Swallowing and voice rehabilitation after head and neck surgery. for UG PG and MCH students. ENT HEAD AND NECK SURGERY

1. SWALLOWING AND VOICE
REHABILITATION AFTER
HEAD AND NECK SURGERY
Speaker – Dr. Diwash Sunar
Juninor Resident
Deparment of ENT, Head and Neck
Surgery
AllMS, New Delhi

2. Swallowing rehabilitation after
Head and Neck Surgery

3. Assessment of Swallowing
Assessments fall into two categories:
• Subjective : based on observations including bedside assessment and by discussion/ history taking
with the patient and their family
• Objective :
 Functional endoscopic evaluation of swallowing (FEES)
Video fluoroscopy swallowing study (VFSS)
( both can define the pathophysiology of the swallow and help establish a rehabilitation programme
with identifiable goals for the patient )

5. 1. COMPENSATORY THERAPIES
- redirect/improve flow of food to eliminate patient’s symptoms
- does not alter the normal swallowing physiology
- Immediate but Temporary
2. REHABILITATIVE THERAPIES
- Direct or Indirect
- change swallowing physiology for betterment of patient
Swallowing after Head and Neck Surgery

6. Compensatory Therapies
1. Postural Modifications
2. Dietary Modifications
( Texture and Volume modifications )
3. Sensory Enhancements
4. Prosthetics
Rehabilitative therapies
DIRECT / INDIRECT
1. Range of motion exercises
2. Resistance exercises
3. Bolus control exercises
4. Chewing exercises
5. Swallowing Maneuver

7. Postural
Modifications
• Eliminate or reduce food
or liquid aspiration
• Also implemented during
instrumental assessment
eg. FEES, VFSS
• Effective upto 80 % in
post surgical HnN Ca
patients
HEAD BACK
Utilizes gravity to clear
the food
CHIN TUCK
Widens vallecula to
prevent food entry into
airways
Head rotation towards
damaged side
Directs bolus towards normal
side
LYING ON ONE SIDE
Eliminates the effect of
gravity on pharyngeal
residue
Head tilt towards normal
side
Eliminates damaged side
from direction of bolus
Head rotation
Pulls cricoid away from
PPW

8. DIET MODIFICATION
TEXTURE MODIFICATION
THICKENING LIQUIDS
Useful when a patient has difficulty in controlling the flow of thin liquids,
leading to spillage and aspiration
THINNING LIQUIDS Suited for patients with pharyngeal residue after the swallow
NOTE :
 Texture modifications are done only when postural modification and other maneuvers are not helpful
 Changing the consistency does not mean Removing certain food from diet
 It may impact nutrition level

9. DIET MODIFICATION
BOLUS VOLUME MODIFICATION
LARGER VOLUME BOLUS
• Effective in more rapid pharyngeal swallow
• Provides greater sensory input and bolus awareness in OC
SMALLER VOLUME BOLUS
• Helpful for patients who require multiple swallows to clear the bolus
• Decrease the post swallow residue in pharynx
• Decrease risk of aspiration

10. SENSORY ENHANCEMENTS
• INDICATION – When there is delay in initiation of the swallow
• Methods :
1. Thermal tactile stimulation
2. Carbonated beverages
3. Sour Bolus
4. Temperature alter
5. Suck swallow technique
6. The method of presentation – Jet feeding

11. Carbonated Beverages
Stimulate the swallow
Sour food bolus
Causes hard and fast swallow
Temperature
 Warm or cool bolus stimulate the swallow
Thermal Tactile stimulation
• Using Laryngeal mirror
• Take the mirror, cold in a cup of ice/cold water
• Stroke the faucial pillars 3-4 times on each side
• Assess the speed of swallow following
stimulation
Advantage:
- Increase oral sensation
- Initiate the swallow process

12. SUCK-SWALLOW TECHNIQUE
Patient produces exaggerated suck
with lips closed
Followed by pulling back the tongue
Attempt to swallow
Rationale:
- Sucking action pulls the saliva back of
mouth and helps trigger the swallows
more rapidly
Method of presentation of food/bolus
By SPOON, CUP or STRAW
than a cup / glass
JET FEEDING ( posterior placement )
Helpful for patients with delayed oral phase
esp Post glossectomy ( Partial or Total )
• Feed is given at the posterior part of mouth,
near the faucial pillars
• Done with syringe or small spoon

