Current trends in laryngectomy rehabilitation: A survey of speech-language pathologists

Current trends in laryngectomy rehabilitation: A survey of speech-language pathologists GERALD L. CULTON, PhD, and JOHN M. GERWIN, MD, FACS, Tuscaloosa and Birmingham, Alabama

This study determined the perceptions of experienced speech-language pathologists regarding current practices in the speech rehabilitation of laryngectomy patients since the introduction of the tracheoesophageal puncture–voice prosthesis technique in 1980. The sample population consisted of 151 experienced speech-language pathologists, or 43% of those who were sent questionnaires. The speech-language pathologists ranked tracheoesophageal puncture–voice prosthesis as their most preferred speech rehabilitation method and the electrolarynx as their least preferred, even though the electrolarynx continues to be the most frequently used method. Variable use of the tracheoesophageal puncture procedure by otolaryngologists was reported, with only a small portion perceived as using it routinely. About 65% of the speech-language pathologists reported that more than half of the laryngectomy patients were being given choices among speech rehabilitation methods. Nearly 50% of the speech-language pathologists reported that fewer than six speech therapy sessions were necessary with tracheoesophageal puncture patients, whereas more than 20% reported the need for 10 sessions or more. Use of manual closure of the tracheostoma by tracheoesophageal puncture patients far outweighed their use of automatic speaking valves. Most speech-language pathologists reported that they were involved in teams with otolaryngologists to determine patient suitability for tracheoesophageal puncture and to troubleshoot problems. Eighteen different categories of medical and speech production problems were reported. (Otolaryngol Head Neck Surg 1998;118:458-63.)

Since the introduction of the tracheoesophageal puncture (TEP) technique of voice restoration after laryngectomy in 1980,1 numerous clinical and research studies have been published from technique modifications2-4 to quality and ease of speech production.5-7 Postsurgical complications and troubleshooting techniques for postTEP problems8,9 have demonstrated that TEP is not a panacea, but others have demonstrated that with adequate pretesting and patient selection, TEP provides successful results.10,11 Preliminary investigations also have focused on the attitudes and practices of otolaryngologists concerning TEP and other methods of voice restoration with laryngectomy patients.12,13 Now that more than a decade has passed since the introduction of TEP, it is important to begin to evaluate its impact on laryngectomy rehabilitation. The purpose

From the Department of Communicative Disorders (Dr. Culton), University of Alabama, Tuscaloosa. Dr. Gerwin is in private practice in Birmingham, Alabama. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, D.C., Sept. 29–Oct. 2, 1996. Reprint requests: John M. Gerwin, MD, FACS, 833 St. Vincent’s Dr., Suite 402, Birmingham, AL 35205. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/81756 458

of this study was to determine the perceptions of experienced speech-language pathologists (SLPs) regarding current practices and changes in the speech rehabilitation of laryngectomy patients during the past 10 years. METHOD

SLPs with experience in laryngectomy rehabilitation comprised the study population. The nearly 90,000 members of the American Speech-Language-Hearing Association are employed in a variety of settings, with only a small portion of them engaged in the rehabilitation of laryngectomized patients. Therefore the SLPs queried were from Veterans Administration Medical Centers, hospitals, those approved by the International Association of Laryngectomees as alaryngeal speech instructors, and those whose names had appeared in the alaryngeal speech literature. The method of data collection was a questionnaire (Appendix) consisting of 15 questions pertaining to the SLPs’ experience with laryngectomy patients; their preferences among the speech rehabilitation methods of the electrolarynx, esophageal speech, and tracheoesophageal (TE) speech; allowance of patient choice of method; use of TEP by otolaryngologists; and specific aspects of TEP care, complications, and troubleshooting. Not all questions were answered by all respondents because of factors such as experience level and

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Table 1. Frequency distribution of SLP respondents (N = 151) Frequency

