Structural Disorders - Midterm

OHNC effects

voice
articulation
resonance
swallowing

OHNC causes

- primarily squamous cell carcinoma
- smoking
- HPV (human papilloma virus)
- alcohol
- smoking + alcohol (synergistic effect)
- chewing tobacco
- environmental exposure
- age
- radiation exposure
- asbestos, wood dust, nickel alloy dust, and silica dust
- gastroesophageal Reflux Disease (GERD)

OHNC locations

- larynx
- oral cavity
- nasal cavity
- nasopharynx
- orophraynx (maxilla and sinuses, tonsils)
- hypopharynx
- cervical esophagus
- neck

additional concerns

- metastasis to lymph nodes (requires a radical neck dissection)
- side effects of treatment: radiotherapy and chemotherapy

care addresses

- physical
- physiological
- social
- psychosocial

counseling OHNC

- be consistent
- be clear
- be empathetic

impact of OHNC

- physically
- most detrimental to personal and social

laryngectomy

surgical procedure where all or part of the larynx is excised
- (1) total = entire
- (2) partial = excision of less than total
- supraglottic = excision of less than total
- hemi = sagittal cut (left or right)

changes from laryngectomy

- entire larynx is removed
- lose laryngeal elevation (makes swallowing harder)
- lose phonatory (taste and smell)
- lose part of airway

esophageal speech

speech is produced by forcing air into the esophagus, forcing it through the narrow constriction of the pharyngoesophageal (PE) segment to produce vibration for sound

advantages of ES

- no external devices necessary
- more natural than an electrolarynx (listeners prefer)
- can somewhat manipulate pitch and loudness
- hands-free

disadvantages of ES

- may take a long time to learn (many patients never do)
- articulation must be excellent
- hard to speak above background noise
- most patients are potential esophageal speakers
- cannot match pitch, loudness, rate, inetll (lower, softer, slower)

contraindications for ES

- neck scar tissue
- extensive resection of the PE segment
- esophageal stenosis (narrowing)
(not a good candidate)

benefits of ES

- sound is preferred to EL
- no equipment
- not mechanical
- hands free
- don't need batteries

drawbacks to ES

- hard to learn
- hard to teach
- not a lot of people know how to teach
- quieter
- no pitch or loudness variations
- difficulty being understood in social settings
- struggle to be understood or inability to speak

what makes successful ES

- extent of surgery (less extent to be good)
- positive attitude
- psychosocial adjustment (support group)
- frequency of tx
- family support

what makes unsuccessful ES

- lack of motivation
- limited physical strength
- radiotherapy
- dysphagia
- limited speech therapy
- effect of TEP (more popular)

not appropriate for ES

- extensive pharyngeal surgery (involving tongue, esophagus, or mandible, radical neck disection)
- coexisting medical problems
- those with hearing loss

injection for ES

- closing the lips, pushing tongue back, squeezing pharyngeal space, forcing air through PE segment, into the esophagus
- build up oral pressure to force PE segment open
- use air that's currently in the oral cavity
- swallowing, forcing, piston-ing

inhalation for ES

- forcing/opening PE segment
- take big breath through the stoma, changes pressure in the lungs (negative pressure)
- thoracic pressure change pulls the PE segment open
- increase negative pressures below PE segment to "suck" air into esophagus
- air rushes in on it's own
- harder to learn/teach

tracheoesophageal speech

- puncture is made through the tracheal wall into the esophagus (surgically created fistula)
- prosthesis is inserted as a one way valve to the esophagus
- air supply from the lungs
- stoma must be occluded (digitally - finger over OR adjustable valve)
- air enters the prosthesis into the esophagus
- air continues up through the PE segment where sound is produced
- sound enters the oral cavity where it is articulated and shaped into words

difficulties/differences to TE

- no VF
- can't voluntarily close or open PE segment
- need 2.5-3x higher amount of pressure
- can be a lot more challenging for those with respiratory problems

advantages to TE

- can provide the most rapid restoration of "near normal" speech
- uses patient's own air supply (own pulmonary air supply)
- speech path sizes and places prosthesis
- little bit of pitch change, good pauses, louder
- pitch is still too low for females