13. Prosthetics
• Soft palate defect
 plastic palate obturator
• Palate paralysis causing velar incompetency
 palatal lift
• Resected tongue
 palate drop or palate lowering device
( augmenting / reshaping )
Compensate for the loss of oropharyngeal
structure post surgery of HnN Ca
palate obturator
palatal lift
palate lowering device

14. REHABILITATIVE THERAPIES
( changes swallowing physiology )
DIRECT
When any food is given or involved
during application
INDIRECT
Swallows own saliva
No liquid or solid food is given
Involves oral and oropharyngeal
strengthening therapy for swallowing
management

15. • Strap muscle and FOM exercises
1. Mendelsohn maneuver
• Airway protection exercises
1. supraglottic swallow
2. Super supraglottic swallow
• BOT exercises
1. Masako maneuver
2. Effortful swallow
3. Gargle
DIRECT EXERCISES ( WITH FOOD ) INDIRECT EXERCISES ( WITHOUT FOOD )
RANGE OF MOTION
EXERCISEES
STRENGTHENING
EXERCISEES
o LIP
o TONGUE
o BASE OF TONGUE
o JAW
o LARYNX
o NECK
o LIP
o TONGUE
o SOFT PALATE
o NECK

16. Mendelsohn maneuver
Indication – in patients with
i. reduced range or duration of laryngeal movement
ii. Reduced or delayed cricopharyngeal opening
iii. Incoordination of pharyngeal swallow
Rationale : In treated HnN Ca patients, this
maneuver produces high BOT pressure, less
pharyngeal residue, prolonged cricopharyngeal
opening
Intension : to increase the duration and extent of
laryngeal elevation , so that the duration of opening
of cricopharynx is prolonged
Instructions :
1. Swallow the saliva a few times. Feel the
adams apple/larynx ( lift up and lower
naturally )
2. Swallow again by pressing the tongue against
palate, feel the larynx but don’t let it drop.
Hold the adam’s apple for 3sec by squeezing
the throat muscles
3. Release and repeat several times
Note : this maneuver can be practiced without
food first, and then with food when patient has
learned to do it correctly

18. SUPRAGLOTTIC SWALLOW
• INDICATION :
In patients with reduced airway protection at vocal
cord level and those having aspiration during the
swallow
• CONTRAINDICATION :
I. Patients with cognitive deficits
II. With T-tube in situ
Instructions :
1. Inhale deeply first and then hold the breath
2. Continue to hold the breath and swallow
3. Immediately after swallow  Cough
4. And then immediately swallow again ( before
inhale )
Note : voluntary holding the breath closes vocal
folds during and before the swallow, thereby
protect food from entering the airway

20. SUPER-SUPRAGLOTTIC SWALLOW
• INDICATION :
In patients with reduced airway closure and those
having aspiration during the swallow
• CONTRAINDICATION :
I. Patients with cognitive deficits
II. With T-tube in situ
Instructions :
1. Inhale deeply first and then hold the breath
TIGHTLY
2. Continue to hold the breath and bear down
as patient swallows
3. Immediately after swallow  Cough
4. And then immediately swallow forcefully
again ( before inhale )
Note : EFFORTFUL breath holding causes
arytenoids to tilt forward, closes the laryngeal
vestibule entrance before and during the
swallow

21. MASAKO MANEUVER
Indication – in patients with
i. BOT resection
ii. Post RT in oropharynx
Intension : to increase BOT and PPW approximation
while swallowing
Instructions :
1. Stick out the tongue
2. Gently bite down on the tip of tongue
3. Swallow the saliva, while patient hold the
tongue out between teeth/lip
4. Pull the tongue back in mouth
Note : this maneuver enhance the movement of
PPW and brings about the contact between BOT
and PPW
• CONTRAINDICATION :
I. Patients with cognitive deficits
II. Those with high risk of Aspiration
III. With T-tube in situ

23. EFFORTFUL SWALLOW
Indication –treated HnN Ca patients with
• Reduced tongue strength
• Reduced laryngeal elevation
• Reduced pharyngeal contraction
• Cricopharyngeal dysmotility
Rationale : this exercise increases pharyngeal
pressure, reduced oral residue, longer laryngeal
closure duration, hyoid elevation, longer UES
relaxation  improves bolus clearance
Instructions :
Note : this exercise may increase nasal
regurgitation, so patient should be counselled
and precautions to be taken
Hold the
food/drink in the
mouth for few
sec

