|Name Of Column||Author||Title||Article Type|
|Musings From The President||Murray Allan||Second Edition-WOTW||News & Events|
|VoicePoints||Barbara Messing, M.A.||Communication Options||Education-Med|
|WebWhispers Columnist||Richard Najarian, RPh||Shopping On The WWW||Experiences|
|Bits, Buts, & Bytes||Dutch||Computer Tips||Experiences|
|Be All That You Can Be||Stan Mruk||Newbie||Experiences|
|Pet Lover's Corner||Judy Greiwe||True Love||Experiences|
|Handy Hints||WW Members||Hints For a Lary||Experiences|
|Welcome New Members||Listing||Welcome||News & Events|
Murray's Mumbles ... Musings from the President
Greetings fellow Webbies and welcome to our second edition of Whispers on the
I continue to contact Lil by telephone and she says that Phil
still can't voice. I apologize, tobacco use is an ADDICTION and this
couple has just proved it to me.
coordinated by Dr. Dan Kelly, Associate Professor ( email@example.com )
Department of Otolaryngology, Head & Neck Surgery
7700 University Court, Suite 3900, West Chester, OH 45069
[ © 2003 Barbara Messing, M.A. ] Communication Options for the Laryngectomee: Focus on Tracheoesophageal
Speech TE speech and the Tracheoesphageal Prosthesis TEP
By Barbara P. Messing, M.A., CCC-SLP, Speech Pathology Manager at the Milton J. Dance Head and Neck Rehabilitation Center at the Greater Baltimore Medical Center, Baltimore, Maryland.
The focus of this article is to explore the in's and out's of tracheoesophageal (TE) speech and the tracheoesophageal prosthesis. TE speech is the one communication option that most closely resembles fluent, natural speech. In many hospitals the tracheoesophageal puncture and prosthesis placement is available as part of the initial surgery or it may be performed several months or years afterwards. Whether one is considering tracheoesophageal speech before or after a layngectomy, an awareness of what tracheoesophageal speech is and how it works is an essential part of the decision making process.
Two other communication options available after the laryngectomy are the electrolarynx and esophageal speech. These three methods of communication are not exclusive from one another. It is feasible to learn and use all three methods of speaking after a laryngectomy. All three post laryngectomy communication options should be introduced to the patient and family members before surgery at a pre-operative counseling session with the rehabilitation team.
A brief description of these two communication methods is provided.
The Electrolarynx is the communication method of choice for many laryngectomees. The electrolarynx is an external vibrating device that generates sound for speaking. At a minimum, it is essential to learn to use an electrolarynx as a back-up communication method. Training with an electrolarynx may be implemented by the Speech Pathologist within two to three days after surgery using placement of a soft tube in the mouth. This provides an immediate way of communicating. The electrolarynx should be maintained as a back-up even if other methods are learned.
Esophageal speech is another method of communication that offers many laryngectomees a hands free speech option. Esophageal speech is produced by either inhaled or injected air taken into the mouth and brought down into the esophagus. The air must be returned quickly from the esophagus. As the air is returned from the esophagus a sound is generated for speaking. It takes time and dedication to learn this method of speaking. It is highly recommended that consideration of this method and subsequent training of esophageal speech be done with a Speech Pathologist.
What is Tracheoesophageal Speech or TE Voicing?
A tract or opening is surgically created from the trachea into the esophagus by the surgeon. This opening enables the passage of air from the trachea into the esophagus. The air enters into the esophagus creating a vibration. This allows an individual who has had a laryngectomy to make or generate sound in an area of their esophagus known as the pharyngoesophageal segment or PE segment.
Before a laryngectomy, voicing and speaking is normally produced with lung powered air. Air comes up from the lungs, passes through the voice box or larynx which causes the vocal folds to vibrate. The vibration generates sound. Words are then formed by the way we move and position our mouth, lips and tongue.
After a laryngectomy, voicing and speaking with a TEP is produced with lung powered air as well. A finger or speaking valve is placed over the stoma blocking the air from coming out of the stoma. The air from the lungs is trapped forcing it to follow the path of least resistance through the shaft of the prosthesis into the esophagus. Vibration is made by the air passing over an area in the esophagus producing sound. As before the laryngectomy, this sound is formed into speech by the movement and shaping of our articulators (mouth, lips, tongue).