31 26 20 18 18 14 6 4 4 2 143*

%

22 18 14 13 13 9 4 3 3 1 100

Federal region

V III IV VI IX II VII X I VIII

Table 2. SLPs’ personal rankings of speech rehabilitation methods Speech method

Best (%)

Middle (%)

Worst (%)

Electrolarynx Esophageal speech TE speech

7 30 69

25 52 22

68 24 7

States

IL, IN, MI, MN, OH, WI DE, MD, PA, VA, WV, DC AL, FL, GA, KY, MS, NC, SC, TN AR, LA, NM, OK, TN AZ, CA, HI, NV NY, NJ IA, KS, MO, NE AK, ID, OR, WA CT, ME, MA, NH, RI, VT CO, MT, ND, SD, UT, WY

*Eight questionnaires had no postmark (151 – 8 = 143).

their willingness to list problems encountered with patients. Questionnaire forms were mailed to 385 SLPs; 34 were returned as undeliverable, and 351 were delivered to the target sample. One hundred sixty-five forms were completed and returned, a return rate of 47%. Fourteen of the forms returned by SLPs indicated they were retired, out of the field, or had no recent experience with laryngectomy patients. Therefore the actual sample population in the study consisted of 151 SLPs, or 43% of those who received the questionnaire forms. To achieve participation from SLPs across the United States, a breakdown of states according to the 10 federal regions was used. SLPs in each region were sent questionnaires. Table 1 contains the geographic frequency distribution of the respondents, with the densely populated regions represented by greater numbers than less populated regions. An attempt was made to locate SLPs with experience because a focus of the study involved respondents’ perceptions of changes in the treatment of laryngectomy patients occurring during the past 10 years. Of the 151 respondents, 84% reported having 11 or more years of experience, 11% had 6 to 10 years, and 5% had less than 5 years of experience. Therefore the goal of reaching experienced clinicians was achieved. RESULTS

One of the goals of the study was to locate SLPs who had clinical experience with the three types of alaryngeal speech production. That goal was achieved in that 89% of the 151 respondents had provided clinical services to laryngectomy patients, including TEP. Among the SLP respondents with the desired experience, 59% had provided speech services to more than 12 TEP patients, 40% to more than 25 patients, and 27% to more than 39 patients.

Table 3. Major method of alaryngeal speech used during previous 10- and 5-year periods Past 10 yr (n = 134) Speech method

Electrolarynx Esophageal speech TE speech Other

Past 5 yr (n = 146)

%

Rank

%

Rank

43 35 21 2

1 2 3 4

39 28 31 2

1 3 2 4

One of the questions required the SLPs to rank the three speech rehabilitation methods according to their own preference. Table 2 contains the results in a percentage format. The TEP method was selected by 69% of the SLPs as most preferable, whereas only 7% judged it to be least preferable. The electrolarynx was selected as most preferable by only 7%, whereas 68% judged it as least preferable. Esophageal speech was judged neither most nor least preferable by 52% of the SLPs. Indications are that TE speech is the most preferable method according to the SLPs, whereas the electrolarynx was judged as the least preferable in comparison with both TEP and esophageal speech. The required ranking question was eschewed by 30 SLPs, some of whom explained that the choice was variable depending on physiologic, psychological, or environmental factors among patients. Nevertheless, 121 (80%) of the 151 respondents made choices based on their own preference. Table 3 contains the data resulting from two questions asking what percentage of the SLPs’ patients used the three different methods of alaryngeal speech as the major method during the previous 10- and 5-year periods. During both periods, the electrolarynx was the most frequently used major method of alaryngeal speech, but its usage declined from 43% during the decade to 39% during the last 5 years. Esophageal speech usage declined from 35% to 28%, whereas TEP speech increased from 21% to 31% during the previous 5 years, moving it ahead of esophageal speech in frequency of usage. TE speech can be produced by manually occluding the tracheostoma with the thumb or through the use of an automatic valve affixed to the neck anterior to the

