[ ? 2003 Barbara Messing, M.A. ]

By Barbara P. Messing, M.A., CCC-SLP, Speech Pathology Manager at the Milton J. Dance Head and Neck Rehabilitation Center at the Greater Baltimore Medical Center, Baltimore, Maryland.

Communication Options for the Laryngectomee: Focus on Tracheoesophageal Speech TE speech and the Tracheoesphageal Prosthesis TEP 

The focus of this article is to explore the in's and out's of tracheoesophageal (TE) speech and the tracheoesophageal prosthesis. TE speech is the one communication option that most closely resembles fluent, natural speech. In many hospitals the tracheoesophageal puncture and prosthesis placement is available as part of the initial surgery or it may be performed several months or years afterwards. Whether one is considering tracheoesophageal speech before or after a layngectomy, an awareness of what tracheoesophageal speech is and how it works is an essential part of the decision making process.

Two other communication options available after the laryngectomy are the electrolarynx and esophageal speech. These three methods of communication are not exclusive from one another. It is feasible to learn and use all three methods of speaking after a laryngectomy. All three post laryngectomy communication options should be introduced to the patient and family members before surgery at a pre-operative counseling session with the rehabilitation team.

A brief description of these two communication methods is provided.

The Electrolarynx is the communication method of choice for many laryngectomees. The electrolarynx is an external vibrating device that generates sound for speaking. At a minimum, it is essential to learn to use an electrolarynx as a back-up communication method. Training with an electrolarynx may be implemented by the Speech Pathologist within two to three days after surgery using placement of a soft tube in the mouth. This provides an immediate way of communicating. The electrolarynx should be maintained as a back-up even if other methods are learned.

Esophageal speech is another method of communication that offers many laryngectomees a hands free speech option. Esophageal speech is produced by either inhaled or injected air taken into the mouth and brought down into the esophagus. The air must be returned quickly from the esophagus. As the air is returned from the esophagus a sound is generated for speaking. It takes time and dedication to learn this method of speaking. It is highly recommended that consideration of this method and subsequent training of esophageal speech be done with a Speech Pathologist.

Tracheoesophageal Speech

What is Tracheoesophageal Speech or TE Voicing?
A tract or opening is surgically created from the trachea into the esophagus by the surgeon. This opening enables the passage of air from the trachea into the esophagus. The air enters into the esophagus creating a vibration. This allows an individual who has had a laryngectomy to make or generate sound in an area of their esophagus known as the pharyngoesophageal segment or PE segment.

Before a laryngectomy, voicing and speaking is normally produced with lung powered air. Air comes up from the lungs, passes through the voice box or larynx which causes the vocal folds to vibrate. The vibration generates sound. Words are then formed by the way we move and position our mouth, lips and tongue.

After a laryngectomy, voicing and speaking with a TEP is produced with lung powered air as well. A finger or speaking valve is placed over the stoma blocking the air from coming out of the stoma. The air from the lungs is trapped forcing it to follow the path of least resistance through the shaft of the prosthesis into the esophagus. Vibration is made by the air passing over an area in the esophagus producing sound. As before the laryngectomy, this sound is formed into speech by the movement and shaping of our articulators (mouth, lips, tongue).

TE speech varies in the way it sounds depending on many factors. Generally speaking, it is lower in pitch than normal voicing for both men and women. Good TE speech is fluent. Fluent TE speech is measured by the number of words spoken and the clarity of that speech. Fluent speech is being able to say approximately 10-20 words or more can be spoken on one breath. The laryngectomee has in TE speech, a method of speaking that most closely resembles natural speech as compared to the electrolarynx or esophageal speech. The use of a speaking valve attachment over the stoma for a person with a TEP allows hands free TE speech. This brings the laryngectomee closer in appearance to natural speech.

Factors that influence successful TE voicing are the extent of the surgical reconstruction; previous cancer treatments to throat (e.g., radiation and chemotherapy), close proximity to a Speech Pathologist with TEP experience, and your ability to care for your stoma and the TEP. All prostheses must be cleaned daily and changed periodically (varies depending on the type). The laryngectomee should be instructed on what to look for and what to do when the prosthesis fails and is ready for a change.

What is a Trachesoesophageal Prosthesis TEP?
A TEP is a prosthetic device made of silicone. The prosthesis is a one-way valve that opens under the positive pressure of air traveling up from the lungs through the valve into the esophagus to produce voice.