TE speech varies in the way it sounds depending on many factors. Generally speaking, it is lower in pitch than normal voicing for both men and women. Good TE speech is fluent. Fluent TE speech is measured by the number of words spoken and the clarity of that speech. Fluent speech is being able to say approximately 10-20 words or more can be spoken on one breath. The laryngectomee has in TE speech, a method of speaking that most closely resembles natural speech as compared to the electrolarynx or esophageal speech. The use of a speaking valve attachment over the stoma for a person with a TEP allows hands free TE speech. This brings the laryngectomee closer in appearance to natural speech.
Factors that influence successful TE voicing are the extent of the surgical reconstruction; previous cancer treatments to throat (e.g., radiation and chemotherapy), close proximity to a Speech Pathologist with TEP experience, and your ability to care for your stoma and the TEP. All prostheses must be cleaned daily and changed periodically (varies depending on the type). The laryngectomee should be instructed on what to look for and what to do when the prosthesis fails and is ready for a change.
What is a Trachesoesophageal Prosthesis TEP?
A TEP is a prosthetic device made of silicone. The prosthesis is a one-way valve that opens under the positive pressure of air traveling up from the lungs through the valve into the esophagus to produce voice.
What are the primary purposes of the TEP?
1. To maintain a stable opening or passage way from the trachea to the esophagus to allow voicing.
2. To protect against saliva, food or refluxed materials leaking from the esophagus into the trachea.
How do I know which prosthesis is right for me?
Several factors need to be considered. In general there are two basic types of prostheses. Patient changeable and the indwelling prosthesis which is changed only by a speech pathologist or a physician. The 'patient changeable' or traditional prostheses are those that can be changed by the patient, the speech pathologist or the physician. Most importantly is that the patient can change the prosthesis, if instructed to do so, by themselves. This allows a level of independence in the care and management of the prosthesis.
Important measurements related to the parts of the prosthesis?
The shaft is the tubular part of the prosthesis. It is measured in diameter (distance around) and length. The shaft length is the distance between the tracheal collar and the esophageal retention collar. The length of the shaft ranges from 4.5 millimeters (mm) to 28 millimeters (mm). Sizing?The length of the prosthesis is determined by the common party wall and measured by the speech pathologist or the physician. The wall of the trachea and the wall of the esophagus form a common wall. The depth of the "wall" between the trachea and the esophagus is similar to a wall between two rooms. It is often referred to as the 'common party wall'. The length of the surgically created opening or TEP is measured and the appropriate size prosthesis is selected. The diameter of the prosthesis, that is the width of the prosthesis, stays as open around as the size of the prosthesis placed into it. The body naturally heals down to meet the size of the prosthesis occupying that opening. The diameters of prosthesis are measured in 'french' measurement. Available diameters vary from 16 french to 22+ french depending on the type of prosthesis.
The size of the tracheoesophageal puncture may change from time to time. Resizing will be done by the speech pathologist or physician. A prosthesis that is too short in length will most likely not maintain the opening of the tracheoesophageal puncture causing it to close down on the back end. Repuncturing by a physician may be necessary if the TEP closes down completely. A prosthesis that is too long may piston or slide in the tract causing irritation to the tissue. Or, it may be so long as to be pushed up against the wall of the esophagus during speaking attempts. Both of these situations will results in a loss of voice and will need to be assessed promptly.
Prosthesis failure? Prosthesis failure happens for different reasons.
1. Leakage of food or liquid through the prosthesis. The prosthesis needs to be changed. Most likely the valve has failed.
2. Leakage of liquid around the prosthesis. There may be an infection or perhaps a more serious medical problem and the body is unable to heal down around the prosthesis.
3. The laryngectomee may be unable to voice. The prosthesis may simply need to be cleaned fixing the problem quickly. The valve may have failed or the size of the prosthesis is incorrect requiring a prosthesis change. When these problems arise the Speech Pathologist will seek to find out why the prosthesis failed.
4. Yeast colonization is the most highly occurring cause of prosthesis failure. Even a small amount of yeast can cause the prosthesis to fail. If yeast colonization is a problem then a prescription for an antifungal medication must be obtained. Nystatin is a medication most commonly prescribed for yeast or candida treatment. It is recommended that the nystatin is swished in the mouth for five minutes and then swallowed. Other antifungal medications may be prescribed. Dentures and tooth brushes should also be treated with antifungal medication as a preventative measure.
TRADITIONAL OR STANDARD PROSTHESES
Why choose a traditional or standard prosthesis?
