Head & Neck Cancer Support Group
Kirklin Clinic – Birmingham, AL
distributed by American Cancer Society, edited by Pat Sanders
The TEP has been around for almost 20 years and many patients have punctures that may indeed be that old. I have noticed over the years that punctures sometimes have a life span of their own and occasionally need to be re-done when they fail to work effectively and become difficult to maintain.
I have my own thoughts as to why the punctures might wear out. First, occluding the stoma with a finger constantly moves the prosthesis in its tract. This can cause granulation tissue to develop, both on the stoma side and on the esophageal side of the fistula. This granulation can make the prosthesis difficult to insert and properly maintain and can lead to decreased voicing. Acid reflux and the bacteria associated with saliva and sputum also enhance granulation formation. Along the same line, I have seen several fistulas actually migrate up and out of the stoma so that they become completely ineffective. My only explanation for this is the continued manipulation over the years pushing the tract and the prosthesis up and out of the stoma. Lastly, I can recall two patients who developed swallowing difficulty from an erosion of the esophagus caused by the tip of the speech prosthesis.
So what do we do when the granulation tissues gets too bad, the fistula migrates out of the stoma, or an erosion develops in the esophagus causing difficulty with swallowing? The first thing we do is stop using the prosthesis for a while and give the area a chance to settle down. In the case of laryngeal granulation tissue we will replace the prosthesis with a small catheter and deal with the granulations. This may involve removal with a LASER or cautery and then several week of healing before replacing the prosthesis. This applies only to granulation in the trachea.
The problem in the esophagus is a little different matter. For esophageal problems like granulation or erosion and for fistulas that migrate out of the stoma we often have to completely disregard the current fistula, let it close and come back in a month or so for a re-puncture. This lets everything heal and creates a more controlled situation for a better placement. Usually the fistula will close once the prosthesis is removed, but it may be necessary to close the tract with an outpatient procedure before the repeat puncture can be done.
After the repuncture, we basically start over with resizing as the tract matures.
Glenn E. Peters, M.D. , F.A.C.S.
Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, Alabama, USA
Adjustable Tracheostoma Valves 101
Many experienced laryngectomees know one of the primary limitations of TEP speech is the need to occlude the stoma with a finger in order to produce voice. This sacrifice is frequently under appreciated by one’s surgeon or therapist. Indeed some laryngectomees find finger occlusion unhygienic, socially obtrusive and otherwise unacceptable. Speech pathologists are more apt to view finger occlusion from an opposing perspective when evaluating a candidate for TEP surgery (e.g. the patient may have difficulties with prosthesis use, because he or she lacks the dexterity to occlude the stoma).
In response to these concerns, 1982 Drs. Blom, Singer and Hamaker developed the first Adjustable Tracheostoma valve, better known as the “Hands-Free” valve or ATSV. This valve is worn in addition to a voice prosthesis and eliminates the need to cover the stoma with a finger during voice production. An ATSV may be worn with ANY type of TEP. Simply stated, an ATSV is a 2-way valve that opens during non-speech breathing (both inhalation and exhalation). This valve closes upon more forceful exhalation such as with speech. * When the ATSV is closed, the air from the lungs is diverted through the TEP and into the Esophagus for voice production. The ATV opens automatically as air pressure diminishes at the end of a phrase. Because ATSVs close with exhalation, they incorporate a method of “emergency release”, which functions in the event of excessively high air pressure, such as is generated while coughing.
There are two models of ATSVs available in the United States. Perhaps the most commonly used ATSV is the Blom-Singer ATSV (INHEALTH Technologies, Caprinteria, CA). This valve was designed in 1995 and has several features that the 1982 prototypes lacked. The Blom-Singer is unique in that the user can control the sensitivity of the valve, while in use, by rotating the valve’s faceplate. This rotation moves a curled silicone diaphragm into varying degrees of resting closure within the valve. The greater the resting closure, the less the effort to produced hands-free voicing. Less effort is not always better. An ATSV in this position may close inadvertently during physical activity. By allowing the user to adjust the sensitivity of closure this problem may be eliminated. If the user has difficulty closing the valve during speech even in the position of greatest resting closure, an alternative “lighter weight” silicone diaphragm is available. A Humdifilter can be attached to the outside of the unit.
