EPISODE 70

[INTRODUCTION]

[0:00:04] MBH: Thanks for joining us at Keys for SLPs, opening new doors for Speech-Language Pathologists to better serve clients throughout the lifespan, a weekly audio course and podcast from SpeechTherapyPD.com.

I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning. Keys for SLPs brings you experts in the field of Speech-Language Pathology, as well as collaborative professionals, patients and caregivers to discuss therapy strategies, research, challenges, triumphs and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive. 

Each episode of Keys for SLPs has an accompanying audio course on SpeechTherapyPD.com, available for 0.1 ASHA CEUs. We are offering an audio course subscription special coupon code to listeners of this podcast. Type the word Keys for $20 off. With hundreds of audio courses on demand and new courses released weekly, it's only $59 per year with the code word Keys. Visit SpeechTherapyPD.com and start earning ASHA CEUs today. 

[EPISODE]

[0:01:23] MBH: Hello, welcome back everyone. This is part two of a two-part series. This episode is Keys to Rehabilitation After Laryngectomy. I'm your host, Mary Beth Hines. Before we get started, we have a few things to mention. I know some of you have already heard all this, who have already listened to part one, but we may have people who are listening tonight who haven't listened to part one or who may be listening in the future to just part two. 

Anyway, per ASHA regulations, here we go. Here are the disclosures. I am the host of Keys for SLPs and receive compensation from SpeechTherapyPD.com. No relevant non-financial disclosures exist. Heather Thompson is an SLP at Cedars-Sinai Medical Center. She receives compensation from SpeechTherapyPD.com for this episode. No relevant non-financial disclosures exist. 

Here are our learning objectives. One, describe different equipment utilized for laryngectomy for communication and safety. Two, explain the importance of the SLP role in preoperative education and counseling in order to facilitate effective communication post laryngectomy. Three, identify four different options for communication post laryngectomy.

Now, we again welcome our guest today, Heather Thompson, MS, CCC-SLP, a Speech-Language Pathologist at Cedars-Sinai Medical Center, specializing in the evaluation and treatment of oropharyngeal swallowing disorders, as well as head and neck cancer, speech and swallowing restoration. She is proficient in the management of voice prostheses following transesophageal voice restoration after total laryngectomy. She has served as a guest lecturer at the University of Southern California and California State University, Los Angeles. 

Most recently, she presented at the Society of Physicians Assistance in Ear, Nose and Throat in Los Angeles, California. She co-authored a book chapter on the role of the SLP and Head and Neck Cancer Management. Currently, she is involved in research in the lung transplant population and participates in community outreach promoting Speech-Language Pathology. We are so happy to have you here on Keys for SLPs to talk about rehabilitation after laryngectomy. 

[0:03:36] HT: Thank you. Thank you so much for having me and talking about laryngectomy, especially after the head and neck cancer talk we just did, I feel like laryngectomy is its own separate entity all in itself. I'm glad that we're able to just talk about laryngectomy on its own. 

[0:04:01] MBH: Well, so am I. It's so interesting for people who may be involved in this niche in our field, as well as for people who are interested in laryngectomy but haven't had a lot of exposure to it prior to now. Thank you for sharing your expertise with us. We're really excited. I know some of you have listened to part one, but the numbers are different, so not everyone has listened, but for those of you who are just joining us, Heather, can you tell us a little bit about your journey that led you to work with people with laryngectomies? 

[0:04:35] HT: Yeah. Laryngectomy is a very different population. I actually started working with adults and pediatrics, so very different ends of the spectrum. Also, it wasn't always in the adult realm and then worked in long-term acute, neuro, and then about 10 years ago, we had a new surgeon to the hospital where I am now, which is Cedars-Sinai in Los Angeles, California, who wanted to start a head and neck cancer program. I wanted to know if there was a speech therapist who was interested in helping grow and build that program. 

At that point, I had volunteered, because I had had experience with laryngectomy and head and neck cancer patients like this much for my graduate school program. Also, when I had worked in acute settings, so I was like the only one who had had this much. I had volunteered. As I said, the last time it was sink-or-swim, so I just dove right in. Now I love it. I don't know if I'm the expert, but I know a lot. 

[0:06:01] MBH: I think you are now after 10 years. I think it's okay. You can call yourself an expert. All right. In part one, you updated the statistics on head and neck cancer. For part two, can you give us an update on laryngectomy in like the past 20 years? 

[0:06:20] HT: Laryngectomy is a very, very small niche population. It's the smallest out of the head and neck cancers. It makes up 1% of head and neck cancer. Very small. And there's only about 10,000, I think the last statistic was 10,270 people currently living in the US with a laryngectomy. That's it. There's not that many. 

