Dr Annie Hurren

OBJECTIVE: To explore community pharmacists' understanding and opinions in relation to the prevention of fungal colonisation of voice prostheses amongst laryngectomy patients. METHOD: Semi-structured interviews were conducted on a purposive sample of 12 community pharmacists from the North of England. Interviews were undertaken until data saturation was reached and responses were transcribed verbatim and analysed using a thematic approach. KEY FINDINGS: Six themes emerged from the data analysis. These were: terminology confusion about laryngectomy, stoma and voice prostheses; smoking as a risk factor for the development of laryngeal cancer; using nystatin to prevent biofilm formation; counselling information related to nystatin; prescription intervention and additional education in relation to laryngectomy. The theme of counselling information related to nystatin use and additional education was a key finding: our data show that when dispensing nystatin to patients with a voice prosthesis, community pharmacists would either give no advice related to medication use or would give incorrect advice that may lead to premature prosthesis failure amongst this patient group. CONCLUSION: This study highlights that community pharmacists lack understanding in relation to laryngectomy and are unaware of the off-label doses and administration methods of the drugs (specifically nystatin) used to prevent fungal colonisation on voice prostheses. Additional information sources in the form of an educational leaflet, possibly obtained through the local department of speech and language therapy, would be perceived as a valuable resource to support community pharmacists who are required to manage these patients in the community.

Perceptual assessment of tracheoesophageal voice quality following total laryngectomy with surgical voice restoration is essential to investigate functional outcomes in relation to surgical procedure and rehabilitation regimes. There is no current tool with established reliability and validity to fulfill this purpose. This study describes the development of a set of new perceptual scales, in relation to core validity and reliability issues. These were investigated using voice stimuli from 55 voice prosthesis speakers and evaluated by 22 judges—12 speech and language therapists (SLTs), 10 Ear, Nose, and Throat surgeons—classified into experienced or not at assessing voice. SLT judges rated more parameters reliably than Ear, Nose, and Throat raters, and SLTs with specialist experience in laryngectomy and laryngeal voice attained the most parameters at an acceptable level of agreement. These scales are ready for clinical use, with the most optimal assessors being expert SLTs. Future studies are needed to ascertain precisely how reliability may relate to training, experience, voice stimuli type, and scale format.

Purpose of review: A consensus and body of robust evidence has developed regarding optimal laryngeal voice outcome measures. This contrasts with a lack of clarity for equivalent assessments in alaryngeal voice. Addressing this situation would enable clinicians to select the best tools currently available to facilitate research, audit and clinical practice. This is important because of the limited knowledge regarding the optimal surgical or reconstruction techniques and rehabilitation regimes for the laryngectomy population. Recent findings: There is currently no evidence to support the use of acoustic instrumental measures in terms of validity. Preliminary data supports the validity of a new tracheoesophageal voice auditory–perceptual tool the SToPS, for professional and naïve raters. Few specific self-rating tools exist with the SECEL having the most evidence regarding validity, reliability and clinical utility. Laryngeal self-report questionnaires have been utilised but concerns have been expressed regarding content validity. Patient self-report outcomes do not concur with professional or naïve judgements which reflects findings in the laryngeal voice literature. Summary: Further research is needed to establish the optimal tools for research and clinical practice. Investigations should also incorporate assessments of real life communication in daily living rather than solely focussing on recordings in laboratory conditions.

Spasm of the pharyngo-oesophageal segment is one of the important causes of tracheo-oesophageal voice failure. Traditionally it has been managed by either prolonged speech therapy, surgical pharyngeal myotomy or pharyngeal plexus neurectomy with varying degrees of success. Botulinum neurotoxin has been found to be effective in relieving pharyngo-oesophageal segment spasm. Since 1995, we have used botulinum toxin injection on 10 laryngectomees with either aphonia or hypertonicity due to pharyngo-oesophageal segment spasm. Early results were analysed by the Sunderland Surgical Voice Restoration Rating scale. Seven of the 10 patients, who were previously completely aphonic, developed voice following this therapy and are using their valve choice as their only method of communication. Out of the three patients who were treated for hypertonic voice, two did derive some benefit from the procedure. One patient developed a hypotonic voice, which lasted for a few months.

Objectives:  The aims of this study were to identify if: (i) size of stoma contributes to quality of life (QoL) in laryngectomees; (ii) stoma size has an impact on routine stoma care and function; and (iii) an optimal stoma size exists below which patients experience stoma problems.

Design:  Cross‐sectional study of laryngectomees.

Setting:  Two tertiary care centres.

Participants:  Fifty‐seven patients who had undergone total laryngectomy one to five years ago and using tracheo‐oesophageal speech as their primary communication means.

Main outcomes measures:  Three main measures were studied:

1 a new study specific questionnaire designed to assess problems with function and care of the end tracheosto‐ ma;

2 QoL as assessed by the head and neck QoL instrument;

3 a precision custom designed sizer to measure the minimum stoma diameter.

Results:  The final study‐specific questionnaire contained four items assessing different aspects of stomal function. From raw total scores an overall stomal score was generated. The stoma score was moderately correlated to emotion and speech domains in head and neck Quality of Life questionnaire, indicating that different concepts were being measured. The mean minimum stoma diameter was 15.9 ± 2.9 mm. There was a significant increase in the area under the receiver operating characteristic curve beyond a threshold value of ≥15 mm; smaller sizes were associated with a poorer stoma score (Mann–Whitney test, P < 0.001). No patient found the stoma sizer use distressing.

Conclusions:  Size of stoma significantly contributes to QoL in laryngectomees and stomas with minimum diameters of 14 mm or less are associated with adverse effects on routine stoma function. The study‐specific stoma function questionnaire appears to be a useful instrument.

