air that is shunted from the trachea to the esophagus sets the remaining pharyngoesophageal segment into vibration if a prosthesis is used.
Deciding on a Communication Method During pre-operative counseling, the client should receive information about speaking after a laryngectomy by the SLP. See an interview with someone scheduled for a laryngectomy. The surgeon and patient should discuss the patient’s options. Recall that everyone’s anatomy is different, and so some clients may not be able to use TE speech. Some may not be good at ES speech. It should be a joint decision between the well-informed client and his/her surgeon and SLP.
Sources of Support for People with aLaryngectomy (PWL) Group therapy with other PWL and their spouses can be very helpful to aid in coping and acceptance issues. Look for local support groups, as well as online resources: http://www.webwhispers.org/index.asp Web Whispers, a very large online support group with helpful information for everyone, including medical professionals http://www.larynxlink.com/Main/ial.htm International Association of Laryngectomees, the online site that represents many local “Lost Cord” and “New Voice” Clubs