I. Patient Considerations
A. Examine the configuration of the stoma.
1. Slope; shape
2. Consider the effect upon the airway with prosthesis in place
3. Approximate size of the prosthesis, e.g., may need a longer size for a larger individual
B. Examine the size of the stoma
1. Can the patient occlude the stoma completely with digital closure, e.g., is the stoma too large?
2. Can the patient manipulate prosthesis in the stoma easily, e.g., is the stoma too small? Will the prosthesis block the airway?
C. Dexterity and manipulability
1. Note neuromuscular coordination, arthritis, missing digits on dominant hand, length (and hygiene) of fingernails.
2. Consider such movements as buttoning a shirt that require good fine motor control.
D. Visual acuity
E. Patient's motivation to use the TEP
1. Consider the following:
a. employment status and need for speech
b. use of other methods of alaryngeal speech
c. social support system
e. emotional stability
d. determine WHO is it that wants the TEP: family, physician, employer, others.
2. The patient must be the one who wants the TEP.
A. Clean tracheostoma and TE port region. Avoid alcohol-based fluids as not to irritate the port.
B. Note any drainage through the port into the airway.
C. Examine the angle of the puncture site
D. (Can re-insert the #18 French catheter to dilate puncture. Slowly rotate the catheter into the esophageal lumen.)
1. Tie off or close the end of the catheter to avoid drainage. Can hold the distal end up.
2. Note any hyperactive responses like exaggerated cough reflex, patient comments about pain, or broken tissue.
3. Could re-insufflate at this point, if necessary.
4. Remove catheter and again observe puncture site for drainage; minimal bleeding may occur but the puncture site should be open.
E. Test the puncture tract by asking the patient to close the stoma digitally, then exhale easily. Voice should occur easily.
1. Note the amount of effort required by the patient to produce TE sound.
2. Note the consistency of voice production.
3. Note vocal quality; loudness is probably better than during insufflation.
4. If no sound is produced, first check the amount of digital pressure to the stoma.
a. Have patient relax; clinician can "close" the stoma.
b. Consider cricopharyngeal spasm.
II. Sizing and Fitting the Prosthesis
A. Use the commercial quality sizing tools: typically Bivona or InHealth
B. Insert sizer promptly; Note "2-click" contacts:
1. Click 1: anterior tracheal wall
2. Click 2: anterior esophageal wall
C. the prosthesis is a one-way stent: it bridges the space between the wall of the trachea and the esophagus.
D. Let the insertion tool hang loose; have the patient dry swallow, then swallow some fluid, e.g., water.
1. Watch the level of the prosthesis or the movement of the insertion tool. Get a sense for the "seating" of the prosthesis in the esophagus.
E. Rotate the insertion tool with the prosthesis in place to allow the retention collar to fully expand along the anterior esophageal wall. Fit "long."
F. Note measurement markings along the top surface of the sizer. Identify the size closest to the opening to the stoma.
1. Note the sizes are the same for Bivona and InHealth products. Custom sizes are available, upon request.
2. Select prosthesis that is the same size as that indicated on the sizer.
G. Attach the properly sized prosthesis to the "insertion tool." May wish to use a water-soluble lubricant, e.g., KY jelly.
1. Remove the sizer and promptly insert the prosthesis into the puncture. Note the clicks. 2. Use enough pressure to overcome the resistance of the tracheal and the esophageal walls. Note the clicks.
3. Recognize that there may be remnants of tissue in the puncture tract. The first insertion will require more effort (force) than later insertions.
4. Test fit as in D and E above.
5. Note the alignment of the port of the prosthesis with the surface of the outside of the stoma. Excess means too large, e.g., too long.
6. Tape the collar to the skin at about "12 o'clock"; remove the insertion tool carefully.
H. Generating tracheoesophageal voice
1. Clinician can seal the stoma with digital closure; have the patient phonate /i/ or /a/. Ask for easy exhalation to let voicing coincide with airflow.
a. Loudness (intensity) will be less than insufflation trials. 2. Request that the patient close the stoma digitally.
