Knowledge and Skills for Speech-Language Pathologists With Respect to Evaluation and Treatment for Tracheoesophageal Puncture and Prosthesis

Knowledge and Skills

ASHA Special Interest Division 3, Working Group on Voice and Voice Disorders

About this Document

This knowledge and skills document is an official statement of the American Speech-Language-Hearing Association (ASHA). This document was prepared by the ASHA Special Interest Division 3, Working Group on Voice and Voice Disorders. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members. The Legislative Council approved the document as official policy of the Association in March 2003.

Table of Contents

The ASHA Scope of Practice (2001) states that the practice of speech-language pathology includes providing services for individuals who undergo tracheoesophageal voice restoration surgery for placement of a tracheoesophageal prosthesis (TEP). The Preferred Practice Patterns (1997) are statements that define universally applicable characteristics of practice. It is required that individuals who practice independently in this area hold the Certificate of Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics, including Principle of Ethics II Rule B, which states: “Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience” (ASHA, 2003). ASHA certification in speech-language pathology is necessary, but meeting certification requirements is not sufficient to qualify a person to perform the preferred practice patterns in speech-language pathology discussed in this report.

Education and training for implementation of a TEP following tracheoesophageal voice restoration surgery may be obtained by a variety of means. Some of the training should take place in a clinical setting allowing the SLP to work with more experienced professionals and a number of patients. SLPs who intend to deliver and manage TEP speakers must ensure that they have the knowledge and skills necessary to provide a continuum of service. These knowledge and skill areas form the basis for assessing clinical competency in this specialized area of practice. Outlined below are the specific objectives, as well as the necessary proficiencies and the knowledge and skills required to accomplish each objective.

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I. Objective: To select appropriate candidates for TEP.

Proficiency in:

  1. Identifying physical, mental, and social factors that contraindicate developing functional TE speech.

    Knowledge/skills needed:

    1. Knowledge of the physical, mental, and social factors that contraindicate or complicate TE speech.

    2. Knowledge of the support systems needed for successful TE speech.

  2. Discussing aspects of tracheoesophageal voice restoration surgery and various TEPs with the patient, significant others, and other health professionals.

    Knowledge/skills needed:

    1. Knowledge of anatomical and physiological requirements for producing tracheoesophageal sound and articulating alaryngeal speech.

    2. Knowledge of tracheoesophageal voice restoration surgical procedures and timing relative to laryngectomy surgery.

    3. Knowledge of the advantages and disadvantages of the tracheoesophageal voice restoration surgical procedure and the various TEPs.

    4. Knowledge of the purpose of a TEP.

    5. Knowledge of prosthesis function, uses, and care.

  3. Evaluating the sound generating potential of the pharyngoesophageal (PE) segment by insufflating the esophagus and interpreting the results.

    Knowledge/skills needed:

    1. Knowledge of the rationale for insufflation of the esophagus to generate sound at the PE segment.

    2. Knowledge of esophageal insufflation test procedures, risks, and infection control.

    3. Knowledge of what constitutes a successful insufflation test response.

    4. Knowledge of the factors that can result in false negative or false positive responses using the insufflation test.

    5. Knowledge of specific patient safety if topical anesthetic is required, and of the setting and/or circumstances in which administration of a topical anesthetic is appropriate (ASHA, 1992).

  4. Participating in administration and interpretation of the results of videofluoroscopy to further assess the structure and function of the PE segment.

    Knowledge/skills needed:

    1. Knowledge of the rationale for completing videofluoroscopy in patients who present with a negative insufflation test or failure to develop appropriate TEP voice post-surgery.

    2. Knowledge of the procedures used by radiologists and speech-language pathologists to perform videofluoroscopy on laryngectomy patients.

    3. Knowledge of the factors distinguishing normal PE segment on videofluoroscopy from fibrotic or hypertrophic segments.

  5. Participating in interpretation of the results of induced muscle relaxation of the PE segment.

    Knowledge/skills needed:

    1. Knowledge of the procedures used by the otolaryngologist to induce muscle relaxation.

    2. Knowledge of what constitutes a successful response subsequent to induced muscle relaxation of the PE segment.

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II. Objective: To successfully fit a TEP.

Proficiency in:

  1. Measuring fistula length.

    Knowledge/skills needed:

    1. Knowledge of indications and contraindications for initiating prosthesis fitting.

    2. Knowledge regarding use of gauges for measuring puncture length.

    3. Knowledge of specific patient safety precautions if topical anesthetic is required, and of the setting and/or circumstances in which administration of a topical anesthetic is appropriate (ASHA, 1992).

  2. Selecting type and style of TE prosthesis.

    Knowledge/skills needed:

    1. Knowledge of the various types of prosthesis features:

      1. Size.

      2. Shape.

      3. Resistance levels.

      4. Insertion techniques.

      5. Placement longevity.

      6. Composition.

    2. Knowledge of how features relate to patient's needs:

      1. Ease of insertion.

      2. Sound production.

      3. Successful stoma occlusion.

    3. Knowledge of the manufacturer's instructions.

  3. Inserting the prosthesis.

    Knowledge/skills needed:

    1. Knowledge of catheters or stents used to modify the lumen of the fistula to make it compatible with easy insertion of a prosthesis.

    2. Knowledge of the appropriate techniques for prosthesis insertion for each available type of prosthesis that may be required.

    3. Knowledge of the safety precautions needed for each type of prosthesis that may be inserted.

    4. Knowledge of specific patient safety precautions if topical anesthetic is required, and of the setting and/or circumstances in which administration of a topical anesthetic is appropriate (ASHA, 1992).