The laryngectomee may choose to use a traditional or standard prosthesis (Figure 1. traditional or standard prosthesis). The benefit of having a traditional or standard prosthesis is that it can be changed by the laryngectomee, the speech pathologist or the physician. The laryngectomee may have the desire to change their own prosthesis rather than depending on the speech pathologist or physician for prosthesis changes. Some patients prefer to be more independent with their prosthesis management while others prefer going to the Speech Pathologist for TEP changes as needed. Individuals who do not live close to a rehabilitation center or a Speech Pathologist may opt for the traditional prosthesis. The traditional or standard prosthesis gives the laryngectomee the choice.
The laryngectomee must have good vision and be able to manipulate the prosthesis and the insertion tool to remove and replace the prosthesis independently. Other factors are related to the placement of the prosthesis. Is the TEP placed is a good position making it easy to see? Is the size of the stoma large enough (preferably 1.5 centimeter opening) to allow easy access to the prosthesis for cleaning and changes.
If a person has a lot of problems with yeast or candida production and requires frequent changes to the prosthesis, the traditional or standard prosthesis may be recommended to them by the Speech Pathologist. The prosthesis can be cleaned and treated with Nystatin to prolong prosthesis life.
Communication Options for the Laryngectomee: Focus on Tracheoesophageal Speech TE speech and the Tracheoesphageal Prosthesis TEP
Why choose an indwelling prosthesis?
The indwelling prosthesis (Figure 4. indwelling prosthesis) may stay in place on average for 4 - 6 months or longer. It should be changed at the one year point regardless of whether or not it has 'failed'. The indwelling prosthesis must not be removed by the laryngectomee. It must be removed and placed by a Speech Pathologist or Physician. Many prefer the indwelling for that very reason. It is cleaned in-situ by the laryngectomee. As with the traditional or standard prostheses, yeast colonization is the primary reason for valve failure. If yeast colonization is a problem and causes valve failures then medication, such as Nystatin, should be prescribed by the physician. Other antifungal medications may be prescribed.
The indwelling prosthesis may provide someone who may otherwise not have been a candidate for a TEP the opportunity to have one. Perhaps they have slight difficulty with either vision or manual dexterity limiting their ability to change their own prosthesis then the indwelling would be a viable option. They may have started with a traditional or standard prosthesis and over time changes with memory or thinking may make it difficult for them to manage their own prosthesis. Changing to an indwelling may be necessary for continuation of TE voicing with less demands on the laryngectomee to manage the prosthesis on their own. They will still need to clean the prosthesis in-situ.
Indwelling prostheses have thicker and wider retention collars enabling the strap to be removed after placement. This can be especially important for the laryngectomee interested in hands free speech. A neck strap may interfere with obtaining an airtight seal around the stoma for placement of an adhesive housing. The housing may be required as an attachment for the hands free speech valve. If the neck strap remains it will be difficult to get the airtight seal necessary for functional hands free speech.
Indwelling Low Pressure Voice Prostheses? Indwelling prostheses have a
flap-type valve and come in 20 french or 22+ shaft diameter (Figure 5. Two types
of indwelling prostheses). Shaft length ranges from 4.5mm to 22mm. After the
prosthesis is placed the strap may be removed by the Speech Pathologist or
physician because of the thicker retention collars. There are 3-4 different
companies who manufacture indwelling prostheses. Use of a specific indwelling
prosthesis over another has much to do with the experience of the Speech
Pathologist, availability of supplies, sizing considerations, success or failure
of previously tried prostheses, the condition of the TEP, problems requiring
modification of the prosthesis and the personal choice of the laryngectomee.
Conclusion? This article sought to provide a basic understanding of
trachesophageal speech and specifics of the TE prosthesis. TE speech is
relatively easy to learn and usually improves over time with instruction and
daily use. Having the appropriate type and size prosthesis will have an impact
on the success of TE voicing. You may meet another laryngectomee who has been
very successful with TE speech or perhaps those who have experienced a great
deal of problems. Most people feel the benefits gained from TE speech outweigh
the occasional problems that may arise.
Each individual finds their own way and selects the communication option or options best suited for their needs. Introduction to electrolarynx, esophageal speech and TE speech by the Speech Pathologist helps to guide you through the decision making process. Informed decisions often yield the most successful outcomes.
By Richard Najarian, RPh., President, Bruce Medical
Supply, Waltham, MA
Wild Wild West or a Wonderful Experience?
Shopping on the World Wide Web
Well, it's both! Although it is the most convenient method of shopping, you must be careful when choosing with whom you do business.
The real good news is that virtually all reputable catalog companies have secure on-line shopping and will guarantee your complete satisfaction. The bad news is that it is very easy to develop a commercial web site that has the superficial appearance of a reliable company. If you're careful, it's a great experience. If not, you could be disappointed and perhaps suffer serious financial consequences.
