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How I support TEP closure:

Surgical voice restoration through tracheoesophageal puncture (TEP) has revolutionised quality of life for many people with a laryngectomy. Morwenna White-Thomson investigates how, when it doesnt work out, the involvement of speech and language therapists might help to improve the success rate of TEP closure.

An open and shut case?

Read this if you are interested in Multidisciplinary working Problem solving clinical issues Making practice more evidence based

s is often the case, my motivation for this article came from clients. Unusually, in 2008, three of our laryngectomy patients required tracheoesophageal puncture (TEP) closure. From this experience and discussion with colleagues in the region, I became aware that this is not always a straightforward process and there is little understanding about what procedures are used, the numbers involved and which practices have better outcomes. I decided to investigate factors that might contribute to the failure of closure through a literature search and survey of ENT units in Southwest England and South Wales (WhiteThomson, 2009). Although not the focus of this article, it was interesting to note that it was not easy for the survey respondents to access basic patient data and thereby provide robust, comparative clinical information. The decision about whether to keep a voice prothesis (valve) in place ultimately lies with the ENT consultant and patient. This decision however is not always straightforward, unless closure is required on medical grounds. Head and Neck cancer is a very multidisciplinary field. It is important that speech and language therapists who often change the voice prostheses, trouble shoot valve, voice and swallowing difficulties and usually know the patients very well are able to have an informed discussion about the risks and benefits of TEP closure.

During exhalation and digital occlusion of the stoma, pulmonary air is directed through the prosthesis and into the oesophagus. The flow of air causes the pharyngoesophageal segment to vibrate and these vibrations become the laryngectomy speakers new voice. This tracheoesophageal voice is the current method of choice for communication post laryngectomy compared with oesophageal voice (which does not require a TEP) or use of an electrolarynx. It is superior to oesophageal voice both subjectively and acoustically (Callanan et al., 1995) However, it is not without complications (Malik et al., 2007). Sometimes repuncture is possible but, if it is not, the TEP has to be closed permanently.

SURGICAL VOICE RESTORATION

Surgical voice restoration via a TEP is one of the most significant developments in head and neck surgery in recent years, and is accepted as the gold standard in voice rehabilitation (Stafford, 2003). A functional voice is essential to a laryngectomy patients quality of life, and in a majority of cases successful voice rehabilitation is achieved (Op de Coul et al., 2000). Surgical voice restoration involves the creation of a fistula, known as a TEP, between the trachea and the oesophagus. A one-way silicone valve is inserted into this fistula which allows air to pass into the oesophagus, but prevents food and fluids entering the lungs.

In a retrospective study of 318 patients at the Netherlands Cancer Institute, 5 per cent of laryngectomy patients required permanent TEP closure (Op de Coul et al., 2000). In my survey of ENT units in South West England and South Wales it was 9 per cent (White-Thomson, 2009). Reasons why a TEP might be closed include persistent peripheral leakage, poor voice quality, an inability to care for the valve due to cognitive or physical difficulties and patient preference (White-Thomson 2009). However, TEP closure is not necessarily as straightforward as its formation (Judd & Bridger, 2008) and the process can be time-consuming and complex. Patients can wait several weeks for spontaneous closure to occur. Conservative methods to encourage closure vary (WhiteThomson, 2009) but might include the use of smaller catheters, cuffed trachy tubes and nasogastric feeding. If such methods are not successful then surgery will be necessary and even then patients may need to undergo more than one procedure. Although factors such as diabetes and hypothyroidism (Aguilar et al., 2001; van As-Brooks & Fuller, 2007) can potentially contribute to poor tissue health and subsequent complications related to healing, my focus is on four areas of relevance to the patients on our unit (figure 1).

TEP CLOSURE

(i) Impact of radiotherapy

Radiotherapy can lead to compromised vascularisation, with thinning of the tissues and fibrosis, which causes stiffening and rigidity. These effects can occur many years after completion of radiotherapy (Kelly, 2007). Otolaryngologists often expect to see problems related to scar formation or devascularisation following radiotherapy but retrospective studies fail to demonstrate any adverse effects with regard to surgical voice restoration (Hilgers & Balm, 1993). However, the severity of problems in radiotherapy patients may be more profound (Andrews et al., 1987) and the dosage could be significant (Singer et al., 1989). If radiotherapy affects tissue health prior to TEP closure (for example contributing to TEP widening), it might also compromise successful closure. Radiotherapy is commonly cited as a cause of peripheral leakage (Margolin et al., 2001) but no studies have shown this to be statistically significant (Kao et al., 1994). Results from papers concerned specifically with surgical procedures for TEP closure are