  4. Assuring the prosthesis is properly seated through the fistula and adequately shunts pulmonary air into the esophagus for sound production during speech.

    Knowledge/skills needed:

    1. Knowledge of the factors that could interfere with prosthesis function (see objective IX).

    2. Knowledge of the testing procedures used to identify prosthesis success or failure.

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III. Objective: To teach the patient to insert the prosthesis and produce voicing.

Proficiency in:

  1. Inserting the prosthesis.

    Knowledge/skills needed:

    1. Knowledge of effective lighting, insertion devices, lubricants, and adhesives.

    2. Knowledge of using catheters or stents to facilitate insertion.

    3. Knowledge of the insertion systems.

    4. Knowledge of the risks associated with prosthesis insertion and withdrawal (e.g., aspiration, bleeding).

    5. Knowledge of safety measures to prevent aspiration of the prosthesis.

  2. Teaching the patient to phonate with the prosthesis.

    Knowledge/skills needed:

    1. Knowledge of behaviors that facilitate production of TE sound.

    2. Knowledge of behaviors counterproductive to production of TE sound.

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IV. Objective: To teach the patient or significant others how to maintain working condition of the prosthesis.

Proficiency in:

  1. Teaching the patient proper hygiene for maintenance of the prosthesis, stoma, and puncture.

    Knowledge/skills needed:

    1. Knowledge of the procedures used to clean the stoma, peristomal site, and prosthesis when it is in the puncture, and when it has been removed.

    2. Knowledge of the effects of the Candida organism on the prosthesis and methods of controlling its growth.

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V. Objective: To select appropriate candidates for a tracheostoma valve.

Proficiency in:

  1. Understanding the advantages and disadvantages of placement of a tracheostoma valve and tracheostoma valve housing.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the tracheostoma valve and its housing.

    2. Knowledge of the relationship between peristomal configuration and tracheostoma valve retention.

    3. Identifying factors that contraindicate or complicate the tracheostoma valve retention.

    4. Knowledge of the physical, mental, and social factors that impact on the care and function of the tracheostoma valve and its housing.

  2. Explaining all aspects of the tracheostoma valve to the patient, significant others, and other health professionals.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the tracheostoma valve.

    2. Identifying physical, mental, and social factors that contraindicate or complicate tracheostoma valve retention.

    3. Knowledge of the relationship between peristomal configuration and tracheostoma valve retention.

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VI. Objective: To successfully fit the tracheostoma with a valve housing and valve.

Proficiency in:

  1. Selecting the appropriate style and type of valve housing.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available valve housings.

    2. Knowledge of how features of the stoma and valve housing relate to the patient's needs.

      1. Ease of fitting.

      2. Stoma shape.

      3. Stoma size.

      4. Stoma contour.

      5. Stoma tissue sensitivity.

  2. Inserting the self-retaining valve housing into the tracheostoma

    Knowledge/skills needed:

    1. Knowledge of the risks associated with self-retaining valve housing insertion and withdrawal (e.g. aspiration, bleeding).

    2. Knowledge of safety measures to prevent aspiration of self-retaining valve housing.

    3. Knowledge of the manufacturer's instructions.

    4. Knowledge of insertion of self-retaining housing into the tracheostoma.

  3. Applying valve housing to the tracheostoma area.

    Knowledge/skills needed:

    1. Knowledge of the procedures used to prepare the peristomal area.

    2. Knowledge of the manufacturer's instructions.

    3. Knowledge of alignment of the housing with the stoma.

  4. Selecting an appropriate tracheostoma valve.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available tracheostoma valves.

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VII. Objective: To teach the patient how to use the tracheostoma valve.

Proficiency in:

  1. Applying the housing and valve over or in the stoma.

    Knowledge/skills needed:

    1. Knowledge of the procedures used to prepare the peristomal area.

    2. Knowledge of the manufacturer's instructions.

    3. Knowledge of alignment of housing with or within the self-retaining stoma.

  2. Explaining safety precautions when using the tracheostoma valve.

    Knowledge/skills needed:

    1. Knowledge of appropriate valve and valve housing use.

    2. Knowledge of the methods to prevent valve and valve housing loss into the lower respiratory tract.

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VIII. Objective: To teach the patient or significant others to care for the tracheostoma valve and valve housing.

Proficiency in:

  1. Cleaning the tracheostoma valve and housing if applicable.

    Knowledge/skills needed:

    1. Knowledge of the manufacturer's instructions.

    2. Knowledge of adhesive solvents.

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IX. Objective: To select appropriate candidates for a heat and moisture exchanger and housing.

Proficiency in:

  1. Understanding the advantages and disadvantages of placement of a heat and moisture exchanger and housing.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the heat and moisture exchanger and its housing.

    2. Knowledge of the relationship between peristomal configuration and the heat and moisture exchanger and its housing.

    3. Identifying factors that contraindicate or complicate heat and moisture exchanger retention.

    4. Knowledge of the physical, mental, and social factors that impact on the care and function of the heat and moisture exchanger and its housing.

  2. Explaining all aspects of the heat and moisture exchanger and housing to the patient, significant others, and other health professionals.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the heat and moisture exchanger and housing.

    2. Identifying physical, mental, and social factors that contraindicate or complicate heat and moisture exchanger retention.

