DR. GHULAM SAQULAINM.B.B.S., D.L.O., F.C.P.S

Head of Department of E.N.TCAPITAL HOSPITAL, ISLAMABAD.

INTRODUCTION OF PROVOX VOICE PROSTHESIS FOR POST LARYNGECTOMY SPEECH REHABILITATION.

INTRODUCTION OF PROVOX VOICE PROSTHESIS IN PAKISTAN

-A STEP TOWARDS

DEVELOPMENT OF ASSISTIVE TECHNOLOGY FOR POST LARYNGECTOMY SPEECH

REHABILITATION.

Key Words: Post-Laryngectomy Speech Rehabilitation, Voice Prosthesis, T-E Fistula.

INTRODUCTION OF PROVOX VOICE PROSTHESIS IN PAKISTAN -

A STEP TOWARDS DEVELOPMENT OF ASSISTIVE TECHNOLOGY FOR POST

LARYNGECTOMY SPEECH REHABILITATION.

ABSTRACT

Laryngectomy is a recognized mode of treatment offered for a variety of laryngeal tumors all over the world including Pakistan. The Physical changes associated with laryngectomy amount to a complex impairment, Speech Impairment being the most dreaded.

Development and use of Assistive Technology is the only promising chapter for these speech Impaired Individuals. This article outlines the procedure and results of the first implants of Provox Voice Prosthesis and subsequent speech Therapy results in Paksitan – A ray of hope for thousands.

ASSISTIVE TECHNOLOGY

DEVELOPMENT

Laryngeal Tumors/ Cancers are on the rise.

Laryngectomy has proved to be a recognized and effective mode of treatment for advanced laryngeal cancer.

Laryngectomy means the removal of the larynx or the voice box.

INTRODUCTION

ASSISTIVE TECHNOLOGY

DEVELOPMENT

The Larynx or voice box lies behind the Adam’s apple

Removal of Larynx results in there being no connection between patient’s mouth& nose above and the trachea or windpipe below.

The Trachea opens through a opening called stoma which is surgically formed at the base of the neck during a laryngectomy operation.

INTRODUCTION

ASSISTIVE TECHNOLOGY

DEVELOPMENT

The Anatomy of the region before operation

INTRODUCTION

After Laryngectomy: The top of wind pipe or trachea is sewn to a opening in the neck called STOMA.

ASSISTIVE TECHNOLOGY

DEVELOPMENT

A Laryngectomee is a person who has had this essential and life saving operation and will result in a group of physical Impairments, speech impairment being the most dreaded.

INTRODUCTION

ASSISTIVE TECHNOLOGY

DEVELOPMENT

Writing, gesture, mouthing (Silent articulation)

An Electrolarynx Oesophageal Voice Other Surgical Options:

Neoglottis reconstruction, laryngoplasty, and laryngeal transplant.

T-E Puncture & Voice Prosthesis Implantation.

1. Blom Singer2. Provox voice prosthesis system.

METHODS OF COMMUNICATION AFTER TOTAL LARYNGECTOMY

INTRODUCTION

NORMAL WAY OF PRODUCING VOICE

For Normal voice production we need:

A source of air - The Lungs

A Vibrating source – The vocal cords in the Larynx

Resonating Chambers – The oropharynx and the nasopharynx.

Articulators – the tongue, lip, palate to shape the sound into words.

INTRODUCTION

ASSISTIVE TECHNOLOGY DEVELOPMENT

Before Layrngectomy: the source of air is the lungs and the vibrating source is the vocal cods

INTRODUCTION

ASSISTIVE TECHNOLOGY

DEVELOPMENT

After Laryngectomy (For Oesophageal speech):

1. The source of air is the oesophagus

2. The vibrating source is muscle fibres in wall of upper oesophagus/ pharynx (PE segment)

(Note: In both instances, articulators, resonators are the same, that is why the accent, dilect and mannerism of speech donot change.)

INTRODUCTION

This study was undertaken as a measure to develop assistive technology to help the post laryngectomy speech disabled patients.

In this study use of Provox 2 Voice Prosthesis was introduced in Pakistan for rehabilitation of Post Laryngectomy Speech Impairment.

Two patients received these prosthesis followed by speech therapy. The first case was operated at NIHd and another at Capital Hospital are presented.