What are the primary purposes of the TEP?
1. To maintain a stable opening or passage way from the trachea to the esophagus to allow voicing.
2. To protect against saliva, food or refluxed materials leaking from the esophagus into the trachea.

How do I know which prosthesis is right for me?
Several factors need to be considered. In general there are two basic types of prostheses. Patient changeable and the indwelling prosthesis which is changed only by a speech pathologist or a physician. The 'patient changeable' or traditional prostheses are those that can be changed by the patient, the speech pathologist or the physician. Most importantly is that the patient can change the prosthesis, if instructed to do so, by themselves. This allows a level of independence in the care and management of the prosthesis.

Important measurements related to the parts of the prosthesis?
The shaft is the tubular part of the prosthesis. It is measured in diameter (distance around) and length. The shaft length is the distance between the tracheal collar and the esophageal retention collar. The length of the shaft ranges from 4.5 millimeters (mm) to 28 millimeters (mm). Sizing?The length of the prosthesis is determined by the common party wall and measured by the speech pathologist or the physician. The wall of the trachea and the wall of the esophagus form a common wall. The depth of the "wall" between the trachea and the esophagus is similar to a wall between two rooms. It is often referred to as the 'common party wall'. The length of the surgically created opening or TEP is measured and the appropriate size prosthesis is selected. The diameter of the prosthesis, that is the width of the prosthesis, stays as open around as the size of the prosthesis placed into it. The body naturally heals down to meet the size of the prosthesis occupying that opening. The diameters of prosthesis are measured in 'french' measurement. Available diameters vary from 16 french to 22+ french depending on the type of prosthesis.

The size of the tracheoesophageal puncture may change from time to time. Resizing will be done by the speech pathologist or physician. A prosthesis that is too short in length will most likely not maintain the opening of the tracheoesophageal puncture causing it to close down on the back end.  Repuncturing by a physician may be necessary if the TEP closes down completely. A prosthesis that is too long may piston or slide in the tract causing irritation to the tissue. Or, it may be so long as to be pushed up against the wall of the esophagus during speaking attempts. Both of these situations will results in a loss of voice and will need to be assessed promptly.

Prosthesis failure? Prosthesis failure happens for different reasons.

        1. Leakage of food or liquid through the prosthesis. The prosthesis needs to be changed. Most likely the valve has failed.
        2. Leakage of liquid around the prosthesis. There may be an infection or perhaps a more serious medical problem and the body is unable to heal down around the prosthesis.
        3. The laryngectomee may be unable to voice. The prosthesis may simply need to be cleaned fixing the problem quickly. The valve may have failed or the size of the prosthesis is incorrect requiring a prosthesis change. When these problems arise the Speech Pathologist will seek to find out why the prosthesis failed.
        4. Yeast colonization is the most highly occurring cause of prosthesis failure. Even a small amount of yeast can cause the prosthesis to fail. If yeast colonization is a problem then a prescription for an antifungal medication must be obtained.  Nystatin is a medication most commonly prescribed for yeast or candida treatment. It is recommended that the nystatin is swished in the mouth for five minutes and then swallowed. Other antifungal medications may be prescribed. Dentures and tooth brushes should also be treated with antifungal medication as a preventative measure.

TRADITIONAL OR STANDARD PROSTHESES

Why choose a traditional or standard prosthesis?
The laryngectomee may choose to use a traditional or standard prosthesis (Figure 1. traditional or standard prosthesis). The benefit of having a traditional or standard prosthesis is that it can be changed by the laryngectomee, the speech pathologist or the physician. The laryngectomee may have the desire to change their own prosthesis rather than depending on the speech pathologist or physician for prosthesis changes. Some patients prefer to be more independent with their prosthesis management while others prefer going to the Speech Pathologist for TEP changes as needed. Individuals who do not live close to a rehabilitation center or a Speech Pathologist may opt for the traditional prosthesis. The traditional or standard prosthesis gives the laryngectomee the choice.

The laryngectomee must have good vision and be able to manipulate the prosthesis and the insertion tool to remove and replace the prosthesis independently. Other factors are related to the placement of the prosthesis. Is the TEP placed is a good position making it easy to see? Is the size of the stoma large enough (preferably 1.5 centimeter opening) to allow easy access to the prosthesis for cleaning and changes.