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Figure 1 Morwennas clients Jack Jack had his laryngectomy operation in January 2008 and had undergone a course of radiotherapy. He developed cognitive difficulties post surgery and was unable to manage his valve. He was admitted to hospital in May and his TEP closed down within 3 days using conservative methods. Interestingly, he was less than five months post TEP formation. David David had his laryngectomy operation in March 1994 and had undergone a course of radiotherapy. By the middle of 2008, he was diagnosed with severe pulmonary fibrosis and presented with fairly gross intra oesophageal reflux which extended to above the level of the clavicles. Due to these co-morbidities, persistent central leakage and good ability to use oesophageal voice, TEP closure was attempted. He underwent surgical closure on two occasions, four weeks apart. The initial attempt was unsuccessful, and the outcome of the second procedure was uncertain as David sadly died. Robert Robert had his laryngectomy operation in March 2007, and did not receive any radiotherapy. One year later he was admitted to hospital with progressive dysphagia, malnutrition and significant weight loss. A nasogastric tube was inserted and four weeks later it was decided to close his TEP. He rarely used his valved voice, and had lung disease and marked breathing difficulties. Over a period of three weeks attempts to close the TEP using conservative methods were unsuccessful, so surgical closure was attempted. Unfortunately a pin-prick leak persisted and eventually his voice prosthesis was reinserted. This process took four months and included 30 days in hospital, theatre time and considerable amounts of input from different members of the multidisciplinary team, not to mention the distress it caused him.

mixed. In a retrospective study of the success rate of a simple closure technique, Moerman et al. (2004) suggested radiotherapy seemed to compromise wound healing. Perfect wound healing with immediate success happened in 6/12 patients. Two patients in this group did not receive radiotherapy. Complications occurred in the other six, who had all received radiotherapy. In a study by Rosen et al. (1997) surgical closure was successful in 13/14 cases, and all but one patient had received a full course of post operative radiotherapy. Unlike Moerman et al. (2004) they concluded that previous irradiation per se did not affect the closure rate. However, it is possible that these conflicting results might be due to the difference in surgical technique as opposed to radiotherapy alone. Inevitably, study numbers are very small, there are other variables, and most patients will have undergone a course of radiotherapy, making it difficult to get statistically significant data. Case series studies reporting successful closure rates do not always identify whether patients have undergone radiotherapy. Hosal & Myers (2001) suggest one TEP failed to close successfully due to the patient being heavily irradiated around the stoma (p.216). Judd & Bridger (2008) specifically advocate vascularised interposition grafts to counteract the effects of radiotherapy. Annyas & Escajadillo (1984) argue that using grafts outside the field of radiotherapy is a good alternative to regional muscle flaps. IN PRACTICE: It remains controversial whether radiotherapy directly affects TEP closure, and opinions differ as to its significance. Nevertheless, radiotherapy is often cited as a cause of poor wound healing and it might have a bearing on the surgical procedure chosen. When assessing a patient prior to TEP closure it is important to be aware of their radiotherapy history. How an individual has responded to radiotherapy in terms of tissue damage might be a better indication of tissue health and subsequent healing than the radiotherapy itself or the dose given.

Head and neck cancer patients often have low nutritional status due to poor dietary intake and high tobacco and alcohol intake, and between 30-50 per cent of newly diagnosed patients are malnourished (Lees et al., 1998). Surgery, radiotherapy and chemotherapy cause acute metabolic stress leading to increased nutrient demand (Black, 2009) and this can be ongoing after healing is apparently complete (Casey, 1998). Laryngectomy patients often experience difficulties with swallowing which can impact on their weight and nutritional health. In Maclean et al.s study (2009), 72 per cent reported dysphagia. This patient group is nutritionally at risk both prior to and post treatment. Casey (1998) states that malnutrition often leads to poor or delayed wound healing. She argues that, although most wounds heal given time, the rate can be improved by identifying those at risk of malnutrition early on and ensuring that diet reflects the increased demands. Gray & Cooper (2001) claim that objective data has failed to support the widely accepted view that nutrition is vital in the healing of wounds. Much of the existing evidence consists of small trials, applying different interventions and outcome measures to very variable populations (NICE, 2006). A significant body of research examines possible causes of wound infections in head and neck cancer patients but multiple contributory factors are difficult to extrapolate (Aguilar et al., 2001). Capuano et al. (2008) found weight loss in patients undergoing concomitant chemoradiotherapy correlated significantly with early mortality, infection and hospital admission in non-compliant patients. In a retrospective study of over 2,000 veteran laryngectomy patients, Schwartz et al. (2003) showed poor nutritional status had strong associations with wound complications. The authors acknowledge a lack of comprehensive data regarding other factors that might influence wound healing. For example, low preoperative albumin was associated with twice the risk of wound

