We are pleased to welcome Joan Olszewski, M.A., CCC-SLP, as our guest host for the
SLP chat tonight, Monday, March 31, 2003.  Ms. Olszewski will be chatting about
Laryngectomy/Alaryngeal Voice Restoration. Joan Olszewski has been a Speech Pathologist
with the VA Pittsburgh Healthcare System for the past 10 years.  She was initially involved
in research focusing on treatment efficacy of adult apraxia of speech.  Within the last 5
years her primary area of interest is alaryngeal speech restoration.  She is well versed in
all of the available products and techniques that SLPs can offer patients having undergone
a total laryngectomy. 

<Robin> Welcome!  Tonight we are chatting about Laryngectomy/Alaryngeal Voice Restoration
          with chat host Joan Olszewski, M.A., CCC-SLP.
<Robin> Why don't we get started? Joan, could you give us some basic information about
<jolszewski> A laryngectomy is a surgical procedure in which all or part of the larynx
          or voice box is removed.  Cancer of the larynx accounts for less than 1% of all
          cancers.  Approximately 12,000 new laryngeal cancers occur every year.
<amy> Why would somebody need one of those? Cancer or something like that?
<jolszewski> Most often a laryngectomy is performed secondary to the presence of a malignant
          tumor which is extensive (T3 or T4).  However, less often a laryngectomy may be
          performed for reasons other than malignancy, including severe trauma to the larynx or
          irreparable supraglottic narrowing or stenosis.
<Robin> Does anyone have a question for Joan about total laryngectomy?
<mashaz> Ok...the efficacy of TEP (tracheoesophageal puncture).
<mashaz> Do people still use it and does it work?
<jolszewski> TEPs can be highly successful if the patient is a good candidate.
<jolszewski> Basically they need intact cognition, good dexterity, adequate vision and
          oral motor skills.
<jolszewski> Following a total laryngectomy the entire larynx (voice box)
   is removed
<jolszewski> With a TEP the surgeon creates a puncture from the tracheal wall to the
          esophagus to allow for placement of a voice prosthesis.
<jolszewski> The voice prosthesis is placed by a SLP or ENT. The TEP is made of silicone
          and allows air from the lungs to travel through the prosthesis into the esophagus
          where it vibrates to create a voice.
<amy> What are some of the common reasons a person would have to have this procedure?
<jolszewski> After the removal of the larynx, the patient no longer has a source of sound
          for speaking.  Luckily, there are a variety of devices and procedures that can allow
          for a verbal communication.  Three speech options following a total laryngectomy are
          tracheoesophageal speech, artificial larynx, and esophageal speech. 
<jolszewski> To achieve tracheoesophageal speech, an ENT creates a surgical puncture through
          the wall that connects the trachea and esophagus.  A silicone prosthesis that
          contains a one-way valve is then placed into the puncture to maintain the opening of
          the puncture.  The patient is taught to digitally occlude the stoma (permanent
          opening in the front of the neck) which directs air from the lungs through the
          prosthesis into the esophagus where it vibrates to create sound. 
<jolszewski> Another option is the artificial larynx.  With these devices electric power is
          used to drive a vibrator that provides a sound source. The device can either be used
          by placing a tube in the mouth and the sound is then articulated into speech or the
          device can be placed on the neck and the sound is delivered through the skin into
          the vocal tract and articulated into speech. 
<jolszewski> Lastly, with esophageal speech the patient is taught to inject or inhale air
          into the esophagus where it is trapped and released up into the mouth and articulated
          into speech.
<jolszewski> Any more questions about the surgery?
<amy> How long does it take usually?
<jolszewski> It can take up to 8-10 hours.
<AdrienneFSU> Joan, we have a range of undergrad, grads, and professionals here tonight-
          can you briefly describe the anatomical consequences of a total laryngectomy and
          why we SLPs are involved?
<jolszewski> With a total laryngectomy the tumor is typically large and requires the removal
          of the entire voice box.  The trachea or windpipe is then brought to the neck and
          sutured into place.  This results in complete separation of the primary airway and
          the oral, pharyngeal and upper digestive pathways.  However, sometimes the tumor is
          less extensive and part of the larynx can be preserved.  For instance, with a
          hemilaryngectomy only ½ of the larynx is removed leaving 1 vocal fold for speech
          purposes.  With a supraglottic laryngectomy, structures above the glottis (vocal
          folds) are excised preserving both of the vocal folds.  With all of these surgeries
          the SLP is typically involved to either assist with restoration of communication or
          swallowing difficulties.