If a person has a lot of problems with yeast or candida production and requires frequent changes to the prosthesis, the traditional or standard prosthesis may be recommended to them by the Speech Pathologist. The prosthesis can be cleaned and treated with Nystatin to prolong prosthesis life.

By Richard Najarian, RPh., President, Bruce Medical Supply, Waltham, MA

Wild Wild West or a Wonderful Experience?
Shopping on the World Wide Web

Well, it's both! Although it is the most convenient method of shopping, you must be careful when choosing with whom you do business.

The real good news is that virtually all reputable catalog companies have secure on-line shopping and will guarantee your complete satisfaction.  The bad news is that it is very easy to develop a commercial web site that has the superficial appearance of a reliable company.  If you're careful, it's a great experience.  If not, you could be disappointed and perhaps suffer serious financial consequences.

The web is a huge repository of easy to locate information.  Some sites have information that is reliable while others have information that is false and misleading.  Unfortunately, it is up to the surfer or buyer to be aware.

Protect yourself by being conscientious, even paranoid, about where you shop and the release of any personal data, especially passwords, credit card information and Social Security numbers.  Providing personal information, name, address and phone number, before being allowed to shop leaves you open to all types of dangerous possibilities.  Defend your privacy.  Just like wandering through the stores at a retail shopping mall, you have a right to remain anonymous.

Some basic A, B, C's to insure that you have a happy and secure shopping experience:

Every reputable company will have all of the following information clearly stated on its website.  If not, just take your shopping elsewhere.

A. Merchant Address and Phone Number:
It should be a complete address, not a Post Office box.  A Toll Free telephone number is always best.  Give them a call to see if they are able to answer some important questions such as: "Is it in stock?" or "When will my order ship?"  You should be suspicious if you reach an answering machine during business hours.  Be very suspicious of the reliability of companies that do not make themselves available to answer your questions.

B. Return Policy:
Read it carefully.  Make sure the company guarantees your complete satisfaction and avoid any company that does not clearly state its policy on the website.  Stay away from companies that require you to request an authorization before a return is considered or accepted.  Some have very strict conditions, such as requiring that the returned item is unused and in the original unopened packaging.  Also, you should clearly avoid doing business with companies that charge you a restocking fee.

C. Credit Card Security:
Using phone, FAX or a secure encrypted on-line transaction is the only way to insure that your personal information remains private.  You should never, under any circumstance, include your credit card number in an E-mail, even if it originates from a "secure" website.  This type of insecure communication could be easily intercepted in transit.

D. Shipping and Handling:
The rates should be clearly stated on the information page of the site.  You should never order from a site unless you know all prices and charges.

E. Secure Transactions:
Most web browsers will indicate to you (with a pop-up window) that the information you send is encrypted to insure security.  For your security, all sophisticated on-line companies will E-mail you an order acknowledgement almost immediately after you enter an order.  If you do not receive an automated response, you should assume the order was not entered properly and your order was not received by the merchant.

After you use the above guide to check out the merchant and feel comfortable with the reliability of the company, you simply navigate through the site, locate the items of interest and place an order.

Some sites are a pleasure to visit while others are extremely frustrating.  The most reliable and enjoyable sites are very easy to navigate, have helpful information, detailed text and descriptive graphics.  Others offer you only a small description and the price.  The more information appearing on a site, the more likely that the site is reliable and you will be completely satisfied with your purchase.

Remember, you are the customer!  The merchant has the responsibility to make sure you are 100% satisfied.  A reputable company will always meet or exceed your expectations.

Happy shopping!


 

