Evaluation and Treatment for Tracheoesophageal Puncture and Prosthesis: Technical Report
ASHA Special Interest Division 3, Working Group on Voice and Voice Disorders
About this Document
This technical report was prepared by Special Interest Division 3, Working Group on Voice and Voice Disorders of the American Speech-Language-Hearing Association (ASHA). Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members. ASHA's Executive Board approved the report in March 2003.
The purpose of this technical report is to: (a) confirm that evaluation and management of patients for tracheoesophageal prosthesis (TEP) after total laryngectomy is within the scope of practice of speech-language pathology; (b) describe the responsibility of the speech-language pathologist (SLP) regarding patient selection, assessment, and management related to TEP use for speech; (c) describe the scientific foundation for this method; (d) review the problems and issues pertinent to this topic; and (e) educate ASHA members and other interested parties about these procedures.
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The TEP shunts pulmonary air to the esophagus and the residual tissue at the juncture of the pharynx and esophagus becomes a vibratory sound source for alaryngeal speech. An opening between the trachea and the esophagus may be created during total laryngectomy surgery or as a secondary procedure after total laryngectomy. Total laryngectomy surgery entails the removal of the hyoid bone, thyroid cartilage, vocal folds, cricoid cartilage, epiglottis, upper two or three rings of the trachea, all of the intrinsic muscles of the larynx, and select extrinsic laryngeal muscles based on patient-specific pathology. Removal of these structures has a profound effect on respiration, swallowing, and speech. In particular, phonation is no longer possible. There are several alternative sound sources for speech without the larynx in place. Tracheoesophageal voice restoration surgery is one option available to individuals who have undergone a total laryngectomy.
During tracheoesophageal voice restoration surgery, an opening, or puncture, is made through the posterior wall of the trachea, extending through the anterior wall of the esophagus. A prosthesis is then inserted into the puncture, or in some cases a stenting catheter is placed at the time of tracheoesophageal voice restoration surgery and then replaced with a prosthesis. When the prosthesis is in place, and the stoma is occluded manually or with a tracheostoma valve, the prosthesis acts as a shunt through which pulmonary air passes during exhalation. The air enters the esophagus and travels through the upper esophageal sphincter, causing the sphincter and surrounding tissues to vibrate. This creates sound that can be used for tracheoesophageal speech. The prosthesis prevents the puncture from closing and also prevents food and liquid from entering the trachea during swallowing.
Prior to 1979, the primary methods of communicating after total laryngectomy were with esophageal speech or an artificial larynx. In 1979, Mark Singer, M.D., an otolaryngologist, and Eric Blom, Ph.D., an SLP, introduced a American Speech-Language-Hearing Association 2004-136 new tracheoesophageal voice restoration surgery and accompanying prosthesis for voice restoration after laryngectomy (Singer & Blom, 1979). Since the introduction of their tracheoesophageal voice restoration surgery and prosthesis, several variations in the surgical approach have been developed. Some of the surgical procedures use methods other than a puncture to create the TE opening. Therefore, the term tracheoesophageal voice restoration or TE surgery will be used as a generic reference when referring to the surgical technique. The term tracheoesophageal prosthesis or TEP will be used as the generic term to refer to the prosthesis placed through the tracheoesophageal puncture site.
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Clinical certification by ASHA ensures that practitioners have met the education, knowledge, and experience requirements established by ASHA for providing clinical services in the professions of speech-language pathology or audiology. ASHA certification in speech-language pathology is necessary, but not sufficient to perform the specific clinical procedure(s) discussed in this report. Practitioners are bound by the ASHA Code of Ethics (ASHA, 2003) to maintain high standards of professional competence. Therefore, practitioners should engage only in “those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience.” If practitioners choose to perform these procedures, indicators should be developed, as part of a continuous quality improvement process, to monitor and evaluate the appropriateness, efficacy, and safety of the procedures.
Education and training for implementation of a TEP may be obtained by a variety of means. Some of the training should take place in a clinical setting allowing the SLP to work with more experienced professionals and a number of patients. SLPs who intend to manage TEP speakers must ensure that they have acquired the knowledge and skills necessary to provide a continuum of service. These knowledge and skill areas form the basis for assessing clinical competency in this specialized area of practice. An accompanying knowledge and skills document (ASHA, 2004) outlines specific objectives to attain adequate preparation for this procedure, as well as the necessary proficiencies and knowledge and skills required to accomplish each objective.