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Table 4. Percentage of patients given choice to select their speech method % SLPs reporting each patient choice category

Patient choice categories

0%-25% 26%-50%

18 17 35 27 38 65

TOTAL

51%-75% 76%-100% TOTAL

Table 5. Percentage of SLPs reporting use of TEP by otolaryngologists

% ENTs

Reported % ENTs who have used TEP

Reported % ENTs who routinely use TEP

0-50 51-100

49 51

65 35

stoma. The automatic valve enables the patient to have both hands free to gesture and is less distracting to listeners because the tracheostoma can be covered by clothing. The SLPs reported that 76% of their TE patients use only the voice prosthesis, manually occluding the tracheostoma for speech production. Only 24% of the patients reportedly use the complete voice restoration system, including the automatic valve. Table 4 contains data concerning the percentages of new laryngectomy patients whom the SLPs thought were given choices to participate in the selection of their alaryngeal speech method. Table 4 shows that 35% of the SLPs reported that fewer than 50% of the laryngectomy patients were given the opportunity to choose, but 65% reported that more than 50% of patients were given some choice. Of the four percentage of choice categories, the most significant was that 38% of the SLPs indicated 76% to 100% of laryngectomy patients participated in selecting their alaryngeal speech method. The SLP respondents also were asked to respond to two questions pertaining to use of TEP by otolaryngologists known to them in their communities. Each was asked to estimate the percentage of otolaryngologists in their community who have used the TEP technique and to estimate the percentage who use the procedure routinely. Table 5 contains the data relating to the two questions. Responses concerning the question about whether the physicians had ever used TEP were almost evenly split because 49% of the SLPs reported fewer than 50% of the otolaryngologists had used it, whereas

Table 6. Number of speech rehabilitation sessions required with TEP patients No. of sessions

% Patients

1-3 4-6 7-9 10+

8 34 =70 36 22

51% reported that 51% to 100% had used the technique. Responses by the SLPs concerning the otolaryngologists’ routine use of TEP were different because 65% reported fewer than 50% use it routinely, and only 35% reported that more than 50% use the TEP technique routinely. The SLPs were asked whether they believed they were functioning as a decision-making team member with laryngectomy patients. Nearly 80% reported they were doing so. The SLPs also were asked whether they were involved in evaluating patient suitability for TEP, such as insufflation testing, motivation, and visual and manual capability. Seventy-six percent reported they were involved in such evaluations, and 24% reported they were not. The number of speech rehabilitation sessions required with TEP patients to the level of independent care and use varied considerably. The results are contained in Table 6, with most (70%) of the SLPs having reported from 4 to 9 sessions as necessary (34% with 4 to 6 sessions, 36% with 7 to 9 sessions). Only 8% reported needing fewer than 3 sessions, whereas 22% reported needing 10 or more sessions. The final two questions asked of the SLPs pertained to postsurgical TEP problems. One question asked them whether they were involved in troubleshooting problems encountered by TEP patients. Ninety-three percent reported that they were involved, whereas only 7% reported they were not. Lastly, the 93% of SLPs who reported they were involved in troubleshooting TEP problems were asked to list the three most prevalent problems they encountered. Because the SLPs were allowed to generate their own descriptions of the problems, 313 problems were variously reported. The problems were collapsed into 18 categories and are listed in Table 7 according to frequency of occurrence. The problems appeared to be mixed in many cases involving medical, speech, psychological, or purely mechanically based complications. SUMMARY AND DISCUSSION

The sample population consisted of 151 experienced SLPs who completed a 15-question form covering a

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Table 7. Eighteen categories of post-TEP problems according to frequency of occurrence Problem