Dutch's Bits, Buts, & Bytes         (1)  Does your local laryngectomee support group have a web site?  If so, make certain that both WebWhispers and the IAL know about it --- both organizations will provide your club with a no-cost LINK from their respective "Clubs" pages.   Would your local group WANT a web page or two, but is just unsure as to how to go about it?  Well, look no further.  For a mere $20.00 per year, the IAL will, with your club's assistance, create and manage a small web site on its own dedicated server specifically addressed to your needs.  All your club needs to do is contact the IAL webmaster (currently ME) and let him know what needs to be said, presented, etc., and what preferred graphics you have, if any.  We'll then work together to create your club's site.  Several local clubs in the USA have already long availed themselves to this low-cost alternative.  Below are a list of those clubs, with LINKS to their IAL-hosted web sites - so you can see what THEY have done: Hui 'Olelo Hawai'i - Honolulu, Hawaii Laryngectomee Club of Montgomery County - Silver Spring, MD Look Who's Talking - Stockton, CA Lost Chord Club of Greater New Haven - New Haven, CT New Voice Club of Northern Virginia - Vienna, VA Orange County Lost Chord Club - Santa Ana, CA Suncoast New Voice Club - Clearwater/St. Petersburg, FL New Voice Society of Greater Vancouver - Vancouver, BC, Canada      If YOUR local club would like something like what the above clubs have done, please contact me at: ialwebmaster@larynxlink.com and I will do my best to fix your group up with a convenient, low-cost Internet presence. (2)  REMINDERS:       The WebWhispers ListServ system will NOT accept/transmit any Emails with embedded graphics (pictures) or with attachments of any kind.  This is to reduce our members' susceptibility to Internet viruses to an absolute minimum.  So, when you receive an Email from our system, it will be annotated with a (WebW) or a (WWHH) in the beginning of the SUBJECT line and will be 100% virus-free.      Also, the WebWhispers system does not treat "FORWARDED" Emails very kindly either.  These tend to get automatically rejected by our server or, if they make it through THAT hurdle, they tend to be rejected by the Moderator due to formatting problems which make them difficult to read.  So, PLEASE, do not use the FORWARD command to send Emails via the ListServ.  If someone sends you something that you feel merits sharing with us, either "Cut and Paste" or "Copy and Paste" desired text into a NEW EMAIL FORM, address it to us, and then send it as a NEW Email.  If you do not know how to "Cut and Paste" or "Copy and Paste", please consult the HELP section of your word-processing software.  In general, however, one "cuts" or "copies" text by highlighting the desired text in the source document using the mouse's cursor, then "right clicks" the mouse and selects "cut" or "copy".  One then goes to the document one wishes to copy TO, places the cursor where they want the desired text to begin, and then "right clicks" the mouse and selects "paste" to enter the text in desired place.  These are really quite easy to do ... and are handy "techniques" to have in your "arsenal of computer skills." (3)  Another Hoax Alert:       According to an Email circulating on the Internet, a new law prohibits the use of license plate frames of any kind, including those bearing school affiliations, sports team logos, etc.  The Email cites a Houston, Texas TV reporter as its source.   However, although Texas recently did pass a law that prohibits decorations that alter or obscure the license tag, the law was not and is not designed to outlaw plate frames.   More information and clarity can be found at: http://www.snopes.com/inboxer/pending/texasplate.asp  (4)  An expansive and neat OnLine Reference Site: Check out Martindale's Reference Desk ... eclectic and very useful:  http://www.martindalecenter.com/

Be All That You Can Be                                                                                                           Stan Mruk  (Laryngectomy - 1995)

Dear "Newbie"                                                                                                                              

I consider myself an "Ole Timer" at 8 ? years out from my surgery.  That doesn't mean that I am an expert in laryngectomee issues or research but I do have a great deal of empathy for the new laryngectomees (Newbies) and believe that they are the ones that can be best served by WebWhispers with its web site and newsletters and by a local support group.  Don't get the impression that those who pass a certain yearly threshold in recovery, 2, 5, or 10 years, have all of the answers.  Living successfully as a laryngectomee is a constant learning process for all of us.

Please do not take offense by my use of the term "newbie".  We've all been there at one time since no one joins our exclusive club with instant seniority.  I believe the first, and one of the most important points, is that despite all the good intentions of the professionals out there, you will learn more about daily life as a lary from a good support group or an experienced lary.  This is not to demean the efforts of the professionals but there is no replacement for having "been there and done that."  Do keep in mind that we laryngectomees can only share life experiences, not replace medical or professional help.  The really smart and truly helpful lary is the one who realizes his/her limitations with regard to advice offered.  Pay attention to that one.

Always keep in mind that what we larys have in common is that we have a hole in our throats and have learned a special way to speak or communicate.  I, for example, have experienced virtually none of the many difficulties expressed by other laryngectomees I have met, but I have another problem, severe emphysema (winning the "daily double" of tobacco use).  I have been surprised it is not as common among our fellows as I would have thought.  At this point in my life, I consider being a laryngectomee a minor inconvenience but the emphysema is a major problem for me.  So don't get the impression that you will experience the exact situation expressed by another laryngectomee.  The rule book for this game is fuzzy at best.