Knowing that there's Ð it's very scary, I feel like, for our patients and for speech therapists who don't work with this population that often, because it's not just Ð you would be surprised at how many respiratory therapists, other doctors, physicians, ENTs, who really are not familiar with this population, it's because it's so small and it's so rare that people will see a laryngectomy and automatically assume that it's a trach patient. That's how rare this population is. We talked about this prior, because smoking has decreased also with chemoradiation coming in, organ preservation, and laryngectomies have gone down. You're not seeing as many, but there are still laryngectomy surgeries being done. They're just done more often at major medical centers. 

[0:08:22] MBH: Okay. I imagine with those numbers being so small, there aren't a lot of doctors who specialize in it. 

[0:08:30] HT: Yeah. There's very, very, very few. That's what I tell my laryngectomy patients, ÒYou have to know you are the expert. Believe it or not, you are going to be the expert. You live in a small town in Nevada. You may not be able to get to Los Angeles, so you need to know how to care for this. Your wife needs to know. YouÕre going to need to be able to tell your fire department how to resuscitate you.Ó Until they have that one incident, they're like, ÒI didn't realize how rare this was until I left my little big city bubble.Ó

[0:09:20] MBH: Well, speaking of which, what are some of the special considerations when resuscitating a laryngectomy patient? 

[0:09:29] HT: We'll probably talk about that when we go a little bit deeper into that preoperative, but the anatomy has completely changed. When the larynx is removed, you reroute, for lack of a better word, the airway, until they become a neck breather. Basically, then the nose is like there for cosmetics. They're breathing through their neck. All CPR, airway needs to be through the neck. If they do CPR and give oxygen through the mouth, they're never going to get it. It has to be through the neck. 

Knowing those different things, the same thing, if they consider this a trach, you can cover a trach. A trach is a one-way valve, you can cover it. If the trach is covered, it's fine. If you cover a laryngectomy stoma, they're not going to be able to breathe. I think those are the things that I feel like the biggest misconceptions with a laryngectomy versus a trach. I think people see a stoma and they automatically want to cover it. You need to have special covers and adapters for that. You also need to do different things for airway protection as well. 

[0:11:06] MBH: So would a fire department have a special oxygen mask or a special mask for CPR to put on the stoma? 

[0:11:18] HT: They should have it. 

[0:11:21] MBH: Okay. 

[0:11:22] HT: They should have it. When I have a Ð once again, when we go into the preoperative, I always tell my patients to contact their local fire department and make sure that they know that there is a laryngectomy patient at the home and that if 911 is called to that home, that they need to have a special adapter for CPR and for resuscitation. Believe it or not, there are still small fire departments that have volunteer fire departments and they don't have it. The vendors do have patients Ð I say, as a backup, always have a plan B. A lot of laryngectomies do have that for their own as well. 

[0:12:23] MBH: Didn't mean to digress, but it's just something that I never thought of. Yeah, we'll get into that a little bit more later. 

[0:12:31] HT: Oh, and Mary Beth, there was a question Ð do you want me to answer it? 

[0:12:37] MBH: Oh, I didn't Ð I just changed my setup here, so I didn't see that down there. Sure. I will ask it, ÒIs it true that when a patient has a laryngectomy, they can be immediately placed on regular thin liquids without a swallow study? I was stuck in this situation once.Ó This SLP was stuck in the situation once.

[0:12:59] HT: I feel like that's a loaded question, because Ð 

[0:13:04] MBH: Those are the best kind of questions. Thank you for asking it. 

[0:13:08] HT: Yeah, right. Thank you for the loaded question. Because protocol after a laryngectomy is you should get a leak test, because there could be a fistula. If there's a fistula, it could go into the airway. Also, if a laryngectomy has a TEP and its leaking, then they can't be on a regular thin liquid diet, because that liquid can go into the airway. I mean, theoretically, could they be placed on a regular thin liquid diet? Yes, but I feel like if you haven't seen the patient, you don't know the patient, you don't know the background, you don't know how the surgery was, or if they've had a leak test, or if they have a fistula, or they're recovering from a fistula. I would probably go for the video swallow study, just to make sure that there are no fistulas that could cause any Ð because you don't want to feed somebody who's had a laryngectomy.

You don't know how far out they are from Ð now, if they're years out from surgery and they've been on a regular diet, they're fine, but if it's somebody that's a new laryngectomy, and you donÕt know if they've eaten or not eaten or if they've had a leak test or not, then you need to go on and do that test, because you don't want to feed somebody, and then they have a fistula. Then all of a sudden, you're feeding them, and things are getting dumped into an airway, or a stomach, or dumped somewhere along the line, because there was a fistula along the way. I hope that makes sense. 

[0:14:58] MBH: I think that does make sense. I have a follow-up question to that. A leak test is just an MBS to see if there's a leak, or is it something else? 