    3. Knowledge of the relationship between peristomal configuration and heat and moisture exchanger retention.

    4. Knowledge of the signs and symptoms of respiration problems related to the heat and moisture exchanger.

    5. Knowledge of changes in airway resistance created by using the heat and moisture exchanger, and the need to adapt to these changes.

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X. Objective: To successfully fit the tracheostoma with a heat and moisture exchanger and housing.

Proficiency in:

  1. Selecting the appropriate style and type of heat and moisture exchanger housing.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available heat and moisture exchanger housings.

    2. Knowledge of how features of the stoma and heat and moisture exchanger housing relate to the patient's needs.

      1. Ease of insertion.

      2. Stoma shape.

      3. Stoma size.

      4. Stoma contour.

      5. Stoma tissue sensitivity.

  2. Inserting the self-retaining heat and moisture exchanger housing into the tracheostoma.

    Knowledge/skills needed:

    1. Knowledge of the risks associated with self-retaining heat and moisture exchanger housing insertion and withdrawal (e.g. aspiration, bleeding).

    2. Knowledge of safety measures to prevent aspiration of self-retaining heat and moisture exchanger housing.

    3. Knowledge of the manufacturer's instructions.

    4. Knowledge of insertion of self-retaining housing into the tracheostoma.

  3. Applying heat and moisture exchanger housing to the tracheostoma area.

    Knowledge/skills needed:

    1. Knowledge of the procedures used to prepare the peristomal area.

    2. Knowledge of the manufacturer's instructions.

    3. Knowledge of alignment of the housing with the stoma.

  4. Selecting an appropriate heat and moisture exchanger.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available heat and moisture exchangers.

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XI. Objective: To teach the patient or significant other how to use the heat and moisture exchanger.

Proficiency in:

  1. Applying the heat and moisture exchanger and housing over or in the self-retaining stoma.

    Knowledge/skills needed:

    1. Knowledge of the procedures used to prepare the peristomal area.

    2. Knowledge of the manufacturer's instructions.

    3. Knowledge of alignment of housing with or within the self-retaining stoma.

  2. Explaining safety precautions when using the heat and moisture exchanger.

    Knowledge/skills needed:

    1. Knowledge of appropriate heat and moisture exchanger and housing use.

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XII. Objective: To teach the patient or significant other to care for the heat and moisture exchanger and housing.

Proficiency in:

  1. Cleaning the heat and moisture exchanger housing if applicable.

    Knowledge/skills needed:

    1. Knowledge of the manufacturer's instructions.

    2. Knowledge of adhesive solvents.

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XIII. Objective: To select appropriate candidates for a laryngectomy tube.

Proficiency in:

  1. Understanding the advantages and disadvantages of placement of a laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the laryngectomy tube.

    2. Knowledge of the relationship between tracheostomal configuration and the laryngectomy tube.

    3. Knowledge of the relationship between TE valve position and the laryngectomy tube.

    4. Identifying factors that contraindicate or complicate laryngectomy tube retention.

    5. Knowledge of the physical, mental, and social factors that impact on the care and function of the laryngectomy tube.

  2. Explaining all aspects of the laryngectomy tube to the patient, significant others, and other health professionals.

    Knowledge/skills needed:

    1. Knowledge of the function, application, use, and care of the laryngectomy tube.

    2. Identifying physical, mental, and social factors that contraindicate or complicate laryngectomy tube retention.

    3. Knowledge of the relationship between tracheostomal configuration and laryngectomy tube retention.

    4. Knowledge of the signs and symptoms of respiration problems related to the laryngectomy tube.

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XIV. Objective: To fit the tracheostoma with a laryngectomy tube.

Proficiency in:

  1. Selecting the appropriate style and type of laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available laryngectomy tubes.

    2. Knowledge of how features of the tracheostoma and laryngectomy tube relate to the patient's needs.

      1. Ease of insertion.

      2. Stoma shape.

      3. Stoma size.

      4. Stoma contour.

      5. Stoma tissue sensitivity.

  2. Inserting the laryngectomy tube into the tracheostoma.

    Knowledge/skills needed:

    1. Knowledge of the risks associated with laryngectomy tube insertion and withdrawal (e.g. aspiration, bleeding).

    2. Knowledge of safety measures to prevent aspiration of the laryngectomy tube.

    3. Knowledge of the manufacturer's instructions.

    4. Knowledge of the insertion of the laryngectomy tube into the tracheostoma.

  3. Selecting an appropriate laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of the types and features of available laryngectomy tubes.

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XV. Objective: To teach the patient how to use the laryngectomy tube.

Proficiency in:

  1. Inserting the laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of procedures used to prepare the tracheostoma area.

    2. Knowledge of the manufacturer's instructions.

    3. Knowledge of alignment of the laryngectomy tube with or without the TEP.

  2. Explaining safety precautions when using the laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of the appropriate laryngectomy tube.

    2. Knowledge of methods to prevent the laryngectomy tube from entering into the lower respiratory tract.

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XVI. Objective: To teach the patient or significant others to care for the laryngectomy tube.

Proficiency in:

  1. Cleaning the laryngectomy tube.

    Knowledge/skills needed:

    1. Knowledge of the manufacturer's instructions.

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XVII. Objective: To effectively problem-solve issues arising with the prosthesis, tracheostoma valve, tracheostoma valve housing, heat and moisture exchanger, or laryngectomy tube.

Proficiency in:

  1. Understanding how to resolve problems with the voice prosthesis.

    Knowledge/skills needed:

    1. Knowledge of possible causes of leakage through or around the prosthesis.

    2. Knowledge of possible causes of blockage of shunted air from the lower respiratory tracts to the esophagus for voice production.

