Prosthetic treatment of the laryngectomized patient

Prosthetic

treatment

of the

laryngectomized

patient

Richard J. Grisius, D.D.S.,* Dorsey J. Moore, D.D.S.,** and William T. Simpkins, Jr., M.A.*** Naval Graduate Den,& School, National Naval Medical Center. R&esda, Md.

lhe first successful total laryngectomy was performed by Billroth in 1873. Today, between 2,500 and 4,000 laryngectomies are performed annually-the majority, on men over 50 years of age. Because of the increasing incidence of laryngeal cancer and the decreasing mortality rate, approximately 25,000 laryngectomy patients are now living in the United States.] Surgical removal of the larynx presents two major problems. First, an alternate airlvay must be provided to allow communication with the tracheobronchial tree. This is achieved by the creation of a permanent stoma in the suprasternal notch area of the neck to provide air exchange while bypassing the nasopharyngeal airway. Although improved surgical procedures have minimized the problems associated with maintaining an adequate tracheal opening, a substantial number of larynor constantly, gectomees may be required to wear a prosthesis, either periodically to prevent stenosis of the stoma. The standard silver alloy laryngectomy tube,? Mhich is inflexible and which is designed with a predetermined curvature and length, presents many problems. Most common are irritation of the stoma and the respiratory mucosa, accompanied by increased mucosal secretion. Tarnish, difficulty in cleansing, and improper angulation of the opening are additional faults. More serious problems include wound inThe opinions or assertions contained herein are those of the authors and are not to 1)~ construed as official or as reflecting the views of the Navy Department, the na\ral service at large, or the Department of the Army. Read at the Annual Antonio, Texas. *Captain **Captain Department. ***Chief, D. C. tJackson

300

(DC)

Meeting

USN;

(DC) Speech

Chief,

USN; Pathology

laryngectomy

of the American Complete Chief,

Academy

Denture

Division,

Maxillofacial

Section,

tube, G. Pilling

Walter

of Maxillofacial Prosthodontics

Prosthetics Reed

Army

& Son Company,

Prosthetics,

Division,

Medical

Center,

Fort Washington,

San

Department. Prosthodontirs Washington. Pa.

Vollme Number

32 :i

Prosthetic

treatment

of laryngectomy

patient

301

fection, erosion of the trachea, and formation of tracheoesophageal fistulas.’ In an attempt to minimize the foregoing complications, laryngectomy tubes have been made of both acrylic resin and hardened glass.:’ Acrylic resin has also been used Glass tubes, however, require the talents of a glassto fabricate stoma1 obturators.’ blower, and there is always a potential risk of breakage, while acrylic resin presents such problems as material degradation and difficulty in achieving proper anatomic curvature and a uniform opening. The second major problem associated with surgical removal of the larynx is vocal rehabilitation of the patient. Since the majority of social relationships are achieved and maintained by speech, its loss threatens the individual’s sense of security, adequacy, and acceptance.’ Various surgical procedures have been attempted to rehabilitate the voice, but most have met with limited success and numerous complications. Artificial voice instruments are an alternative, but they do not produce a voice of good quality. The resultant sound is noisy, monotonous, and unattractive. The most efficient method of achieving vocal rehabilitation is generally considered to be esophageal, or alaryngeal, speech. The technique requires the implosion and entrapment of a column of air in the upper part of the esophagus. Controlled release of the air causes the walls of the esophagus to vibrate and produce sounds similar to those produced by the vocal cords. These esophageal sounds are then articulated by the lips, teeth, tongue, and cheeks. Even though the voice is harsh and low pitched, it does simulate natural speech. Although the prime requisites for alaryngeal speech are practice and motivation, anatomic limitations of the surgical sites may prevent the patient from achieving adequate volume and durability for extended speech. The surgical procedures required for total laryngectomy and radical neck dissection may result in reduced activity of the pharyngeal segment of the esophagus. Reduced innervation or lack of adequate sphincter activity in this segment can complicate the patient’s ability to achieve alaryngeal speech.” The application of digital pressure to various levels of the esophagus is an aid in producing audible alaryngeal speech, but this technique makes it diflicult for the patient to perform tasks requiring the use of both hands while speaking. This article describes the treatment of a laryngectomized patient who experienced difficulties both with the standard laryngectomy tube and with the production of esophageal speech. It includes a method of fabricating a custom laryngectomy tube of silicone rubber. It also describes a custom prosthetic aid developed to place controlied tension on the pharyngeal segment of the esophagus, thus enabling the patient to produce louder alaryngeal speech and also to form longer phrases with less effort. REPORT OF TREATMENT On Sept. 29, 1971, a 56-year-old man underwent an operation for cancer of the larynx at the Naval Hospital, National Naval Medical Center, Bethesda, Md. Surgical procedures included removal of the larynx, a radical neck dissection, and performance of a low tracheostomy to develop a permanent stoma. Custom silicone-rubber laryngectomy tube. The patient was first seen in the