[0:15:07] HT: Yeah. It's an MBS to see if there's a leak. What happens after Ð so the doctor will remove the larynx, and then what they do is they'll do a reconstruction. So they'll either do a gastric pull-up, and they'll reconstruct that way, or they'll take a flap of skin, and they'll do a neopharynx, and they'll rebuild the esophagus. They cut off the Ð so here's the neopharynx, and then they reroute this way. All the food and liquid can go this way into the stomach, and then the airway goes this way. It's a two-way system. 

If they've just had the surgery, and this tissue hasn't all formed, and there's a hole, then what can happen is if they're eating or drinking food or liquid could go and then could go out this way. That's where you could get into a problem. So, you want to do a leak test to make sure that there's no fistula. However, if it's a laryngectomy patient that's been out for several years, has been on a regular thin liquid diet, and you've assessed Ð they've had a TEP, so our voice process is in pace, and you look, and you give them liquid, and there's no water going or liquid going around the TEP or through the TEP, so you know there's no liquid going around, then yes, you can give them food or liquid without the video swallow. 

If it's like a new laryngectomy, you don't know that they've had that, I would just go on and get the video swallow study just to make sure. But then also too, you don't know this patient, you don't know if there's restriction, they're new to you, so objective studies are always just best anyway, because if they have radiation, there could be strictures, there could be Ð it's just probably best, or like, it's just always best. 

[0:17:32] MBH: Yeah. Err on the side of caution in that case. That participant said, thank you, you really clarified that for them. So, thank you for answering it. Okay, and keep those questions coming. We're going to go through the content that we have prepared, but it's great to jump around too, so feel free to ask questions now or at the end. All right, so we reviewed, we really dove into the multidisciplinary team in part one. I would imagine it's a pretty similar team for the laryngectomy team. Do you want to quickly just for those who didn't listen to part one, just quickly go through those people? 

[0:18:15] HT: Yes. Your multidisciplinary team is your otolaryngologist or your ENT laryngologist. Then you also have your radiation oncologist, and that would be if the patient needs radiation. You have your oncologist. Then we also talked about how we have a palliative care/supportive medicine/pain management doctor. A social worker who is actually, I feel like the cheerleader, you need a social worker for a laryngectomy patient. For the families, for the patient, they will say they don't need it, you need a social worker. Dietician and we have a dentist. I think I named physical therapist, occupational therapist. I think I hit just about everybody. 

[0:19:17] MBH: I think you did. Okay, and we have another question. The person said, ÒCan you clarify what is a TEP?Ó 

[0:19:25] HT: That is the tracheoesophageal voice prosthesis. That is a voice prosthesis that can be placed at the time of laryngectomy, or after her laryngectomy. What it does Ð it's placed in the neopharynx between, I guess, the esophagus. What it does is the patient will take a breath and they'll push in on a piece of equipment, which is called a heat moisture exchange. I wish I had a picture of it. 

What it does is it, they take a breath, it's like they're holding their breath, and it re-routes the air through this device. It causes the esophagus to vibrate, and then it re-routes the air up through the mouth so that the laryngectomy patient can speak. Even though a laryngectomy patient doesn't have a voice or vocal cords, if they have this voice prosthesis, they're able to voice using this transesophageal voice prosthesis. 

[0:20:39] MBH: Okay. Thank you. How long have TEPs been around? 

[0:20:45] HT: I should have looked that up. I think Blom-Singer is the one who developed it. I think in the 1970s. 

[0:20:54] MBH: Okay. 

[0:20:55] HT: 1970s is when I think it came out. 

[0:20:58] MBH: Okay. So, quite a while. Okay. 

[0:21:00] HT: Maybe 1980s. 

[0:21:02] MBH: Okay. They've been around. They've been around. If any of our participants know that answer, feel free to put it in the chat. All right, so when working with a patient preoperatively, what are the most important topics that you will cover? 

[0:21:18] HT: Preoperatively is like what we were just talking about. You just want to go over everything, initially. The first thing is you want to talk about the changes in anatomy and physiology that are going to impact speech, swallowing, and breathing. It's all going to change. Speech, they're not going to be able to speak. Their larynx is gone. Even after surgery, if a voice prosthesis is placed, or there's an electrolarynx, or there's a writing tablet, you know, whatever mode, they're not going to be able to talk. 

They're not going to wake up after surgery and be able to communicate. You have to be able to tell them, ÒThat's going to happen.Ó They're not going to get it. Swallowing is going to change, because aspiration won't be as big of a risk, because remember, now it's a two-way system. You don't have to worry about necessarily the epiglottis having to close and things going down and aspirating, because you have that two-way system. 

It's going to be closed off. However, they're rebuilding your esophagus, so it's going to move different. Its taste is going to be different. How things move down because that's all going to be impacted because it's all closed off. Breathing is different. They can't jump into a swimming pool, because if they jump into the swimming pool, this hole is open, and water is going to fill up in their lungs because they rerouted the airway to go out. They're breathing here. So, that means, no swimming. 

