Development and evaluation of a novel tracheostoma button and fixation system (Provox LaryButton and LaryClip adhesive) to facilitate hands-free tracheoesophageal speech

Automatic speaking valve in tracheo-esophageal speech: treatment proposal for a widespread usage

PURPOSE

Aim of this study was to calculate the percentage of the Automatic Speaking Valve (ASV) use in a large cohort of laryngectomized patients with voice prosthesis (VP) and to analyze the main reasons for non-use. Subsequently, a specific rehabilitation training was proposed.

METHODS

One hundred-ten laryngectomized patients with VP were enrolled in the first phase of the study (census). Among them, 57 patients were included in the second phase (intervention), in which a training based on moving phonatory exercises was proposed. Structured questionnaires were used before and after training in order to investigate ASV use rate (days/week and hours/day; reasons for impeding the ASV use), average adhesive life-time during ASV use; hands-free speech duration; skin irritation. Patients also expressed their degree of on a VAS scale from 0 to 100.

RESULTS

In the census phase the percentage of use of ASV (everyday, without problems) was equal to 17.27% (19/110 patients). The main causes of disuse concerned excessive fatigue and poor durability of the adhesives. The analysis of the results pre vs. post-training showed a statistically significant increase (p < 0.05) in all the investigated parameters. Patients reported a good level of treatment compliance (average frequency of performing exercises equal to 4.2 ± 2.5 days/week for 1.4 ± 1.01 h/day) and high degrees of satisfaction. After treatment, the percentage of use of AVS increased by 43% reaching a rate of 60% (66/110 patients).

CONCLUSION

A specific and targeted approach that simulate the phonatory and breathing difficulties of everyday life can increase the ASV usage rate.

Improving Hands-Free Speech Rehabilitation in Laryngectomized Patients with a Moldable Adhesive

OBJECTIVE

This study aims to assess the product performance of a new moldable peristomal adhesive with corresponding heating pad designed to facilitate and improve automatic speaking valve (ASV) fixation for hands-free speech in laryngectomized patients.

METHODS

Twenty laryngectomized patients, all regular adhesive users with prior ASV experience, were included. Study-specific questionnaires were used for data collection at baseline and after two weeks of moldable adhesive use. The primary outcome parameters were adhesive lifetime during hands-free speech, use and duration of hands-free speech, and patient preference. Additional outcome parameters were satisfaction, comfort, fit, and usability.

RESULTS

The moldable adhesive enabled ASV fixation adequate for hands-free speech in the majority of participants. Overall, the moldable adhesive significantly increased adhesive lifetime and duration of hands-free speech compared to participants' baseline adhesives (p < 0.05), regardless of stoma depth, skin irritation, or regular use of hands-free speech at baseline. The participants who preferred the moldable adhesive (55% of participants) experienced a significant increase in the adhesive lifetime (median of 24 h, range 8-144 h) and improved comfort, fit, and ease of speech.

CONCLUSION

The moldable adhesive's lifetime and functional aspects, including the ease of use and custom fit, are encouraging outcomes and enable more laryngectomized patients to use hands-free speech more regularly.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2965-2970, 2023.

Improving Hands-free Speech Rehabilitation in Patients With a Laryngectomy: Proof-of-Concept of an Intratracheal Fixation Device

Permanent hands-free speech with the use of an automatic speaking valve (ASV) is regarded as the optimal voice rehabilitation after total laryngectomy. Due to fixation problems, regular ASV use in patients with a laryngectomy is limited. We have developed an intratracheal fixation device (ITFD) composed of an intratracheal button augmented by hydrophilic foam around its shaft. This study evaluates the short-term effectiveness and experienced comfort of this ITFD during hands-free speech in 7 participants with a laryngectomy. We found that 4 of 7 participants had secure ASV fixation inside the tracheostoma during hands-free speech for at least 30 minutes with the ITFD. The ITFD's comfort was perceived positively overall. The insertion was perceived as being mildly uncomfortable but not painful. This proof-of-concept study demonstrates the feasibility of the ITFD that might improve stomal attachment of ASVs, and it provides the basis for further development toward a prototype suitable for long-term daily use.

