Next Step Therapy Blog: ‘Lost Voices’

SENECA, Pa. – Heidi Underwood, MS CCC SLP, of Next Step Therapy, submitted the following article: “Lost Voices.”

I have had the opportunity to work in several different settings as a speech pathologist. In each place, I have met great patients who have touched me in some way. I remember working in a rehab facility years ago. The nurses would always give us a heads-up on patients who were being admitted. One morning a nurse said to me, “We have a new patient coming for you. He is a total laryngectomy.” I was excited to meet this new patient as I had recently been certified in voice restoration after laryngectomy.

Upon the patient’s arrival, I made my way to his room to meet him and complete his evaluation. When I entered his room, I met a very nice man who had several questions for me. He had to write these, of course, because his larynx (voice box) was removed (laryngectomy) because of cancer. One of his first questions was “When will I talk again?” My heart sank. I stood there trying to pull myself together on the inside. How was I going to tell this man he wouldn’t speak again, well speak again the way he was used to.

Laryngectomy is a major life change. I spent the next hour and half explaining all of the changes that occurred to his body. The larynx contains the vocal folds. This is the entrance to the airway. The vocal cords serve two main purposes. These include air way protection during swallowing and vibration for voice production. When the voice box is removed, the patient is no longer able to voice or breathe through his/her mouth or nose. The patient now breathes through a hole in the neck, called a stoma.

There are three main ways that a patient can voice after removal of the larynx. These are esophageal speech, use of an electrolarynx, and tracheoesophageal speech.

In esophageal speech, the patient swallows air and then expels it out of his/her esophagus. It is just like a burp. The top of the esophagus vibrates to produce sound like the vocal cords used to do. This is the least popular of the voicing options.

Another option is the use of an electrolarynx. This is a six inch cylinder which vibrates when the patient holds it against his/her neck. Again, this vibrates the tissues to produce sound.

The third option and most popular is speech. During tracheoesophageal, speech air is diverted through a plastic prosthesis which is placed inside the neck between the trachea and esophagus. You have probably seen people put their finger over the stoma, so they can voice. When the stoma is covered, air is forced through the voice prosthesis into the esophagus. This results in vibration of the top of the esophagus. This prosthesis contains a one way valve that allows air to pass into the esophagus, but it doesn’t let food or liquids back through into the trachea. These are expensive and some insurance companies don’t cover the cost. They typically need changed by a certified speech language pathologist every three to six months. Some last longer, and some don’t last a month. A build-up of yeast on the back of the prosthesis causes it to stay open resulting in leakage of liquid into the airway. If the prosthesis isn’t changed, the patient can develop pneumonia.

You can imagine how overwhelming all of this was to my patient, and this was just the voicing options. There are so many other things that change. Swallowing, smell, and taste are just a few changes. It’s even a challenge to shower because no water can get into the stoma which is a direct shot to the lungs. The patient is unable to smell and taste because the nose and mouth are disconnected from the air way. Have you ever been told to hold your nose when eating something you don’t like? This exactly what it’s like for a person who has undergone a laryngectomy.

I always stress the importance of covering the stoma with a foam cover to protect the air way. One patient came to my office one day and said he understood why. I said, “Oh really, why?” He proceeded to tell me that he had to cough out a bug that had decided to fly into his windpipe.

Unfortunately more and more patients are undergoing laryngectomies. Patient and caregiver education is so important for these patients. There are several support groups out there. Two of these are WebWhispers.com and the International Association of Laryngectomees.

My rehab patient was very grateful for my explanations and guidance. I changed his prosthesis during and long after his rehab stay. I’m so fortunate to be able to work with such great patients.

A little bit of patience, understanding, and education can make such a difference in a patient’s state of mind.

Heidi