Rehabilitation after treatment of cancer larynx sujay susikar
REHABILITATIONAFTER LARYNGEAL SURGERY Dr Sujay Susikar PG in Surgical Oncology Prof Dr R Rajaraman’s Unit Department of surgiacl oncology Govt Royapettah Hospital
Physiology of Speech3 basic elements are necessary:(1) Power source,(2) Sound source,(3) Sound modifier.For laryngeal speakers• lung air is the power source,• larynx is the sound source,• vocal tract ( pharynx, oral cavity) is the sound modifier.
Assessment of speech after treatment Depends on site of lesion Template of surgical deficit Respiration Insufflation testing Resonance Nasometry Phonation VFSS FEES
VFSSThe studies are captured using fluoroscopy in video or digitized format that allows detailed analysis of the oropharyngeal swallowing and speech processPenetration Contrast enters the airway, remains at or above vocal foldsAspiration Contrast passes glottis
Treatment of post op speech disordersVaried depending on the site:Alaryngeal speech: Tracheoesophageal prostheses Artificial larynx Esophageal speech
Rehabilitation after laryngectomy After total laryngectomy (TL), the sound source is removed and the lungs are disconnected from the vocal tract.Successful voice restoration following total laryngectomy (TL) requires identification of an Alternative sound source Viable power source.
Rehabilitation after laryngectomy Stoma careRehab of speech: Tracheo esophageal voice Artificial larynx Esophageal voiceExperienced speech pathologist essential
Esophageal speech Principle: Esophageal speech is produced by insufflation of the esophagus and controlled egress of air release that vibrates the pharyngoesophageal (PE) segment for sound production. Anatomic structures for articulation and resonance are usually unaltered Articulated by the tongue, lips and teeth Speech pathologist teaches insufflation behavior
Esophageal speechTechniques: Injection involves using the articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. Inhalation involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax so air insufflates the esophagus.Both techniques are based on the pressure differential principle that air flows from areas of higher pressure to areas of lower pressure.
Esophageal speechAdvantage: Does not utilize devices or implants No further surgery is required.Disadvantage: Time intensive learning Difficulties with phrasing and loudness
Tracheo esophageal voice Preferred modality Based on concept of shunting of tracheal air to the pharynx thro fistulous tract during exhalation to produce sound thro vibration of the mucosa of the upper esophageal segment
Tracheo esophageal voicePrinciple: A surgical fistula is created in the wall separating the trachea and esophagus. A one-way valved prosthesis is placed in the puncture tract, allowing lung air to pass into the esophagus. The lung air induces vibration of the PE segment for sound production. The mechanics of the one-way valve allow lung air to pass into the esophagus without food and liquids passing into the trachea.
Tracheo esophageal voiceSelection criteria Motivated and mentally stable. Adequate understanding of their anatomy, and the mechanics of the prosthesis. Sufficient manual dexterity and visual acuity to care for the stoma and the prosthesis. Should not have significant stenosis of the hypopharynx. Be able to produce speech following esophageal insufflation via a properly positioned esophageal catheter (the Taub test). Adequate pulmonary reserve. Should have a stoma of adequate depth and diameter to accept a prosthesis without airway compromise. It is worth noting that several of these requirements (1,2,4,5) are also necessary for good esophageal speech.
Tracheo esophageal voiceAdvantages: The air supply for speech is pulmonary Phonation sounds natural, and Voice restoration occurs within 2 weeks of surgery.Disadvantages: Additional surgery is required for secondary punctures, The prosthesis must be maintained, and Aspiration may occur if liquids leak through a malfunctioning valve.
Tracheo esophageal voiceTechniques of tracheo esophageal puncture: Primary secondary
Primary TEP Constructed after stoma before the pharynx is closedAdvantages: Avoiding a secondary procedure Provides early voice rehabilition TEP fistula can be used as a temporary feeding esophagostomyDisadvantages: Initial sensitive stoma Stoma migration with healing Delayed speech with post op RT
Secondary TEPAdvantages: Healing stabilized May have developed good esophageal voiceDisadvantages: Two operations Aphonic much longer Myotomy may be necessary Secondary TE puncture is considered for patients at risk of developing a fistula such as those who have severe radiation sequelae.
Tracheo Esophageal ProsthesisDuckbill Size: The prosthesis is 6-28 mm in length and 16F or 20F in diameter. Advantages: It has good durability, can be changed independently, and is inexpensive. Disadvantages: Airflow resistance is increased.Low resistance/pressure Size: It is 6-28 mm in length and 16F or 20F in diameter. Advantages: It has decreased airflow resistance, has shorter esophageal extension, and can be change independently. Disadvantages: It has decreased durability and is sensitive to esophageal pressure changes.Indwelling It is 6-22 mm in length and 20F or 22F in diameter. Advantages: It has decreased airflow resistance, increased security from dislodgement, and a removable strap. Disadvantages: It is clinician-dependent and has the potential for gastric distention from excess air insufflation. It is expensive
Hands-free tracheostoma valves2 primary functions: Hands-free speech and Housing for heat and moisture filters. Adhered to the neck, with a valve housing directly over the stoma. For speech, the air pressure generated during increased exhalatory effort closes the tracheostoma valve and directs air back through the tracheoesophageal prosthesis
Complications of TEP Failure of voice restoration Bleeding from around the tract Air in the stomach Salivary leak thro or around the prosthesis Aphonia during RT Mediastinitis Cervical cellulitis Cervical spine fracture Aspiration of the prosthesis
Electronic larynx Principle: An external mechanical sound source is substituted for the larynx. Anatomic structures for articulation and resonance are usually unaltered. External device placed against the neck or an intraoral type Electronically driven Sound articulated by tongue, lips and teeth
Electronic larynx Neck type - placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted into the oropharynx and articulated normally. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. A small tube is placed toward the posterior oral cavity, and the generated sound is then articulated. The tube has minimal effect on articulatory accuracy if the patient is taught properly and learns to use it well. A third type of electrolarynx has been developed using an electromyograph (EMG) transducer in the strap muscles to activate a sound source for hands-free use.
Electronic larynxAdvantages: Short learning time Can be used in immediate post op Relative availability and low costDisadvantages: Mechanical soumd Dependence on batteries Need for maintanence of intraoral tubes
Aphonia following voice prosthesis placementCauses: Post treatment edema Spasm of cricopharyngeus Pharyngeal stenosisEvaluation: VFSSManagement: Stenosis – dilatation Spasm- botulinum toxin injection
Treatment of post op speech disordersRehabilitation of velum: Optimization of respiratory volume Increase precision of articulation Increase volume intensity Slow the rate of articulation Use biofeedback for frequently spoken words Use of reconstruction or prosthetic management
Treatment of post op speech disordersRehabilitation of oral articulation: Maximizing coordination of articulation Use of contrastive drills Use of intelligibility drills Implementing speech strategies
Rehabilitation after partial laryngeal procedures: Both comunication and swallowing Can result in some compromise of phonation Swallowing generally adversely affected only in short term Post op dysphagia- due to decrease in sensation and altered anatomy Risk of penetration and aspiration
Support during treatment with chemoradiationAfter treatment issues: Stiffness Edema Frozen neck Fibrosis Xerostomia StenosisManagement: Good supportive care- management of mucositis Adequate analgesia Management of depression Maintenance of nutrition Monitoring by the treatment team
Rehabilitation after chemoradiation Relief from xerostomia Maintanence of mobility Reduction of aspiration Improvement in voice