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Rehabilitation After Total Laryngectomy

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First, Understand What Changes After Total Laryngectomy

1. Voice - the vocal cords are gone
2. Smell and taste - because air no longer passes through the nose
3. Normal breathing - a permanent hole (stoma) is made in the neck; the patient breathes through this stoma, not the nose or mouth

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PILLAR 1 - VOICE AND SPEECH REHABILITATION

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Method 1: Tracheoesophageal Puncture (TEP) + Voice Prosthesis (VP)

How does it work? (Simple Explanation)

• A small hole (puncture) is made between the windpipe (trachea) and the food pipe (esophagus) - this is called the tracheoesophageal puncture (TEP)
• A small silicone one-way valve device (called a voice prosthesis) is placed in this hole
• When the patient wants to speak, they cover their stoma with a finger or a special button, forcing air from the lungs through the prosthesis into the esophagus
• This air causes vibrations in the throat (pharyngoesophageal segment), producing a voice

Primary vs. Secondary TEP

• Primary TEP: Done at the same time as the laryngectomy surgery (preferred). The patient wakes up from surgery with the prosthesis already in place and can start voice rehabilitation around day 10 after surgery.
• Secondary TEP: Done weeks later as a separate procedure (only needed in certain complex cases, such as when the stomach is pulled up to reconstruct the throat - wait 4 to 5 weeks).

The Voice Prosthesis (VP) Device

• Currently the most popular device is the Provox Vega (Atos Medical, Sweden)
• It is a silicone, one-way valve - air can pass from trachea to esophagus for speaking, but food/liquid cannot flow back the other way
• Device lifespan: usually 4 to 6 months before it needs replacement (some last up to 11.5 years!)
• Replacement is done in the outpatient clinic - simple procedure, no anesthesia needed

Why does the VP leak or fail?

1. Candida (fungal) biofilm grows on the valve, preventing it from closing properly - fluids then leak through the prosthesis into the airway (transprosthetic leakage)
2. Esophageal underpressure during breathing causes the valve to open inadvertently, leading to air swallowing (aerophagia) and leakage
   • Special devices like Provox ActiValve use a magnet to keep the valve closed and solve this problem

Troubleshooting VP Problems (Simplified)

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The Pharyngoesophageal (PE) Segment - Key to Good TEP Voice

• A short myotomy (cutting a bit of muscle at the upper esophagus) prevents hypertonicity
• Botulinum toxin (Botox) injection into the PE segment fixes hypertonicity after surgery if it develops

1. Short myotomy of upper esophageal sphincter - prevents PE segment hypertonicity
2. Suture the trachea into a separate hole in the lower skin flap - makes a stable stoma
3. Cut the sternal heads of the SCM muscles - prevents a "deep" stoma that's hard to manage
4. Close the throat in a T-shape without tension - prevents pseudovallecula (false pocket) formation

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Method 2: Esophageal Speech

How does it work?

• The patient learns to swallow (or inject) air into the esophagus and then release it in a controlled way
• The walls of the esophagus/PE segment vibrate to produce sound
• This sound is shaped into words using the mouth and tongue

Pros and Cons

• Pros: No device needed, no maintenance cost, hands-free
• Cons: Very difficult to learn (only about 25-30% of patients master it), voice quality is lower, speaking takes more effort

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Method 3: Electrolarynx (Artificial Larynx)

How does it work?

• A battery-powered vibrating device is held against the neck or cheek
• It sends vibrations through the skin into the throat
• The patient mouths words normally - the device provides the "buzzing" sound instead of vocal cords

Pros and Cons

• Pros: Easy to use right away, even in the first days after surgery (written communication or electrolarynx while TEP heals)
• Cons: Electronic/robotic voice quality, device must be held in place, not usable in noisy environments

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Comparison of Three Voice Methods

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PILLAR 2 - PULMONARY (BREATHING) REHABILITATION

The Problem

• Normally, the nose warms, humidifies, and filters inhaled air
• After laryngectomy, breathing is through the stoma (neck hole) - air is cold, dry, unfiltered
• This causes excessive mucus production, coughing, respiratory infections, and lost moisture (500 mL more water loss per day compared to nasal breathing)

The Solution: Heat and Moisture Exchanger (HME)

What is an HME?

• A small foam/filter device worn over the stoma, kept in place by a peristomal adhesive wafer stuck to the neck skin
• It captures moisture and warmth from exhaled air and returns it on the next inhale
• Functions like an "artificial nose"

Benefits of HME:

• Retains about 60% of the extra water loss through the stoma
• Reduces coughing and mucus
• Decreases risk of respiratory infections
• Less noisy than external humidifiers
• Can be combined with a hands-free speaking valve (a button that closes automatically when the patient speaks, so no finger is needed to cover the stoma)

HME Starting Point:

• Can be applied from day 1 after surgery during the wound-healing period
• The peristomal adhesive is safe over healing incisions
• Using HME early is better than using an external room humidifier

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PILLAR 3 - OLFACTION (SMELL AND TASTE) REHABILITATION

The Problem

• After laryngectomy, all air goes in/out through the stoma - none through the nose
• Without airflow through the nose, smell receptors are never stimulated
• Loss of smell also severely reduces taste (most of what we call "taste" is actually smell)
• This leads to reduced appetite and worse quality of life

The Solution: NAIM (Nasal Airflow Inducing Maneuver)

How does it work?

1. The patient opens their mouth and gently lowers their jaw and tongue, as if doing a very gentle, polite yawn - but without actually inhaling through the stoma
2. This movement creates a subtle negative pressure in the oral and nasal cavity
3. Air gently flows into the nose, stimulating smell receptors
4. The technique is taught by a speech-language pathologist (SLP)

Results:

• Clear improvement in olfaction (smell)
• Improved taste perception
• Improved quality of life
• Should be part of every laryngectomy rehabilitation program

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THE MULTIDISCIPLINARY TEAM

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TIMELINE OF REHABILITATION (Simplified)

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EFFECT ON QUALITY OF LIFE (QoL)

• Areas that often don't fully recover: physical function, social interaction, speech intelligibility, smell/taste, and dyspnoea
• Areas that can reach near-normal levels: overall QoL, psychological well-being (especially with good rehabilitation support)
• Patients who undergo total laryngectomy with TEP can achieve better vocal function than some patients treated with chemotherapy + radiation (which can cause severe long-term swallowing and voice problems)
• Returning to work is possible - especially for younger patients, clerical workers, self-employed individuals, and those with high motivation and social support

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KEY TAKEAWAYS (Summary)

1. TEP + Voice Prosthesis is the gold standard for voice after laryngectomy - it gives the best, most natural-sounding voice
2. Primary TEP (done at the same time as surgery) is preferred - gets you talking faster
3. HME is essential for lung health - it's an "artificial nose" for the stoma
4. NAIM (polite yawn) restores smell and taste - often overlooked but very important
5. Multidisciplinary team is the key to good outcomes - surgeon alone cannot do this
6. Radiotherapy does NOT prevent VP use - most patients tolerate it fine
7. Infection at TEP site: Never remove the VP, just upsize and treat with antibiotics
8. Candida is the main enemy of the voice prosthesis - probiotics (yogurt) can help

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