disadvantages to TE

- surgery always carries risk
- fistula may stenosis
- (slight) risk of aspiration
- stoma stenosis
- infection (high risk)
- radiation-induced fistula closure
- granulation buildup
- prolapse
- leakage around the prosthesis with subsequent aspiration
- candida

main failure of TE

- candida
- created a pathway from the esophagus to the lungs, any problems with swallowing or the valve, food or candida may come through the prosthesis
- put things in the prosthesis to ward of candida

issues for alaryngeal speech

- pulmonary issues (COPD)
- radical neck dissection
- radiation

when prosthesis is going bad

wet, gurgly voice
- something is getting through or around the prosthesis
- can lead to infection

HME

heat and moisture exchanger
- foam filter captures humidity
- creates warm and humid air going into the lungs
- IMPROVES RESPIRATORY HEALTH

complications TE

- esophageal perforation (most significant)
- secondary mediastinal infection
- cervical osteomyelitis (disk degeneration)
- rare, pharyngocutaneous leakage (aka, fistula)
- drainage, antibiotics, flap surgery
- stenosis, narrowing (use of laryngectomy tube)
- necrosis (tissue dying)
- granulation tissue (cautery, growth on/around stoma)

candidacy for TE

- motivated
- willing to undergo surgery
- willing to maintain prosthesis (hygiene)
- can occlude (digital)
- good dexterity, good vision
- respiratory health

contraindications for TE

- cognitive issues (in-dwellings have helped this issue)
- chronic alcoholism (poor decision making, poor health, candida)
- radiation (exceeds 70Gy - range normally 40-80, worried about tissue health)
- small stoma (makes difficult to breathe and produce speech)

primary hole for TE

- made during the laryngectomy
- depends on the ENT/physician
- benefits: done all at once, don't need another surgery

secondary puncture for TE

- done after the laryngectomy
- benefit: good for letting everything heal

candidates for TE

- motivated
- willing to undergo surgery
- willing to maintain prosthesis
- can occlude

insufflation testing

adequacy of PE segment for voicing
- how to determine if someone can produce tracheoesophageal speech
- catheter inserted about 25 cm past PE segment
- air is introduced into esophagus to vibrate PE segment
- > 8 seconds = ok
- if high-pitched, strained = failure

failure with insufflation testing

- fibrosis
- misplacement
- radiation-induced edema
- hyper-hypo tonicity of the PE segment

hypertonicity of PE segment treatment

- myotomy (muscle clipping, makes it easier to release airflow, surgical procedure)
- plexus neurectomy (oblate portions of the nerve signal going to the PE segment)
- botox (into PE segment musculature, paralyzes receptors site, lasts 3-6 months, results in relaxation, only 1 injection usually does it, PREFER)

time of placement

when the physician tells us to

patients need to know

- need to understand how voice is produced
- what to do in case of dislodgment (need red rubber catheters if they can't fish it out)
- know the indications of failure (wet, gurgly voice, leakage around and through - prosthesis or sizing failure, strained voice)

prosthesis is leaking around

sizing problem, need a larger one
TE

prosthesis is leaking through

need a brand new prosthesis
TE

why laryngectomy

- presence of a malignant tumor
- depends on: size, location, invasiveness, spread of tumor
- necessary due to: trauma (MVA, gunshot, stab, blunt force), nonfunctional larynx w/ aspiration, irreparable supraglottic stenosis

laryngectomy impacts

- communication
- psychological
- family
- economic

laryngectomy procedure

- entire larynx is removed, including the hyoid bone
- trachea is connected to a stoma in the anterior part of the neck
- esophagus and airway are subsequently separated
- radiation or chemotherapy is often necessary to eliminate any small traces of cancer

electrolarynx

produced by electrical devices that vibrate the air in the oral cavity for use in articulation
- place against the neck
- transfers resonance into the neck
- requires no phonatory system
- need optimal placement to get the best resonance

problems with electrolarynx

- struggle being heard in a loud environment
- leathery tissue caused from surgery and radiation (prohibits effective transfer of resonance)
- in loud environment, struggle to be heard, drowns out/masks the voice
- females don't prefer - too low frequency