I had a patient that was a big scuba diver, and I was like, ÒYou're not going to be able to do that anymore.Ó Sitting in a hot tub, taking a bath. That's all changing. As we talked about, CPR, it has to happen here, making sure that family members know this isn't covered. It's not a trach. Do not let people call it a trach, even in the hospital. That's how you're going to get in trouble. Then also making sure you're not going to be able to talk immediately after surgery, but what are your communication options? 

There's a writing tablet. There's text-to-speech options. There's an electrolarynx, which you can use right away. Esophageal speech could be an option. The tracheoesophageal voice prosthesis could be an option, which would be the TEP. You may not be able to use it immediately after surgery, but a week or so after the swelling goes down, you could be trained on that. That's an option. Telling them about communication options that are there. 

Then also, just how we talked about swallowing, you're not going to eat immediately. You have to have that leak test. We need to assess to make sure that everything's closed up, that there's no holes, so that when you drink nothing leaks to go into your lungs, and then you'll start with a liquid diet, pureed foods. You're also going to tell them about equipment and supplies. At our facility, we start them right away with what's called a lary tube Ð Atos calls them a lary tube. I think InHealth calls them a laryngectomy tube. 

They look different than a trach tube. Then what goes on it is a filter, which is called a HME, which is a Heat Moisture Exchange. We put that on immediately, so they can get used to it to help with the breathing. Also, too, so nursing staff can get used to this looks different. It doesn't look like a trach. They're immediately going into that. Looking into that, we introduce them, like my acute colleague, she'll either come over, I give her the name, I will introduce, I will say, ÒThis is my acute colleague.Ó

Expectations with future appointments, like, ÒThis is a long road. You are not going to get communication right away.Ó You know, setting up that realistic expectation. We try to connect them with another patient who's had a laryngectomy and with a local support group. If able, I try to see them two or three sessions prior, if they will. A lot of times they will not but usually family members are willing. 

Also, too, this is where I feel like the social worker is very key, because the social worker is there and they can set up, ÒLet's talk about disability. Let's talk about how your life's going to change. Have you talked to your family members? Have you talked to your friends?Ó Also, starting with that supportive counseling. Those first sessions, it's a lot of information. I think it's very interesting, because my acute colleague goes, ÒYou will see them two or three times and they will say that they don't remember anything, but yet they come and they have their writing tablet and their electrolarynx, so I know that they met with you.Ó 

Then afterwards, you find yourself, you repeat it seven times and about the seventh time they get it, because it's such a life-changing event. I think they get so caught on, ÒI've got to get the cancer out,Ó and on that survival that how much of a life change that it is really doesn't hit until after the surgery. The family members get it, but I don't know that the patients really get it until after a month or so into it. 

[0:28:33] MBH: Most of your patients come with a family member? 

[0:28:36] HT: Yeah. I would say all do, initially. 

[0:28:39] MBH: All right, so early on, those co-treatments with the social worker probably help. 

[0:28:48] HT: Well, I see them first, initially. Then I loop in the social worker. Then after that, if they want to see us together, they can. Usually the first ones, they don't want to see me with the social worker. They want to see individually. After the surgery, they are willing to see me with the social worker, because the communication is too difficult. I think they see me as a crutch. They know they need the social worker, but they need help saying things to the social worker. 

[0:29:30] MBH: Well, let's talk about options for communication. What are the options? We've mentioned a few. Esophageal speech and the electrolarynx and the tracheoesophageal voice prosthesis. Of course, there's ACC. Then backup options, too. Be my guest. Just dive into whatever you want to dive into. 

[0:29:54] HT: I think, first of all, well, initially for surgery, you've got to give them something. We typically go the route of Ñ we're fortunate Ñ in California, the California Telephone Access Program, anybody who lives in the state of California can have a free electrolarynx. At the preoperative counseling, we are able to fill out a form, and they are able to get an electrolarynx. We give that to the patient and tell them to bring it to the hospital, or I have it shipped to the hospital, and I give it to my acute colleague, and she has it. 

The benefit to that, it's cheap, it's affordable, and you can use it immediately after surgery, with minimal care. It's easy to learn. The downfall to that is it sounds mechanical. If they have a tremor in their hand or hearing loss, it could impede their success. They may have problems with placement. That becomes frustrating. There's always the writing tablets, text-to-speech. Those are low-tech communication options. I feel like it's a quick mint. I always tell patients, ÒYou need to have a backup. If you're going to use an electrolarynx, you need to have a backup method if that breaks.Ó If it's a writing tablet, it's a writing tablet. 

Boogie boards are those little writing tablets. They're like the old etch-a-sketch. Text-to-speech, there's tons of those options as well. Also, too, it's getting more steam, if their voice is okay prior to Ð I have a patient that is on the fence, he has carcinosarcoma, which is a slow-growing tumor. He may need a laryngectomy or a partial laryngectomy. We actually did voice banking and voice preservation to save his voice. If you have the option of voice recording, so that at a later time, if he wants to, he can type out words and phrases, and it's in his own voice. We recorded it in Spanish and English. That's also another option that's gaining more traction for the laryngectomy population. 