24. Gargle
• Helpful in BOT strengthening
Instruction :
Lean back to about a 45 degree angle so
the gargling water runs down into the
throat—but don't swallow! Instead, exhale
through your throat, producing bubbles
pull the tongue back during a gargle and
hold for 1 sec

25. INDIRECT EXERCISES ( WITHOUT FOOD )
RANGE OF MOTION
EXERCISEES
STRENGTHENING
EXERCISEES
o LIP
o TONGUE
o BASE OF TONGUE
o JAW
o LARYNX
o NECK
o LIP
o TONGUE
o SOFT PALATE
o NECK
ROM EXERCISES
• Are Passive
• Designed to improve the movement by
extending the target structure in
particular direction to get the strong
contraction.
• Recommendations : 5-10 repetition's of
each exercise for 5-10 sessions/day
STRENGTHENING EXERCISEES
• Are Active exercises
• done against resistance

26. LIP EXERCISES
• ROM exercise
• Open mouth as wide as possible - hold for 5 sec
• Close lips as tight as possible – hold for 5 sec
• Pucker the lips – hold for 5 sec
• Smile as wide as possible – hold for 5 sec
( To perform 10times looking at a mirror )
• Strengthening exercise
1. Button & Thread Exercise
• To take large button with smooth edges
• Hold it between the lips
in front of teeth on the weaker side
• Try to pull it out against the hold of lips
• Try to hold for 5 sec
2. Straw Drinking
• Fit the straw tightly between the lips
• To drink liquid with straw followed by effortful swallow
• Drink thickened beverages, yoghurt or pudding

27. TONGUE EXERCISES
INDICATIONS – who underwent
Glossectomy
Flap reconstruction for tongue/OC
Fibrosis after RT
ROM exercise
1. Keep the mouth relaxed
2. Stick out the tonue as far
as possible
3. Move the tongue to left
corner of mouth
stretching as far as
possible
4. Repeat the extension on
right side
5. To elevate tongue tip
6. To retract the tongue
7. Protrude the tongue up
as if trying to touch tip of
nose
8. Protrude the tongue up
as if trying to touch the
chin
Every step to hold for 2 sec
Repeat 10 times
3 times a day
With the help of mirror
• Strengthening exercise
i. Push up against the tongue depressor
using front of the tongue
ii. Same using back of tongue
iii. Push against the tongue depressor to
the left
iv. Same to the right

28. BASE OF TONGUE EXERCISE
• Retraction of BOT and approximation with PPW is
needed for effective swallow
• Mendelsohn maneuver, Effortful swallow and Super-
supraglottic swallow - help in BOT retraction
• To retract base of tongue
1. Pretend to gargle
2. Pretend to yawn
BOT ROM EXERCISE
1. Yawn and hold the tongue in its
backward position for count of 5
2. Pretend to gargle, holding the tongue
in its extreme retracted position for
count of 5
3. Pull the tongue back and hold it in
extreme retracted position for count
of 5
Repeat the exercises 10 times

29. JAW OPENING EXERCISES
Usual indications :
• Trismus – OSMF, Buccal Ca
• Resection of muscles of mastication
• Fibrosis following mandibulectomy
• Post RT fibrosis
Exercises that help for opening jaw
1. Jaw ROM exercise
2. Stretching with Stacked wooden spatula
3. Stretching with mechanical devices
JAW ROM EXERCISE
1. Ask to open mouth as wide as
possible without any pain
2. Hold for 2 sec
3. Then move the jaw to left side as
far as possible
4. Hold for 2 sec
5. Redo the steps in right side
6. Try to move the jaw in circular
movement ( as in chewing )
To be repeated 5-10 times in each
session
5-10 sessions per day

30. THERABITE JAW OPENER STACKED TONGUE DEPRESSOR
TRISMUS SCREW

31. SOFT PALATE STRENGTHENING EXERCISE
 Soft palate weakness and Nasal regurgitation are a
common complication after Surgery of Oral cavity.
 Blowing exercises against resistance
 Ask patient to
1. Blow a balloon
2. Blow wind musical instrument like Conch
3. Piano with blowing tube