Following the success of the Blom-Singer ATSV, Bivona produced two models of ATSVs. The ATSV II and I. The first ATSV functions in a similar manner to the Blom-Singer ATSV. The ATSV II uses a flat diaphragm which slides closed during forceful exhalation. The force of exhalation required to close the valve varies and is controlled through counter-resistance supplied by a coil spring. These coil springs come in 15, 20, 25 and 30 grams. The 15-gram spring is frequently used with laryngectomees who, due to pulmonary disease, lack the ability to generate sufficient air pressure to close a standard ATSV. Once a selected spring is in place it cannot be adjusted while in use. The Bivona is not compatible with a Humdifilter or HME.
Although not yet available in the United States, the Provox FreeHands HME has been in use in Europe since the summer of 2001. Provox is currently seeking FDA approval for this product and hopes to launch the product in the United States by September 2002. This new ATSV uses a low profile design and is therefore relatively unnoticeable when worn under clothes. FreeHands closes via an internal elastic membrane with a “Multi-Magnet” system. This membrane unfurls during exhalation, thereby closing off the valve’s side openings. The valve remains closed with two small magnets. The force of inhalation releases the magnets. A second feature of FreeHands is an adjustable pressure cough relief valve. One may alter the distance between the two magnets that control this feature, and therefore increase or decrease the force needed for opening the valve in the event of coughing. Thirdly, the valve can be rotated to “on” and “off” positions. The off position allows the user to complete more physically challenging activities without inadvertently closing off the speaking valve. Additionally, the Provox FreeHands has an integrated Heat Moisture Exchanger (HME) below the actual valve mechanism.
Despite the ever-growing choices of ATSVs, research suggests that only 35-65% of laryngectomees use ATSVs on a daily basis. One reason sited for this statistic is the inability for a large number of laryngectomees to establish a functional duration (e.g. 8-12 hours) of ATSV seal. Some individuals become very creative in their attempts to gain that elusive airtight ATSV attachment. Typically, ATSVs are either attached in one of two ways, either externally against the skin surrounding the stoma (Peristomal) or within the trachea (Intertracheal).
Peristomal attachment requires a flexible PVC, silicone, or adhesive baseplate. This baseplate is attached to the skin surrounding the stoma. The ATSV is then placed into the base. Products in the form of liquid adhesive to tape and foam disks are available from a number of suppliers. The exact combination of these products varies considerably from patient to patient and is often a matter of trial and error. Tracheostoma architecture, particularly if the peristomal area is deeply recessed, may make peristomal attachment difficult. Some clinicians heat a PVC baseplate until it is pliable and then shape it to fit around the recessed area. A technique that can be used with most baseplates (PVC and adhesive) is to gently pull the muscles and tissues of the neck surrounding the stoma back to a flat position. The neck is held in this position until the adhesive is fully dried and the baseplate is laminated to the neck. Some basic tips to facilitate a good seal, regardless of the type of baseplate used, are:
1. Thoroughly cleanse the skin prior to attaching the valve.
2. Allow the adhesives to dry completely prior to applying additional glue or tape disks.
3. Carefully work out air bubbles prior to attaching the baseplate to the skin and again during lamination of the plate to the skin.
4. Allow the plate to adhere to the skin for several minutes prior to inserting the ATSV.
5. Consistently use a Humidifilter or HME. ATSV seals are maintained for longer periods of time if they are not subjected to excessive secretions.
Laryngectomees with deep set stomas or those who have problems with stoma stenosis may benefit from the intertracheal method of ATV placement. In this method a soft silicone tube such as the Barton Button is inserted into the stoma. The Barton Button comes in varying sizes and must be fitted by a Speech Pathologist or Physician. This Barton Button has a retention collar on its proximal end that locks into the lip of the tracheostoma. The ATSV locks directly into the button. No adhesive is required. The Barton Button requires fenestration, in some cases, to allow adequate airflow into the TEP. Unfortunately, the Barton Button does not adhere well to many stomas, because they lack a smooth, contiguous ledge. If a standard Barton Button does not fit well and an airtight seal cannot be maintained, it may be modified or customized by a maxillofacial prosthodontist.