Analysis of tracheostoma morphology

OBJECTIVES

Existing fixation methods of automatic speaking valves (ASVs) suffer from shortcomings which partly are the result of insufficient conformity of the intratracheal fixation method's shape to the tracheostoma anatomy. However, quantitative data are lacking and will be helpful to analyse solutions for airtight fixation. This article provides such data.

PATIENTS AND METHODS

The tracheostoma morphology was measured in computerized tomography scans of 20 laryngectomized patients. Measured were transverse and sagittal diameters, transition angle between skin level and tracheostoma lumen and between the tracheostoma lumen to the trachea, TE valve placement and stoma depth.

RESULTS

The mean transverse and sagittal diameters of the stoma at the peristomal lip are 19.2 mm [standard deviation (SD 5.2 mm)] and 17.6 mm (SD 5.3 mm), respectively. The mean transition angles are 84.5° (SD 15.6°) at skin level and 153.6° (SD 11.7°) into the trachea. The mean distance between TE valve and peristomal lip is 13.5 mm (SD 7.0 mm). The mean stoma depth is 14.0 mm (SD 6.4 mm).

CONCLUSIONS

Due to the large variation, no 'average tracheostoma morphology', suitable for shaping a generic intratracheal fixation device, can be defined. Therefore, providing an airtight fixation in each patient would require a large range of different sizes, customization or a new approach.

Ex vivo humidifying capacity and patient acceptability of stoma cloths in laryngectomized individuals

BACKGROUND

Heat and moisture exchangers (HMEs) improve respiratory function after laryngectomy, but there is virtually no information on the benefit of traditional stoma cloths or other covers.

METHODS

Two sequential studies were performed: (1) an ex vivo test was used to compare the humidifying capacity of stoma cloths to other coverings; and (2) a 4-week randomized trial was then performed to assess patient acceptability of cloths both alone and with an HME (N = 18).

RESULTS

The humidifying capacity of the coverings tested varied widely. For stoma cloths, a humidifying capacity of 13.7 mg/L was found to decrease to 8.5 mg/L if air-leaks around the cloth occurred. Patients who used HMEs disliked stoma cloths because they interfered with voicing, they became soiled more easily, and were less effective at reducing coughing and mucus production.

CONCLUSION

Although less acceptable to patients who use an HME, stoma cloths do provide significant humidifying capacity and should be encouraged when HMEs are unavailable or inappropriate. © 2017 Wiley Periodicals, Inc. Head Neck 39: 921-931, 2017.

[Satisfaction of patients with tracheostomal epithesis]

BACKGROUND

The utilization of craniofacial prosthesis has proven to be very successful for craniofacial defects. However, there is a lack of knowledge about the value of an epithesis for voice rehabilitation in patients with tracheostomy. The aim of this study was to describe application of the tracheostomy epithesis and to present a systematic analysis of the functional results of this prosthetic technique.

MATERIALS AND METHODS

This retrospective analysis included 48 patients on follow-up being treated in three different centers after laryngectomy and/or tracheostomy between 2008 and 2014. Subjects were given a questionnaire with items such as speech quality, quality of life, free hand speech ability, respiratory quality and sufficient tracheostomal sealing comparing values before and after application of an individually custom-made tracheostomy epithesis. Twenty-eight answered the questionnaire and could be reported.

RESULTS

Twenty-eight of 48 patients were consistently being included in follow-up. The statistical analysis revealed a significant improvement of tracheostoma occlusion (p < 0.05) and improvement in free hand speech ability (p < 0.05). A leakage of air during voice production could be prevented in 59.3% after application of an epithesis. Quality of life correlated directly with successful utilization of an epithesis.

CONCLUSION

In the literature, different industrialized products are described to realize occlusion of the tracheostoma for sufficient speech production without using the hands. In numerous cases commercial solutions fail and the patients need individual modifications. Our study first describes the evaluation of custom-made tracheostomal epithesis. From our observed results we advocate the individual tracheostomal epithesis as a durable solution for voice rehabilitation.

Patients' experiences with HMEs and attachments after total laryngectomy

OBJECTIVES

The short-term and long-term beneficial effects of HME use by laryngectomees are well described in literature. In this study, we document how laryngectomised patients, who previously did not use an HME, get accustomed to the use of HME and attachments.

PARTICIPANTS

Thirty patients, who were at least 3 months post-laryngectomy and previously did not use an HME, were followed for 12 weeks and were asked to complete questionnaires about their experiences with the HME and attachments.