    3. Knowledge of precautions to prevent changes in tissue or side effects thereof.

    4. Knowledge of the possible causes of substandard alaryngeal voice following post-prosthesis fitting.

    5. Knowledge of precautions to prevent aspiration of the prosthesis either during or after placement.

    6. Knowledge of possible dysphagia symptoms related to prosthesis sizing or malfunction.

    7. Knowledge of the signs and symptoms of respiration problems related to the prosthesis.

  2. Understanding how to resolve problems with the tracheostoma valve.

    Knowledge/skills needed:

    1. Knowledge of precautions to prevent aspiration of the tracheostoma valve either during or after placement.

    2. Knowledge of the possible causes of substandard alaryngeal voice either during or after placement of the tracheostoma valve.

    3. Knowledge of the signs and symptoms of respiration problems related to the tracheostoma valve.

  3. Understanding how to resolve problems with the tracheostoma valve housing

    Knowledge/skills needed:

    1. Knowledge of the precautions to prevent changes in tissue or side effects thereof.

    2. Knowledge of the reasons for not attaining an adequate seal of the tracheostoma valve housing around and within the self-retaining stoma site.

    3. Knowledge of the possible causes of substandard alaryngeal voice following placement of the tracheostoma valve housing.

    4. Knowledge of the signs and symptoms of respiration problems related to the tracheostoma valve housing.

  4. Understanding how to resolve problems with the heat and moisture exchanger.

    Knowledge/skills needed:

    1. Knowledge of precautions to prevent aspiration of the heat and moisture exchanger either during or after placement.

    2. Knowledge of the signs and symptoms of respiration problems related to the heat and moisture exchanger.

  5. Understanding how to resolve problems with the heat and moisture exchanger housing.

    Knowledge/skills needed:

    1. Knowledge of precautions to prevent changes in tissue or side effects thereof.

    2. Knowledge of the reasons for not attaining an adequate seal of the heat and moisture exchanger housing around or within the self-retaining stoma site.

    3. Knowledge of the signs and symptoms of respiration problems related to the heat and moisture exchanger housing.

  6. Understanding how to resolve problems with a laryngectomy tube.

    1. Knowledge of precautions to prevent changes in tissue or side effects thereof.

    2. Knowledge of the signs and symptoms of respiration problems related to a laryngectomy tube.

    3. Knowledge of the reasons for not attaining adequate placement of the laryngectomy tube.

    4. Knowledge of the possible causes of substandard alaryngeal voice following placement of a laryngectomy tube.

  7. Understanding the emotional issues arising with TEP, TE valve, tracheostoma valve, heat and moisture exchanger, and/or laryngectomy tube use.

    Knowledge/skills needed:

    1. Knowledge of psychosocial behaviors indicative of emotional issues related to use of the TEP, TE valve, tracheostoma valve, heat and moisture exchanger, and/or laryngectomy tube.

    2. Knowledge of the resources available to individuals who are negatively impacted by emotional issues related to the use of a TE valve, tracheostoma valve, heat and moisture exchanger, and/or laryngectomy tube.

  8. Understanding your role relative to those of other health care providers.

    Knowledge/skills needed:

    1. Knowledge of the factors that would precipitate referral of an individual using a TEP, TE valve, tracheostoma valve, heat and moisture exchanger and/or laryngectomy tube to other health care providers.

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Model Curriculum for Knowledge and Skills:

The following is a model curriculum for working with individuals with tracheoesophageal puncture and prosthesis with possible appropriate modes of training that might be pursued for acquiring the knowledge and skills to meet the objectives listed above.

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I. Training approaches for attaining knowledge and skills in tracheoesophageal puncture and prosthesis populations.

Suggested training approaches: didactic/classroom, mentoring, supervised clinical experience, continuing education.

  1. Evaluating vocal tract, respiratory, and esophageal anatomy/physiology.

  2. Assessment of treatment outcomes.

  3. Interdisciplinary communication/collaboration.

  4. Patient education.

  5. Biofeedback.

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II. Normal and disordered anatomy and physiology.

Suggested training approaches for learning the following components: didactic/classroom, mentoring, supervised clinical experience, continuing education, videotape review, experience.

  1. Normal anatomy and physiology of voice production

    1. Normal anatomy.

      1. Respiratory system anatomy.

        1. Skeletal framework.

        2. Muscular components.

      2. Phonatory system anatomy.

        1. Skeletal framework.

        2. Muscular components.

        3. Vocal fold histology.

      3. Vocal tract anatomy.

        1. Pharyngeal.

        2. Oral.

        3. Nasal.

      4. Esophageal anatomy.

        1. Muscular components.

        2. Epithelium histology.

    2. Laryngectomy anatomy.

      1. Variations in surgical approaches.

      2. Respiratory system anatomical changes.

      3. Phonatory system anatomical changes.

      4. Esophageal anatomical changes.

    3. Normal physiology.

      1. Aerodynamic Principles.

        1. Aerodynamic-myoelastic theory.

        2. Continuity law of incompressible fluids.

        3. Bernoulli's law of conservation of energy.

      2. Source-Filter Theory.

      3. Vocal parameters and relation to physiology.

        1. Pitch/frequency.

        2. Loudness/intensity.

        3. Quality/spectral energy.

      4. Deglutition.

        1. Normal.

        2. Post-laryngectomy.

    4. Pathophysiology

      1. Organic.

        1. Cancer or malignant growths.

        2. Benign mass lesions.

        3. Inflammation.

        4. Irritation.

        5. Trauma.

      2. Non-organic.

        1. Muscle tension dysphonia.

        2. Psychogenic.

        3. Maladaptive phonatory habits.

        4. Phonotraumatic vocal behaviors.

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III. Instrumentation.

