Studied by 35 peopleOHNC 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 <500Hz
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
larynx will be lost = no voice
there is oral speech after a laryngectomy
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
Note
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