(ii) Impact of nutrition

complications compared to patients with normal levels. However, low albumin levels can be an indication of chronic infection as well as malnutrition. In many papers on the outcome of surgical closure of TEPs, nutritional status is rarely mentioned. This supports Gray & Coopers claim (2001) that good nutrition is often seen as a low priority amongst health care professionals. Despite the lack of objective data, NICE (2006) guidelines (based on a combination of clinical evidence, clinical experience and expertise) state that nutritional interventions in malnourished hospital patients can reduce complications, lengths of stay and mortality. They recommend all patients are screened on admission to identify those who are malnourished or at risk of becoming so. IN PRACTICE: There are many reasons why laryngectomy patients might become malnourished. They often have poor nutrition at the time of diagnosis and treatments can impact further. Although more research is needed into the impact of poor nutrition on wound healing and the benefits of supplementation, the link between nutrition and wound healing cannot be ignored. Speech and language therapists are in a good position to be aware of any problems with swallowing, weight loss or nutrition. If there are any concerns, they should liaise with dietetic colleagues about nutritional screening and assessment prior to surgery. Given the ongoing nature of the healing process, it is also important to take into account the potential impact of poor nutrition with patients who have been discharged with an apparently healed TEP, only to return some weeks later with a slight leak.

(iii) Impact of reflux

Reflux is known to cause laryngopharygeal injury and poor mucosal healing and is associated with contact ulcers, granulomas and chronic laryngitis (Seikaly & Park, 1995).