RESULTS

Results show that when patients start using an HME, they report some difficulties with breathing resistance during the first 2 weeks of use. However, after 6 weeks, they have become accustomed to the breathing resistance and after 12 weeks over 96% reports that breathing was equal or less strenuous compared with breathing though an open stoma. Only a small proportion of patients experienced problems with increased coughing when starting HME use.

CONCLUSIONS

This study provides insight in the way laryngectomised patients are experiencing the use of HMEs in the first weeks. These outcomes can contribute to a better knowledge of HME use by healthcare providers and help them to manage patient expectations and improving support to patients in achieving compliant HME use.

Development and first data of a customized short tracheal cannula based on digital data

PURPOSE

At the moment, there is an inadequate margin fit of commercially available stoma buttons. The aim of the present study was to develop a customized short tracheal cannula based on digital data. Furthermore, the applied material has to be evaluated considering germ colonization and appropriate cleaning procedures.

METHODS

Computed tomographies of 53 patients who underwent laryngectomy were surveyed. Based on the digital data, a customized short tracheal cannula was created and manufactured from silicone. The new cannula was incorporated in ten patients and worn for 4 weeks. A clinical examination of an otolaryngologist and subjective assessment of the patients were carried out. Furthermore, microbiological test considering germ colonization was performed.

RESULTS

The customized short tracheal cannula could be incorporated in all patients. The clinical results showed no irritation or mucosal lesions. The subjective individual evaluation by the patients was promising. The proposals for improvement could be considered. The microbiological examination revealed a higher contamination of the silicone compared to the silver cannulas. Both chemical and mechanical decontamination showed sufficient results.

CONCLUSION

A workflow for development and manufacturing of a customized short tracheal cannula from digital data could be established. The cannula is compatible to standard equipment and routine cleaning procedures. Clinical studies are required to evaluate the potential benefit for patients.

Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands

PURPOSE OF REVIEW

Total laryngectomy rehabilitation (TLR) in Europe is not uniform, with quite some differences in approach and infrastructure between various countries. In, for example, the Netherlands, Switzerland, Scandinavia, and more recently also in the UK, head and neck cancer (HNC) treatment and rehabilitation shows a high level of centralization in dedicated HNC centres. In other European countries, the level of centralization is lower, with more patients treated in low-volume hospitals. This article focusses on the situation in the Netherlands and, where applicable, will discuss the regional variations in Europe.

RECENT FINDINGS

Prosthetic surgical voice restoration (PSVR) presently is the method of choice in Europe, and use of oesophageal and electrolarynx voice has moved to the background. In most European countries (except the UK and Ireland), PSVR is physician driven, with an indispensable role for speech-language pathologists and increasingly for oncology nurses. Indwelling voice prostheses are mostly preferred, also because these devices can be implanted at the time of trachea-oesophageal puncture. Pulmonary rehabilitation is achieved with heat and moisture exchangers, which, based on extensive clinical and basic physiology research, are considered an obligatory therapy measure. In addition to PSVR, also issues such as smoking cessation, dysphagia/swallowing rehabilitation, and olfaction/taste rehabilitation are discussed. Especially, the latter has shown great progress over the last decade and is another example of increasing implementation of evidence-based practice in TLR.

SUMMARY

TLR has shown considerable progress over the last decades, and through the intensified collaboration between all clinicians involved, significantly has improved vocal, pulmonary, and olfactory rehabilitation after total laryngectomy.

Further experience with modification of an intraluminal button for hands-free tracheoesophageal speech after laryngectomy

Tracheoesophageal (TE) speech using a voice prosthesis and hands-free speaking valve with an intraluminal attachment is the gold standard for voice restoration after total laryngectomy. Modification of a standard self-retaining silicone cannula or laryngectomy button often aids in the attachment of a speaking valve within the tracheal lumen for hands-free TE speech production. An increased number of laryngectomized individuals are able to achieve hands-free TE speech when the standard length, flange, and diameter of a silicone button is customized to accommodate individual tracheostomal contours. A technique is presented for modification of a standard silicone laryngectomy button to facilitate hands-free TE speech after total laryngectomy.

