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The Role of the Speech Pathologist in Laryngectomy Management: An OverviewSpeech pathologists receive little exposure to laryngectomy during university training. In a survey by Melvin, Frank and Robinson (2001), 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*.Duties of the speech pathologist in laryngectomy management have been described (American Speech-Language-Hearing Association, 2004; Doyle, 1994). These duties may include the following:
Laryngectomy in Palliative CareSpeech pathologists working in palliative care may encounter clients who have undergone a total laryngectomy* (Perry, Shaw & Cotton, 2003; Perry, 1997). Despite advances in medical technology, many patients with head and neck cancer will not be able to be cured, and will thus require care which is supportive rather than curative (Bulman, 1998). This supportive, or palliative, care may be required over an extended duration (Bulman, 1998).The speech pathologist's role in palliative laryngectomy cases is reported to be mostly concerned with communication assessment and intervention*. However, any eating or swallowing difficulties these clients have must also be addressed (Palmer & Graham, 2004). The speech pathologist's role with laryngectomy clients in palliative care may include*:
SwallowingChanges in a client's ability to eat and swallow post-laryngectomy directly relate to their overall quality of life (Eadie & Doyle, 2005).Due to the nature of total laryngectomy, dysphagia assessment and intervention is less of a main role of the speech pathologist than it is with other clients with palliative care needs*. However, total laryngectomy clients still have a risk of dysphagic complications, with dysphagia incidence in these clients ranging from 10-58% (Groher, 1997). Dysphagia following total laryngectomy may be due to surgery-related changes to the cricopharyngeal muscle (Groher, 1997); tumour recurrence; narrowing of the oesophagus; fistula formation; second primary tumour in the oesophagus; or an abscess (Balfe et al., 1982, as cited in Groher, 1997). Irradiation may also have a negative impact on upper oesophageal motility (Hanks et al., 1981, as cited in Groher, 1997). A client with a tracheoesophageal puncture (TEP) may experience swallowing complications, such as aspiration of food or fluid through the TEP or tracheoesophageal valve*; aspiration of the voice prosthesis; narrowing or blockage of the hypopharynx, external tracheostoma or oesophagus; and stoma infection (Groher, 1997). In such cases, the speech pathologist will be directly involved in problem solving to minimise aspiration risk and maintain the client's safety and comfort during oral intake*. If oral intake becomes unsafe, percutaneous gastrostomy (PEG) feeding may help provide hydration and nutrition for clients during palliation (Bulman, 1998). See DYSPHAGIA section of this website. Changes to Communication EffectivenessClients who are in a poorer physical condition may be less likely to successfully achieve voice restoration by various means following laryngectomy (Mendenhall et al., 2002). Thus, it may be inferred that laryngectomy clients in palliative care may be less likely to be able to use voice as a method of communication. For a palliative client with total laryngectomy, the success of achieving voice restoration may vary depending on the primary site and extent of the cancer; method of closure; use of radiotherapy (RT); selection bias (Mendenhall et al., 2002); client age and motivation; and/or coexisting bronchitis (Bulman, 1998). Additional reasons for these clients being unable to maintain their method of speech have been provided by Ward, Koh, Frisby and Hodge (2003) in relation to use of a tracheoesophageal valve (see Methods of Voice Restoration below). These reasons include hypertonicity of the pharyngo-oesophageal segment; stricture; migration of the tracheoesophageal puncture (TEP); recurrent fistula granulation; candida and subsequent leakage of the voice prosthesis; decline in health status; difficulties maintaining the stoma; and poor voice quality.In cases where speech is not a viable option, use of augmentative and alternative communication (AAC) devices or writing (Palmer & Graham, 2004) may be more appropriate. More than one communication method may be used concurrently (Palmer & Graham, 2004). Please see the COMMUNICATION section of website for more information. The ability of a laryngectomy client to communicate directly impacts upon the client's quality of life (Eadie & Doyle, 2005; Palmer & Graham, 2004). It is thus essential to ensure the client always has an effective means of communication, even if it is something as simple as a bell to call for nursing help, a writing board, or pen and paper (Coltart, 1998). In palliative care, this may become increasingly important*. Methods of Voice RestorationThere are several methods by which a client may establish voice post-laryngectomy (Doyle, 1994; Coltart, 1998).The most commonly used means of voice restoration following