A variation of the intertracheal attachment is the Provox Lary Tube. The Lary Tube is a soft silicone tube that, like the Barton Button, must be fit by a Speech Pathologist or Physician. The Lary tube with a (blue) retention ring is most useful with ATSVs, because the retention ring locks into the Provox adhesive base plates. The Lary tube is generally longer than the Barton Button must be fenestrated to allow for TEP voicing. To attach the Lary tube, first a peristomal adhesive base plate is placed (see above). Once the adhesive is fully laminated to the skin, the tube in placed. Proper alignment of the peristomal housing is critical, because it may alter the fenestration of the Lary Tube. Finally, the ATSV is snapped into the Lary Tube.
In some circumstances a laryngectomee will not be able to use an ATSV for functional periods of time due to excessive intratracheal pressure, commonly referred to as “back pressure”. Back pressure literally pushes the baseplate away from the skin, causing an audible air leak. Ideally, a person considering an ATSV should have his or her back pressure measured by the Speech Pathologist. This noninvasive procedure and can be accomplished in the office. During conversational speech, manometric readings are taken. A successful ATSV user will typically have a pressure reading of 30-35 cm H20, with higher levels suggesting shorter ATSV seal duration. For some patients simply a reduction in (sound) volume is all that is required, as many TEP speakers initially attempt to speak too forcefully for the valve housing.
It is important to recognize that back pressure is related to the type of TEP used. For example a 16-FR diameter TEP has a higher resistance than a 20-French TEP and therefore is more apt to accompany excessive back pressure. Resistance also varies with model of TEP. Additionally, hypertonicity within the pharyngeal-esophageal segment (PE segment) is related to excessive back pressure. If present, these problems can generally be resolved by your physician and speech pathologist. .
Adjustable tracheostoma valves have restored hands free communication to many laryngectomees who elect to use TEP voicing. However, the road to a successful use does not come automatically to many. Additionally, some individuals who can use ATSVs successfully choose not to do so. ATSVs are not for everyone, but for most individuals with motivation, knowledge and patience successful ATSV use is an obtainable goal.
*University of Groningen Department of Biomedical Engineering is currently developing and evaluating an inhalation-based ATV.
Katie Dietrich-Burns, M.S., CCC-SLP
Clinical Specialist- Head and Neck Disorders
The Milton J. Dance, Jr. Head & Neck Rehabilitation Center
THE RIGHT TOUCH, II
Second in a series on stretching and self-massage
In this session, we will deal with the shoulders, upper back, rib cage and chest. Let's get right to work.
In the first of this series, I mentioned the need to recognize your tools, as they are many and varied. Today, we will incorporate a tennis ball as a massage tool. You may not want to share your pet's toy so it’s better to have one designated for your use only!
In the first part of this session, you will be sitting in a chair with a strong back. Plant your feet firmly on the ground and stretch tall from your spine, lengthening your spine, vertebra by vertebra. Notice your breath. Keep your breathing easy and deep. We’ll begin this session with some warming up movements. Stretch your right arm above your head, reaching really high, then let your left arm follow, reaching over your head toward the ceiling. Keep your head straight and your eyes looking forward. Gently stretch your fingers, then your hands, up, one at a time, as if climbing a ladder. Allow your rib cage to release with these gentle stretches, and be aware of your breath. Feel your sitting bones remain in contact with the chair you are in as you reach your arms toward the sky. Climb ten rungs on the ladder, then allow your arms to come to your sides, bringing one down at a time. Check your spine for length, and then check in with your breathing. Are you relaxed? Is more breath coming in?
Next, with your arms to your side, gently reach your right fingers toward the floor. Allow your ribs to curve toward the side, and form a C-shape, finally allowing your head to follow to complete the curve. Don’t lean over so far as to lose your balance! Hold this stretch to a count of ten, slowly come back to the starting point and rest for a couple of seconds. Repeat on the left side.