They need to have good voicing prior to the surgery. If they don't have a good voice or good speech prior to the surgery, it's not really an option. The other thing is, too, I go back and forth with it, because if they get a TEP, they're going to get, which is the tracheoesophageal voice prosthesis, they're going to get a new voice that may sound better. I go back and forth with the voice banking, but for this patient, we did do that. That's another way of voice preservation as well. 

[0:33:19] MBH: You're saying if they have some voicing challenges before the surgery, then the TEP could actually sound better than that, but if they don't have any vocal challenges, then the voice banking might be worth it. Does insurance cover voice banking, Heather? 

[0:33:38] HT: Yeah. You would code it like a speech articulation session. 

[0:33:46] MBH: Okay. 

[0:33:46] HT: It's like a preoperative counseling visit. 

[0:33:49] MBH: But does it cover the cost of the voice banking with the voice banking company? 

[0:33:54] HT: It does not, but there are companies, there are different organizations that you can reach out to, every once in a while you can reach out to, depending upon the time of year, and that's where the social worker comes into place. Depending on the time of year, the social worker can help you. The American Cancer Association, if you reach out to them, depending upon the time of year, if they still have money and funding and grants, the social worker can reach out. If they have money available, they can help you with a grant that could also pay for it. Some of these organizations, that's one, the Head and Neck Cancer Association, also too, sometimes they give grants to help pay for these as well. Also, within the UK, they also do those, as well. 

[0:34:53] MBH: Okay. That's interesting. We have a question from one of our participants about the name of the company that does voice banking, but there are a few different companies out there, aren't there? 

[0:35:04] HT: Yeah. There's a few different ones. Acapela is one company that does it. There's one called ModelTalker. Those are the two that I'm the most familiar with. Then there's also another company my co-worker was telling me about, and I can't think of the name of it that she really liked, but thereÕs more out there that are becoming more available. I know the big difference between ModelTalker and Acapela is Acapela you can record in multiple languages, whereas ModelTalker, you can only record, I think, in English. That would be one versus the other. There's pros and cons, but those are two that I am familiar with. That's voice banking. 

Esophageal speech is also an option. It's a more natural-sounding voice. It's not robotic compared to the electrolarynx. Independent Aids, it's free. We like free, but a con is, if they have tension, or if they have that fibrotic, if they've had that radiation, it can make it harder to speak, and they may not be able to talk loudly. Then you have the frustration, and it can take four months up to a year for them to learn. Then there's also that, so they have to really bite into that. That's the downfall to that one. 

[0:36:44] MBH: Can you briefly describe what esophageal speech is for those who haven't learned about it, or maybe haven't learned about it in a while? 

[0:36:52] HT: What esophageal speech is, you would take a gasp of air, and you take the back tip of your tongue, and you kind of compress that air into your esophagus. It's almost like you're burping. And you use that vibration for voice. They just burp in your voice, and they basically, what they can do is reroute that air to vibrate the esophagus. They use the tongue tip to cause that vibration in the esophagus for their speech. That's the only thing I can think of is itÕs like youÕre burping your words, like on the playground, like how kids do that. I can't do it, but the people who can do it can do it very well. 

[0:37:53] MBH: And not have to rely, they're independent, they don't have to rely on anything else. 

[0:37:57] HT: Well, and I think the thing of it is, it's free, but it does take several months to learn how to do this. Then the other thing is the tracheoesophageal prosthesis, and that the pro to it, it's quick, easy, it's a more natural sounding voice. You can also do it hands-free. You can get to the point where you can use a hands-free device. The con is more daily care, it can be more expensive. It could be harder for people who have had a lot of radiation. 

Also, too, you would need to be close to probably a facility to go back and forth, if you wanted to change it in and out. You could change the voice prosthesis yourself, but what I find is patients like going to, they don't want to change a voice prosthesis, nor do their caregivers. They want the speech pathologist to change it. 

[0:39:04] MBH: Okay. How is it changed? 

[0:39:07] HT: It's changed by the Speech-Language Pathologist. I think the company guarantees it for like four to six weeks. I have patients that can keep it for six months, some a year if they can clean it. Every three to six months, I will check it, but what you do is you would just remove it. You have to pull it and it has to go over that airway, and then you take it out, and then you just put it back into the fistula or the trach that's in that neopharynx that the doctor created. After the surgery, either the doctor will create another fistula in the neopharynx for the air to go through to the esophagus to cause it to vibrate or a few weeks after the surgery, or if the patient decides after the surgery that they would like a voice prosthesis, then they will place a fistula in the neopharynx for the voice prosthesis. 

