Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey

Objective: Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence. Method: A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses. Results: Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making. Conclusion: Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment

Dysphagia After Total Laryngectomy

Previous thought was that total laryngectomy and difficulty with swallowing were incongruous. Patients were counseled that the loss of their larynx would leave them without a vocal source, but that swallowing would not be affected. Successful rehabilitation was defined as being cancer-free and regaining functional communication. Patients were not queried and frequently did not complain of dysphagia as long as they were able to maintain an oral diet. Knowledge has changed, and this article will focus on dysphagia in the patient with laryngectomy and will discuss anatomical sites to physiologic problems

Effect of Aging on Tracheoesophageal Speech Rehabilitation

Objective: 1) To determine whether tracheoesophageal puncture usage changes as a function of age. 2) To determine whether age is associated with voice deteroriation, need for repuncture, or dependence in stomal care. Method: Retrospective chart review on individuals following total laryngectomy and tracheoesophageal puncture (TEP) and minimum 1-year follow-up data after prosthesis placement. Data reviewed included demographic variables and medical/surgical factors related to laryngectomy. Outcome measures of voice deterioration, TEP use, repuncture, and change in dependent prosthesis management were compared with age. Results: Sixty-nine individuals were identified that met criteria; 58 men and 11 women. Mean age was 65 years (range, 43-88 years). Nine individuals, mean age of 70.0 years, did not use their prosthesis for speech purposes; 2 chose never to use it and the remainder became unable to speak due to further medical issues. Deterioration in speech was further noted in five individuals, mean age of 79.4 years. Seven individuals, mean age of 58.6 years, required a re-puncture due to extrusion. Six individuals with a mean age of 76.3 years became dependent over time for daily stoma management. Conclusion: Age was significantly associated with deterioration in alaryngeal voice quality and need for dependence in stoma care for older individuals while repunctures were associated with a younger age. These results support careful selection criteria and counseling when considering a tracheoesophageal puncture in an older aged individual

Longitudinal tracheoesophageal puncture size stability

The purpose of this study is to investigate prosthesis size stability over time and determine which factors influence need for change in size. Retrospective chart review. Teaching hospital. Retrospective chart review was performed on all individuals who had previously undergone total laryngectomy and tracheoesophageal puncture and had a minimum of 3 years of consistent and consecutive follow-up data after their prosthesis was initially placed. Data reviewed included demographic variables of age at time of tracheoesophageal puncture, ethnicity, and sex. Fifty patients were identified who met criteria for study inclusion with a mean age of 64.7 years (range, 43-86 years) with 41 (82%) men and 9 (18%) women. Surgical management was equally divided between those who underwent total laryngectomy (n = 25) as primary treatment vs those who had salvage laryngectomy (n = 25) for persistent or recurrent disease. Prosthesis size was stable, with no change in diameter or length, in only 5 (10%) patients and unstable in 45 (90%), as they were changed at least once. The only factor that demonstrated statistical significance was sex (Fisher exact test = 0.035), with women being more likely to have a stable prosthesis size over time. The results of this study demonstrate that 90% of patients who underwent total laryngectomy and tracheoesophageal puncture required a change in their prosthesis size beyond the first 3 months of expected healing. These results support the need for continual reassessment of the fistula tract when changing the prosthesis to ensure appropriate fit

SWALLOWING OUTCOMES FOR ELDERLY INPATIENTS REFERRED WITH DYSPHAGIA

Academi

Changing trends of speech outcomes after total laryngectomy in the 21st century: a single-center study

To describe the speech rehabilitation outcomes of patients undergoing total laryngectomy (TL) in the 21st century. Retrospective chart review. Tertiary academic center Retrospective review of 167 patients who underwent TL from June 2000 to February 2012. Demographics, disease variables, and surgical factors were reviewed. Primary alaryngeal speech modality, speech outcome, and tracheoesophageal puncture (TEP) complication rates were assessed. Overall TEP speech success rate (primary or secondary) was 72%. Overall TEP speech success rate was 76% for those with primary TEP and was 68% for those with secondary TEP. TEP speech success rates at first, second, and beyond second year were 75%, 72%, and 70%, respectively. Success rates for primary TL, salvage TL, primary TL with pharyngeal reconstruction, or salvage TL with pharyngeal reconstruction groups were 71%, 72%, 73%, and 71%, respectively. TEP-related complications occurred in 43% of patients, with no difference in complication rates between primary versus salvage TL or primary versus secondary TEP. For those with complications, TEP success rate was 65%. This study showed TEP speech-outcome success rates lower than what has been historically reported. There was no significant difference in TEP speech outcome between primary versus salvage TL or primary versus secondary TEP. Patients with TEP-related complications had TEP speech-outcome success rates comparable to those without any complication. TEP may continue to be a superior option as a mode of speech in patients with TL, including those undergoing salvage TL. 4

Do Baseline Modified Barium Swallow at One Month Following Completion of Radiation Therapy in Head and Neck Cancer Patients?