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Although there is less information about the effects on laryngectomy patients (Pattani et al., 2009), reflux has been cited as a cause for TEP enlargement and reduced tissue health (Gerwin et al., 1997; van As-Brooks & Fuller, 2007). Reflux is common in patients with laryngeal and pharyngeal carcinoma (Copper et al., 2000), and Smit et al. (1998) found a high incidence of reflux in laryngectomy patients. Jobe et al. (2002) suggested that tracheoesophageal voicing may worsen or even cause gastroesophageal reflux (GORD) secondary to the gastric insufflation that can occur by using the oesophagus as a reservoir for air during voicing. Although medical treatment can effectively reduce the acid content and volume of reflux, there is no mechanical barrier against regurgitation to the level of the TEP. Seikaly & Park (1995) suggest GORD may play a role in pharyngocutaneous fistula formation after laryngectomy, and that prophylactic anti-reflux medication significantly decreases the incidence of fistulas. It is possible therefore that reflux might play a role in the failure of TEP closure. Lorenz (2009) claims that, in a majority of cases, atrophy of the party wall with consecutive puncture enlargement appears to be caused by pathological reflux. IN PRACTICE Given our understanding of the effects of reflux on the larynx and the link being made between pharyngocutaneous fistulas, tissue atrophy, enlarged TEPs and GORD, it would seem prudent to screen for reflux when planning TEP closure. A careful history needs to be taken for symptoms of reflux prior to surgery. If suspected, treatment with anti-reflux medication is indicated. Purse string suturing is one of the simplest methods used. In my survey (White-Thomson, 2009), four units reported failed purse string procedures, two reported variable results and one did not use purse strings due to potential continued leakage. Malik et al. (2007) also found limited success with purse strings suturing. Samuel (2009) explains that with posterior tracheal wall suturing the oesophageal opening and the tract are not addressed, resulting in penetration of saliva and leakage through the repaired tracheal opening. Hosal & Myers (2001) describe a simple surgical technique (similar to that used with David and Robert, figure 1, p.25) with separation of the tract and suturing of the tracheal and oesophageal mucosa. Multiple layer closure of the oesophageal fistula to prevent leakage was successful in 8/9 cases. In the retrospective study by Op de Coul et al. (2000) nineteen patients underwent TEP closure for persistent peripheral leakage. All had sectioning of the fistula tract and closure of the oesophagus in two layers and the trachea in one layer. Although no details were given, it is reasonable to assume the surgery was successful, as eighteen patients went on to have a repuncture. However, using a very similar technique, Moerman et al. (2004) only had immediate success in 6/12 cases, and recommended its use be limited to nonirradiated patients. Other surgeons advocate closure using an interpostition graft. Some recommend a dermal graft; Rosen et al. (1997) had good outcomes in 13/14 patients and suggest that use of more bulky muscle flaps compromise the tracheal and oesophageal lumens, and Annyas & Escajadillo (1984) argue that the success of regional flaps can be put at risk due to radiotherapy tissue damage. In heavily irradiated patients or in other high risk conditions prone to fistula formation, the introduction of non-irradiated tissue from a site separate from the head and neck might be beneficial, for example the pectoralis major myofascial flap (Singer et al., 1989). There appears to be some clinical consensus about the benefits of sternocleidomastoid muscle flaps (Singer et al., 1989; Porter, 2009; Samuel, 2009; White-Thomson, 2009). In a case series of five patients over seven years, Judd & Bridger (2008) describe a 100 per cent successful use of a rotated sternocleidomastoid muscle as an interposition graft. They argue that, because the graft has a broad base, it can maintain a healthy vascular supply on which the repaired fistula openings can heal, and a second wound site is not needed. In patients with persistent fistulas despite several surgical attempts, Schmitz et al. (2009) reported successful use of a septal button. For a TEP that was located low in the trachea, Gehrking et al. (2007) described an allogenous collagen graft. Margolin et al. (2001) showed promising results with injection of granulocyte macrophage colony stimulating factor in promoting healing of tissues with peripheral leakage; this might have implications for the closure of TEPs in future. In practice: Matching surgical simplicity with success rate can be a challenge and many factors will influence successful closure irrespective of surgical technique. The decision regarding type of surgical procedure lies with the operating surgeon but it appears that purse string sutures are not reliable, while the introduction of an interposition graft affords consistently good results. TEP closure is relatively rare but it can be complicated, time consuming and costly. More research is required to fully understand the impact of radiotherapy, nutrition, reflux and surgery on outcomes. There is, however, sufficient evidence to argue that patients need to be given a comprehensive assessment prior to surgery to identify any risk factors that might compromise healing. Measures such as anti-reflux medication, additional nutritional support or use of a specific surgical technique can then be taken to ensure the best possible outcomes for TEP closure. I would be very interested to receive feedback on this article and to learn more about current practice in other centres. SLTP Morwenna White-Thomson is principal speech and language therapist and clinical team leader in ENT with North Bristol NHS Trust, email morwenna.white-thomson@nbt.nhs.uk. The full report of Morwennas regional survey is available at www.speechmag.com/Members/Extras.

(iv) Impact of surgical method

Surgeons use a variety of procedures for closing a TEP. Patients have already experienced major surgery, have often undergone radiotherapy and have generally struggled for a period of time with TEP related failure. Although keen to resolve these problems they are often wary of undergoing further surgery, so the aim must be to provide successful closure with the simplest technique. Most TEPs epithelialise or develop fibrosis over a period of a few months (Samuel, 2009). Because of this, long-term fistulas often do not close spontaneously (Judd & Bridger, 2008). However, de-epithelialisation or cautery to the edges of the tract may accelerate closure (Malik et al., 2007). In Holland there is consensus in practice. If a TEP is less than six months old, the valve is removed and rapid closure anticipated. If the TEP is more than six months old, a fresh cut closure is used followed by suturing or a flap repair (van As-Brooks, 2009).

