Structural Disorders - Midterm

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OHNC effects

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OHNC effects

voice articulation resonance swallowing

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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)

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OHNC locations

  • larynx

  • oral cavity

  • nasal cavity

  • nasopharynx

  • orophraynx (maxilla and sinuses, tonsils)

  • hypopharynx

  • cervical esophagus

  • neck

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additional concerns

  • metastasis to lymph nodes (requires a radical neck dissection)

  • side effects of treatment: radiotherapy and chemotherapy

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care addresses

  • physical

  • physiological

  • social

  • psychosocial

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counseling OHNC

  • be consistent

  • be clear

  • be empathetic

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impact of OHNC

  • physically

  • most detrimental to personal and social

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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)

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changes from laryngectomy

  • entire larynx is removed

  • lose laryngeal elevation (makes swallowing harder)

  • lose phonatory (taste and smell)

  • lose part of airway

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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

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advantages of ES

  • no external devices necessary

  • more natural than an electrolarynx (listeners prefer)

  • can somewhat manipulate pitch and loudness

  • hands-free

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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)

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contraindications for ES

  • neck scar tissue

  • extensive resection of the PE segment

  • esophageal stenosis (narrowing) (not a good candidate)

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benefits of ES

  • sound is preferred to EL

  • no equipment

  • not mechanical

  • hands free

  • don't need batteries

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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

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what makes successful ES

  • extent of surgery (less extent to be good)

  • positive attitude

  • psychosocial adjustment (support group)

  • frequency of tx

  • family support

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what makes unsuccessful ES

  • lack of motivation

  • limited physical strength

  • radiotherapy

  • dysphagia

  • limited speech therapy

  • effect of TEP (more popular)

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not appropriate for ES

  • extensive pharyngeal surgery (involving tongue, esophagus, or mandible, radical neck disection)

  • coexisting medical problems

  • those with hearing loss

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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

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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

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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

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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

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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

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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

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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

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issues for alaryngeal speech

  • pulmonary issues (COPD)

  • radical neck dissection

  • radiation

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when prosthesis is going bad

wet, gurgly voice

  • something is getting through or around the prosthesis

  • can lead to infection

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HME

heat and moisture exchanger

  • foam filter captures humidity

  • creates warm and humid air going into the lungs

  • IMPROVES RESPIRATORY HEALTH

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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)

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candidacy for TE

  • motivated

  • willing to undergo surgery

  • willing to maintain prosthesis (hygiene)

  • can occlude (digital)

  • good dexterity, good vision

  • respiratory health

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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)

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primary hole for TE

  • made during the laryngectomy

  • depends on the ENT/physician

  • benefits: done all at once, don't need another surgery

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secondary puncture for TE

  • done after the laryngectomy

  • benefit: good for letting everything heal

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candidates for TE

  • motivated

  • willing to undergo surgery

  • willing to maintain prosthesis

  • can occlude

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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

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failure with insufflation testing

  • fibrosis

  • misplacement

  • radiation-induced edema

  • hyper-hypo tonicity of the PE segment

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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)

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time of placement

when the physician tells us to

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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)

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prosthesis is leaking around

sizing problem, need a larger one TE

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prosthesis is leaking through

need a brand new prosthesis TE

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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

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laryngectomy impacts

  • communication

  • psychological

  • family

  • economic

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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

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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

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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

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TNM system

  • T: tumor size

  • N: nodes involved

  • M: numbers of organs involved (metastasized)

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T1

confined to one site, normal fold mobility

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T2

more than one site in supraglottic larynx, normal fold mobility

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T3

immobile TVF or extension into postcricoid, medial pyriforms, or pre-epiglottic areas

  • large tumor, total laryngectomy

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T4

invasion of cartilage or tissue beyond the larynx

  • very large, may obstruct airway

  • total laryngectomy

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Nx

nodes cannot be assessed

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N0

no regional lymph node involved

  • total laryngectomy

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N1

single, ipsilateral node (3 cm or less)

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N2

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

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N2a

single ipsi node

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N2b

multiple ipsi nodes

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N2c

ipsi or contra node involvement

  • spread, radical neck dissection

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N3

lymph node involvement anywhere > 6cm

  • spread, radical neck dissection

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Mx

distant metastasis cannot be assessed

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M0

no distant metastasis

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M1

distant metastasis

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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

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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

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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

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advantages of electrolarynx

  • easily learned

  • portable

  • can be used against the neck or orally with an adapter

  • doesn't require pulmonary support

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disadvantages of electrolarynx

  • mechanical sound

  • requires use of one hand

  • limited pitch inflection

  • operating costs such as batteries and repairs

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intelligibility with electrolarynx

  • on-off problems

  • lack of pitch

  • lack of loudness

  • less sound energy <500Hz

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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)

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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

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candidacy for ES

NOT appropriate:

  • extensive pharyngeal surgery: involving tongue, esophagus, or mandible

  • coexisting medical problems

  • those with hearing loss

  • damaged PE segment

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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%

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use phonemes with high interval pressures when starting out

  • helps force air into esophagus

  • hard to make voice/voiceless distinctions

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vowel choice importance

no tongue position

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primary PE segment

done at the same time as the laryngectomy

  • depends on the ENT/physician

  • don't need another surgery

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secondary PE segment

done after the laryngectomy after everything has healed

  • requires more healing time

  • not worried about the tissue as much

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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

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insufflation failing

  • fibrosis

  • misplacement

  • radiation-induced edema

  • hypertonia (too much tightness, can still dilate/work with esophagus)

  • hypotonia (not enough tone is PE segment)

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preoperative counseling

  • abundant and competent support from SLP

  • critical role to success

  • volunteer alaryngeal speaker

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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

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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

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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

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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

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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)

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