For updating your knowledge, visit one of the workshops organized by the Global Postlaryngectomy Rehabilitation Academy.
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Download the complete PDF of the 4th edition "A practical guide to postlaryngectomy rehabilitation, including the Provox system"; editor: Frans J.M. Hilgers; publisher: The Netherlands Cancer Institute / Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; CD-Rom 2003; ISBN 90-75575-05-X.
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Introduction
The increasing use of voice prostheses has improved the prospects of vocal rehabilitation after total laryngectomy considerably. Consistently high success rates have been reported in the last 20 years, after the first description of a useful prosthetic device by Singer and Blom in 1979. Compared with esophageal and electrolarynx speech, a higher percentage of patients achieve an acceptable voice, enabling communication under almost all social circumstances. Success rates up to 90% are not exceptional any longer, making prosthetic voice rehabilitation the method of choice for early and reliable restoration of oral communication after total laryngectomy.
In general, two types of voice prosthesis can be distinguished, i.e. non-indwelling and indwelling devices. The former devices can be removed and replaced by the patient. The latter stay in place permanently and have to be removed and replaced by the clinician at the end of the device life, which is determined by leakage of fluids through the prosthesis or an increased airflow resistance. Indwelling devices have the definite advantage that the patient’s dexterity plays a less important role in the daily maintenance of the device, which mainly consists of cleaning with a brush and/or a flushing device without the need of regularly replacing the prosthesis. Even with increasing age and/or decreasing health a useful (prosthetic) voice can be preserved.
Based on our experiences with surgical and prosthetic voice rehabilitation (Staffieri’s procedure, and the Blom-Singer, Panje, and Groningen prostheses), acquired since 1979 in the Department of Otolaryngology-Head & Neck Surgery of the Netherlands Cancer Institute, we co-developed since 1988 a novel low-resistance, indwelling silicon voice prosthesis, Provox, in close collaboration with the medical engineering industry.1,2 It has been successfully used in our Institute since then in all laryngectomized patients. The long-term clinical results obtained with this voice prosthesis are favorable.3-6
Additional instruments and devices to facilitate its application have been developed as well. 1 Their use, along with the surgical techniques involved and the management of many of the clinical and technical aspects, are the subject of this manual. The subsequent development of a second generation (Provox2) voice prosthesis for bidirectional, i.e. anterograde and retrograde, application is a further improvement of the Provox system.7 The anterograde replacement in the outpatient office has considerably decreased the discomfort of this procedure for the patient and the medical professionals involved.7,8
The problem of post-laryngectomy pulmonary function disorders has also been addressed extensively in our clinic.9-11 The relevance of simultaneous pulmonary rehabilitation for optimal voice restoration and an improved quality of life has become increasingly clear in recent years.12-14 The development of a novel, dedicated ‘valved’ Heat and Moisture Exchanger (HME, Provox HME) has added a new tool to the armamentarium of the clinicians, in this respect.15-17
Hands-free speech is the ultimate goal of postlaryngectomy voice rehabilitation, preferably taking care of pulmonary protection and rehabilitation at the same time. This is now possible with the newly developed Provox FreeHands HME.18
A further problem resulting from the permanent disconnection of the upper and lower airways is a deterioration of the sense of smell. The main cause for this disturbing side effect of total laryngectomy is the lack of a nasal airflow, which normally transports odorous substances to the olfactory epithelium high up in the nose. There are two types of smelling: ‘passive’ and ‘active’ smelling. Passive smelling continuously takes place during normal nasal breathing, whereas active smelling (‘sniffing’) is used intentionally. Re-cent research in our Institute has given more insight in the magnitude of the olfaction problem after total laryngectomy.19 Stoma breathing precludes passive smelling and only some 30% of the patients is still able to actively smell something. However, it now appears to be possible to restore olfaction in a considerable number of laryngectomized individuals. 20,21 The nasal airflow-inducing maneuver (or ‘polite yawning’ technique), which enables active smelling again, will be described in detail.
It should be stressed that vocal, pulmonary and olfactory rehabilitation after total laryngectomy is a multi-disciplinary team effort and that the motivation of the Otolaryngologist, the (head&neck) oncology nurse, the speech therapist and last, but not least, the patient is mandatory to obtain optimal results.
In general, two types of voice prosthesis can be distinguished, i.e. non-indwelling and indwelling devices. The former devices can be removed and replaced by the patient. The latter stay in place permanently and have to be removed and replaced by the clinician at the end of the device life, which is determined by leakage of fluids through the prosthesis or an increased airflow resistance. Indwelling devices have the definite advantage that the patient’s dexterity plays a less important role in the daily maintenance of the device, which mainly consists of cleaning with a brush and/or a flushing device without the need of regularly replacing the prosthesis. Even with increasing age and/or decreasing health a useful (prosthetic) voice can be preserved.
Based on our experiences with surgical and prosthetic voice rehabilitation (Staffieri’s procedure, and the Blom-Singer, Panje, and Groningen prostheses), acquired since 1979 in the Department of Otolaryngology-Head & Neck Surgery of the Netherlands Cancer Institute, we co-developed since 1988 a novel low-resistance, indwelling silicon voice prosthesis, Provox, in close collaboration with the medical engineering industry.1,2 It has been successfully used in our Institute since then in all laryngectomized patients. The long-term clinical results obtained with this voice prosthesis are favorable.3-6
Additional instruments and devices to facilitate its application have been developed as well. 1 Their use, along with the surgical techniques involved and the management of many of the clinical and technical aspects, are the subject of this manual. The subsequent development of a second generation (Provox2) voice prosthesis for bidirectional, i.e. anterograde and retrograde, application is a further improvement of the Provox system.7 The anterograde replacement in the outpatient office has considerably decreased the discomfort of this procedure for the patient and the medical professionals involved.7,8
The problem of post-laryngectomy pulmonary function disorders has also been addressed extensively in our clinic.9-11 The relevance of simultaneous pulmonary rehabilitation for optimal voice restoration and an improved quality of life has become increasingly clear in recent years.12-14 The development of a novel, dedicated ‘valved’ Heat and Moisture Exchanger (HME, Provox HME) has added a new tool to the armamentarium of the clinicians, in this respect.15-17
Hands-free speech is the ultimate goal of postlaryngectomy voice rehabilitation, preferably taking care of pulmonary protection and rehabilitation at the same time. This is now possible with the newly developed Provox FreeHands HME.18
A further problem resulting from the permanent disconnection of the upper and lower airways is a deterioration of the sense of smell. The main cause for this disturbing side effect of total laryngectomy is the lack of a nasal airflow, which normally transports odorous substances to the olfactory epithelium high up in the nose. There are two types of smelling: ‘passive’ and ‘active’ smelling. Passive smelling continuously takes place during normal nasal breathing, whereas active smelling (‘sniffing’) is used intentionally. Re-cent research in our Institute has given more insight in the magnitude of the olfaction problem after total laryngectomy.19 Stoma breathing precludes passive smelling and only some 30% of the patients is still able to actively smell something. However, it now appears to be possible to restore olfaction in a considerable number of laryngectomized individuals. 20,21 The nasal airflow-inducing maneuver (or ‘polite yawning’ technique), which enables active smelling again, will be described in detail.
It should be stressed that vocal, pulmonary and olfactory rehabilitation after total laryngectomy is a multi-disciplinary team effort and that the motivation of the Otolaryngologist, the (head&neck) oncology nurse, the speech therapist and last, but not least, the patient is mandatory to obtain optimal results.