There are two ways to live as a lary, the hard way is when you try to do it alone; the easy way is when you take advantage of advice from those caring larys out there who have gone before you and are more than willing to share what they have learned.

Till next time,
BE ALL THAT YOU CAN BE!

Pet Lover's Corner

Judy and Dave Greiwe decided to add a new pet to their household.  Actually, Judy decided, and we   asked for pictures of the introduction of new baby kitty to Emilio, the dog-in-residence!   True Love             by Judy Greiwe   Pet people think there must be something wrong with non-pet people. How can they   look at an adorable kitten and not see the personality, sweetness, softness and love   in that little ball of fur? The big day finally arrived, Emilio was to meet and greet his new little brother! (Love = Control)    Emilio shares his favorite mousie.   (Love = sharing) My husband is a non-pet person.  When he looks at the sweetest kitten on earth, he sees a sneaky, slithery, stalking, red-eyed devil.  He tolerates my lovely animals because he loves me. (Tolerates = Loves)   Our dog baby, Emilio, is a pet animal-person.  He loves   his Baby Kitty.    (Loves  = Tolerates)

Hopefully Handy Hints (1)  Get an inverter for your vehicle.  This will convert the 12 volt DC to 110 volt AC and you can plug your existing AL battery charger into it.  This will charge your battery while on the road.  You can also use it to power other items that do not use too much current.  They cost about 30 bucks and can be purchased in just about any store that sells electronics. Jim Lauder (Lauder Enterprises) (2)  Using a Servox or any artificial larynx with the ChatterVox usually works quite well.  You use the AL on one side of your neck (or mouth, in the case of an oral placement), and put the mic to the other side to avoid picking up the motor noise from the AL or the popping and hissing sounds from letters like P and S.  You also don't want the mic to block people's view of your lips moving.  To avoid feedback with a Servox voice or a regular voice, you should experiment with the volume of your voice and the volume setting of the amplifier to get the amplification you want.  In general, if the mic is to the left of your mouth, you want the amplifier speaker a little toward the right side of your body and visa versa.  The better the separation, the louder amplification you can get without feedback.  If you sit at a table or desk, you will probably have to turn the CV speaker to the side or take it off and put it on the table.  You may have to turn the volume down in an elevator or a very small room and you learn not to lean the side with your speaker into a filing cabinet or wall.   A teacher learns to scoot the speaker around toward the back if talking while writing on the blackboard. Dorothy Lennox (Luminaud)

 

Welcome To Our New Members

     We welcome the 21 new members who joined us during September 2003:

Caren Altieri Sicklerville, NJ	Donald Brewer St. Simons Island, GA	Deborah Brown - SLP Student Las Cruces, NM
Tim & Karen Burger Marion, MI	Becky Cihota - SLP Student Huntington, WV	Tom Cox Cornwall, Ont., Canada
James Cronin Norwood, MA	Douglass Dipper Long Beach, CA	Bryan Ellison Old Bridge, NJ
Terry Hilton Carrollton, OH	Anne Kapiloff Tamarac, FL	Larry Kempter Evans, GA
Peter King Thornlie, W. Australia	Marianne Maloy - SLP Albany, NY	Mike Metcalf Ft. Lauderdale, FL
Jackie Moody - Caregiver Diamondhead, MS	Butch Mosley Granite, OK	Jo. C. Naylor - SLP Corpus Christi, TX
Luis Sevilla Quito, Ecuador	John R. Sharp, Jr. Clearwater, FL	George Whitbeck Tampa, FL

WebWhispers is an Internet-based laryngectomee support group.   It is a member of the International Association of Laryngectomees.           The current officers are:   Murray Allan..............................President   Pat Sanders............V.P.-Web Information   Terry Duga.........V.P.-Finance and Admin.   Libby Fitzgerald.....V.P.-Member Services   Dutch Helms...........................Webmaster          WebWhispers welcomes all those diagnosed with cancer of the   larynx or who have lost their voices for other reasons, their   caregivers, friends and medical personnel.  For complete information   on membership or for questions about this publication, contact   Dutch Helms at: webmaster@webwhispers.org

Disclaimer: The information offered via the WebWhispers Nu-Voice Club and in http://www.webwhispers.org is not intended as a substitute for professional medical help or advice but is to be used only as an aid in   understanding current medical knowledge.  A physician should always be    consulted for any health problem or medical condition.

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