ASSISTIVE TECHNOLOGY

DEVELOPMENTMATERIAL AND METHODS

THE PROVOX VOICE REHABILITATION SYSTEM The Provox Voice Prosthesis: It is a self retaining,

indwelling, easy to manage device for prosthetic voice rehabilitation for laryngectomized patients with TE fistula, also when created for several other types of prosthesis.

It is made of medical grade silicone rubber and is avialable in 5 lengths: 4.5,6,8,10,12. The other dimensions are:

Dia of Oesophageal flange: 14.5 mm Oval tracheal flange:12 x 16 mm Inner dia: 5 mm and outer dia of shaft:7.5 mm The tracheal flange includes an introductory string. The valve is moulded ini one piece with the prosthesis

and is supported by a radiopaque ring (20% Ba sulphate) which increases its X-ray visibility.

ASSISTIVE TECHNOLOGY

DEVELOPMENTMATERIAL AND METHODS

MATERIAL AND METHODS

The provox voice prosthesis is inserted in a T-E fistula and remains in situ with out replacement by the patient for long periods.

It can be inserted as a primary procedure or as a secondary puncture procedure.

Guide Wire: Each prosthesis is provided with a guide wire to ease insertion.

Trocar and Cannula: For creation of T-E fistula. Pharynx Protector: Aids primary insertion. Brush: A Special Plug: For temporary leakage. Heat and Moisture Exchanger (HME): Is available

for pulmonary and improved vocal rehabilitation which contains a special valve with a spring for easy and comfortable digital closure of stoma.

Stoma Vent & Filter:

Provox 2 prosthesis inserter:

MATERIAL AND METHODS

MATERIAL AND METHODS

MATERIAL AND METHODS

CASE RECORDS:Case No: 1 Mr. Mohammad Sharif, a

male aged 61 years, a resident of Rawalpindi developed Carcinoma of larynx and was subjected to laryngectomy two years back with subsequent loss of voice. He was admitted on 12.6.2002 in E.N.T Dept. of NIHd for Provox-2 Voice Prosthesis implantation and Speech Rehabilitation.

MATERIAL AND METHODS

Case No: 2 Mr. Mehboob, a male

aged 61 years, resident of Rawalpindi, had laryngectomy done for supraglottic carcinoma of larynx on 17.6.2002 with loss of voice. He was admitted to E.N.T department, Capital Hospital on 25.10.2002 and received a voice prosthesis implant on 29.10.2002, followed by speech therapy.

WORKUP:Apart from regular General, Systemic and E.N.T

examination: Inspection of the pharynx for stenosis or webs at

base of tongue Checking of stomal size Barium swallow to check size of PE segment. Speech Therapists Evaluation: Including Insufflation

testTo predict outcome of PVP Implantation12 Fr Nasogastric cather introduced to PE segment

and air was blown to obtain speech. Other necessary investigations for fitness for

general anaesthesia.

MATERIAL AND METHODS

SURGERY:(In both the cases secondary

implantation procedure was planned)

Preoperative preparation NPO after midnight. Consent: Patient was

explained the procedure and the possible hazards and benefits.

Anaesthesia: General Anaesthesia with

intubation through the stoma was used.

MATERIAL AND METHODS

Operation Procedure:

With the patient in supine postion and drapes in place after cleaning the area.

Small size scope passed into the pharynx.

MATERIAL AND METHODS

Scope end palpated and through superior wall of stoma.

Trocar and cannula used to make a standard size T-E fistula.

MATERIAL AND METHODS

Size of prosthesis to be used assessed using a provox measure guage.

MATERIAL AND METHODS

Provox 2 voice prosthesis implanted using a guide wire.

Post operatively the prosthesis was not in position on the oesophageal side and we had to reimplant the prosthesis in one of the patients.

MATERIAL AND METHODS

RESULTS

Mr. Sharif was able to count up to 8 after 24 hrs after surgery and speak fluently after 1 week.

Mr. Mehboob had lot of secretion and coughing preoperatively and was able to count up to 6 after 2 days and improved significantly afterwards.

PROVOX VOICE PROSTHESIS

IMPLANTATION

CONCLUSION

Provox 2 Voice Prosthesis implantation is a simple procedure with excellent

results.

PROVOX VOICE PROSTHESIS

IMPLANTATION

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