Academi

Changing Trends of Speech Outcomes after Total Laryngectomy in the 21st Century

Objectives: Management of laryngeal cancer has changed significantly in the past decade. Total laryngectomy (TL) has been mainly reserved for patients with recurrence or failure after chemo-radiation or patients requiring major ablative and reconstructive surgeries. Tracheoesophageal puncture (TEP) continues to be the gold standard for speech rehabilitation, yet it is unknown what the overall speech outcomes are for individuals undergoing TL in the 21st century. Our study will describe the speech rehabilitation outcomes of patients after TL in the 21st century. Methods: This is a retrospective analysis of 391 patients who underwent TL from June 2000 to February 2012 with a minimum of one year follow-up. Demographic variables and medical/surgical factors related to laryngectomy will be reviewed. Patient speech rehabilitation outcomes will be assessed and categorized into the following groups: 1) use of esophageal speech; 2) use of electrolarynx; 3) use of TEP; 4) failure to achieve functional speech; and 5) non-compliant. To be in groups 1, 2, or 3, patients must use speech as the dominant mode of communication. Results: Patients who underwent TL in the 21st century may have overall decreased success rate in speech rehabilitation; there may be decreased success rate in the use of esophageal speech and TEP. Conclusions: The current gold standard for speech rehabilitation should be readdressed, as it may not adequately meet the need of the current patient populations. More up-to-date techniques and technologies are needed to improve the communication and speech rehabilitation of current laryngectomy patients

Integration of a Medical Voice Program in the Performing Community: Establishing an Extended Voice Team Network

This article will summarize the process of establishing and growing relationships with professional voice users and vocal organizations in the community, including educational institutions, large- and small-scale performing arts organizations, professional associations, individual professional voice users and teachers, and others. We will present a review of the literature and recommendations regarding integration of a voice program into the professional voice community. This will include identification of appropriate organizations and individuals for the extended voice network, methods of outreach, cultivation of relationships, and difficulties encountered. The idea of multidisciplinary treatment of voice disorders through a voice team has been well-established in the literature. Although many voice teams are further integrating themselves into their local communities, there has been little written about this. We hope that by sharing our process, we may provide information to others and learn more ourselves about how to better serve our professional voice communities

Quantifying Subjective and Objective Measures of Singing After Different Warm-Up Durations

Performing vocal warm-ups prior to singing repertoire has been shown to change the perceived quality and acoustic parameters of the voice. To date, there are no studies that specifically compare singers’ and listeners’ perceptions of vocal quality after various warm-up durations. To determine if specific warm-up durations (0, 5, 10, or 15 minutes) change subjective and objective measures of voice. Prospective cohort study. Information related to demographics, singing practice, medical history, and vocal hygiene were collected. First- and second-year collegiate classical voice majors completed a series of four warm-up times, 1 week apart, prior to singing Caro mio ben in a standard key for their voice type. A modified Voice Range Profile (mVRP), and the Evaluation of the Ability to Sing Easily (EASE) scale were completed. Participants blindly rated 30-second recorded audio clips using the Auditory-Perceptual Rating Instrument for Operatic Singing. Four independent expert blinded listeners rated all audio clips for each participant in random order. Six first-year and three second-year classical vocal performance majors completed all measures. Results of the EASE scale showed decreased scores with 5- and 10-minute warm-up duration, compared to 0 and 15 minutes of warm-up (P = 0.029 for the total EASE score and P = 0.044 for Rasch score). Delayed perceptual analysis of voice yielded nearly equal medians between warm-up durations for both self and expert-listener ratings. The mVRP showed that both 5 and 10 minutes of warm-up duration led to increased highest fundamental frequency for females (P = 0.017). This pilot study demonstrates the immediate self-perceived benefit for all participants and increased frequency range for females after performing 5 and 10 minutes of vocal warm-up. No significant differences were found in delayed perceptual analyses completed by the participants or the expert raters after the different warm-up durations. Future investigations should include a larger population and different levels of education and genres of singing