When is the last time you gave yourself a big hug? Reach your right arm across your chest, and then your left arm across your chest under the right one. Give yourself a big squeeze. Then open your arms, stretching them slowly out, then, with palms turned facing behind you, stretch your arms as far back as you can, opening your chest as you breathe. Pull your shoulder blades together to increase the stretch. Hold to a count of ten, and then release. Bring your left arm across your chest, following with the right arm underneath, and hug yourself again. Then, allow your arms to stretch back as you did before. Feel your breath as your chest opens. Hold to a count of ten and release. Give your fingers, then your hands, then your arms a good shake.
What happened to the tennis ball you have? If you left it on the floor, the cat probably batted it under the couch, so dig it out. It's time to use it. It will be used here as an "active" compression tool. Holding the tennis ball in your left hand, press it against the tissues on your upper chest, your pectoral muscles. [The pectoral muscles are two large fan shaped muscles covering the upper rib cage.] Keeping your hand relaxed, press and roll the ball slowly to compress the muscles in your chest. Use whatever pressure is comfortable for you. If you find a sore spot, by all means give it some special attention. Press the ball on these sore spots, hold and breathe to a count of ten. Allow the tissues to relax and soften as you press the ball into them. Work the sternum [in the middle of the chest] and as close under your collarbone as you can. Roll and press the ball on the area of your chest where your arm meets your torso. [Stay away from your underarm.] You can even roll the ball on your rib cage. Switch the ball into your right hand BEFORE your left hand gets tired. Remember, the name of this game is: Feel Really Good!!
Try this: place the ball between your back and the chair back. Press gently and allow the tissues of your back to relax around the ball. Hold to a count of fifteen. Release and move the ball to the next spot, repeating the process of compress and release, covering as much of your back as you can comfortably reach.
The tennis ball has a variety of uses. It will be used here as a "passive" compression tool. Try this out, and if the pressure is too hard for you, place a folded towel between you and the ball.
Find a comfortable place to lie on the floor. A carpeted area is best. Have the tennis ball close by. Gently lower yourself to the floor, working your way to a lie-down-with-your-knees-bent-up position, feet flat on the floor. Take a few breaths and really relax. The clue to make this next massage work is patience. Roll over a little to your left and place the ball under your back on the right side. You can work any area of the back except directly on the spine. Use your legs to raise yourself over and then lower yourself onto the ball, allowing your body weight to do the work. As you feel the pressure of the ball between you and the floor, use your breath as a tool to allow the tight tissues to soften. Breathe into the pressure and allow the breath to escape slowly from your chest. Feel your body mold around the ball. You can lie on the same spot until you no longer feel the ball there, or for as long as it takes for the tissues to release. When you are ready to work the next area, lift your body up with your legs and pelvis, then roll one direction or another on the ball to find the next spot. Work on your back for ten to fifteen minutes, and take care when coming back to a sitting position. Slowly push yourself to standing.
The rest of this session will be done standing in a doorway. Choose an unobstructed doorway, the narrower, the better. Stand right at the outside of the door. Hold your palms together 12 inches in front of your chest, heels of the hands toward the chest, fingers pointing away from you, elbows out to the side. Relax your shoulders and breathe. On an out breath, squeeze the entire hands together, palms to fingertips, holding firmly to a count of ten. Then drop your arms to your sides for a count of five. Step your entire body into the doorway with one foot in front of the other. Raise your hands and arms up onto the outside of the door jamb, placing your fingers, palms, forearms and elbows on the jamb, right at chest height. Gently lean your body onto the forward leg, doing a small easy lunge, allowing the chest to open as you move forward, stretching through your upper body and chest. Hold this stretch to a count of ten. Release your arms. Give them a shake. Relax and repeat, this time leaning forward onto the other leg. Good going! Give yourself another hug. This hug is not just to congratulate yourself but it relaxes the tissues just stretched in the chest, so it's needed.
Remember that these times you give to yourself are very important in your wellness, no matter where you are in your life. Regular massage and stretching is an adjunct to your total health program!
Shari Aizenman, Atlanta, GA