Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs.

BACKGROUND: After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context. AIMS: (1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy. METHODS & PROCEDURES: A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis. OUTCOMES & RESULTS: The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general. CONCLUSIONS & IMPLICATIONS: The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require. WHAT THIS PAPER ADDS: What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

Evaluation of a pharmacy supported e-cigarette smoking cessation intervention in Northwest England.

BACKGROUND: Cigarette smoking cessation has been described as the world's most important public health intervention. Electronic cigarettes are a relatively new tool for assisting smoking cessation but there is a lack of data on their efficacy. This article reports on a pharmacy supported e-cigarette smoking cessation intervention undertaken in a metropolitan area in the north of England. METHODS: Longitudinal mixed-methods evaluation incorporating analysis of secondary data, interviews with service users, and interviews with service providers at 3-month and 12-month follow-up, with an additional text message survey of service users at 12-month follow-up. RESULTS: The four-week follow-up data suggest that for every twenty people given an e-cigarette, six quit smoking tobacco and three people cut their cigarette intake by more than five cigarettes per day. Long-term follow-up results were positive but only a small number of participants were still engaged with the study at 12 months. Service users and providers spoke positively about the combination of e-cigarettes and pharmacy support. CONCLUSIONS: E-cigarette distribution combined with pharmacy support appears to be an agreeable and effective intervention for smoking cessation, but further data are needed on long-term quit rates and health effects.

Patient advocacy in head and neck cancer: Realities, challenges and the role of the multi-disciplinary team.

This paper explores the concept of advocacy in head and neck cancer. We define inherent challenges in the development and success of advocacy within this context and offer ways to embed it within clinical practice. We outline what advocacy is, ways in which it may benefit people with head and neck cancer and the engagement required from healthcare professionals to facilitate advocacy to improve outcomes.

Evaluating the effect of different voice prostheses on alaryngeal voice quality.

OBJECTIVE: To investigate the difference between voice prostheses in terms of voice quality as experienced by patients and as judged by expert raters. METHODS: Subjects had up to six voice prostheses placed in a random order. A voice sample was elicited for each patient on each prosthesis. Auditory perceptual voice analysis of each voice sample was undertaken by expert raters using the Sunderland Tracheoesophageal Voice Perceptual Scale (SToPS). Raters also identified the best overall prosthesis for voice for each patient. Raters were blinded to patient details, type of laryngectomy surgery, type of voice prosthesis, and scores of other raters. After each prosthesis trial, patients self-evaluated voice using a questionnaire developed for this purpose. RESULTS: Expert raters were not able to identify a best overall voice prosthesis using SToPS. Expert raters most frequently chose the Blom-Singer Classic Indwelling (InHealth Technologies, Carpinteria, CA) as the overall best prosthesis for voice for each patient. Patient self-evaluation scores indicated a preference for the Blom-Singer Classic Indwelling Prosthesis (InHealth Technologies) for voice, whereas preference for best overall prosthesis was for the Provox NID (Atos Medical AB, Hörby, Sweden) CONCLUSION: Expert raters did not identify a best prosthesis for voice using SToPS, although the Blom-Singer Classic Indwelling (InHealth Technologies) was most frequently chosen as best for voice. Patient self-evaluation indicated a difference between preference of prosthesis for voice and preference for best overall voice prosthesis. Individual patients had their own personal preferences, suggesting they should be involved in the choice of their voice prosthesis. LEVEL OF EVIDENCE: 4. Laryngoscope, 2460-2466, 2018.

An Investigation of the Post-laryngectomy Swallow Using Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing (FEES).

This study investigates the post-laryngectomy swallow. Presence and degree of residue on the post-laryngectomy swallow as observed on videofluoroscopy and FEES is described. In addition, videofluoroscopy and FEES are assessed for reliability and inter-instrument agreement. 30 laryngectomy subjects underwent dysphagia evaluation using simultaneous videofluoroscopy and FEES. These were reviewed post-examination by three expert raters using a rating scale designed for this purpose. Raters were blinded to subject details, type of laryngectomy surgery, pairing of FEES and videofluoroscopy examinations and the scores of other raters. There was a finding of residue in 78% of videofluoroscopy ratings, and 83% of FEES ratings. Comparison of the tools indicated poor inter-rater reliability and poor inter-instrument agreement. Dysphagia is an issue post laryngectomy as measured by patient self-report and by instrumental evaluation. However, alternative dysphagia rating tools and dysphagia evaluation tools are required to enable accurate identification and intervention for underlying swallow physiology post laryngectomy.

Swallowing after laryngectomy.

PURPOSE OF REVIEW: This article examines the emergence of dysphagia as an area for rehabilitation postlaryngectomy. The use of dysphagia evaluation tools postlaryngectomy is described and the causes of dysphagia discussed. RECENT FINDINGS: Although the risk of aspiration postlaryngectomy is low, significant symptoms of dysphagia can exist in this patient population. A comprehensive evaluation is the cornerstone for both the identification and management of postlaryngectomy dysphagia. The tool predominantly used to evaluate laryngectomy to date has been videofluoroscopy. The use of this tool in this patient population is described together with fibreoptic endoscopic evaluation of swallowing and manometry. Common causes for dysphagia postlaryngectomy are outlined. Some of the surgical and behavioural interventions used to manage postlaryngectomy dysphagia are discussed. SUMMARY: A significant proportion of postlaryngectomy patients can present with dysphagia. Comprehensive swallowing evaluation can illuminate the causes of dysphagia in this patient population and facilitate their management.

Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience from a single reconstructive center.

BACKGROUND: Reconstruction following pharyngolaryngectomy presents a complex reconstructive challenge, and a single-stage, reliable reconstruction allowing prompt discharge from the hospital and return of swallowing and speech function is required. The authors present their 10-year experience of 43 jejunal free flaps for pharyngolaryngectomy reconstruction by a single team and outline their operative algorithm to minimize postoperative morbidity. METHODS: The data for patients who underwent jejunal free flap reconstruction of circumferential pharyngoesophageal defects between March of 2000 and September of 2009 were reviewed retrospectively. All cases were included for analysis. RESULTS: There were 31 male patients and 12 female patients, with 100 percent acute flap survival. The authors' overall benign pharyngocutaneous fistula rate was two of 43 (5 percent), with two of 29 (7 percent) occurring in the group without a prophylactic pectoralis muscle flap and zero of 14 occurring in the group that had a prophylactic pectoralis muscle flap. No fistulas occurred when the anastomosis was performed with the gastrointestinal stapler (zero of 48). The authors' overall benign stricture rate was six of 43 (14 percent). Thirty-six patients received either a primary or secondary tracheoesophageal puncture; of these, 28 of 36 (78 percent) used their tracheoesophageal puncture as their primary mode of communication. CONCLUSION: The authors' recommendations for minimizing fistulas and stricture rate, following free jejunal reconstruction, include the gastrointestinal stapler for bowel anastomosis whenever possible, and the use of a prophylactic pedicled pectoralis major muscle flap for patients exposed to previous radiotherapy.