The web is a huge repository of easy to locate information. Some sites have information that is reliable while others have information that is false and misleading. Unfortunately, it is up to the surfer or buyer to be aware.
Protect yourself by being conscientious, even paranoid, about where you shop and the release of any personal data, especially passwords, credit card information and Social Security numbers. Providing personal information, name, address and phone number, before being allowed to shop leaves you open to all types of dangerous possibilities. Defend your privacy. Just like wandering through the stores at a retail shopping mall, you have a right to remain anonymous.
Some basic A, B, C's to insure that you have a happy and secure shopping experience:
Every reputable company will have all of the following information clearly stated on its website. If not, just take your shopping elsewhere.
A. Merchant Address and Phone Number:
It should be a complete address, not a Post Office box. A Toll Free telephone number is always best. Give them a call to see if they are able to answer some important questions such as: "Is it in stock?" or "When will my order ship?" You should be suspicious if you reach an answering machine during business hours. Be very suspicious of the reliability of companies that do not make themselves available to answer your questions.
B. Return Policy:
Read it carefully. Make sure the company guarantees your complete satisfaction and avoid any company that does not clearly state its policy on the website. Stay away from companies that require you to request an authorization before a return is considered or accepted. Some have very strict conditions, such as requiring that the returned item is unused and in the original unopened packaging. Also, you should clearly avoid doing business with companies that charge you a restocking fee.
C. Credit Card Security:
Using phone, FAX or a secure encrypted on-line transaction is the only way to insure that your personal information remains private. You should never, under any circumstance, include your credit card number in an E-mail, even if it originates from a "secure" website. This type of insecure communication could be easily intercepted in transit.
D. Shipping and Handling:
The rates should be clearly stated on the information page of the site. You should never order from a site unless you know all prices and charges.
E. Secure Transactions:
Most web browsers will indicate to you (with a pop-up window) that the information you send is encrypted to insure security. For your security, all sophisticated on-line companies will E-mail you an order acknowledgement almost immediately after you enter an order. If you do not receive an automated response, you should assume the order was not entered properly and your order was not received by the merchant.
After you use the above guide to check out the merchant and feel comfortable with the reliability of the company, you simply navigate through the site, locate the items of interest and place an order.
Some sites are a pleasure to visit while others are extremely frustrating. The most reliable and enjoyable sites are very easy to navigate, have helpful information, detailed text and descriptive graphics. Others offer you only a small description and the price. The more information appearing on a site, the more likely that the site is reliable and you will be completely satisfied with your purchase.
Remember, you are the customer! The merchant has the responsibility to make sure you are 100% satisfied. A reputable company will always meet or exceed your expectations.
Bits, Buts, & Bytes
(1) Does your local laryngectomee support group have a web site? If so, make certain that both WebWhispers and the IAL know about it --- both organizations will provide your club with a no-cost LINK from their respective "Clubs" pages. Would your local group WANT a web page or two, but is just unsure as to how to go about it? Well, look no further. For a mere $20.00 per year, the IAL will, with your club's assistance, create and manage a small web site on its own dedicated server specifically addressed to your needs. All your club needs to do is contact the IAL webmaster (currently ME) and let him know what needs to be said, presented, etc., and what preferred graphics you have, if any. We'll then work together to create your club's site. Several local clubs in the USA have already long availed themselves to this low-cost alternative. Below are a list of those clubs, with LINKS to their IAL-hosted web sites - so you can see what THEY have done:
Hui 'Olelo Hawai'i - Honolulu, Hawaii
If YOUR local club would like something like what the above clubs have done, please contact me at: firstname.lastname@example.org and I will do my best to fix your group up with a convenient, low-cost Internet presence.
(3) Another Hoax Alert:
According to an Email circulating on the Internet, a new law prohibits the use of license plate frames of any kind, including those bearing school affiliations, sports team logos, etc. The Email cites a Houston, Texas TV reporter as its source. However, although Texas recently did pass a law that prohibits decorations that alter or obscure the license tag, the law was not and is not designed to outlaw plate frames. More information and clarity can be found at: http://www.snopes.com/inboxer/pending/texasplate.asp
(4) An expansive and neat OnLine Reference Site:
out Martindale's Reference Desk ... eclectic and very useful:
Be All That You Can Be
Stan Mruk (Laryngectomy - 1995)
I consider myself an "Ole Timer" at 8 ? years out from my surgery. That doesn't mean that I am an expert in laryngectomee issues or research but I do have a great deal of empathy for the new laryngectomees (Newbies) and believe that they are the ones that can be best served by WebWhispers with its web site and newsletters and by a local support group. Don't get the impression that those who pass a certain yearly threshold in recovery, 2, 5, or 10 years, have all of the answers. Living successfully as a laryngectomee is a constant learning process for all of us.
