Speech Therapy after Laryngectomy: Vocal and Swallow Rehabilitation

Alexander McGuiggan
had Speech Therapy
after Laryngectomy

Three men.  Three different symptoms.  Alexander McGuiggan noticed a hoarse voice at Christmas and by March his voice had deteriorated to a whisper.

Stewart Farmer noticed difficulty breathing that suddenly progressed and he was constantly short of breath.

Alec Smith noticed a tickly throat and husky voice at the end of the day.  Two years later he had no voice, a bad cough, was breathless and produced huge amounts of phlegm and mucus.

Each of these men had different symptoms, yet each was diagnosed with cancer of the larynx.  And each of them underwent treatment that included a  laryngectomy, radiation therapy and speech therapy.  Fortunately, each had success with their treatments.  With the help of speech therapy after laryngectomy they were able to re-gain their ability to speak and swallow.

Speech therapy after laryngectomy teaches people to breath in a new way.  It helps people re-gain olfactory function.  But most importantly, it is vital for learning to speak and swallow.  Speech therapy often starts before surgery or radiation therapy.  To understand treatment and therapy, it is first important to understand the mechanism of cancer of the larynx, then the components of therapy:

The Larynx:

The larynx is located at the upper end of the trachea.  It contains two bands of muscles called vocal cords.  Vocal cords prevent food and liquids from entering the airway, and are important for breathing, speaking and swallowing.

Cancer of the larynx:

Cancer of the larynx occurs when malignant cells enter the larynx.  It may be caused by excessive smoking, drinking, or exposure to HPV.  Often times, the cause of larynx cancer is unknown.

Medical Treatment:

Medical treatment of larynx cancer may include one or a combination of the following treatments:

• Chemotherapy
• Radiation therapy
• Surgery

Surgery:  Partial vs Total Laryngectomy

For people who require surgery, they will have one of two possible procedures:

1.  Partial Laryngectomy:  this  involves removal of the part of the larynx harboring the tumor.
2.  Total Laryngectomy:  this involves removal of the entire larynx and some adjacent tissues

If a total laryngectomy is required, it results in the following changes:

• The trachea is re-directed and is no longer connected to the nose and the mouth
• A permanent opening called a stoma is created at the base of the neck that cannot be reversed or closed
• Air passes in and out of the lungs through the stoma

Laryngectomy Vs. Tracheostomy

Laryngectomy  and tracheostomy are two procedures that create an opening in the trachea with placement of a stoma.  Although they are similar in this way, they are different in the following ways:

Tracheostomy	Laryngectomy
A hole is created in the trachea through an incision through the neck	Complete removal of the larynx with re-direction of the trachea.
Mainly used to treat airway obstruction.	Used to treat cancer of the larynx
Patient is still able to breathe through the nose and mouth	Patient now breathes through a stoma
Speech occurs through a speaking valve. There is no change in the voice and it sounds normal.	Speech occurs through TEP or electrolaryx. Speech is never "normal" again.
Changes are usually temporary	Changes are permanent and not reversible.

Laryngectomy Airway

Pulmonary Changes after Laryngectomy:

Because the trachea is re-directed and is no longer connected to the nose and the mouth, patients who undergo laryngectomy can no longer cough mucous into their mouth or blow their nose.  Instead, they cough up mucous through the stoma.  Inhaled air no longer humidified by the nose and mouth.  Instead, air must be moistened by spraying the stoma filter with water.

Swallowing Changes after Laryngectomy:

With laryngectomy, the epiglottis and hyoid bone are removed and the esophagus is reconstructed.  Because of this, there is disruption in air pressure regulation, saliva production, and peristalsis during swallowing.  In addition, the sense of taste and smell are disrupted as air no longer passes through the nose.

Laryngectomy Stoma

Laryngectomy Care:

After a laryngectomy, the skin around the stoma needs to be cleaned twice a day to prevent odor, irritation and infection.  If the skin becomes irritated or red, it should be left uncovered and use of solvents should be avoided for two days.

The most important part of stoma care is to make sure no water or foreign objects enter the stoma.  People with laryngectomy must be very careful while bathing, showering or shaving.  They need to avoid cleaning the stoma with thin paper towels or tissues to prevent paper from entering the stoma. Instead, they should use a cloth towel.  In addition, they need to avoid spraying anything directly into the stoma.  Instead, they should spray the stoma cover with water 2-3 times per day to keep it hydrated.