32. LARYNX EXERCISE
• After HnN surgery and post RT
 reduction in laryngeal elevation
• Mendelsohn maneuver and Falsetto
voice : common exercises advised to
increase ROM of larynx
Falsetto Voice
 Patient is asked to slide up the pitch scale of
voice as high as possible
 High note should be held for several seconds
with effort
( This exercise helps in increasing the laryngeal
ROM mainly elevation, as it is required for
adequate swallowing without Aspiration )

33. NECK EXERCISE – SHAKER EXERCISE
INDICATION
post surgery and Post RT HnN Ca patients to
improve swallowing
CONTRAINDICATIONS
Limitations in neck mobility
Patients with T-tube in situ
RATIONALE
Shaker exercise significantly improves anterior
laryngeal excursion and AP diameter of UES
2 parts of Shaker Exercise
Sustained Exercise
( Isometric )
Repetitive Exercise
( Isokinetic )
Ask the patient to do Both the parts
3 times daily
For 6-8 weeks

34. SUSTAINED EXERCISE ( ISOMETRIC )
• Lie down on back
• Do not use pillow
• Shoulders must be flat against the surface
• Lift up the head
• Bring the chin down to the chest
• Keep the head lifted for 60 sec
• Then lower the head and rest for 60 sec
• Repeat these steps 3 times
REPETITIVE EXERCISE ( ISOKINETIC )
• Lie down on back
• Do not use pillow
• Shoulders must be flat against the surface
• Lift up the head
• Bring the chin down to the chest
• Then immediately lower the head
• Repeat these steps 30 times

37. Voice Rehabilitation after
Head and Neck Surgery

38. • Types of Alaryngeal speech
• Primary speech restoration
• Secondary speech restoration
• Prosthesis
• Troubleshooting TEP
Voice Rehabilitation after Head and Neck Surgery

39. TYPES OF ALARYNGEAL SPEECH
• External sound source
( eg : Electrolarynx and Cooper Rands )
• Oesophageal speech
- Use of pharyngeal mucosa as a vibratory sound source
- utilizing the oesophagus rather than the lungs as an air supply
• Tracheoesophageal speech
- reconnecting the lungs to the pharynx with a surgical shunt ( eg :
Staffieri shunt , Amatsu’s Operation ) or with a valved prosthesis in a fistula ( eg :
Blom singer prosthesis)

40. 1. External sound source
2 types
• External type ( Electrolarynx )
- placed against the neck
- sound vibration generated from a metal or plastic
head of the device
- transmitted through the tissues in the pharynx,
hypopharynx and oral cavity
- then articulated normally as speech
• An oral type
- a small tube is placed in the oral cavity and which
generates the sound and is then articulated.
- more useful in post op type when neck tenderness is more
- eg ; Cooper Rands

41. Advantage of the electrolarynx
 Portability
 Relatively short learning time
 Ability to use it immediately post op
Disadvantage of the electrolarynx
 mechanical, monotonous and robot like sound quality
 Difficult to understand in noisy environment
 Necessity to use a hand to operate the control
 Dependence on charge/batteries

42. Cooper Rand electronic speech aid
 Oral device – vibrator delivers vibrations to the tube which
is placed in the mouth
 Vibrates pharyngeal mucosa to create and articulate speech
 Better for post surgery where neck is in healing process

43. 2. Oesophageal speech
• Trapping air in the mouth or pharynx
and propel it into the oesophagus
• Patient can then reflux the air up
through the oesophagus, vibrating the
pharyngeal mucosa or PE segment
• This produces a belch – like sound that
can be articulated by the tongue, lips
and teeth
Oesophageal speech

44. Advantages :
• Simple and hands free method
• No added surgery / repeated procedures
• No added cost
• Can provide an alternate means of
speech in those using other methods
Disadvantages :
• Difficult to train and long learning curve
• Requires intense speech therapy
• Success rate is patient dependent and
often poor

45. 3. Tracheo-Oesophageal speech
• Method of choice
• Involves creating a simple TEP between the posterior
wall of the tracheotome and the upper oesophagus into
which a one way valve is inserted
• The valve prevents salivary and liquid coming into the
airway
• By occluding the stoma, it allows air during exhalation to be shunted into the pharynx
• Sound is then produced by vibrating the mucosa of PE segment
• Speech is then produced by the articulation of this sound in the oral cavity