TNM system

- T: tumor size
- N: nodes involved
- M: numbers of organs involved (metastasized)

T1

confined to one site, normal fold mobility

T2

more than one site in supraglottic larynx, normal fold mobility

T3

immobile TVF or extension into postcricoid, medial pyriforms, or pre-epiglottic areas
- large tumor, total laryngectomy

T4

invasion of cartilage or tissue beyond the larynx
- very large, may obstruct airway
- total laryngectomy

Nx

nodes cannot be assessed

N0

no regional lymph node involved
- total laryngectomy

N1

single, ipsilateral node (3 cm or less)

N2

single, ipsilateral node (3-6 cm) or contralateral nodes no greater than 6cm

N2a

single ipsi node

N2b

multiple ipsi nodes

N2c

ipsi or contra node involvement
- spread, radical neck dissection

N3

lymph node involvement anywhere > 6cm
- spread, radical neck dissection

Mx

distant metastasis cannot be assessed

M0

no distant metastasis

M1

distant metastasis

location of laryngeal tumor

- supraglottic: raised edges and ulcerations
- glottic: irregular thickening w/ possible white, cauliflower appearance
- subglottic: diffuse and white or reddish-brown
- transglottic: crosses the glottis, weblike

symptoms of laryngeal cancer

- hoarseness (prolonged)
- unproductive cough
- dysphagia
- coughing up bloody mucus
- pain
- neck mass
- airway obstruction (stridor)
- weight loss
- tenderness in laryngeal area

goals with electrolarynx

- correct/consistent placements (sweet spot)
- slowed speech and over-articulation
- device on-off control during speech (make appropriate pauses, attention to non-verbal behaviors

advantages of electrolarynx

- easily learned
- portable
- can be used against the neck or orally with an adapter
- doesn't require pulmonary support

disadvantages of electrolarynx

- mechanical sound
- requires use of one hand
- limited pitch inflection
- operating costs such as batteries and repairs

intelligibility with electrolarynx

- on-off problems
- lack of pitch
- lack of loudness
- less sound energy

acceptability with electrolarynx

- listeners find it mechanical
- how the quality of voice is perceived
- do they like their voice and how others think of it
- may be a great speaker but they don't like it (could cause social withdrawal)

placement of electrolarynx

- need greatest resonance
- vibrating section needs to be flush with neck tissues
- oral-tube requires exploration by clinician for best location
- trail and error
- use a mirror for feedback, mark sweet spot with tape
- want to use their dominant side

candidacy for ES

NOT appropriate:
- extensive pharyngeal surgery: involving tongue, esophagus, or mandible
- coexisting medical problems
- those with hearing loss
- damaged PE segment

function of ES

an individual's ability to produce "esophageal speech that is sufficiently intelligible, fluent, and comfortable to support resumption of the communication functions assumed prior to laryngectomy"
- failure rate: 40-74%

use phonemes with high interval pressures when starting out

- helps force air into esophagus
- hard to make voice/voiceless distinctions

vowel choice importance

no tongue position

primary PE segment

done at the same time as the laryngectomy
- depends on the ENT/physician
- don't need another surgery

secondary PE segment

done after the laryngectomy after everything has healed
- requires more healing time
- not worried about the tissue as much

insufflation testing

tests adequacy of PE segment for voicing
- catheter inserted about 25 cm past PE segment
- air is introduced into esophagus to vibrate PE segment
- > 8 seconds = ok
- if high-pitched or strained = failure
- DOES NOT tell you how much effort that took

insufflation failing

- fibrosis
- misplacement
- radiation-induced edema
- hypertonia (too much tightness, can still dilate/work with esophagus)
- hypotonia (not enough tone is PE segment)

preoperative counseling

- abundant and competent support from SLP
- critical role to success
- volunteer alaryngeal speaker