Abstract

Objective:  To investigate the inter and intra reliability of raters (in relation to both profession and expertise) when judging two alaryngeal voice parameters: ‘Overall Grade’ and ‘Neoglottal Tonicity’. Reliable perceptual assessment is essential for surgical and therapeutic outcome measurement but has been minimally researched to date.

Design:  Test of inter and intra rater agreement from audio recordings of 55 tracheoesophageal speakers.

Setting:  Cancer Unit.

Participants:  Twelve speech and language therapists and ten Ear, Nose and Throat surgeons.

Main outcome measures:  Perceptual voice parameters of ‘Overall Grade’ rated with a 0–3 equally appearing interval scale and ‘Neoglottal Tonicity’ with an 11‐point bipolar semantic scale.

Results:  All raters achieved ‘good’ agreement for ‘Overall Grade’ with mean weighted kappa coefficients of 0.78 for intra and 0.70 for inter‐rater agreement. All raters achieved ‘good’ intra‐rater agreement for ‘Neoglottal Tonicity’ (0.64) but inter‐rater agreement was only ‘moderate’ (0.40). However, the expert speech and language therapists sub‐group attained ‘good’ inter‐rater agreement with this parameter (0.63). The effect of ‘Neoglottal Tonicity’ on ‘Overall Grade’ was examined utilising only expert speech and language therapists data. Linear regression analysis resulted in an r‐squared coefficient of 0.67. Analysis of the perceptual impression of hypotonicity and hypertonicity in relation to mean ‘Overall Grade’ score demonstrated neither tone was linked to a more favourable grade (P = 0.42).

Conclusions:  Expert speech and language therapist raters may be the optimal judges for tracheoesophageal voice assessment. Tonicity appears to be a good predictor of ‘Overall Grade’. These scales have clinical applicability to investigate techniques that facilitate optotonic neoglottal voice quality.

Clin. Otolaryngol. 2009, 34, 533–538.

Abstract

Objective This study aimed to determine the number, reasons and costs of surgical voice restoration related tracheoesophageal valve attendances over 36 months at a head and neck oncology unit. Method Demographic, medical and valve related details from all patient contacts were recorded, including self-change information, urgent appointment information, modifications required and costs of prostheses. Results Over 3 years, 99 patients underwent 970 valve changes. The main reasons for changes were central leakage, prophylactic change and self-change at home. Changes were significantly more frequent in the first 12 months (mean, 42 days) compared with longstanding patients (mean, 109.96). Intervals between changes were unpredictable; no predictive factors reached statistical significance. Mean expenditure on valves was £966.63 per week (including value added tax and in-house customisation). Conclusion Valve lifespan is comparable with outcomes in similar units despite more pre-emptive and patient-led changes and more comprehensive data inclusion. Investigation into how patient satisfaction and costs relate to valve selection and units’ service delivery models is needed.

Background Phonetic transcription is recognized in regulatory standards as an essential skill for Speech and Language Therapists (SLTs) in the assessment, diagnosis and management of clients with speech difficulties. Previous research has identified that approaches to phonetic transcription vary, and that SLTs often lack confidence in transcribing. However, SLTs’ views and working practices have not been investigated in detail, particularly in terms of whole service approaches and following the recent increase in telehealth. Aims To investigate SLTs’ views about phonetic transcription, their working practices at both individual and service levels, and the factors that influence these. Methods & Procedures A total of 19 SLTs from the UK were recruited to online focus groups via social media and local networks. Participants discussed their views of, and practices in, phonetic transcription. Themes were identified using reflexive thematic analysis. Outcomes & Results Three broad themes were generated division and unity; one small part of a big job; and fit for purpose. SLTs were uniformly proud of their ability to phonetically transcribe and viewed this as a unique skill, but clear differences existed between different groups of SLTs in their views and practices. Investing in phonetic transcription was not always a priority for SLTs or services, and although many felt under-confident in their skills they considered these to be adequate for the populations they usually encounter. SLTs make an early judgement about possible therapy targets, which influences the level of detail used in their phonetic transcription. Practical barriers are often not addressed at service level, and assessment via telehealth poses some specific challenges. Conclusions & Implications SLTs and services would benefit from increased investment in phonetic transcription in terms of time, opportunities for continuing professional development (CPD) and initiatives such as electronic patient records (EPRs) which support the use of phonetic symbols. Identifying target sounds at an early stage raises questions about the implications of disregarding other features of speech, and the selection of appropriate intervention approaches. Further research is needed to analyse actual rather than reported practices, and to consider the relationship between phonetic transcription and intervention approaches. Future studies could also identify precise CPD requirements and evaluate the effectiveness of CPD. What this paper adds What is already known on the subject Previous research has demonstrated that SLTs often lack confidence in phonetic transcription and that practices are varied, with relatively little use of narrow transcription. SLTs are interested in opportunities to maintain and develop transcription skills but do not often undertake CPD for transcription. What this paper adds to existing knowledge By using focus groups as a forum for discussions, this study provides a rich and detailed insight into SLTs’ views about clinical transcription and their working practices, with previously unreported details about the reasons for these practices in a clinical context and at a service-wide level. What are the potential or actual clinical implications of this work? Transcription is often de-prioritized in non-specialist contexts, with practical barriers and a lack of clear and consistent protocols at a whole-service level. There is an opportunity for service managers to address the systemic difficulties in using transcription effectively by raising the profile and value of transcription amongst clinicians, and promoting CPD opportunities, using the findings of this study as a rationale for funding this. Together, these recommendations have the potential to improve client outcomes through more accurate assessment and diagnosis, and hence more appropriate intervention.