<AdrienneFSU> Does everyone understand what happens to the air flow after laryngectomy and
          how that affects speech?
<jolszewski> Following the total laryngectomy the patient no longer breathes through their
             mouth and nose. They now inhale and exhale from the hole in their neck also called
          the stoma.
<AdrienneFSU> So the purpose of a TEP would be to direct air up to the mouth?
<jolszewski> Yes, as mentioned earlier, with a TEP air from the lungs is directed through the
          prosthesis into the esophagus where the air vibrates to create sound and the sound
          is then articulated into speech.
<Roxann> What is an "indwelling" prosthesis?
<jolszewski> An indwelling prosthesis is a prosthesis that is placed by either an SLP or MD
          and is left in place until it requires replacement which can be anywhere from 2-8
<Robin> Why is that used?
<jolszewski> Indwelling prostheses are good options for patients who are either not
          comfortable or not capable for independently changing a prosthesis.
<AdrienneFSU> What type of assessment do you do to determine which speech option you go
          with and how does patient cognition impact your decision?
<jolszewski> During preoperative assessment, you should assess their vision, manual dexterity
          and general cognition.  They must possess adequate vision and manual dexterity to
          enable them to clean the prosthesis on a daily basis and to achieve digital occlusion
          of the stoma.  Adequate vision and manual dexterity are particularly needed if they
          choose the type of prosthesis that they change independently (non-indwelling).  If
          these skills are slightly compromised, they may be a more appropriate candidate for
          an indwelling prosthesis that is changed only by the SLP or MD.  However, even with
          and indwelling prosthesis their vision and manual dexterity should be functional so
          that they are able to clean the prosthesis properly.
<Robin> The role of the SLP is so important pre-surgery, if we can get to the patient.
<AdrienneFSU> How would you get that paid for? Can you bill for patient education?
<jolszewski> That's a good question. I work at a VA so I do not follow the same billing
          guidelines as the private sector. We would code it as evaluation for prosthetic
<Roxann> When I worked in the private sector, insurance stopped paying for pre-op counseling.
<Robin> Really, thats a shame.
<jolszewski> This really is a crucial part of the rehabilitation process. We've have found
          much greater success with patients who we were able to meet and assess prior to the
<Robin> How often do you find that the patient does NOT fully understand the physiological
          changes that will take place?
<jolszewski> Well it can be very overwhelming, however, we use illustrations and videos to
          help. I think generally they understand if it is explained thoroughly.
<AdrienneFSU> Do doctors not explain it or does it just not sink in with patients?
<Robin> I remember having a patient once who really didn't understand what was going to
          happen, based on the doctor's explanation.
<jolszewski> MDs do discuss general change, however, I think the SLP plays a major role in
          discussing the changes in detail.
<jolszewski> We generally plan on teaching all patients how to use the artificial larynx
          regardless if they choose to have a TEP.
<AdrienneFSU> When do you talk about hygiene and protective measures, like shower covers,
<jolszewski> Usually after the surgery prior to discharge.
<Robin> How long is a patient typically hospitalized after a laryngectomy?
<AdrienneFSU> What sort of follow up schedule is typical?
<jolszewski> Length of hospitalization can vary, but typically at least 10-14 days.
<AdrienneFSU> You see them every 2 weeks? For how long?
<Rhonda> Then is there outpatient follow up?
<jolszewski> It depends on which speech option is chosen. In the beginning we do see them
          generally once a week for several weeks.
<jolszewski> If they learn to use an electrolarynx they generally need less outpatient tx,
          however, with a TEP they are life timers.
<AdrienneFSU> wow
<jolszewski> If they were given an indwelling they rely on the SLP to change future
          prostheses. With a non-indwelling they still run into some problems and need
<Robin> It is getting late....Joan, thank you for sharing your expertise with us!
<mashaz> I'm sorry all, I must go...BYE!
<Robin> Thanks to everyone for being here!