Please do not take offense by my use of the term "newbie". We've all been there at one time since no one joins our exclusive club with instant seniority. I believe the first, and one of the most important points, is that despite all the good intentions of the professionals out there, you will learn more about daily life as a lary from a good support group or an experienced lary. This is not to demean the efforts of the professionals but there is no replacement for having "been there and done that." Do keep in mind that we laryngectomees can only share life experiences, not replace medical or professional help. The really smart and truly helpful lary is the one who realizes his/her limitations with regard to advice offered. Pay attention to that one.
Always keep in mind that what we larys have in common is that we have a hole in our throats and have learned a special way to speak or communicate. I, for example, have experienced virtually none of the many difficulties expressed by other laryngectomees I have met, but I have another problem, severe emphysema (winning the "daily double" of tobacco use). I have been surprised it is not as common among our fellows as I would have thought. At this point in my life, I consider being a laryngectomee a minor inconvenience but the emphysema is a major problem for me. So don't get the impression that you will experience the exact situation expressed by another laryngectomee. The rule book for this game is fuzzy at best.
There are two ways to live as a lary, the hard way is when you try to do it alone; the easy way is when you take advantage of advice from those caring larys out there who have gone before you and are more than willing to share what they have learned.
Till next time,
BE ALL THAT YOU CAN BE!
Judy and Dave Greiwe decided to add a
new pet to their household. Actually, Judy decided, and we
Pet people think there must be something wrong with non-pet people. How can they
look at an adorable kitten and not see the personality, sweetness, softness and love
in that little ball of fur?
The big day finally arrived, Emilio was to meet
and greet his new little brother!
(Love = Control)
Emilio shares his favorite mousie. (Love = sharing)
Hopefully Handy Hints
(1) Get an inverter for your vehicle. This will convert the 12 volt DC to 110 volt AC and you can plug your existing AL battery charger into it. This will charge your battery while on the road. You can also use it to power other items that do not use too much current. They cost about 30 bucks and can be purchased in just about any store that sells electronics.
Jim Lauder (Lauder Enterprises)
(2) Using a Servox or any artificial larynx with
the ChatterVox usually works quite well. You use the AL on one side of
your neck (or mouth, in the case of an oral placement), and put the mic to the
other side to avoid picking up the motor noise from the AL or the popping and
hissing sounds from letters like P and S. You also don't want the mic to
block people's view of your lips moving.
To avoid feedback with a Servox voice or a regular voice, you should
experiment with the volume of your voice and the volume setting of the
amplifier to get the amplification you want. In general, if the mic is
to the left of your mouth, you want the amplifier speaker a little toward the
right side of your body and visa versa. The better the separation, the
louder amplification you can get without feedback. If you sit at a table or
desk, you will probably have to turn the CV speaker to the side or take it off
and put it on the table. You may have to turn the volume down in an elevator
or a very small room and you learn not to lean the side with your speaker into
a filing cabinet or wall. A teacher learns to scoot the speaker around
toward the back if talking while writing on the blackboard.
Welcome To Our New Members
We welcome the 21 new members who joined us during September 2003:
St. Simons Island, GA
Deborah Brown - SLP Student
Las Cruces, NM
Tim & Karen Burger
Becky Cihota - SLP Student
Cornwall, Ont., Canada
Long Beach, CA
Old Bridge, NJ
Thornlie, W. Australia
Marianne Maloy - SLP
Ft. Lauderdale, FL
Jackie Moody - Caregiver
Jo. C. Naylor - SLP
Corpus Christi, TX
John R. Sharp, Jr.
WebWhispers is an Internet-based laryngectomee support group.
It is a member of the International Association of Laryngectomees.
The current officers are:
Pat Sanders............V.P.-Web Information
Terry Duga.........V.P.-Finance and Admin.
Libby Fitzgerald.....V.P.-Member Services
WebWhispers welcomes all those diagnosed with cancer of the
larynx or who have lost their voices for other reasons, their
caregivers, friends and medical personnel. For complete information
on membership or for questions about this publication, contact
Dutch Helms at: email@example.com
© 2003 WebWhispers