Suggested training approaches: didactic/classroom, mentoring, supervised clinical experience, continuing education, videotape review, experience.

  1. Videofluoroscopy.

  2. Flexible nasoendoscopy.

  3. Aerodynamic.

  4. Acoustic recordings and analysis.

  5. Electroglottography.

  6. Electromyography.

  7. Radiology and radiation therapy.

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IV. Tracheoesophageal Prostheses and Related Materials.

Suggested training approaches: didactic/classroom, mentoring, supervised clinical experience, continuing education, videotape review, experience.

  1. Prosthetic devices.

  2. Insertion devices.

  3. Lubricants.

  4. Adhesives.

  5. Catheters and stents.

  6. Tracheostoma valves.

  7. Tracheostoma valve housing.

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V. Evaluation and Management of TE Speech.

Suggested training approaches: didactic/classroom, mentoring, supervised clinical experience, continuing education, videotape review, experience.

  1. Patient characteristics.

  2. Insufflation testing.

  3. Prosthesis placement and evaluation.

  4. Voice and speech intervention with TEP.

  5. Alternative speech methods.

  6. Tracheostoma placement and evaluation.

  7. TEP, stoma, TE valve, TE valve housing care and maintenance.

  8. Parameters for documentation.

  9. Psychosocial status of patient and adjustment issues.

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VI. Patient safety.

Suggested training approaches: didactic/classroom, mentoring, supervised clinical experience, continuing education, videotape review, experience.

  1. Universal precautions.

    1. Differences between techniques.

    2. Targeted microbes.

      1. Varieties of hepatitis.

      2. HIV.

      3. TB.

      4. Methocillin-resistant Staphaurus (MRSA).

      5. Vancomycin-resistant Enterococcus (VRE).

      6. Other.

  2. Cleaning agents.

    1. Various agents.

      1. Cold sterilization agents.

      2. Gluteraldehyde.

      3. Bleach.

      4. Hot sterilization.

      5. Enzymatic washes.

  3. General patient and clinician safety.

    1. Control of transmission of disease via:

      1. Eyeglasses.

      2. Glove.

      3. Biohazard receptacles.

  4. Anesthetics.

    1. Various agents.

      1. Hurricane.

      2. Lidocaine.

      3. Xylocaine.

      4. Astra.

      5. Cetacaine.

      6. Others

    2. Pharmacological effects of above agents.

    3. Dosage and side effects.

    4. Indications and contraindications.

  5. Decongestants.

    1. Various agents.

      1. Afrin.

      2. Neosinefrin.

    2. Pharmacological effects of above agents.

    3. Dosage and side effects.

    4. Indications and contraindications.

  6. Patient-specific concerns.

    1. Informed/photographic consent as appropriate.

      1. Patient benefits.

      2. Patient risks.

    2. Precautions.

      1. Adverse/allergic reactions to topical agents.

      2. Vasovagal response.

        1. Signs/symptoms.

        2. Treatment.

      3. Minimizing irritation.

        1. Inflammation.

        2. Granulation.

        3. Coughing.

        4. Gagging.

        5. Excessive mucus secretion.

        6. Bleeding.

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Botulinum toxin (BOTOX).: Neurotoxin generated by clostridium bacteria that temporarily impairs the release of acetylcholine (ACh) across the nerve synapse resulting in muscle paralysis.

Esophageal speech.: Speech resulting from the trapping of air in the upper aspect of the esophagus and using its expulsion for verbalization.

Heat and moisture exchanger.: A prosthetic device that helps regulate heat and humidity of inspired air. Held in place by a tracheostoma valve housing that may fit within the tracheostoma (self-retaining) or be attached to the peristomal skin.

Insufflation.: This procedure tests the vibratory capability of an individual's PE segment by transferring air from the stoma site to below the PE segment through a transnasally placed catheter.

Laryngectomy.: A surgical procedure that entails removal of the larynx.

Laryngectomy tube.: A prosthetic device that is placed in the tracheostoma to maintain the appropriate size and contour of the stomal opening.

Myotomy.: Disabling a muscle belly by dividing it into multiple components.

Pharyngeal neurectomy.: Procedure that disrupts pharyngeal constrictor innervation to alleviate spasms while retaining residual resting tone of the upper esophageal segment.

Pharyngoesophageal (PE).: Residual muscle tissue consisting of the segment inferior constrictor muscle extending to the upper portion of the esophagus following total laryngectomy. Also known as the “neoglottis.”

Tracheoesophageal puncture procedure.: A surgically made opening leading from the posterior tracheal wall through the anterior esophageal wall.

Tracheoesophageal Prosthesis (TEP).: A prosthetic device that is placed into a puncture between the trachea and the esophagus that is employed to generate tracheoesophageal speech, prevent aspiration, and maintain the integrity of the puncture.

Tracheostoma.: Formed by attaching the trachea to the neck immediately above the sternum through which the laryngectomized patient breathes; also may be referred to as a “stoma.”

Tracheostoma valve.: An optional daytime prosthesis designed to eliminate the need for finger occlusion of the tracheostoma. Held in place by a tracheostoma valve housing that may fit within the tracheostoma (self-retaining) or be attached to the peristomal skin.