[Finger-free speech with the Provox FreeHands HME Automatic Tracheostoma Valve system. Clinical long-term experience]

INTRODUCTION

The use of voice prostheses allows excellent rehabilitation of laryngectomized patients but it is considered a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gestures or to work with both hands. An automatic tracheostoma valve helps patients to overcome this problem.

PATIENTS, MATERIAL AND METHODS

A total of 17 laryngectomized patients were asked to join a long-term study 18 months after having been fitted with a Provox FreeHands HME Automatic Tracheostoma Valve system. The patients completed a questionnaire in order to assess satisfaction, voice quality, wearing comfort, fixation, potential problems and the effectiveness of the HME cassette.

RESULTS

Of the 17 patients 4 discontinued the study due to problems of securing the valve to the skin (n=2) or fistula leakage (n=2). Of the remaining patients 7 wore the valve daily for an average of 6 h. Of the patients 76% considered it a great advantage to be able to speak without using their hands. With the Provox FreeHands HME Automatic Tracheostoma Valve system, maximum phonation time was 8.5 s (+/-6.8) and the dynamic range was 21.7 decibels (+/-5.6).

CONCLUSION

The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent long-term compliance and good voice rehabilitation.

3D stereophotogrammetry for the assessment of tracheostoma anatomy

CONCLUSION

3D stereophotogrammetry is a useful tool for quantitative assessment of tracheostoma anatomy, and thus in future could possibly play a role in solving current problems with peristomal and intratracheal fixation of stoma appliances.

OBJECTIVES

Differences in tracheostoma anatomy between laryngectomized patients are held partly responsible for the differences in duration of attachment of standard peristomal adhesives for heat and moisture exchangers (HMEs) and automatic stoma valves (ASVs). Accurate information on a set of basic stoma anatomy parameters should be helpful to overcome fixation problems in individual patients and in the general laryngectomy population.

PATIENTS AND METHODS

This was an exploratory observational pilot study in 20 laryngectomized patients. Three-dimensional (3D) images of the tracheostoma and surrounding tissue were captured with a 3D digital camera, which applies the advanced principles of stereophotogrammetry. Data were analysed by using a 3D editing program. The following tracheostoma parameters were measured for each patient: horizontal and vertical diameters, circumference, depth and surface.

RESULTS

Inter-observer outcomes show a mean stoma circumference of 58.2 mm (SD 11.6 mm). The mean surface was calculated at 186.6 mm2 (SD 61 mm2). The mean size of the stoma's horizontal diameter and vertical diameter was 14.7 mm (SD 2.9 mm) and 19.0 mm (SD 3.4 mm), respectively. The mean depth of the stoma in relation to the right sternal head of the m. sternocleidomastoideus was 15.5 mm (SD 5.4 mm) and in relation to the left it was 16 mm (SD 5.6 mm).

Hands-free speech after surgical voice rehabilitation with a Provox® voice prosthesis: experience with the Provox FreeHands HME tracheostoma valve® system

Excellent results have been reported with the use of voice prostheses for the rehabilitation of laryngectomees. Patients, however, consider it a disadvantage that the tracheostoma must be closed manually for speech production. This limits their ability to simultaneously communicate by gesture or to work with both hands. An automatic tracheostoma valve helps patients overcome this problem. We describe a prospective clinical trial evaluating our experience with the Provox FreeHands HME Automatic Tracheostoma Valve system. Twenty-four laryngectomees were randomly selected from the patients who had undergone laryngectomy at the ENT Department. Immediately, after 4 weeks and 6 months later having been fitted with a Provox FreeHands HME, the patients were asked to complete a questionnaire in order to assess their satisfaction, voice quality, wearing comfort, fixation, potential problems, and the effectiveness of the HME cassette. In addition, we investigated relevant voice quality parameters including dynamics range, frequency range of the speaking voice, and maximum phonation time. Seven patients discontinued the study due to problems of securing the valve to the skin (four patients) or recurrent cancer (three patients). Ten of the remaining 17 patients wore the valve daily for an average of 8.4 h. A total of 88% of the patients considered it a great advantage to be able to speak without having to use their hands. With the Provox FreeHands HME, maximum phonation time was 8.7 (+/-6.2) s and the dynamic range was 21.9 (+/-5.8) decibels. The results show that the Provox FreeHands HME Automatic Tracheostoma Valve system not only allows hands-free speech but is also associated with excellent compliance and good voice rehabilitation.