Speech Therapy after Laryngectomy

Speech therapy after laryngectomy includes:

• Swallow Rehabilitation - transitioning from a feeding tube to eating by mouth

• Pulmonary Rehabilitation - learning to protect the airway and breath in a new way
• Olfactory Rehabilitation - using the Nasal Airway Induced Maneuver to maximize smell and taste
• Vocal Rehabilitation - training in esophageal speech techniques and voice production devices

Swallow Rehabilitation:

Olfactory Rehabilitation: The Nasal Airway Induced Maneuver

Because air no longer passes through the nose, taste and smell are impaired after laryngectomy.  Fortunately, there is an exercise called the Nasal Airway Induced Maneuver that can help.  In one study, 46% of laryngectomy patients trained in this maneuver re-gained their sense of smell.   Also called "Closed Mouth Yawning", it involves lowering the jaw, the floor of the mouth, the tongue, and soft palate with lips closed. This induces negative pressure in the oral cavity and oropharynx which generates airflow in the nasal cavity.

Vocal Rehabilitation:  3 types of speech

Because laryngectomy involves removal of the vocal cords, normal vocalization is not possible.  There are three types of alternative speech:

1.  Esophageal Speech

Technique:

• Air is swallowed into cervical esophagus
• The swallowed air is expelled out causing vibrations of the pharyngeal mucosa
• These vibrations, along with articulations of the tongue cause speech to occur

Obstructions to Esophageal Speech:

Impediments to development of esophageal speech can include:

• Cricopharyngeal spams (this may be treated with cricopharyngeal myotomy or Botox injections to enable development of esophageal speech)
• Reflux esophagitis
• Thinning of muscle wall in PE segment
• Denervation of muscle in the PE segment
• Poorly motivated patients

Advantages of Esophageal Speech:

•  Hands are free

• No further surgeries or equipment are required

Disadvantages of Esophageal Speech:

•  Significant training is required and 40% of patients are not able to develop esophageal speech

• Quality of voice is poor
• Patient is only able to speak in shorts bursts and cannot speak continuously
• Patients are not able to control loudness and pitch control
• Frequency is 65 Hz which is significantly lower than normal male and female voices

2.  Electrolarynx Speech

Technique:

• Battery operated vibrating device is held in the submandibular region
• Muscle contracture and changes in facial muscle tension causes the rudiments of speech
• Initial training to use the device begins before surgery

Electrolarynx for Voice Production

Advantages of Electrolarynx:

• Easy to learn how to use
• Allows immediate communication
• Additional surgery is avoided
• Can be used while training in other Vocal Rehabilitation techniques

 

Hands Free Electrolarynx

Disadvantages of Electrolarynx:

Starting at $600, cost could be an issue for some

Speech quality is mechanical

Difficulty to use on the phone

 3.  Tracheo-Esophageal Prosthesis (TEP) Speech

Technique:

• A small hole is made in the rear of the stoma leading to the esophagus. Once this puncture heals, a prosthesis is fitted and inserted into the opening.
• To speak, you cover the stoma with your thumb or finger and simply force air through the prosthesis into the esophagus. This air movement vibrates the walls of the esophagus and you can create sounds and words normally with your lips, teeth, and tongue, etc.
• The prosthesis has a one-way valve in it to prevent swallowed food and liquids from entering your stoma. Additionally, your stoma can be covered with a special valve, called a Hands-Free that closes when you wish to speak, thus forcing air into the prosthesis.
• TEP is considered the gold standard among various voice rehabilitation procedures.

TEP Can be indwelling or non-indwelling:

Indwelling Prosthesis	Non-Indwelling Prosthesis
Can be left in place for 3-6 months	Removed and cleaned every 2-3 days
Requires a specialist for placement	Can be place by patient
Less maintenance	Periodic maintenance

Advantages of TEP:

• Can be performed after laryngectomy, radiation or chemo therapy, neck dissection
• Fistula can be used for esophago-gastric feeding during immediate PO period
• Easily reversible
• Speech develops faster than Esophageal Speech
• High success rate
• Speech is intelligible and closely resembles laryngeal speech

Disadvantages of TEP:

•  Unless using the Hands Free model, patients need to manually cover stoma during voicing

• Patients must have good pulmonary reserve
• Additional surgical procedure is needed to introduce it.
• If not applied correctly, posterior esophageal wall could be punctured.

By working with a speech therapist trained in these alternative speech options, people who undergo laryngectomy can re-gain the type of speech and voicing that works best for them.

It is encouraging to know the number of laryngectomies decreased by 48% between 1997 and 2008, and the number of new cases of laryngeal cancer decreased 33% during the same time. For those who face laryngectomy, advances in technology and the availability of speech therapy after laryngectomy ensure they will be able to re-gain the best possible speech and swallow function for the best possible quality of life.

Jaime Richardson

Mandy Bell and Jaime Richardson are two of the speech therapists at Therapy Achievements who work

with Head and Neck cancer patients. They are certified in myofascial release and have advanced training in treatment of swallow dysfunction.

Mandy Bell

For more information on how Therapy Achievements can help with treatment of Head and Neck cancer or to set up an appointment, call 25-509-4398.