3 things necessary for preoperative counseling

1. larynx will be lost = no voice
2. there is oral speech after a laryngectomy
3. establish a communication method for post-surgery

responsibilities of SLP pre-op

- provide information regarding alaryngeal speech options
- determine functional communications needs by discussing with patient, spouse, family, friends
- build your relationship with the individual based on trust
- monitor and empathize
- monitor and facilitate overall rehabilitation
- become their advocate

postoperative counseling

- is the patient medically stable?
- what is the radiation/chemotherapy plan?
- reassess oromotor function
- reassess speech-language
- determine anatomical changes
- attempt to schedule a visit from another alaryngeal speaker

affects of radiation

- first 1-2 weeks will feel great
- 4-6 weeks after will feel not good
- leads to leathery tissue (struggle finding sweet spot)
- sensitive, burning sensation

essentials to explain post-op

- explain the laryngeal excision affects on crying, laughing, humming, etc.
- trachea connected to stoma in front of the neck (coughing, crusting)
- loss of taste and smell
- no voice early in post-op period (writing, gestures, communication board)
- alaryngeal speech options are available - SLP will assist them
- make sure that you are clear as possible and that they know what to expect (often times they do not)

clinical evaluation

know premorbid function (what they could do before) and how that might influence treatment

COPD/emphysema rate

80% or 4/5 people will have history of COPD or emphysema in a total laryngectomy
- need to have a pulmonary function test done before and after (SLP advocates)

patient history

helps determine what type alaryngeal speech option may be best
- how are they communicating now?
- read/write?
- comprehension?
- social life (how isolated/extroverted are they)
- overall medical condition (know right away if total laryngectomy/RND)
- pulmonary test (SLP advocates for)
- employment history (based on what their job is and if they'll be returning)

exams

- hygiene
- emotional stability
- hearing evaluation
- oral mech (not being able to open the jaw, etc.)
- TNM staging (where they are in their treatment process)
- imaging
- pain
- necrosis (dying of tissue)

assessing for EL speech

- articulation
- placement of EL (use mirror)
- avoid excessive expiration (hear stoma noise, masking)
- phrase length, appropriate pauses, etc.
- work on +v, -v sound distinction (voiced and voiceless)

assessing for ES speech

- require reduced respiratory support (should not be difficult, don't strain/force air out through esophagus)
- good articulation? needs to be excellent
- can they 'burp' (importance: can set the PE segment into vibration, can create enough air pressure to release it through PE segment)
- motivation
- your ability (SLP)

assessing for TE speech

- healing complete?
- respiratory health?
- radiation (and chemo if present) complete? (wait till done)
- disease-free
- medically stable
- stoma > 1.5-2.0 cm in size?
- healthy TE wall?
- can't start until the doctor says you can

what client needs for TE speech

- motivation
- eyesight
- dexterity
- hygiene
- alertness
- post-surgical anatomy
- mentally stable
- understand how the prothesis works
- positive insufflation test results (say 'ah' for 8 seconds)

considerations for TE speech

- how is tissue integrity?
- thickness of TE wall
- check published resistance of each prosthesis
- WHY: want to have the lowest resistance prosthesis, larger diameter = better flow, want to prevent leaks through the prosthesis, start with 16 low resistance prosthesis

TE speech simpleness

- careful candidate selection
- patient education
- careful follow-up

TE problems

- TEP
- TEP prosthesis and tract
- PE segment (can have spasm)
- if problem with voice, take the prosthesis out and have them phonate through an open tract (if can now, problem with prosthesis - if can't now, problem with PE segment)

effortful speech TEP

- to troubleshoot, ask them to phonate through open fistula (open tract)
- if they can, check prosthesis
- stuck?
- gelcap?
- overfitting?
- forceful digital occlusion

delayed aphonia or dysphonia

- may be prosthesis problem
- closure of tract?
- prosthesis was too short
- granulation build-up (not so much)
- false tract created? (not so much)
- stenosis?

reduce PE spasm

- myotomy
- plexus neurectomy
- botox (botox best, only need one time)

leakage

- through: problem is prosthesis (debris, candida, gelcap)
- around: sizing issue, could lead to . . . (pistoning - prosthesis will slide back and forth)

prostheses deteriorate

- normal
- 3-9 months depending on nystatin and cleaning
- directly related to candida