[0:40:15] MBH: Okay, but you're going in through the stoma in the neck. 

[0:40:20] HT: Yeah.

[0:40:21] MBH: To remove it. 

[0:40:22] HT: Yeah, to remove it. 

[0:40:24] MBH: Okay. Wow, that's exciting. 

[0:40:27] HT: Yeah, fun.

[0:40:30] MBH: Are there ever any problems with bacteria Ð you said keeping it clean is important? 

[0:40:38] HT: Well, I think they're always, I mean, because you've got to think of it, at that backside of it, it's always going to have food. Reflux, they've got to manage that reflux. If they don't manage it, it's going to wear it down. That means if they wear it down, it's going to leak. That leakage can come through, which means they're going to aspirate into their lungs, then you're going to have aspiration pneumonia because there's leakage through and around that TEP. There's that. Food could get trapped in there, so you have to clean it, and you do have to care for it. People who do clean it and care for it, also antibiotics can break it down. 

[0:41:37] MBH: Oh, interesting. Okay. All right. Then how many of your patients, like what percentage of your patients opt for AAC, beyond the writing pad? 

[0:41:49] HT: After the initial, like very few. They use it initially after surgery, or they may use it as a crutch, initially. Then they usually take a path of an electrolarynx, or the TEP, because it's not as quick. The electrolarynx, or the voice prosthesis would be quicker. 

[0:42:13] MBH: Okay. Also, just back to the electrolarynx for a second. You said it's free for those in California, so it's a cheap option, but are they cheap themselves? If someone's living in a state where they're not covered, do you know how much they cost? 

[0:42:28] HT: I think it's covered through insurance, through Medicare. I think both of the big vendors, I think it comes in like the laryngectomy kits that they would get postoperative. Then,  I think there was another question about, ÒHow do you make sure the bacteria doesn't go into the lungs when you clean it?Ó So, if the TEP is like this, and the lungs are here, and then right here is the esophagus, the brush goes like this. You're literally pushing it into the esophageal side. There's no way that Ð so when you're pushing it in, anything that goes in is going to drop down on that side, and then you're going to pull it out. 

There's not going to be a lot, and then there's also little plunger things of water and things for you to push, so that you're pushing things down on that side. If that makes sense. Then the brushes are long enough to avoid any of that happening, and they have these little wire things on it, so they're going to catch things. It's going to be very hard for anything to drop through. 

[0:43:53] MBH: Okay, we have another question from our participants. Thank you to so many people for writing questions. Okay, but you have to pull it out right. I think she's Ð 

[0:44:03] HT: Yeah. It's the way that Ð I wish I had the brush to show you, because if you could see the way the brush was twilled around, it's going to Ð when you're pushing it in, the hole is so tight, you're pushing it in, but then when you pull it out, the way that the wires are on the brush, it catches any of those particles in there, that it doesn't really fall out. Because it's not wet or crumbly at that point, it just attaches in the brush, so then when it comes out, the caregiver can clean it, and then go back in. 

If any minimal drops in, it's so minimal or microscopic. There's also the air thing too, but like, if you could see the brush, it's so wiry that it just collects all of the things. The thing of it is, the food very rarely is going to go that deep into the TEP, because if it does, then there's going to be a bigger problem. You're really just pushing it in that way, and then pulling it out. The bigger thing that you're going to see is more so, it's going to be mucous. 

[0:45:26] MBH: Okay. Okay. I know you have been talking to SpeechTheraphyPD.com about coming back and doing a seminar, and I can really see why this subject would be good for a video. You could actually bring in some of the equipment and maybe even bring in a patient or client and show how some of these things work. 

[0:45:47] HT: Well, yeah. That's what I was going to say. I feel bad. I encourage you, if you could look on the Atos website at the brush, or if you looked at an actual cleaning, I'm sure they can give a good enough description, but if you could actually look at the brush or look at the cleaning, it would be like, ÒOh, I get it. I get what she's talking about now.Ó Because it's not going to go that far in. 

Yeah. It would be a concern, because if it's going that far in where you're like, ÒOh, when we're cleaning, it's coming that far in.Ó Then you probably need to change the TEP, because that means the TEP is broken down, or there's probably something where it's pushing, the food is pushing back up. You've got some kind of pressure that's coming back into there, so you probably have a stricture, and they need to be dilated because it's going too far in. You probably have a bigger problem, if it's going that far in where you're like, ÒHey, I'm cleaning, and food could be dropping in.Ó

[0:46:58] MBH: Okay. Oh, lovely. All right. Anything you wanted to say about any other backup options besides a pad of paper? It's important to always have a backup option. 