Reflections Do I have an awareness of risk and protective factors that may influence recovery or progress? Do I remain alert to the unintended negative consequences of any intervention, whether surgical, medical or words? Do I record data in a way that enables me to compare outcomes?
Do you wish to comment on the impact this article has had on you? Please see guidance for Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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References
Aguilar, O.G., Pardo, H.A., Vannelli, A., Simkin, D.O., Rossi, A., Rubino, A. & Simkin, D. (2001) Total Laryngectomy: Pre- and Intrasurgical Variables of Infection Risk, Int surg 86, pp.42-48. Andrews, J.C., Mickel, R.A., Hanson, D.G., Monahan, G.P. & Ward, P.H. (1987) Major complications following tracheoesophageal puncture for voice rehabilitation, Laryngoscope 97, pp.562-567. Annyas, A.A. & Escajadillo, J.R. (1984) Closure of tracheoesophageal fistulas after removal of the voice prosthesis, Laryngoscope 94, pp.1244-1245. Black, L. (2009) Nutrition following treatment for head and neck cancer. Master classes in Head and Neck Cancer management, Bristol. Callanan, V., Gurr, P., Baldwin, D., WhiteThomson, M., Beckinsale, J. & Bennett, J. (1995) Provox valve use for post-laryngectomy voice rehabilitation, Journal of Laryngology and Otology 109, pp.1068-1071. Capuano, G., Grosso, A., Gentile, P.C., Battista, M., Bianciardi, F., Di Palma, A., Pavese, I., Satta, F., Tosti, M., Palladino, A., Coiro, G. & Di Palma, M. (2008) Influence of weight on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy, Head Neck 30, pp.503-508. Casey, G. (1998) The importance of nutrition in wound healing, Nursing Standard 13(3), pp.51-56. Copper, M.P., Smit, C.F., Stanojcic, L.D., Devriese, P.P., Schouwenburg, P.F. & Mathus-Vliegen, L.M.H. (2000) High incidence of laryngopharyngeal reflux in patients with head and neck cancer, Laryngoscope 110, pp.1007-1011. Gehrking, E., Raap, M. & Sommer, K.D. (2007) Classification and Management of Tracheoesophageal and Tracheopharyngeal Fistulas after Laryngectomy, Laryngoscope 117, pp.1943-1951. Gerwin, J.M., Culton, G.L. & Gerwin, K.S. (1997) Hiatal Hernia and Reflux Complicating Prosthetic Speech, American Journal of Otolaryngology 18(1), pp.66-68. Gray, D. & Cooper, P. (2001) Nutrition and Wound Healing: What is the Link?, Journal of Wound Care 10, pp.86-89. Hilgers, F.J.M. & Balm, A.J.M. (1993) Longterm results of vocal rehabilitation after total laryngectomy with the low-resistance, indwelling Provox voice prosthesis system, Clin Otolaryngol 18, pp.517-523. Hosal, S.A. & Myers, E.N. (2001) How I do it: closure of tracheoesophageal puncture site, Head Neck 23, pp.214-216. Jobe, B.A., Rosenthal, E., Wiesberg, T.T., Cohen, J.I., Domreis, J.S., Deveney, C.W. & Sheppard, B. (2002) Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech, The American Journal of Surgery 183, pp.539-543. Judd, O. & Bridger, M. (2008) Failed voice restoration: closure of the tracheo-oesophageal fistula, Clinical Otolaryngology 33, pp.255-264. Kao, W.W., Mohr, R. M., Kimmel, C.A., Getch, C. & Silverman C. (1994) The Outcome and Techniques of Primary and Secondary Tracheoesophageal Puncture, Archives of Otolaryngology-Head & Neck Surgery 120 (3), pp.301-307. Kelly, L. (2007) Radiation and Chemotherapy, in Ward, E.C. & van As-Brooks, C.J. (eds) Head and Neck Cancer: treatment, rehabilitation and outcomes. San Diego: Plural Publishing. Chapter 3. Lees, J., Machtay, M., Unger, L., Einstein, G., Weber, R., Chalian, A. & Rosenthal, D. (1998) Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck, Archives of Otolaryngology, Head and Neck Surgery 124, pp.871-875.