TRACHEOSTOMA VALVES I. Two-way speaking valves
A. Basic Components (valve mechanisms for InHealth and Bivona are different)
2. Valve unit and diaphragm
3. Face plate and crossbar
1. Remains open during quiet respiration; increased pressure on exhalation will close the diaphragm mechanism
2. Proper fitting will allow for prompt opening upon inhalation; proper fitting should allow for controlled closure during physical activity, e.g., strenuous exercise
3. Obvious function is to allow the speaker to use both hands freely rather than rely upon digital closure for speech production
C. Fitting and Attachments
1. Gently clean the area around the lumen of the stoma with adhesive remover, alcohol dampened cloth, wipes, etc.
Ask the patient to "hold your breath" while cleaning around the stoma to reduce the likelihood of a spontaneous cough 2. Trim excess from the prosthesis tab; do not trim off the portion of the tab with the attachment hole for the "insertion tool"
3. Peel backing paper from one side of a tape disc; attach firmly and evenly to the housing---remove only the adhesive that will touch the surface of the housing
4. Port of housing should have the projected end away from the tape disc; e.g., the extruded end should not be placed into the stoma
5. Can use adhesive fluid to attach the tab of the prosthesis; "paint" fluid around the lumen of the stoma. Ask the patient to "hold your breath" so the odor does not stimulate a cough.
a. Allow about 4-5 minutes for the adhesive liquid to "set up" and dry.
6. Remove the remaining paper cover from the tape disc; attach the housing over the center of the stoma
a. Irregular stoma sites: consider application of the foam pad. Cut to size or mold into "divots", if necessary.
7. Press the housing flush and firmly against the skin of the stoma. Be sure that the prosthesis is visible and located at "12 o'clock" in the lumen of the stoma.
8. Hold the valve by its rim; rotate the valve into the housing port. It will snap into place.
a. InHealth Adjustable vs. Bivona Tracheostoma kits
InHealth: adjustable silicone diaphragm is managed via the crossbar. Note fully closed vs. fully open positioning Bivona: diaphragm tension is adjusted via 15, 25 and 30 gram springs D. Removal
1. Remove the valve first. Hold the edges of the valve to pull it away from the housing. Do NOT pull on the crossbar (InHealth).
2. Gently pull the edge of the housing away from the skin. Pull the housing away from the neck.
3. Clean the skin area around the stoma with an adhesive remover, alcohol swap, etc.
REFERENCES This list is only a sampling of some of the work available on topics related to tracheoesophageal speech & fitting of the prosthetics.
Blom, E.D., Singer, M.I., and Hamaker, R.C. (1985). An improved esophageal insufflation test. Archives of Otolaryngology, 111, 211-1212. Diedrich, W.M., and Youngstrom, K.A. (1966). Alaryngeal Speech. Springfield, IL: Charles C. Thomas. Garth, R.J.N., McRae, A., and Rhys Evans, P.H. (1991) Tracheo-
oesophageal puncture: A review of problems and complications.
Journal of Laryngology and Otolaryngology, 105, 750-754. Hamaker, R. C., Singer, M.I., Blom, E.D., and Daniels, H.A. (1985).
Primary voice restoration at laryngectomy. Archives of
Otolaryngology, 111, 182-186. Hilgers, F.J.M., and Schouwenburg. P.F. (1990). A new low-
resistance, self-retaining prosthesis (Provox) for voice
rehabilitation after total laryngectomy. Laryngoscope, 100,
Johnson, J.T., Beery, Q.C., Aramany, M.A., and Sigler, B.
(1986).Vocal restoration and the large irregular tracheostoma. Laryngoscope, 96, 214-215. Lewin, J.S., Baugh, R.F., and Baker, S.R. (1987). An objective method for prediction of tracheoesophageal speech production. Journal of Speech and Hearing Disorders, 52, 212-217. Mahieu, H.F., Hendrick, K.F., Saene, V., Rosingh, H.J., and
Schutte, H.K. (1986). Candida vegetations on silicone voice
prostheses. Archives of Otolaryngology: Head and Neck Surgery, 112, 321-325. Maniglia, A.J., Leder, S.B., Goodwin, Jr., W.J., Sawyer, R., and Sasaki, C.T. (1989) Speech restoration and complications of primary versus secondary tracheoesophageal puncture following total laryngectomy. Head and Neck Surgery, 11, 524-527. Shapiro, M.F., and Ramanathan, V.R. (1982). Trachea stoma vent voice prosthesis. Laryngoscope, 92, 1126-1129. Singer, M.I., and Blom, E.D. (1981). Selective myotomy for voice restoration after total laryngectomy. Archives of Otolaryngology, 107, 670-673. Singer, M.I., Blom, E.D., and hamaker, R.C. (1981). Further
experience with voice restoration after total laryngectomy.
Annals of Otolaryngology, Rhinology and Laryngology, 90, 498-