[0:47:14] HT: I mean, I always tell, I had a colleague tell me this, and I thought it was the best description. I think it's just the best description in life for any kind of AAC, even if you're doing AAC in general for any population, stroke, but even with laryngectomy is like, I have Ð I wear contacts, but if I lose my contacts, I have glasses. That's what I tell my laryngectomy patients. You have your voice prosthesis, but if it breaks down, what is your backup option? That's what I say. ÒYou have your electrolarynx. If it breaks, what's your backup option? Do you have another one? Do you have your writing tablet? Do you have a voice prosthesis? Can you use esophageal speech? Do you have your text-to-speech app? What is your backup option?Ó

Because if their TEP is not working or is messed up like there is a structure, or their electrolarynx is in charge, they've lost their communication. Then it becomes a problem. That's why I always say, especially for laryngectomy, always have a backup option, but I think if you're working with any kind of AAC, or any communication, always make sure that those AAC users have a backup. Like I said, I always give that. I have contacts, but if I lose my contacts, I have my glasses. 

[0:48:53] MBH: Good advice. Good advice for sure. Okay, so when someone has decided what option they're going to use, what is the usual course of treatment? 

[0:49:04] HT: With the electrolarynx, it started immediately in the hospital. We started right away in the hospital, because we just say, ÒHey, look ÐÓ like I said, we have the benefit in California, it's free. We're like, let's just try it. If you don't like it, you don't like it. Let's just try it and see how it goes, because it's a free option so they automatically start it. My colleague goes in every day or every other day, ÒLet's practice with the word list, practicing placement.Ó If they're doing it every day and practicing it back and forth within a week to two weeks, they can be pretty prolific users. They can probably get it down pat pretty quickly to where they're able to be understood, can even talk on the phone doing really well. 

With the TEP, it's the same. If they jump into it and learn it, I see them one or two times a week after they get their TEP in. If they get it as a primary placement, we don't address it until they see me post-op. Not necessarily that they can't, it's just, we found it's just too overwhelming for them that it's just way too much for the patient. It's just better if we address it all on the outpatient side. So we just do it all then. 

[0:50:48] MBH: Okay. Do you ever have anyone come in and already know how to use it? 

[0:50:52] HT: No, because it's just this thing that's in their neck and they don't know how to use it. That breathing coordination, it's all overwhelming, because you have to take a breath. You breathe, push and talk. You don't just talk. So, learning how to do all of that is just so overwhelming. 

[0:51:15] MBH: Plus, they're in pain after the surgery. 

[0:51:18] HT: Well, and there's pain after surgery, but then I think there's also, too, you have to learn how to clean your laryngectomy tube. You have to learn how to use your device. You have to learn how to care for your stoma, how to care for all of these different things. I think learning how to care for all of these different things becomes so overwhelming that to add another thing on top of it just becomes too much. 

[0:51:50] MBH: Okay. Usually, that's, what did you say, a week or two after? How long are they usually in the hospital? 

[0:51:58] HT: Ideally, theyÕre in the hospital seven days. 

[0:52:00] MBH: Okay. Well, that's a significant amount of time considering how hospital stays have shortened. 

[0:52:07] HT: That's the ideal. 

[0:52:10] MBH: Yeah. 

[0:52:10] HT: That's the ideal, but sometimes it can be two weeks, sometimes it could be a month. If there's no complications. 

[0:52:21] MBH: Okay. All right. Then with any of the other options, is there any special protocol? 

[0:52:32] HT: Well, no. I think it's all a learning process. And I think that's the important thing with the preoperative is that they have to know that, and I tell them preoperatively, ÒIt is a year before you're used to everything.Ó The communication part is only one piece to it, like you forget all of the things that a larynx does. People forget that smelling is going to be different. Because that system's cut off. We also forget like lifting, you use your larynx. Going to the bathroom, so constipation, that's your larynx. That's different. That could be an issue. They have to get used to all of those things. Cleaning their stoma, putting on an HME, talking different, doing things different. It's all a learning process. 

[0:53:42] MBH: There's a lot to consider. All right, well, I think we have time for one, maybe two case studies. 

[0:53:51] HT: Well, there were two case studies, mainly that I feel like for me, that were the big thing to talk about. It was more of a compare and contrast. One was to highlight, we actually discussed this at ASHA, I think it was actually when I met you and we had discussed doing this. It was talking about the importance of preoperative counseling for the laryngectomy population. 

The first patient I had, she actually came, she had three preoperative sessions with me. She went to a support group. She met with a laryngectomy patient. She met with a social worker. She did all the things. She was prepared for her surgery. She knew she wanted a TEP. Then after surgery, she used the writing tablet, because she knew she wanted the TEP. One month after surgery, she got her TEP. Within the month, she was speaking fluently with the TEP. A month after that, she was using hands-free, completely independent. So, like three months after her surgery, she's back to teaching. 

[0:55:27] MBH: Wow. Wow. That's incredible. 