Frequency

Leakage around/through prosthesis Insertion/fitting problems Sizing the prosthesis Secretions/inadequate cleaning Inability to speak/speak consistently Air seal/leakage around housing Psychological problems-learning, fear, motivation, lack of independence Difficulty with valve operation/pressure Candida, granuloma Esophageal stenosis, dysphagia Hypertonic, cricopharyngeal spasm Dislodgement of prosthesis Poor voice/sound quality Prosthesis failure/short period of operation Problems with digital stoma valving Patient selection error, physical limitations Puncture/fistula migration Small stoma TOTAL

variety of issues concerning their perceptions about the alaryngeal speech rehabilitation of laryngectomy patients during the past 10 years. Perhaps the most significant finding was the seeming incongruency between the SLPs’ strong preference for TEP speech over both esophageal and electrolarynx speech, contrasted with their reports that electrolarynx speech has been the most used major method throughout the decade. Incongruency also was added by data resulting from three other questions. Nearly 80% of the SLPs reported that they functioned as part of the decision-making team with laryngectomy patients. Given the SLPs’ strong preference for TEP speech and their reported input, it would seem that more patients should be using that speech method. The other two questions provided data from the SLPs indicating that not all otolaryngologists have attempted the TEP procedure and that most of them do not use the method routinely. Perhaps the lack of routine consideration and use of the TEP surgery by otolaryngologists has kept its usage below that of the electrolarynx. If TEP is not used, the electrolarynx and esophageal speech are the remaining options, and they will result in much greater usage of the electrolarynx because many patients are unable to learn and develop esophageal speech to a functional level. The data did indicate, however, that 35% of the SLPs reported that 51% to 100% of the otolaryngologists are routinely using TEP and that TE speech has replaced esophageal speech in frequency of usage during the past 5 years. The data from the SLPs also indicated that patients are now being given more opportunity to participate in the selection of their speech rehabilitation method. Through

42 41 33 28 24 20 20 17 17 13 10 9 9 8 7 6 6 3 313

%

14 13 11 9 8 6 6 5 5 4 3 3 3 3 2 2 2 1 100

increased personal contacts and videotaped presentations of alaryngeal speakers, it is reasonable to expect increased use of TEP in the future based on the many reports of listeners preferring it over the other methods. Human variability appears responsible for the data concerning high usage of manual occlusion of the tracheostoma during speech. Although the use of the automatic tracheostoma valve virtually normalizes TE speech for laryngectomy patients, it requires daily usage of time, hygiene, and the development of routine habit to be successful. Apparently, not all patients are able or willing to meet such requirements. Finally, the long list of post-TEP problems reportedly encountered requiring troubleshooting provides evidence that TEP is not without complications. Data from our and other reports seem to indicate that troubleshooting problems of various types should be expected with TEP. Successful treatment with TEP should be associated with pretesting, patient selection, and team decision-making and treatment. This study must be considered as an early investigation into it as an evolving method of laryngectomy rehabilitation. Further investigation into the data presented here as well as the questions raised seems necessary. REFERENCES 1. Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;89: 529-33. 2. Panje WR. Prosthetic vocal restoration following laryngectomy: the voice button. Ann Otol Rhinol Laryngol 1981;90:116-20. 3. Stiernberg CM, Bailey BJ, Calhoun KH, Perez DG. Primary tracheoesophageal fistula procedures for voice restoration: the University of Texas Medical Branch experience. Laryngoscope 1987;97:820-4.

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4. Maniglia AJ. Newer technique of TE fistula for vocal rehabilitation after laryngectomy. Laryngoscope 1985;95:1064-6. 5. Pindzola RH, Cain BH. Acceptability ratings of tracheoesophageal speech. Laryngoscope 1988;98:394-7. 6. Robbins J. Acoustic differentiation of laryngeal, esophageal and tracheoesophageal speech. J Speech Hear Res 1984;27:55785. 7. Pindzola RH, Cain BH. Duration and frequency characteristics of tracheoesophageal speech. Ann Otol Rhinol Laryngol 1989;98:960-4. 8. Mehle ME, Lavertu P, Meeker SS, Tucker HM, Wood BG. Complications of secondary tracheoesophageal puncture: the Cleveland Clinic Foundation experience. Otolaryngol Head Neck Surg 1992;106:189-92. 9. Izdebski K, Reed CG, Ross JC, Hilsinger RL. Problems with tra-