Lorenz (2009) Poster in German, paper in preparation. Laryngectomee Rehabilitation and Surgical Voice Restoration Masterclass, Bristol. Maclean, J., Cotton, S. & Perry, A. (2009) PostLaryngectomy: Its Hard to Swallow: An Australian Study of Prevalence and Self-reports of Swallowing Function After a Total Laryngectomy, Dysphagia 24(2), pp.172-179. Malik, T., Bruce, I. & Cherry, J. (2007) Surgical complications of tracheoesophageal puncture and speech valves, Otolaryngol Head Neck Surg. 15(2), pp.117-122. Margolin, G., Masucci, G., Kuylenstierna, R., Bjorck, G., Hertegard, S. & Karling, J. (2001) Leakage around voice prosthesis in laryngectomees: treatment with local GM-CSF, Head Neck 23, pp.1006-1010. Moerman, M., Vermeersch, H. & Heylbroeck, P. (2004) A simple surgical technique for tracheoesophageal fistula closure, Eur Arch Otorhinolaryngo 261, pp.381-385. National Institute for Health and Clinical Excellence (NICE) (2006) Nutrition support for adults: Oral nutrition support, enteral tube feeding and parental nutrition, Clinical Guideline 32. Available at: http://guidance.nice.org.uk/CG32 (Accessed: 23 July 2010). Op de Coul, B.M.R., Hilgers, F.J.M., Balm, A.J.M., Tan, I.B., van den Hoogen, F. J.A. & van Tinteren, H. (2000) A Decade of Postlaryngectomy Vocal Rehabilitation in 318 Patients, Arch Otolaryngol Head Neck Surg 126, pp.1320-1328. Pattani, K.M., Morgan, M. & Nathan, C.O. (2009) Reflux as a Cause of Tracheoesophageal Puncture Failure, Laryngoscope 119, pp.121-125. Porter, G. (2009) Personal communication. Rosen, A., Scher, N. & Panje, W.R. (1997) Surgical closure of persisting failed tracheoesophageal voice fistula, Ann Otol Rhinol Laryngol 106, pp.775-778. Samuel, P. (2009) Personal communication. Schmitz, S., Van Damme, J. & Hamoir, M. (2009) A simple technique for closure of persistent tracheoesophageal fistula after total laryngectomy, Otolaryngology-Head and Neck Surgery 140, pp.601-603. Schwartz, S.R., Yeuh, B., Maynard, C., Daley, J., Henderson, W. & Khuri, S.F. (2003) Predictors of wound complications after laryngectomy: A study of over 2000 patients, Otolaryngology- Head and Neck Surgery 131(1), pp.61-68. Seikaly, H. & Park, P. (1995) Gastroesophageal reflux prophylaxis decreases the incidence of pharyngocutaneous fistula after total laryngectomy, Laryngoscope 105, pp.1220-1222. Singer, M.I., Hamaker, R.C. & Blom, E.D. (1989) Revision procedure for the Tracheoesophageal Puncture, Laryngoscope 99(7), pp.761-763. Smit, C.F., Tan, J., Mathus-Vliegen, L.M.H., Devriese, P.P., Brandsen, M., Grolman, W. & Schouwenburg, P.F. (1998) High incidence of gastropharyngeal and gastroesophageal reflux after total laryngectomy, Head and Neck pp. 619-622. Stafford, F.W. (2003) Current indications and complications of tracheoesophageal puncture for voice restoration after laryngectomy, Current opinion in Otolaryngology & Head and Neck Surgery 11, pp.89-95. van As-Brooks, C.J. & Fuller, D. (2007) Prosthetic tracheoesophageal voice restoration following total laryngectomy, in Ward, E.C. & van AsBrooks, C.J. (eds) Head and Neck Cancer, treatment, rehabilitation and outcomes. San Diego: Plural Publishing. Chapter 9. van-As Brooks, C. (2009) Laryngectomee Rehabilitation and Surgical Voice Restoration. Masterclass, Bristol. White-Thomson M. (2009) Survey of ENT units in South West England and South Wales. Available at http://www.speechmag.com/Members/Extras. (Accessed: 23 July 2010).

Resources
People with certain disabilities that affect reading (visual impairment, physical disability, severe learning disability) can apply for membership of Bookshare, a nonprofit organisation that provides books in accessible formats. www.bookshare.org A live online digital radio station with the primary aim of presenting information and entertainment of interest to people with a disability or limiting medical condition. www.ableradio.com Leisure activities and accommodation throughout the UK and abroad for people with sensory and physical impairments, their friends and families. www.holidaysforall.org Source = MNDA Cheshire Avril Webster of Off We Go! Books has signed a contract with ITV Signed Stories, and some of her books are now on the website. www.signedstories.com A case study of I CANs consultancy involvement in service redesign in Wiltshire www.ican.org.uk/consultancy/~/ media/ICAN%20website/Consultancy/ CaseStudyWiltshire_20May_2010.ashx Cricks WriteOnline now includes WorkSpace, a visual mind mapping tool so users can structure their thinking before a writing task. www.cricksoft.com/uk/products/WriteOnline/ workspace.htm The informal Verbal Reasoning Skills Assessment collated by Maggie Johnson and used in East Kent (formerly known as Canterbury & Thanet) can be purchased for 15. Tel. Denise Pritchard, 01843 282310 Vowels: Short Vowel Contrasts pack (illustrated words organised as minimal pairs) now available from Black Sheep Press, 37 + VAT. www.blacksheeppress.co.uk The Tardive Dyskinesia Center provides information on the condition (whose symptoms mimic those of Parkinsons Disease), and treatment. www.tardivedyskinesia.com A free information and advice service about bilingualism for families and educators. www.bilingualism-matters.org.uk The Encephalitis Society has reported on a wearable digital camera, designed to take photos passively while being worn by the user, as an aid for people with memory loss. www.viconrevue.com; www.encephalitis.info

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Ref. White-Thomson, M. (2010) How I support TEP closure: An open and shut case?, Speech & Language Therapy in Practice Autumn, pp.24-27.

