Communication Interventions Post HNC Tx

communication interventions

1. speech

2. voice

3. AAC

voice interventions

behavioral therapy and surgical interventions

speech changes

reduced intelligibility and reduced control of airflow emission

reduced intelligibility due to

articulation errors, reduced ROM, impaired strength

reduced control of airflow emission results in

hypernasality

how to assess trismus

perceptual voice eval such as CAPE-V, rainbow passage, conversations they have in daily functional tasks

impaired speech intelligibility caused by

1. surgical resections

2. mucosal changes from CRT

3. cranial nerve palsy

primary closure vs free flap

primary closure allows majority of structure to remain while free flaps dont function

mucosal changes from CRT

-mucositis

-inflammation

-radiation fibrosis

most common cranial nerve palsy

glossopharyngeal, vagus, hypoglossal

type of HNC that has least impact on speech intelligibility

nasopharyngeal may only have hyponasality

reduced lip closure intervention

1. stretching

2. resistance exercises

3. IOPI

passive stretches

with assistance typically hand; muscle not moving on own

active lip closure stretches

lip rounding by saying ooo and lip retraction by smiling

lip closure resistance exercises considerations

strengthen only after addressing ROM and make as functional as possible

IOPI for lip closure

bilateral labial placements via lip press

lip closure functional exercises

-straw drinking

-holding air or water in mouth

lingual strength and ROM intervention

1. passive stretch

2. active stretch

3. lingual resistance

lingual passive stretches

gauze or wet wash cloth, relax tongue, stretch anterior and bilateral

lingual active stretches

-protrude the tongue and hold then lateralize left and right with hold

-teeth tracking

-anterior to posterior hard and soft palate stretch

lingual resistance

IOPI in anterior and posterior placements

jaw ROM

trismus secondary to RT; slow passive repetitions of mouth opening with prolonged hold of at least 30 seconds; stacked tongue depressors or TheraBite used

mild trismus mm

35 mm; 3 fingers

moderate trismus mm

25 mm; 2 fingers

severe trismus mm

15 mm; 1 finger

female average jaw ROM

45-55 mm

male average jaw ROM

50-60 mm

articulation retraining

-identification of disordered phonemes

-can anticipate changes based on location of surgical resection

-practice in all word positions, phrases, sentences, and spontaneous speech

-use mirror for visual biofeedback

what kind of stretch does a TheraBite facilitate for a pt with trisumus?

passive

prosthetics after surgery

4-6 weeks if no RT planned; may have temporary or surgical prosthetic screwed in place

prosthetics after RT

6-8 weeks; may have temporary or RT prosthetic that is removable

prosthetics: palatal lift

lifts residual velar mucosa in the instance of nerve impairment and/or limited muscle function; can be shaped to unilateral or bilateral lift

palatal lift impact on speech and swallowing

less nasal air emission aka hypernasality on nasal sounds and voiced sounds and helps with nasal regurgitation and pressure generation for swallowing

prosthetics: palatal obturator

seals VP port and/or resected tissue area; reduces nasopharyngeal regurgitation; improves intraoral pressure

prosthetics: speech bulb

-fills VP space for absent or limited velar movement or superior pharyngeal constrictor movement

- improves both voice and swallow

-assess with plosive sounds and FEES

prosthetics: palatal augmentation

lowers palatal vault to offset lingual resections; improves articulation and bolus management

which prosthetic option would best facilitate improved intraoral bolus pressure following a hard palate resection?

palatal obturator

which prosthetic option would best facilitate both improved voice and swallow function?

speech bulb because fills defect in naso-oropharynx

voice changes post HNC tx

-structure changes to vocal folds

-function: compensatory behaviors such as hyperfunction, strain, fatigue

voice changes may be due tumor and/or treatment

1. dynamic changes to tension and length of VF due to edema following RT

2. increased supraglottic hyperfunction of false VF

3. diffuse laryngeal edema

long term voice outcomes

VF stiffness, flaccid VF, paresis or paralysis

voice repeat comprehensive evaluation

1. perceptual measures

2. acoustic and aerodynamic measures

3. videostroboscopy

voice interventions

-behavioral therapy with SLP

-interventions with ENT

laser excision

1. limited to superficial lamina propria, reinkes space, and vocal ligament for near normal voice production

2. deeper resections extending to vocalis muscle marked by increased dysphonia and worse longterm outcomes

deeper resections extending to vocalis muscle interventions

lipoinjection and medialization thyroplasty

common complaints post laser excision

increased vocal effort, poor respiratory coordination, reduced pitch and volume

___% of patients report dysphonia after CRT

50

voice changes post CRT

-radiation induced fibrosis, mucositis, atrophy, xerostomia

-decreased amplitude and mucosal wave

-irregular phase symmetry, glottic closure, and periodicity

-increased supraglottic compression

acoustic changes post CRT

reduced pitch, reduced loudness, rough voice

mechanisms of voice changes in CRT

xerostomia, fibrotic stiffness, inflammation

behavioral interventions with SLP: indirect therapy

hygiene education

behavioral interventions with SLP: direct therapy

1. laryngeal adduction with sustained phonation

2. flexibility tasks with pitch glides to reduce stiffness and improve mucosal wave and amplitude

interventions with ENT

1. poor glottic closure: injection laryngoplasty

2. stiffness: steroid injection