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References

Normal and Disordered Anatomy and Physiology

Aronson, A. E. (1985). Clinical voice disorders. New York: Thieme Medical.

Blitzer, A., Mitchell, F. B., Sasaki, C. T., Fahn, S., & Harris, K. S. (1992). Neurologic disorders of the larynx. New York: Thieme Medical.

Boone, D. R., & McFarlane, S. C. (2000). The voice and voice therapy. Needham Heights, MA: Allyn & Bacon.

Colton, R. H., & Casper, J. K. (1990). Understanding voice problems. Baltimore: Williams & Wilkins.

Greene, M. C., & Matheson, L. (1992). The voice and its disorders. San Diego: Singular.

Hirano, M., & Kakita, Y. (1985). Cover-body theory of vocal fold vibration. In R. G. Daniloff (Ed.), Speech Science (pp. 1–46). San Diego: College Hill.

Mohri, M., Ohtsuki, N., & Amatsu, M. (1990). Esophageal contractility synchronous with expiration. Annals of Otology, Rhinology and Laryngology, 108(8), 806–809.

Morrison, M. D., Rammage, L. A., & Nichol, H. (1982). A management guide for the disordered voice. American Academy of Otolaryngology-Head and Neck Surgery Foundation.

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Laryngeal Cancer and Post Surgical Anatomy, Physiology, Social, and Speech Issues

Carr, M. M., Schmidbauer, J. A., Majaess, L., & Smith, R. L. (2000). Communication after laryngectomy: An assessment of quality of life. Otolaryngology Head and Neck Surgery, 122(1), 39–43.

Fagan, J. J., & Myers, E. N. (2000). Laser ablation of granulation tissue at the tracheoesophageal puncture site. Head and Neck, 22(7), 714–716.

Finizia, C., & Bergman, B. (2001). Health related quality of life in patients with laryngeal cancer: A post treatment comparison of different modes of communication. Laryngoscope, 111(5), 918–923.

Hamaker, R. C., & Hamaker, R. A. (1995). Surgical treatment of laryngeal cancer. Seminars in Speech and Language, 16(3), 221–231.

McAuliffe, M. J., Ward, E. C., Bassett, L., & Perkins, K. (2000). Functional speech outcomes after laryngectomy and pharyngolaryngectomy. Archives of Otolaryngology, Head and Neck Surgery, 126(6), 705–709.

McFarlane, S. C., & Watterson, T. L. (1995). General principles of working to develop alaryngeal speech. Seminars in Speech and Language, 16(3), 175–179.

McIvor, J., Evans, P. F., Perry, A., & Cheesman, A. D. (1990). Radiological assessment of post laryngectomy speech. Clinical Radiology, 41, 312–316.

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Equipment and Technique for Tracheoesophageal Voice Restoration Surgical Procedures and TEPs

Annyas, A. A., Nijdam, H. F., Escajadillo, J. R., Mahieu, H. R., & Leever, H. (1984). Groningen prosthesis for voice rehabilitation after laryngectomy. Clinical Otolaryngology, 9, 51–54.

Ackerstaff, A. H., Hilgers, F. J. M., Aaronson, N. K., Balm, A. J. M., & van Zandwijk, N. (1993). Improvements in respiratory and psychosocial functioning following total laryngectomy by the use of heat and moisture exchanger. Annals of Otology, Rhinology, and Laryngology, 102, 878–883.

Ackerstaff, A. H., Hilgers, F. J. M., Aaronson, N. K., de Boer, M. F., Meeuwis, C. A., Knegt, P. P. M., van Zandwijk, N., & Balm, A. J. M. (1995). Heat and moisture exchangers as a treatment option in the postoperative rehabilitation of laryngectomized patients. Clinical Otolaryngology, 20, 504–509.

Barton, D., DeSanto, L., Pearson, B. W., & Keith, R. (1988). An endostromal tracheostomy tube for leakproof retention of the Blom-Singer stomal valve. Otolaryngology Head and Neck Surgery, 99(1), 38–41.

Blitzer, A., Komisar, A., Baredes, S., Brin, M. F., & Stewart, C. (1995). Voice failure after tracheoesophageal puncture: Management with botulinum. Otolaryngology, Head and Neck Surgery, 113(6), 668–670.

Blom, E. D. (1995). Tracheoesophagel speech. In S. C. McFarlane & T. L. Watterson (Eds.), Seminars in Speech and Language (p. 3). New York: Thieme Medical.

Blom, E. D., & Hamaker, R. C. (1996). Tracheoesophageal voice restoration following total laryngectomy. In E. N. Meyers & J. Suen (Eds.), Cancer of the Head and Neck (pp. 839–852). Philadelphia: W.B. Saunders.

Blom, E. D., Pauloski, B. R., & Hamaker, R. C. (1995). Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part I: Speech characteristics. Laryngoscope, 105(10), 1093–1103.

Blom, E. D., & Singer, M. I. (1979). Surgical-prosthetic approaches for postlaryngectomy voice restoration. In R. L. Keith & F. L. Darley (Eds.), Laryngectomee Rehabilitation. Houston: College-Hill.

Blom, E. D., Singer, M. I., & Hamaker, R. C. (1982). Tracheostoma valve for postlaryngetomy voice rehabilitation. Annals of Otology, Rhinology and Laryngology, 91, 576.

Blom, E. D., Singer, M. I., & Hamaker, R. C. (1985). An improved esophageal insufflation test. Archives of Otolaryngology, 111, 211–212.