10. 11. 12. 13.

cheoesophageal fistula voice restoration in totally laryngectomized patients. Arch Otolaryngol Head Neck Surg 1994;120: 840-5. Gerwin JM, Culton GL, Prosthetic voice restoration with the tracheostomal valve: a clinical experience. Am J Otolaryngol 1993; 6:432-9. Lavertu P, Guay ME, Meeker SS, et al. Secondary tracheoesophageal puncture: factors predictive of voice quality and prosthesis use. Head Neck 1996;18:393-8. Lopez MJ, Kraybill W, McElray TH, Guerra O. Voice rehabilitation practices among head and neck surgeons. Ann Otol Rhinol Laryngol 1987;96:261-3. Webster PM, Duguay MJ. Surgeon’s reported attitudes and practices regarding alaryngeal speech. Ann Otol Rhinol Laryngol 1990;99:197-200.

APPENDIX: ALARYNGEAL SPEECH QUESTIONNAIRE (Should be completed by a certified speech-language pathologist.) The series of questions below is designed to provide important information concerning various speech rehabilitation methods for laryngectomy patients in the United States, during the past 10 years. Please answer the questions and return the form in the accompanying envelope. 1. How many years have you been a practicing certified speech-language pathologist? (Circle) 0-5 6-10 11+ 2.

Rank the laryngectomy speech rehabilitation methods from 1 to 3 according to your own preference, with “1” being the most preferable. _______ electrolarynx _______ esophageal speech _______ tracheoesophageal speech

3. Over the past 5 years, indicate what percentage of your laryngectomy patients have used as their major method of communication _______ electrolarynx? _______ esophageal speech? _______ tracheoesophageal speech? _______ other (writing, signing, computer, etc.)? (=100%) 4. Indicate what percentage of your laryngectomy patients have, over the past 10 years, used as their major method of communication _______ electrolarynx? _______ esophageal speech? _______ tracheoesophageal speech? _______ other (writing, signing, computer, etc.)? (=100%) 5. Have you provided services to laryngectomy patients with tracheoesophageal puncture? Yes ________ No _________ (If Yes, continue. If No, go to question 8.)

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6. How many tracheoesophageal patients have you treated? (Circle) 1-12 13-25 26-38 39+ 7. What percentages of your tracheoesophageal patients use: ______% voice prosthesis only (finger occludes stoma) ______% voice prosthesis with automatic valve 8. In your community, what percentage of new laryngectomy patients do you think are given the opportunity to select their own speech method from the viable choices. (Circle) 0%-25% 26%-50% 51%-75% 76%-100% 9. What percentage of the ENT physicians known to you in your community have used the tracheoesophageal puncture procedure? (Circle) 0%-25% 26%-50% 51%-75% 76%-100% 10. What percentage of the above physicians seem to use routinely the tracheoesophageal puncture procedure? (Circle) 0%-25% 26%-50% 51%-75% 76%-100% 11. Is your role in the speech rehabilitation of laryngectomy patients that of a decision-making team member? Stop here if you do not treat tracheoesophageal patients. Yes _________ No _________ 12. Are you involved in evaluating patient suitability for tracheoesophageal puncture (e.g., insufflation testing, motivation)? Yes _________ No _________ 13. On average, how many sessions do you have with tracheoesophageal patients from prepuncture testing to independent care and use? (Circle) 1-3 4-6 7-9 10+ 14. Are you involved in “troubleshooting” the inevitable problems encountered by tracheoesophageal puncture patients? Yes _______ No ________ 15. If you answered yes to question 14, list the three most prevalent problems you have encountered that require troubleshooting. 1)___________________________________________________________ 2)___________________________________________________________ 3)___________________________________________________________