Survey of ENT units in South West England and South Wales Morwenna White-Thomson, 2009 Survey results
The aim of the survey was to gain information about the practice of Ear, Nose and Throat (ENT) units in the region regarding tracheoesophageal puncture (TEP) closure and so contribute to the knowledge base in this area. Introduction Questionnaires were sent out to 18 ENT units in the South West of England and South Wales. Response patterns 25 questionnaires were sent out to ENT consultants, 11 responded from 10 different units 15 questionnaires were sent out to SLTs, 10 responded 13 questionnaires were sent out to CNSs, 5 responded 1 questionnaire was sent out to an ENT Nurse Practitioner, I responded 1 questionnaire was sent out to an ENT Sister, no response From 2 Units, the consultant, CNS/ENT Nurse Practitioner and the SLT responded From 4 Units the Consultant and the SLT responded From 4 Units the SLT alone responded From 3 Units the Consultant alone responded From 3 Units the CNS alone responded From 1 unit the Consultant and CNS responded ENT units work very differently from one another and in some units the SLT is the main valve changer, in others it is the CNS and in others they share the valve changing service. It was often either the SLT or the CNS that responded on behalf of a particular unit. Only 2 units returned a questionnaire from both an SLT and a CNS. SLT and CNS responses covered 13 units in total. 55 questionnaires were sent out in total, and 26 were returned (~ 47%) 17/18 units responded, which was excellent at 94% Numbers of laryngectomy operations, and planned TEP closures There have been 437 total laryngectomy operations carried out in the last 5 years in 15 units (2 units did not do laryngectomy operations at their hospital).

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This is an average of 29 operations per unit over a period of 5 years, or approx 6 operations per year. Over a 5 year period the minimum number was 6 and the maximum was 50. This is a range of 44. Of the 12 units who provided me with the numbers of planned TEP closures, there were 351 laryngectomy operations and 31 TEP closures, which is 9%. These figures are a good estimation as opposed to being exact, as some responders reported that their figures were approximate. Reasons for TEP closure There were 19 reasons for TEP closure given: Persistent peripheral leakage/fistula widening, central leakage, leakage through and around the prosthesis, patient choice, wound/skin breakdown, poor/no voice quality, patient not using valve, patient unable to care for valve, migrating TEP, aerophagia, tears post party wall, oesophageal voice, granulation, pulmonary secretions, pulmonary fibrosis, poor dexterity/awkward stoma shape, cognitive difficulties, reflux, palliative. It was a combination of reasons that resulted in a decision to close a TEP. The five most common reasons cited were: Patient choice/unwanted valve Patient not using valve Patient unable to care for valve Leakage around/fistula widening Oesophageal voice 7 7 6 5 4

More information is required in order to understand why patients were not wanting their valves or not using them. Spontaneous closure under controlled conditions Most TEPs were not found to close spontaneously. Only 3 questionnaires were returned stating that TEPs did close spontaneously. This amounted to 5 patients one of whom still had a pinprick leak 2 months on. 7 responses stated that TEPs sometimes closed and of the 4 respondents who detailed this: 4 patients TEPs closed spontaneously 8 patients TEPs did not close spontaneously

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In 2 patients the status of closure was uncertain Also, one unit responded that TEPs did not usually close spontaneously. 4 questionnaires were returned stating that TEPs did not close spontaneously and of the 3 respondents who detailed this, there were 7 patients in total. There were 2 units where the Consultant and the SLT responded differently. Both consultants responded that TEPs did not close spontaneously, but the 2 SLTs responded sometimes and 1/3 This might be due to the fact that the consultants were referring to their own caseloads and the SLTs were looking at the unit as a whole. In summary, of the 26 patients whose details were given, 8 closed spontaneously (30.8%) 16 did not close spontaneously (61.5%) 2 their status was uncertain, following attempted closure (7.7%) There is therefore a significant failure rate for the spontaneous closure of the TEPs at between 61.5% - 69.2%