[0:55:29] HT: Completely independent. Our second patient came from an outside facility. No preoperative counseling. He came in off the street. They found the tumor in the larynx. It was emergent. He couldn't breathe. No preoperative counseling. They had to do it emergent. He was going to die. They did the emergent laryngectomy. He came in. No preoperative counseling at all. No clue. No ideas. By the time he got to me postoperative, he's still trying to figure out how to care for the laryngectomy, how to use the electrolarynx. 

Three months out, he still was learning the word level with the electrolarynx and gesturing with the family, was not fluent. For me, what that showed was the importance. That was just our case study, but what that showed just in that case study, just those three sessions with that preoperative counseling, with her meeting with the support group, knowing, ÒHey, this is the equipment. I'm going to have to clean it. This is the course. This is the care.Ó That preparation got her that much ahead. So, just even looking at that, I was like, we have a role with these patients. We have a huge role with these patients. 

If you have a patient or you're at a facility where they do this, advocate for that preoperative counseling, let them know, ÒYes, they're going to forget half of it, but what they hold on to and they remember, they're going to remember and they're going to keep it going. They're going to know that they're going to have to see you and they're holding on to something. It's going to help with their recovery and getting back to their functional, getting back to their life.Ó That's ultimately where we want them to be. 

[0:57:51] MBH: Exactly. Well, those two case studies really do demonstrate the importance of preoperative counseling. Just having a plan. 

[0:57:59] HT: Yeah.

[0:58:00] MBH: Knowing what Ð I always say, life is a lot about expectations. Knowing what your expectations are, having realistic expectations, that can really help. 

[0:58:12] HT: Yeah.

[0:58:13] MBH: Get you through. 

[0:58:14] HT: Yeah. 

[0:58:15] MBH: We do have a question in the chat. Feel free, our participants, our live participants, feel free to ask any other questions. This person says, ÒThis is not directly related to the topic today, but what is a good way to break into medical speech pathology? Most jobs want you to have experience with swallowing, fees, etc.Ó So, she's asking you, Heather, as someone who has been in medical speech pathology, and that wasnÕt your whole career, you had some time in early intervention as well. 

[0:58:52] HT: Yeah. I always tell people, there are jobs, well, at least here. I also moved from Nashville and then Tennessee. There are hospitals in facilities, especially in smaller communities and the outlying communities. There are hospitals that have pediatrics and adults, where they will see pediatrics and adults. I always tell people to go for the per diem job in the small hospital, that you're like, ÒI don't want to drive 30 minutes there, 45 minutes there,Ó that is willing to teach you and say like, ÒHey, look. I will take on the kid caseload, but will somebody train me on that fees or train me on the video swallow or give me the adult experience?Ó 

If you can find that per diem job, or you can find the job where they're willing to cross-train you, where they see peds and adults, or a hospital that has both, that's where I tell people, that's where you're going to get your in, because in those hospitals, they would much rather use the resource from within and have somebody that's cross-trained, than hire another person. They always are looking for somebody. That would be my advice. If you can find a hospital to do per diem or just get into a hospital anywhere, that small hospital where they're willing to train you. 

[1:00:36] MBH: Excellent advice. Excellent advice. Also, there are lots of continuing education opportunities out there. We have a lot of courses on SpeechTherapyPD.com, as well. All right, well, we are just about out of time. I make sure we don't have another Ð oh. That the person says, thank you. You are welcome. Thank you to everyone who's been asking questions tonight. We really appreciate it. All right, do you have anything else that you would like to add Heather? 

[1:01:08] HT: No, just thank you for having me this evening. I appreciate it. Hopefully, I was able to give you guys some tips and tricks for survival with laryngectomy, if one ever comes your way. 

[1:01:24] MBH: Oh, speaking of tips and tricks, you did mention that you had some resources that you would suggest. 

[1:01:30] HT: Oh, I was going to say, I think I know what to do. I always tell people to Ð because I didn't have pictures or talking about things today to get better insight, I always recommend going to the vendors. It's Atos Medical. A-T-O-S Medical. On that vendor website, they have pictures. They have informational videos, go there. There's also InHealth, I-N-H-E-A-L-T-H. They have great, some of their pictures actually are some of my favorite. Their website, once again, they're another vendor, great pictures, great videos, great topics, a great place to find research, health articles. 

Also, I find the head and neck cancer community, especially those that work with laryngectomy patients. You can probably reach out to any of us. We're always willing to help, so even to the education coordinators at InHealth, education coordinators at Atos, they're always willing to help and are of help if you need us or feel free to reach out to me as well. 

[1:02:55] MBH: Well, thank you. Thanks everyone. Have a great evening. We'll see you next time. 

[1:03:00] HT: Thank you. 

[1:03:01] MBH: Thank you. 

[OUTRO]

[1:03:02] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to SpeechTherapyPD.com to learn more about earning ASHA CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]
KFSP 70		Transcript

	©Ê2023 Keys for SLPs	1