Voice 6 - HNC + Trach

cancer happens when

the DNA within normal cells gets damaged and abnormal cells grow rapidly

cancer usually forms as a

tumour

signs and symptoms of cancer depend on

• location

• size

• effect on surrounding organs, blood vessels, or nerves

• metastasis

common cancer symptoms

• fatigue

• weight loss

• impaired immune function

HNC locations

• oral cavity

• paranasal sinuses

• salivary glands

• nasal cavities

• pharynx

• larynx

what is the most common symptom of glottal cancer?

dysphonia

why are cancers in the supraglottis, subglottis, or hypopharynx discovered later?

symptoms are vague

non voice HNC symptoms

• globus

• persistent cough/throat clear

• discomfort in throat

• persistent sore throat

• burning when swallowing

• difficulty breathing

• referred pain to one ear

• unexplained weight loss

most common risk factor used to be

smoking

most common risk factor now is

HPV

Staging - T

size of tumour and extension into neighbouring tissues

Staging - N

any spread into nearby lymph nodes

Staging - M

describes any spread to other organ systems

laryngeal cancer caused by uncontrolled multiplication of cells in the

epithelium

• a squamous cell carcinoma

most squamous cell cancers of the larynx and hypopharynx start as pre-cancer called

dysplasia

true or false: dysplasia always turns into cancer

false, often goes away on its own, especially if underlying cause (like smoking) is stopped

what is foremost in planning treatment?

functional preservation of all or part of the larynx

true or false: surgery, radiation, and chemo are considered curative for HNC

false: chemo is not

side effects of radiation

• mucositis

• radionecrosis

• xerostomia

• trismus

• fibrosis

• lymphodema

• dysphagia

• stricture

• dental loss/tooth decay

free flaps

tissue detached from blood supply at donor site then transfered to recipient site

pedicle flaps

tissue is left partly attached to the donor site to supply tissue with blood

cordotomy

excision of vocal cord

• goal is to remove Ca without a trach

• aspiration risk

• likely reduce vocal quality

hemilaryngectomy

excision of 1 side of larynx

supraglottic laryngectomy

excision of everything above the glottis

supracricoid laryngectomy

excision of everything above the cricoid

total laryngectomy

removal of all structures of the larynx

total laryngectomy reconstruction: trachea sutured to

base of neck

total laryngectomy reconstruction: a ____ is created for breathing

stoma

total laryngectomy reconstruction: the pharyngeal wall is

sutured together

total laryngectomy reconstruction: inferior portion of the pharynx is joined to the

upper esophagus

total laryngectomy reconstruction: superior portion of the pharynx sutured to the

base of tongue

total laryngectomy after effects

• loss of sound generator

• need to learn an artificial way of talking

• no aspiration risk (but can still have dysphagia)

• reduced air filtration

• reduced air humidification

• loss of smell (affects taste)

• increased risk for drowning

what is the most common complication after total laryngectomy

pharyngocutaneous fistula

• 3-8th day post op

• infection and aspiration risk

surgically created fistula used to

accomodate a tracheoesophageal prosthesis → leakage = aspiration risk

diverticulum

aka pseudo epiglottis caused by fold of mucous membrane/scar tissue

• creates pocket where food gets stuck during swallow

esophageal tightness

common problem following laryngectomy due to scarring or tightness of closure → difficulty passing food → treated with dilation

Heat moisture exchange system

dry air can cause increased mucous buildup with thicker secretion → HME helps → also warms air because nose can’t

three speech rehab options

• artificial larynx

• esophageal speech

• surgical prosthetics

how many modes of communication should you teach?

2

what generally is the most preferred speech alternative

TEP

when using an electrolarynx you should instruct clients to

slightly over articulate words without over exaggerating oral movements

if fibrosis precludes the neck, you can place an EL on the

cheek

what can you use for speech post surgery when healing is still incomplete?

intraoral electrolarynx

what’s the first thing you should do when teaching how to use an EL?

find the sweet spot

what is the primary goal of a tracheoesophageal fistula

to channel pulmonary air into the esophagus where the air sets the pharyngoesophageal segment into vibration

when a patient uses a voice prosthesis, the stoma may be occluded by

a thumb/finger or a tracheostoma valve

esophageal speech is like

burping the alphabet

what vibrates in esophageal speech

cricopharyngeus muscle of the upper esophagus and the middle and inferior pharyngeal constrictor muscles

what is the first step of developing esophageal speech

learning how to place air into the upper esophagus

two major methods of esophageal speech

inhalation method

injection method (glossopharyngeal press and consonant injection)

true or false: you should counsel the laryngectomee only preoperatively

false, should counsel pre and post op

what is the priority in earliest stages of admission to ICU?

medical stability

how does SLP assist in the ICU

identifying a mode of communication or establishing a safe method of nutritional intake

hypoxemia

not enough oxygen in the bloodstream

hypercapnia

too much carbon dioxide in the bloodstream

some examples of conditions that require tx in the ICU

• COPD

• ALS

• TBI

• stroke

most adult patients are on

positive pressure volume cycled ventilatiors

in mechanical ventilation during inspiration what is delivered to the patient and what happens

• preset tidal volume delivered

• both intrathoracic pressure and volume increase *** move in the same direction unlike a spontaneously breathing person

mechanical ventilation expiration

port valve opened and exhalation is essentially passive → next breath triggered by patient or given automatically by vent

typically weaning occurs when

• patients assume a greater part of the breathing work as condition improves

• gas exchange shows stable oxygenation

laryngeal injury after intubation

• dysphonia

• throat pain

• cough

• increase of secretions

• pain when swallowing

where is trach tube inserted?

at or below 2nd or 3rd tracheal ring

advantages of trach tube

easy access to LRS for suctioning, decrease of subglottal stenosis, improved weaning, increased pt comfort, improved options for commincation and oral hygiene

complications of trach

loss of taste and smell, increased secretions, tracheal granuloma or stenosis, tracheoesophageal fistula, respiratory infection

3 basic parts of trach tube

• obturator

• outer canula

• innter canula

if you are going to use a speaking valve what do you NEED to be sure of?

that the cuff is deflated!!! the balloon on the outside will be deflated as a signal

steps for communication with trach tube

1. have pt inhale

2. instruct them to digitally occlude

3. pt voices on exhalation