Blom, E. D., Singer, M. I., & Hamaker, R. C. (1986). A prospective study of tracheoesophageal speech. Archives of Otolaryngology, Head and Neck Surgery, 112, 440–447.

Blom, E. D., Singer, M. I., & Hamaker, R. C. (1998). Tracheoesophageal voice restoration following total laryngectomy. San Diego: Singular.

Bosone, Z. T. (1994). Tracheoesophageal fistulization/puncture for voice restoration: Presurgical considerations and trouble shooting procedures. In R. L. Keith & F. L. Darley (Eds.), Laryngectomee Rehabilitation (pp. 359–381). Austin: Pro-Ed.

Crum, R. (1996). Attachment of the adjustable tracheostoma valve and housing from the view of a laryngectomee. ORL-Head and Neck Nursing, 14(1), 15–16.

Grolman, W., Blom, E. D., Branson, R. D., Schouwenburg, P. F., & Hamaker, R. C. (1997). An efficiency comparison of four heat and moisture exchangers used in the laryngectomized patient. Laryngoscope, 107, 814–820.

Guttman, M. R. (1932). Rehabilitation of the voice of laryngectomized patients. Archives of Otolaryngology, 15, 478–479.

Hamaker, R. C., Singer, M. I., Blom, E. D., & Daniels, H. A. (1985). Primary voice restoration at laryngectomy. Archives of Otolaryngology, 111, 182–186.

Henley-Cohn, J. (1981). New techniques for insertion of laryngeal prosthesis. Laryngoscope, 91, 1957–1959.

Hilgers, F. J. M., Aaronson, N. K., Ackerstaff, A. H., Schouwenburg, P. F., & van Zandwijk, N. (1991). The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy. Clinical Otolaryngology, 16, 152–156.

Hilgers, F. J. M., & Schouwenburg, P. F. (1990). A new low-resistance, self-retaining, prosthesis (Provox) for voice rehabilitation after total laryngectomy. Laryngoscope, 100, 1202–1207.

Hoffman, H. T., Fischer, H., VanDemark, D., Peterson, K. L., McCulloch, T. M., Karnell, L. H., & Funk, G. F. (1997). Botulinum neurotoxin injection after total laryngectomy. Head and Neck, 19(2), 92–97.

Leder, S. B., & Sasaki, C. T. (1995). Incidence, timing, and importance of tracheoesophageal prosthesis resizing for successful tracheoesophageal speech production. Laryngoscope, 105(8), 827–832.

Lewin, J. S., Bishop-Leone, J. K., Forman, A. D., & Diaz, E. M. (2001). Further experience with Botox injection for tracheoesophageal speech failure. Head and Neck, 23(6), 456–460.

Lewin, J. S., Lemon, J., Bishop-Leone, J. K., Leyk, S., Martin, J. W., & Gillenwater, A. M. (2000). Experience with Barton button and peristomal breathing valve attachments for hands-free tracheoesophageal speech. Head and Neck, 22(2), 142–148.

Maniglia, A. J. (1985). Newer technique of tracheoesophageal fistula for vocal rehabilitation after total laryngectomy. Laryngoscope, 95, 1064–1066.

McGarvey, S. D., & Weinberg, B. (1984). Esophageal insufflation testing in nonlaryngectomized adults. Journal of Speech and Hearing Disorders, 49, 272–277.

Medina, J. E., & Reiner, S. A. (1990). Pharyngeal myotomy for voice restoration: A midline approach. Laryngoscope, 100, 309–312.

Meleca, R. J., Dworkin, J. P., Zormeier, M. M., Simpson, M. L., Shibuya, T., & Mathog, R. H. (2000). Videostroboscopy of the pharyngoesophageal segment in laryngectomy patients treated with botulinum toxin. Otolaryngology, Head and Neck Surgery, 123(1Pt 1), 38–43.

Mitchell, F. B., Kirkland, R. H., & Morrison, W. V. (1981). The Blom-Singer endoscopic technique under local anesthesia for restoration of voice after laryngectomy. Journal of the Tennessee Medical Association, 74, 867–869.

Panje, W. R. (1981). Prosthetic vocal rehabilitation following laryngectomy: The voice button. Annals of Otology, Rhinology and Laryngology, 90, 116–120.

Panje, W. R., VanDemark, D., & McCabe, B. F. (1981). Voice button prosthesis rehabilitation of the laryngectomee. Annals of Otology, Rhinology and Laryngology, 90, 503–505.

Pauloski, B. R., Blom, E. D., Logemann, J. A., & Hamaker, R. C. (1995). Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part II. Swallow characteristics. Laryngoscope, 105, 1104–1110.

Singer, M. I., & Blom, E. D. Tracheoesophageal puncture: A surgical prosthetic method or postlaryngectomy speech restoration. 1979. Paper presented at the Third International Symposium on Plastic and Reconstructive Surgery of the Head and Neck, New Orleans.

Singer, M. I., & Blom, E. D. (1980). An endoscopic technique for restoration of voice after laryngectomy. Annals of Otology, Rhinology and Laryngology, 89(6), 529–533.

Singer, M. I., & Blom, E. D. (1981). Selective myotomy for voice restoration after total laryngectomy. Archives of Otolaryngology, 107, 670–673.

Singer, M. I., Blom, E. D., & Hamaker, R. C. (1986). Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope, 96(1), 50–53.