Methods used for conservative closure in controlled conditions 7 units responded with details regarding conservative methods of TEP closure. There was a general consensus that patients could be kept in hospital overnight to encourage spontaneous closure. If unsuccessful, smaller catheters, cuffed trachy tubes and nasogastric feeding were used. The time allowed for spontaneous closure ranged from at least a week to one month. One unit had used cautery but had not found it to be successful. Another unit used a cuffed trachy tube and pureed food for 10 days rather than nasogastric feeding. Surgical procedures 11 units responded:

6 used sternomastoid flaps 1local flap 1 local flap and pectoralis major flap 1 fascial flap 2 did not use flaps

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Surgical success/failure 8 units reported that surgery was successful. 7 of these units used flap repairs and 1 used excision of tract and suturing in layers 1 unit stated that the outcome of surgery was successful eventually/rarely using local flap repair. This unit might use purse string sutures initially, and then if not successful try a local flap. One patient went on to have a pectoralis major flap repair. With unsuccessful repairs, 1 unit used division of tract and suturing in layers and the other a sternomastoid flap repair followed by purse string sutures. Purse strings These were generally felt to be unsuccessful. 3 units who had used purse strings reported that they had failed to close the TEP One unit will try purse string sutures and then reported if they fail, then flaps used Several units responded negatively on the use of purse strings: not ideal, not good for leaking around dont work. Managing a TEP that might potentially have benefited from closure, by using a dummy valve, or a valve with plug 12 units responded to this question. 5 had never used a dummy valve or a plug to manage a TEP 7 units had used a dummy valve for a number of reasons: anticipation that TEP would not close spontaneously due to recurrence or previous chemo/radiotherapy, end of life management patient not coping with travelling for valve changes managing failure of surgical closure. Dummy valves were felt to be useful in these situations, whereas plugs were felt to be a temporary measure and often difficult to insert.

Summary From discussion with professional colleagues in the region I became aware that TEP closure for laryngectomy patients is not always a straightforward process. There is also little understanding about what procedures are being

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used, what numbers are involved and whether certain practices have better outcomes than others. The aim of this survey therefore was to get a better understanding of the experiences of ENT units in Southwest England and South Wales with regards to numbers of TEP closures, conservative and surgical approaches and success rates. The percentage of TEP closure is higher than reported in the literature (5%) at 9%. However, six units responded with approximate numbers which means that this figure is not exact. There is a popular conception that a majority of TEPs close down using conservative methods. However in this survey only between 30.8% and 38.5% of TEPs closed down spontaneously. There were a vast number of different reasons given for TEP closure (19 in all) and often there was more than one reason given per patient. Further research is needed in order to get a more detailed understanding as to the most common reasons that TEPs are closed. There was broad agreement regarding the practice for conservative methods of closure from the seven respondents who detailed this. If the TEP did not close overnight, then smaller catheters, cuffed trachy tubes and nasogastric feeding were used. Units waited for spontaneous closure for between one and four weeks. By far the most popular surgical procedure was a sternomastoid flap repair. Eight units reported successful closure with flap repairs, five using sternomastoid repair, one local flap, one fascial flap and one pectoralis major flap following failure of other surgical procedures. Only one unit reported success using excision of the tract and suturing in layers with no interposition graft. Two units reported failed closure: one using a sternomastoid flap and one using division of the tract and suturing in layers. There was a general consensus that purse strings suturing was not very effective and some acknowledgement that TEPs often did not close with minor surgery and therefore needed several procedures in order to achieve complete closure. One unit advocated direct closure immediately as this allowed repuncture within three weeks and voice within four weeks. 58% of units managed some problematic TEPs with dummy valves. This was for a variety of reasons eg for patients who are palliative and following an assessment that surgical closure might not be successful.

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There are many subtle variations between how different ENT units provide their service to laryngectomy patients as well as huge individual patient variation. In an attempt not to miss any information, I did not offer a list of possible responses to my questions, but rather encouraged free text. I also sent out slightly different questionnaires to consultants and to SLTs/CNSs. All these factors made analysis of the results difficult. Also not every unit was able to provide me with exact data. Obviously, health professionals are very stretched and answering questionnaires cannot be a priority but I also believe that it is not as easy as it should be to access often very basic patient data. The results from these questionnaires have provided useful insights into the practices of ENT units in the region, especially regarding causes of TEP closure and surgical preferences. More detailed research is needed in order for us to continue to improve the service we offer to this small but often complex and timeconsuming patient group.