laryngectomy is a tracheoesophageal puncture (TEP) with voice prosthesis (Ryan, Yong, Pracy & Simo, 2004; Perry, Shaw & Cotton, 2003; Ward et al., 2003; Mendenhall et al., 2002; Iversen-Thorburn & Hayden, 2000, as cited in Palmer & Graham, 2004). This method is frequently recommended by clinicians (Mendenhall et al., 2002; Frowen & Perry, 2001), with numerous authors reporting higher rates of voice success (Op de Coul et al., 2000; Blom et al., 1986, as cited in Coltart, 1998; Singer et al., 1981, as cited in Doyle, 1994), client satisfaction (Palmer & Graham, 2004; Perry, Shaw & Cotton, 2003; Clements et al., 1997), and self-reported quality of life (Eadie & Doyle, 2005) than other methods of voice restoration. An artificial larynx, or electrolarynx, is also a common method used today to restore voice post-laryngectomy (Perry, Shaw & Cotton, 2003; Palmer & Graham, 2004; Mendenhall et al., 2002). It may be especially useful as a temporary means directly following surgery (Ward et al., 2003), or when speech via a TEP is not a viable option (Coltart, 1998). An electrolarynx allows rapid communication for users, and can be less frustrating than oesophageal speech (Coltart, 1998). However, some clients may not be suitable for this device due to scarring or hard, fibrotic skin following radiotherapy to the neck (Roland et al., 1995, as cited in Coltart, 1998), and the resulting voice tends to sound monotonous (Dhillon & East, 1994, as cited in Coltart, 1998). Oesophageal speech is a third option for voice restoration. Palmer and Graham (2004) present a review of the literature on oesophageal speech, which shows that its success rates have varied widely, and that it is less commonly used than other methods of voice restoration (see also Ryan at al., 2004; Perry, Shaw & Cotton, 2003; Mendenhall et al., 2002). Stoma CareCaring for the external stoma is generally the role of nursing staff (Boucher, 1996; Haynes, 1996), another carer, or the clients themselves (Haynes, 1996), rather than the speech pathologist. The speech pathologist is more directly involved when there is a complication regarding the site, such as leakage of the voice prosthesis*.ReferencesAmerican Speech-Language-Hearing Association (ASHA) (2004). Roles and responsibilities of Speech-language pathologists with respect to evaluation and treatment for tracheoesophageal puncture and prosthesis. The ASHA leader, Supplement no. 24, 9(8), 135-139. Boucher, M. (1996). When laryngectomy complicates care. RN, 59(8), 40-45. Bulman, C. (1998). A ten year audit of the management of cancers of the larynx and pharynx. The Journal of Laryngology and Otology, 112(10), 948-953. Clements, K., Rassekh, C., Seikaly, H., Hokanson, J., & Calhoun, K. (1997). Communication after laryngectomy: An assessment of patient satisfaction. Archives of Otolaryngology - Head and Neck Surgery, 123(1), 493-496. Coltart, L. (1998). Voice restoration after laryngectomy. Nursing Standard, 13(12): 36-40. Doyle, P. (1994). Foundations of voice and speech rehabilitation following laryngeal cancer. California: Singular Publishing Group Inc. 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), 393-399. Groher, M. (1997). Mechanical disorders of swallowing. In M. Groher (Ed.), Dysphagia: Diagnosis and management (3rd ed., pp. 73-106). Melbourne: Butterworth-Heinemann. Haynes, V. (1996). Caring for the laryngectomy patient. American Journal of Nursing, 96(5), 16B-16K. 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, 9(2), 129-40. Mendenhall W., Morris, C., Stringer, S. Amdur, R., Hinerman, R., Villaret, D., & Thomas Robbins, K. (2002). Voice rehabilitation after total laryngectomy and postoperative radiation therapy. Journal of Clinical Oncology, 20(10), 2500-2505. Op de Coul, B., Hilgers, F., Balm, A., Tan, I., van den Hoogen, F., & van Tinteren, H. (2000). A decade of postlaryngectomy vocal rehabilitation in 318 patients. Archives of Otolaryngology - Head and Neck Surgery, 126, 1320-1328. Palmer, A., & Graham, M. (2004). The relationship between communication and quality of life in alaryngeal speakers. Journal of Speech-Language Pathology and Audiology, 28(1), 6-24. Perry, A., Shaw, M., & Cotton, S. (2003). An evaluation of functional outcomes (speech, swallowing) in patients attending speech pathology after head and neck cancer treatement(s): Results and analysis at 12 months post-intervention. The Journal of Laryngology and Otology, 117, 368-381. Perry, A. (1997). The role of the speech and language therapist in voice restoration after laryngectomy. The Journal of Laryngology and Otology, 111(1), 4-7. Ryan, C., Yong, L., Pracy, P., & Simo, R. (2004). Current trends in voice rehabilitation following laryngectomy in Britain. Australian Journal of Oto-Laryngology, 7(1), 26-29. Ward, E., Koh, S., Frisby, J., & Hodge, R. (2003). Differential modes of alaryngeal communication and long-term voice outcomes following pharyngolaryngectomy and laryngectomy. Folia Phoniatrica et Logopedica, 55(1), 39-49. | ||||||||||||||||||||||||||||||||||
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