46. Advantages
• More quickly and easily attained
• Sounds Natural
• Has improved intensity and duration of speech,
achieving more words with one breath when
compared to oesophageal speakers
Tracheoesophageal speech

47. Primary vs Secondary TEP placement
• Initially TEP described as a secondary procedure, performed at least 4 weeks after laryngectomy
• In that, catheter was used to stent the surgically created tracheoesophageal fistula and a voice
prosthesis was placed after 4 weeks
• After several years, primary TEP was adopted in which TEP was performed directly at the time of
laryngectomy
• this avoids the need of catheter stenting, risk of fistula tract or esophageal erosion, avoids
multiple procedures and enables early voice rehabilitation
• If the upper esophagus is resected and replaced with stomach or jejunum in primary surgery – it
is preferable to delay voice restoration for some times

49. Primary voice restoration
• It is now the standard practice
Basic Principles
• To conserve as much pharyngeal mucosa as possible, particularly over the postcricoid
region, piriform fossa and vallecula
• Thyropharyngeus and cricopharyngeus muscle should be dissected off the thyroid lamina
on both sides and preserve as much as possible
• Ideally, transverse mucosal width of at least 6cm is necessary to enable the adequate
swallowing and effortless TE speech
• If the residual mucosal strip is < 6cm , augmentation of mucosa with flap is to be done

50. PRINCIPLE STEPS TO FOLLOW FOR PRIMARY VOICE RESTORATION
Cricopharyngeal myotomy
• Once the larynx is removed, a myotomy of the UES is carried out.
• This is important to avoid hypertonicity and spasm of muscles during
attempted phonation and to allow expansion of the upper oesophagus
providing an air reservoir below the PE segment
Tracheo-esophageal
puncture
• Puncture is done in the midline about 1-1.5 cm below the cut end of the
posterior tracheal wall
Pharyngeal closure
• Horizontal closure of the pharyngeal defect is preferred using
absorbable sutures in mucosa first and then in muscle layer.
• This produces a wider pharynx above the PE segment which is
beneficial to improve resonance for speech.
• Pharyngeal mucosa closure should be done without tension to prevent
pseudo-vallecula formation

51. PRINCIPLE STEPS TO FOLLOW FOR PRIMARY VOICE RESTORATION – CONT.
Repair of the suprahyoid
muscles
• Suture the suprahyoid muscles down to the thyropharyngeus.
• This provide support to the mucosa above the repair and avoid a
pseudoepiglottis formation, Which may affect swallow and speech later
Reinnervation of the
pharynx
• The cut ends of the SLN and RLN may be reimplanted into the
muscular wall of the reconstructed pharynx and upper oesophagus
respectively in the hope that this may restore some sensory and motor
reinnervation
Stoma Reconstruction
• Size, shape and contour of the stoma and surrounding skin should be of
size that can be occluded with digital pressure.
• Margins of the trachea can be sutured to the medial margins of the
SCM to secure it and provide stability

52. Voice Prosthesis
NON INDWELLING INDWELLING
 Can be removed or replaced by patient
 Daily maintenance includes cleaning &
flushing
 Patient dexterity play major role ( for
regular cleaning )
 Eg : Blom-singer Duckbill and Low
resistance VP and Panje
 Stay in place permanently and has to be
replaced by surgeon only when needed
 longer life span
 shorter learning curve
 Eg : Groningen device, provox, Blom-singer

54. Groningen ultra-low-resistance voice prosthesis with the valve and
semicircular slit in the hat of the esophageal flange
Blom – singer voice prosthesis with silver oxide coating
Blom – singer Duckbill voice prosthesis
• Non indwelling
• One way slit valve
• Low pressure system
Panje Voice Button
• Biflanged silicon tube with
one way valve
• self-retaining flanges
• Provide passage for air
from the trachea to the
esophagus
• Cleaned every 2 days
and reinserted by
patient

55. Provox® ActiValve®
• Primarily designed for patients who experience early
leakage through the voice prosthesis.
• The blue fluoroplastic material of the valve flap and
ring - insusceptible to destruction by candida.
• The magnets will prevent the valve flap from opening
inadvertently while breathing or swallowing.
• Significantly longest average device life