302

Grisius,

Moore,

and Sinlpkim

Fig. 1. Permanent

stoma in the suprasternal

notch area of the nwk

Maxillofacial Prosthetics Division, Prosthodontics l>epartment, Naval Graduate Dental School, on Nov. 26. 197 1. Kefcrral of the patient for consultation by the Ear, Nose, and ‘l’hroat Service of the Naval Hospital included a request that prosthetic assistance be provided, because the tracheal stoma was contracting. and the standard silver-plated laryngectomy tube was both ineffective and irritating as a result of the position and angulation of the stoma behind the suprastcrnal notch (Fig. 1). The standard laryngectomy tube was iiiodificd to serve as a template for use in making an impression of both the stoma and the surrounding structures. Baseplate wax was adapted to the cervical portion of the tube to serve as an impression tray. Adhesive* was sprayed on both the wax and the cervical portion of the tube to enhance the retention of the impression material. Suction was used to clear the trachea of secretions before making the impression and was readily available throughout the entire procedure. Special care was taken to keep the laryngectomy tube unobstructed to ensure an adequate airway during the impression procedures. Quick-setting irreversible hydrocolloid impression material? was used to make an impression of the anatomic contours of the depression and the stoma1 opening (Fig. 2, A ‘1. Artificial dental stone was then poured in stages to create a three-piece mold, and copper tubing of a gauge comparable to the internal diameter of the standard laryngectomy tube was incorporated into the mold to maintain an adequate airway. in the finished prosthesis (Fig. 2, B) Since the opening of the stoma was directed toward the patient’s chin, the mold was modified to incorporate a deflector in the finished prosthesis that would direct air and tracheobronchial secretions away from the patient’s face. Silicone rubber was selected as the material for the prosthesis, because it is flexible, inert, and adjustable. In addition, it can be molded to reproduce anatomic detail, and multiple prostheses can be custom-made for the patient from the same mold. Inert earth pigments were blended into room-temperature-vulcanizing silicone rubber1 to reproduce the basic skin shade, and the colored silicone was then *Hold, W. A. Getz Corp.. Chicago, 111. f Jeltrate (fast set), The L. D. Caulk Company, $382 medical

Milford,

Silastic. Dow Cornins, Inc., Midland,

Mich.

Del.

Prosthetic

treatment

of laryngectomy

patient

303

Fig. 2. (A) A standard laryngectomy tube modified as a tray with an impression of the stoma and surrounding structures. (B) A three-section mold with copper tubing incorporated to provide an airway. (C) A completed silicone-rubber custom laryngectomy tube. (Note the modification to deflect air and tracheobronchial secretions away from the patient’s face.) (D) A custom laryngectomy tube is in position to prevent stenosis of the stoma.

packed into the stone mold. Nylon mesh was incorporated to add edge strength? and fabric tape ties were embedded in the silicone rubber before the mold was closed (Fig. 2, C and D) The patient was provided with duplicate prostheses, together with instructions in their care and maintenance. The patient tolerated the laryngectomy prosthesis well, and its accurate adaptation to the anatomic contours provided improved patient comfort. As an aid in preventing stenosis of the stoma, the prosthesis was worn constantly for approximately three weeks and then was worn only at night for another four weeks until the stoma1 opening was stabilized. T’ocal rehabilitation prosthesis. The patient was referred to the Speech Pathology Section, Audiology and Speech Center, Walter Reed Army Medical Center, Washington, II. C., to be taught alaryngeal speech accommodation. Although his progress \vas rapid, it was noted that he had a tendency to turn his head toward his left shoulder while simultaneously exerting muscular tension on the esophageal wall. Although this accommodation allowed him to produce alaryngeal speech with less effort, he would stand sideways with his left shoulder toward the listener. Not only did he appear to have a torticollis, or wryneck, but constant tension of the neck and shoulder musculature left him aching and uncomfortable. The application of digital pressure to the pharyngeal section of the esophagus could also create tension on the esophageal wall, thus allowing the patient to resume