Speech-language pathologists should take the following steps before engaging in independent patient management for TEP:
Inform institutional and/or regulatory bodies, such as state licensure boards, that these procedures are recognized by ASHA to be within the SLP scope of practice (ASHA, 2001);
Confer with state licensure boards to ensure that there is no limitation imposed on the scope of SLP practice that restricts the performance of these procedures;
Check professional liability insurance to ensure that there is no exclusion applicable to these procedures;
Follow universal precautions to prevent the risk of disease transmission from blood-borne or mucusborne pathogens, contained in the Centers for Disease Control Morbidity and Mortality Weekly Report (1988), or ASHA's AIDS/HIV update (ASHA, 1990);
Have available immediate emergency medical assistance;
Hold a current Basic Life Support Certificate.
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Total laryngectomy alters respiration, swallowing, and speech. The most profound effect is the inability to produce voice for speech. Esophageal speech has historically been the method of choice for alaryngeal communication. In this method, air is injected or “inhaled” into the pharyngoesophageal (PE) segment and immediately expelled, setting the PE segment into vibration. Some laryngectomees prefer an artificial larynx to esophageal speech. An artificial larynx known as the electrolarynx introduces sound for speech through an instrument externally placed against the throat, or oral structures, or a tube, or fitted prosthetic electrolarynx inserted into the mouth while speaking. There are some forms of artificial larynx that use the air exhaled from the tracheostoma site to generate sound that is then diverted directly into the vocal tract through an oral tube. Recently, a human laryngeal transplant was successfully completed; however, future availability of this procedure for individuals subsequent to laryngectomy remains unknown (Strome, 1999).
Guttman (1932) described one of the first surgical reconstructions for vocal rehabilitation following a larygectomy. He described a procedure in which a needle was passed through the tracheostoma to penetrate the hypopharynx and create a puncture. Guttman reported that the patient subsequently developed a good voice for speaking when the stoma was occluded during exhalation. However, he also indicated that there was difficulty with leakage of secretions into the trachea. Over the years, various TE shunt procedures have been reported in the literature, but unwanted fistula problems and aspiration into the trachea continued to be an adverse side effect.
Blom and Singer introduced a new TE surgery technique and use of a valved appliance referred to as a “voice prosthesis” in 1979. This prosthesis shunts pulmonary air from the trachea into the esophagus for sound generation during speaking. Since the introduction of this technique, studies have established differences between speech using a TEP and standard esophageal voice processes (Blom, 1995; Doyle, Danhauer, & Reed, 1988; Hillman, Walsh, Fisher, Wolf, & Hong, 1998; Max, De Bruyn, & Steurs, 1997; McAuliffe, Ward, Bassett & Perkins, 2000; McIvor, Evans, Perry, & Cheesman, 1990; Most, Tobin, & Mimran, 2000; Prosek & Vreeland, 2001; Robbins, 1984; Robbins, Fisher, Blom, & Singer, 1984; Sedory, Hamlet, & Conner, 1989). One difference relates to listener perception of speech intelligibility for speakers using esophageal or TEP voicing during speech. In general, listeners rated TEP speakers as significantly easier to understand than those using esophageal voicing (Doyle et al., 1988). However, Max et al. (1997) indicated that speech context can influence listener intelligibility ratings. That is, TEP and esophageal speakers appear comparable on intelligibility measures when producing multi-syllabic words and sentences. However, intelligibility measures suggested that TEP speakers were more easily understood than esophageal speakers while producing monosyllabic words. A second difference relates to acoustic measures of esophageal and TEP speech. TEP speech has been found to differ from esophageal speech across the parameters of voicing duration, number of syllables, and intensity (Sedory et al., 1989). Specifically, TEP speakers exhibited longer phonation times, more syllables per breath, and greater intensity than those using esophageal speech (Sedory et al., 1989). However, listener preference did not distinguish between speaker groups. This finding suggests that acoustic differences may not influence listener preference. Of note with the latter findings, however, is that all esophageal speakers were initially selected based on their demonstration of excellent use of esophageal speech. Thus, skill level with each method of voice generation may be a factor for consideration when judging intelligibility.