56. Selecting a prosthesis
• Candidate dexterity : if the patient is unable or unwilling to change the valve independently,
 indwelling prosthesis offer more security
• Phonatory effort : if the voice quality is effortless, loud and consistent, then patient should be
offered higher resistance device with increased durability.
if the voice quality is strained and effortful, a lower resistance device with
greater diameter may be appropriate
• Thickness of the posterior wall :
Too long prosthesis can cause a “pistoning effect” and consequent leakage around prosthesis,
Too short prosthesis may result in failure of function ( failure to speech )
• Durability : if the device recurrently leaks in less than a couple of months with no treatable cause ( eg :
candida infection ), a device with higher resistance and durability should be considered
• Cost : patients should be provided cost options when selecting a device

57. TE puncture Dilator being gently advanced into
TE puncture
Dilator securely fastened in TE puncture
Prosthesis loaded on the insertor and gently
advanced into
the puncture site
Valve securely confirmed in place and strap is cut
( only for indwelling )
Final picture
Indwelling Prosthesis sitting
securely in place
General steps of fitting a prosthesis

58. Troubleshooting TEP
Problem Likely causes Solution
NON SPEAKING
1. Device fault
2. PE segment spasm
1. Clean the device in situ. If still no speech,
device may need replacement
2. Assess with EMG or USG. If spasm present 
Botox injection
PERI PROSTHETIC LEAKAGE
1. Pistoning due to longer TEP
2. Widened fistula
A silastic ring can be placed – if still persistent
then change size the prosthesis
PERI PROSTHETIC LEAKAGE
+ NON SPEAKING
Granulation formation
Remove TEP and allow granulations to settle or
remove with laser.
Reinsert the prosthesis later
PERSISTENT LEAKAGE
1. Intractable fistula
2. Growth of biofilm on the valve
1. Surgical closure of the fistula or a silicon
obturator to close the defect
2. Consumption of Probiotics ( certain yoghurts
) have proven to be effective

59. Prosthesis extrusion
 Prosthesis may become dislodged during cleaning or coughing
 If not replaced immediately the tract may close down.
A catheter or dilator can be used to keep the tract open
until the prosthesis can be replaced
 Non indwelling prosthesis –more prone to dislodgement from the TEP tract
( more flimsy retention collars )
 For partial extrusion of prosthesis :
 rule out underlying infection or tissue hypertrophy
 If the prosthesis is completely extruded,
it is important to check whether dislodgement has occurred toward the
trachea or into the esophagus –
a proper Flexible endoscopy of the trachea should be done.
 if negative, radiology of thorax +/- abdomen should be conducted

60. • THANK YOU

61. Selection criteria for Secondary voice restoration
• Patient must be motivated
• Mentally sound
• Must have adequate understanding of post surgical anatomy and of TEP prosthesis
• Should not have alcohol or other substance dependency
• Must demonstrate adequate manual dexterity and ability to manage prosthesis
• Vision must be sufficient for purpose of managing tracheostoma and prosthesis
• Should have positive tonicity result in Oesophageal air insufflation test
• Should not have significant pharyngeal stenosis or stricture
• Must have adequate pulmonary support for prosthesis use
• Should have adequate depth and diameter of stoma for prosthesis to avoid airway occlusion
• Should have an intact TE posterior wall

62. Surgical technique for Secondary Voice voice restoration
• The method described by Singer and Blom in 1980
• The forceps are inserted alongside a pharyngeal speculum into the oesophageal opening
under direct vision and advanced down to the level of tracheostome where the tip can be
seen and palpated as it tents up the posterior tracheal wall in a similar way to the primary
puncture technique
• An incision is made through the posterior wall of the stoma in midline on to the tips of
forceps. Which are advanced into the trachea
• The end of the catheter ( 14G ) is then introduced int other forceps and withdrawn into the
pharynx, passed caudally and released
• The catheter is sutured to the skin above the tracheostome ( If a foleys catheter is used, the
balloon is inflated with 1.5mL of saline to prevent dislodgment )
• Remain for 2-7 days
• Replace with suitable prosthesis after measuring the length of the tract

63. • Botulinum toxin – is used to provide a chemical neurectomy and is the
treatment of choice for failed TE speech. When the failure is due to
spasm or hypertonicity
• Myotomy – is reserved for circumstance where botulinum is
ineffective or is required repeatedly