Sloan, P. M., McGriffin, J. M., & O'Dwyer, T. P. (1991). Esophageal insufflation and videofluoroscopy for evaluation of esophageal speech in laryngectomy patients: Clinical implications. Radiology, 181(2), 433–437.

Spofford, B., Jafek, B., & Barcz, D. (1984). An improved method for creating tracheoesophageal fistulas for Blom-Singer or Panje voice prostheses. Laryngoscope, 94(2), 257–258.

Strome, M. (1999). Laryngotracheal. Available from http://www.clevelandclinic.org/otol/laryn/hello.htm.

Weinberg, B., & Moon, J. B. (1986). Airway resistances of Blom-Singer and Panje low pressure tracheoesophageal puncture prostheses. Journal of Speech and Hearing Disorders, 51, 169–172.

Yoshida, G. Y., Hamaker, R. C., Singer, M. I., Blom, E. D., & Charles, G. A. (1989). Primary voice restoration at laryngectomy. 1989 update. Laryngoscope, 99, 1093–1095.

Zanoff, D. J., Wold, D., Montague, J. C., Krueger, K., & Drummond, S. (1990). Tracheoesophageal speech: With and without tracheostoma valve. Laryngoscope, 100, 498–502.

Zormeier, M. M., Meleca, R. J., Simpson, M. L., Dworkin, J. P., Klein, R., Gross, M., & Mathog, R. H. (1999). Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy. Otolaryngology, Head and Neck Surgery, 123(Pt1), 38–43.

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Outcomes of Tracheoesophageal Voice Restoration Surgical Procedure/TEP

Balle, V. H., Rindso, L., & Thomsen, J. C. (2000). Primary speech restoration at laryngectomy by insertion of voice prosthesis—10 years experience. Acta Otolaryngologyl Supplement, 543, 244–245.

Doyle, P. C., Danhauer, J. L., & Reed, C. G. (1988). Listeners' perceptions of consonants produced by esophageal and tracheoesophageal talkers. Journal of Speech and Hearing Disorders, 53, 400–407.

Geraghty, J. A., Wenig, B. L., Smith, B. E., & Portugal, L. G. (1996). Long-term follow-up of tracheoesophageal puncture results. Annals of Otology, Rhinology and Laryngology, 105(7), 501–503.

Grolman, W., Blom, E. D., Branson, R. D., Schouwenburg, P. F., & Hamaker, R. C. (1997). An efficiency comparison of four heat and moisture exchangers used in the laryngectomized patient. Laryngoscope, 107, 814–820.

Max, L., DeBruyn, W., & Steurs, W. (1997). Intelligibility of oesophageal and tracheo-oesophageal speech: Preliminary observations. In European Journal of Disorders of Communication (Vol. 32, pp. 429–440). London: Royal College of Speech and Language Therapists.

McAuliffe, M. J., Ward, E. C., Bassett, L., & Perkins, K. (2000). Functional speech outcomes after laryngectomy and pharyngolaryngectomy. Archives of Otolaryngology and Head and Neck Surgery, 126(6), 705–709.

McIvor, J., Evans, P. F., Perry, A., & Cheesman, A. D. (1990). Radiological assessment of post laryngectomy speech. Clinical Radiology, 41, 312–316.

Medina, J. E., & Reiner, S. A. (1990). Pharyngeal myotomy for voice restoration: A midline approach. Laryngoscope, 100, 309–312.

Most, T., Tobin, Y., & Mimran, R. C. (2000). Acoustic and perceptual characteristics of esophageal and tracheoesophageal speech production. Journal of Communication Disorders, 33(2), 165–180.

Prosek, R. A., & Vreeland, L. L. (2001). The intelligibility of time-domain-edited esophageal speech. Journal of Speech Language, and Hearing Research, 44(3), 525–534.

Robbins, J. (1984). Acoustic differentiation of laryngeal esophageal and tracheoesophageal speech. Journal of Speech and Hearing Research, 27, 577–585.

Robbins, J., Fisher, H., Blom, E., & Singer, M. (1984). A comparative acoustic study of normal, esophageal, and tracheoesophageal speech production. Journal of Speech and Hearing Disorders, 49, 202–210.

Ryan, W. J. How people communicate after laryngectomy. 1979. Paper presented at ASHA Convention, Atlanta, GA.

Sedory, S. E., Hamlet, S. L., & Conner, N. P. (1989). Comparisons of perceptual and acoustic characteristics of tracheoesophageal and excellent esophageal speech. Journal of Speech and Hearing Disorders, 54, 209–214.

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Patient Safety

American Speech-Language-Hearing Association. (1990, December). Report Update. AIDS/HIV: Implications for speech-language pathologists and audiologists. ASHA, 32, 46–48.

American Speech-Language-Hearing Association. (1992, March). Sedation and topical anesthetics in audiology and speech-language pathology. Asha, 34(Suppl. 7), 41–42.

Centers for Disease Control. (1988). Morbidity and mortality weekly report: Perspectives in disease prevention and health promotion. CDC, 37, 377–388.

McFarlane, S. C. (1990). Videolaryngoendoscopy and voice disorders. In Seminars in Speech and Language. New York: Thieme Medical.

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Professional Issues

American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2003). Code of ethics. Rockville, MD: Author.

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Index terms: prosthetic devices, trachea, voice

Reference this material as: American Speech-Language-Hearing Association. (2004). Knowledge and skills for speech-language pathologists with respect to evaluation and treatment for tracheoesophageal puncture and prosthesis [Knowledge and Skills]. Available from www.asha.org/policy.

© Copyright 2004 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.KS2004-00070

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