Several studies have described physical requirements for successful use of the TEP. Panje (1981) recommends that pulmonary function be adequate to support sound generation. Thus, individuals with asthma and severe lung disease may not be appropriate candidates for TEP. Additional patient selection criteria for the TEP include cognitive level, ability to digitally occlude the stoma, and visual and sensorimotor skills for manipulation and care of the voice prosthesis and puncture (Bosone, 1994). Blom (1995) and Blom, Singer, and Hamaker (1985) describe a method for evaluating the adequacy of the PE segment prior to the TE surgery procedure by esophageal air insufflation testing. This procedure tests the vibratory capability of an individual's PE segment by transferring air from the stoma site to below the PE segment through a transnasally placed catheter. If it is determined that an individual's PE segment cannot adequately vibrate via insufflation testing, alternative intervention techniques may be applied to facilitate improved PE segment vibration. These techniques currently may include Botox® injections (Blom, Pauloski, & Hamaker, 1995; Hoffman et al., 1997; Lewin, Bishop-Leone, Forman, & Diaz, 2001; Zormeier et al., 1999), myotomy of varying portions of the constrictor muscles (Medina & Reiner, 1990; Singer & Blom, 1981), and pharyngeal plexus neurectomy (Blom, Pauloski, & Hamaker, 1995; Singer, Blom, & Hamaker, 1986).
TE surgical procedures have varied since 1979 with regard to method for creating the puncture site (Maniglia; 1985; Mitchell, Kirkland, & Morrison; 1981; Singer & Blom, 1980; Spofford, Jafek, & Barcz; 1984), timing of the procedure relative to radiation treatment (Panje, 1981) and laryngectomy procedure (Annyas, Nijdam, Escajadillo, Mahieu, & Leever, 1984; Hamaker, Singer, Blom, & Daniels; 1985; Panje, VanDemark, & McCabe, 1981; Yoshida, Hamaker, Singer, Blom, & Charles, 1989), and ancillary procedures (Medina & Reiner; 1990). In addition to variations in surgical procedure, several choices of prosthetic devices are now available, varying in size (Leder & Sasaki, 1995), shape (Henley-Cohn; 1981; Panje, 1981), resistance level (Hilgers & Schouwenburg; 1990), insertion technique (Henley-Cohn,1981; Hilgers & Schouwenburg, 1990), valve placement longevity (Hilgers & Schouwenburg, 1990), and prosthetic materials (Blom & Singer, 1979; Panje, 1981). In addition, current methods for using TE prostheses now offer the option of a “hands-free” tracheostomal valve instead of a manual stomal occlusion (Barton, DeSanto, Pearson, & Keith, 1988; Blom & Hamaker, 1996; Blom, Singer, & Hamaker, 1982; Lewin et al., 2000; Zanoff, Wold, Montague, Krueger, & Drummond, 1990).
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The large body of published research, of which only a portion has been cited in this report, illustrates the many creative ways TEPs have been applied to basic issues in alaryngeal speech rehabilitation. While these advances have been impressive, the field may expect to see even greater developments in the future. For example, advances in TEPs allowing longer indwelling longevity would eliminate the frequency of user problems related to prosthesis function, complications, and subsequent reliance on health care professionals. Another advance may be improved intratracheal methods for hands-free occlusion for TEP function. In addition, advances in peristomal and intratracheal prostheses may lead to improved adhesive materials and methods for applying tracheoesophageal valves. Future training techniques may also emerge that maximize TEP speech intelligibility.
There are, no doubt, other exciting areas in which technology and creativity will enhance the accessibility and quality of the tracheoesophageal procedures and prostheses that we currently use. Investigators and researchers in the fields of speech and hearing sciences have been and will continue to be important partners with our colleagues from many other related disciplines who contribute to these advances in science and clinical care.
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Botulinum toxin (BOTOX): Neurotoxin generated by the clostridium bacteria that temporarily impairs the release of acetylcholine (Ach) across the nerve synapse resulting in muscle paralysis.
Esophageal speech: Speech resulting from the trapping of air in the upper aspect of the esophagus and using its expulsion for verbalization.
Laryngectomy: A surgical procedure that entails removal of the larynx.
Myotomy: Disabling a muscle belly by dividing it into multiple components.
Puncture: An opening leading from one hollow organ to another permitting passage of fluids and air.
Tracheoesophageal prosthesis: A prosthetic device that is placed into a puncture between the trachea and the esophagus that is employed to generate tracheoesophageal speech, prevent aspiration, and maintain the integrity of the puncture.
Tracheoesophageal puncture: An opening leading from the posterior tracheal wall through the anterior esophageal wall.
Tracheostoma: An opening, formed by attaching the trachea to the neck immediately above the sternum, through which the laryngectomized patient breathes; also may be referred to as a “stoma.”
Pharyngeal neurectomy: Procedure that disrupts pharyngeal constrictor innervation to alleviate spasms while retaining the residual resting tone of the upper esophageal segment.
Pharyngoesophageal segment: Remaining muscle tissue consisting of the inferior constrictor muscle extending to the upper portion of the esophagus subsequent to a total laryngectomy. Also known as the “neoglottis.”
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