Speech in patients who are tracheostomy-tube dependent was nonexistent prior to the late 1980s. The development of the Passy-Muir valve has enabled patients to produce lung-powered speech. The Passy-Muir valve is a one-way valve that fits directly over the opening of the tracheostomy tube. The patient may breathe freely through the tracheostomy tube. Speech is created when the patient exhales hard enough to close the Passy-Muir valve and the air is thus directed up through the vocal cords and out the mouth (Fig 23l6.-10).11
FIG. 236-10. The Passy-Muir valve is a one-way valve that fits directly on the opening of the tracheostomy tube. Speech is created when the patient exhales as air is passed up through the vocal cords and out the mouth.
Complications with the Passy-Muir valve may initially present as airway obstruction or an inability to speak. In such cases, the speaking device should be removed from the tracheostomy tube so that air can pass freely during both inhalation and exhalation. If this does not improve the situation, the physician should assess the tracheostomy tube for evidence of obstruction.
Speech in postlaryngectomy patients has also improved dramatically with the use of the Blom-Singer voice prosthesis. This one-way valve is surgically placed between the posterior wall of the trachea through the anterior wall of the cervical esophagus. To speak, patients exhale while occluding the tracheal stoma with their thumb, thus forcing the exhaled air into the esophagus. The air vibrates the esophagus (as a belch does) and the resultant tone is used to provide speech. 11 Two common complications with the Blom-Singer speech devices are aspiration of the valve and dislodgment. Patients with aspiration are likely to present with persistent cough and respiratory distress. Initial evaluation may include passing a flexible scope into the tracheal stoma to see if the prosthesis has been dislodged. In addition, a chest radiograph may show the valve. If there is suspicion of aspiration, an otolaryngologic consultation is indicated for further bronchoscopic evaluation.
A more common problem is dislodgment or extrusion of the prosthesis. If the prosthesis has just fallen out, recannulate the tracheoesophageal fistula as soon as possible using a small Foley catheter (10 or 12 French). Many times, a stiffer tube, such as a red rubber catheter, facilitates cannulation of the fistula. Sterile surgical lubricant or lidocaine jelly may be applied to the tube or on a cotton swab applicator, which can identify the fistula prior to placement of the tube. If the fistula can be cannulated, the tube should be secured to the neck or chest, and the patient should follow up with a speech pathologist or otolaryngologist the next day. If recannulation is not easily achieved, repeated attempts are not recommended because they may result in formation of a false tract. If recannulation is unsuccessful, an otolaryngologist should be consulted immediately.
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