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Grisius, Moore, and Simpkins

Fig. , 3. The appIication of digital pressure to the pharyngeal section of the esophagus enables the patient to assume normal posture and perform alaryngeal speec:h with minimal effort.

normal posture and to speak with minimal expenditure of imploded air (Fig. 3 /. This method of accommodation, however, limited the tasks he could perform while carrying on a conversation. For example, he was handicapped if he wanted to use the telephone and to make notes at the same time. Accordingly, the patient was again referred to the Maxillofacial Prosthetics Division with a request that. if possible, a prosthetic aid be provided to simulate digital pressure, Elastic tape,” 1 inch in width, was first adapted to the patient’s neck as a collar. The ends were overlapped and held in place by hook and loop tape.? Softened modeling plastir was added to the collar at the critical pressure point in the neck to make an impression of the anatomic contours. Low-fusing wax$ was used to per,feet the impression and to develop adequate pressure to minimize the effort of maintaining prolonged alaryngeal speech (Fig. 4, A ) . Artificial dental stone was poured into the impression which had been attached to the elastic tape. The tape was marked, and the mold was scored to ensure exact realignment of the collar after the mold had been separated. After the mold had set, all residual impression material was removed, and the mold was packed with room-temperature-vfulcanizing silicone rubber.8 The tape was accurately repositioned and maintained in place while the silicone rubber cured overnight. The finished speech aid (Fig. 4, B) was adapted to the patient (Fig. 4, C!, and “Elastic tape, L. Laufer & Company, New York, N. 1.. ~Velcro, Smalley and Bates, Inc., New York, N. Y. $Adaptol, j. F. Jelenko & Company, Inc., New Rochelle, SType A adhesive, Dow Corning, Inc., Midland, Mich.

N. Y.

Volume= 32 Number 3

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Fig. 4. (A) An impression developed for making a speech aid. (B) The impression is duplicated in silicone rubber and adapted to the elastic tape. (C) A completed speech aid is in position to minimize the effort of maintaining prolonged alaryngeal speech.

Fig. 5. The modified speech aid is incorporated into an ascot. Fig. 6. The patient is wearing an ascot containing modified prosthetic

speech aid

he was instructed in its care and maintenance. As the patient progressed in alaryngeal speech accommodation, the silicone rubber bulb was gradually reduced in size. Later, for esthetics, the collar was replaced by incorporating both the bulb and the elastic tape into an ascot (Figs. 5 and 6). While wearing the prosthetic aid, the patient became very proficient in alaryngeal speech. He was subsequently elected to serve as president of a disabled veterans’ organization in his state and enthusiastically addressed large audiences with minimal effort.

SUMMARY

Methods have been presented that will enable the maxillofacial prosthetist to assist in the treatment of the laryngectomized patient. These include construction of a custom laryngectomy tube of silicone rubber that will aid in preventing steno& of the stoma while minimizing complications and adding to patient comfort. Vocal rehabilitation of the laryngectomee is the most important aspect of posroperative therapy. The learning of alaryngeal speech may be complicated by neuromuscular deficiencies or anatomic limitations resulting from the surgical procedure. A prosthetic speech aid can benefit some of these patients by maintaining pressure on the pharyngeal segment of the esophagus to increase voice volume and minimize air expenditure. References I.

Publication of the International Association of Laryngectomees: First Aid for Laryzlgectomees, sponsored by The American Cancer Society, 1973. 2. Converse, J. M.: Reconstructive Plastic Surgery, Philadelphia, 1964, W. B. Saunders Company, p. 406. 3. Swerdlow, H., Ketcham, A. S., and de Kernion. J.: Tracheostomy Prostheses, J. PROSTHET. DENT. 22: 84-87, 1969. 4. Harley, W. T., and Rothwell, K. S.: Fabrication of Tracheostomy Obturators. J PROSTHET. DEN,T. 25: 679-683, 1971. i. Adler, S.: Speech After Laryngectomy. .4m. J. Nur,. 69: 2138-2141. 1969. 6. Diedrich, W. M., and Youngstrum, K. :i.: .i\laryngcal Speech, Sprinqfield, Ill., 1966. Charles C Thomas, Publisher, p. 137. NAVAL GRAIIUATE DENTAL NATIONAL NAVAL MEDICAL BETHESI>A, MI,. 20014

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