Voice rehabilitation following laryngectomy

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Voice rehabilitation following laryngectomy

  1. 1. Voice Rehabilitationfollowing Laryngectomy Balasubramanian Thiagarajan
  2. 2. Introduction Total Laryngectomy is still the preferred management modality in advanced laryngeal malignancies Advances in medical oncology and radiation oncology combined with traditional surgical methods has increased longevity of these patients TEP (Tracheo-oesophageal puncture) is considered gold standard among various voice rehabilitation procedures A good percentage of patients undergoing total Laryngectomy regain esophageal voice The current 5 yr. survival rate of patients following total Laryngectomy is about 80%An initiative of drtbalus otolaryngology online
  3. 3. Functional alterations following totalLaryngectomy Loss of smell Changes in normal swallowing mechanism Changes in the pattern of respiration Most importantly Loss of speech. The importance of this function is not realized till it is lostAn initiative of drtbalus otolaryngology online
  4. 4. Components of phonation Articulators (Lips, tongue, teeth) Larynx (Vibrator) Lung (Bellows)An initiative of drtbalus otolaryngology online
  5. 5. Requirements for normal phonation Active respiratory support Adequate glottic closure Normal mucosal covering of vocal cord Adequate vocal cord length and tension controlAn initiative of drtbalus otolaryngology online
  6. 6. Glottic cycle One opening and one closing incident of glottis is known as glottic cycle The frequency of glottic cycle is determined by subglottic air pressure This frequency is unique for each individualAn initiative of drtbalus otolaryngology online
  7. 7. Vocal fold vibratory phases During phonation two types of vibratory phases occur (Open and closed phases) In open phase glottis is at least partially open Open phase can be divided into opening and closing phases In opening phase the vocal cords move away from one another In closing phase the vocal folds move closer to each other in unison Closed phase indicate complete closure of glottic chinkAn initiative of drtbalus otolaryngology online
  8. 8. Vocal folds vibratory patterns Falsetto Modal voice Glottal fryAn initiative of drtbalus otolaryngology online
  9. 9. Falsetto vibration Vocal cord closure is not complete There is minimal air leak between the cords Only upper edge of vocal fold vibrates Also known as light voiceAn initiative of drtbalus otolaryngology online
  10. 10. Modal voice This is the basic frequency at which a pt. phonates Complete glottal closure occurs during this phase Vocal fold mucosa vibrates independently of the underlying vocalis muscle Modal frequency in adult males is around 120 Hz Modal frequency in adult females is around 200 HzAn initiative of drtbalus otolaryngology online
  11. 11. Glottal fry Low frequency phonation In this type of vocal fold vibration closed phase is longer when compared with that of open phase The vocal fold mucosa and vocalis muscle vibrate in unisonAn initiative of drtbalus otolaryngology online
  12. 12. Mucosal wave Very important physiological parameter to be noted during vocal fold motion It is the undulation that occurs over vocal fold mucosa This wave travels in infero superior direction The speed of this wave 0.5 – 1 m/sec Symmetry of these waves between both sides should be evaluated. Even mild degrees of asymmetry is pathologicalAn initiative of drtbalus otolaryngology online
  13. 13. Methods of speech followingLaryngectomy Also known as alaryngeal speech Esophageal speech Electro larynx TEP (Tracheo-oesophageal puncture)An initiative of drtbalus otolaryngology online
  14. 14. An initiative of drtbalus otolaryngology online
  15. 15. Esophageal speechAlaryngeal speechAn initiative of drtbalus otolaryngology online
  16. 16. Contd… All pts. Develop some degree of esophageal speech following Laryngectomy All alaryngeal speech modalities are compared with this modality Till 1970’s this was the gold standard for all other post Laryngectomy speech rehabilitation proceduresAn initiative of drtbalus otolaryngology online
  17. 17. Esophageal speech - Physiology Air is swallowed into cervical esophagus This swallowed air is expelled out causing vibrations of pharyngeal mucosa These vibrations along with articulations of tongue cause speech to occur The exact vibrating portion of pharynx is the pharyngo-oesophageal segment The vibrating muscles and mucosa of cervical oesophagus and hypopharynx cause speechAn initiative of drtbalus otolaryngology online
  18. 18. Oesophageal speech – PE segment This segment is made up of musculature and mucosa of lower cervical area (C5-C7 segments). Vibration of this segment causes speech in pts. Without larynx Cricopharyngeal area is important Cricopharyngeal spasm in these pts. Can lead to failure in developing Oesophageal speech Cricopharyngeal myotomy may help these pts. in developing Oesophageal speechAn initiative of drtbalus otolaryngology online
  19. 19. Pumping air into cervical oesophagus Injection method Inhalational methodAn initiative of drtbalus otolaryngology online
  20. 20. Injection method Enough positive pressure is built inside oral cavity to force air into cervical oesophagus Lip closure and tongue elevation against palate causes increase intraoral pressure Air is injected into the cervical oesophagus by voluntary swallowing This method is also known as tongue pumping / glossopharyngeal press / glossopharyngeal closure This method is really useful before uttering plosives / fricatives / affricativesAn initiative of drtbalus otolaryngology online
  21. 21. Inhalational method Uses the negative pressure used in normal breathing to allow air to enter cervical oesophagus Air pressure in the cervical oesophagus below Cricopharyngeal sphincter is the same negative pressure as that of thoracic cavity Pts. Learn how to relax Cricopharyngeal sphincter during inspiration allowing air to flow into cervical oesophagus as it enters the lungs Pts. Are encouraged to consume carbonated drinks which facilitates air entry into cervical oesophagus helping in generation of Oesophageal speechAn initiative of drtbalus otolaryngology online
  22. 22. Esophageal speech - Advantages Patient’s hands are free No additional surgery / prosthesis needed. Hence no extra cost for the pt. Pts. Get easily adapted to esophageal voiceAn initiative of drtbalus otolaryngology online
  23. 23. Esophageal speech - Disadvantages Nearly 40% of pts fail to develop esophageal speech Quality of voice generated is rather poor Pt. may not be able to continuously speak using esophageal voice without interruption. They will be able to speak only in short bursts Significant training is necessary Loudness / pitch control is difficult Fundamental frequency of esophageal speech is 65 Hz which is lower than that of male and female frequenciesAn initiative of drtbalus otolaryngology online
  24. 24. Esophageal speech developmentcauses for failure Presence of cricopharyngeal spasm Presence of reflux esophagitis Abnormalities involving PE segment – like thinning of muscle wall in that area Denervation of muscle in the PE segment Poorly motivated patientAn initiative of drtbalus otolaryngology online
  25. 25. Cricopharyngeal spasm Cricopharyngeal myotomy Botulinum toxin injection – 30 units can be injected via the tracheostome over the posterior pharyngeal wall bulgeAn initiative of drtbalus otolaryngology online
  26. 26. Electrolarynx These are battery operated vibrating devices It is held in the submandibular region Muscle contraction and changes in facial muscle tension causes rudiments of speech Initial training to use this equipment should begin even before surgeryAn initiative of drtbalus otolaryngology online
  27. 27. Electrolarynx - Types Pneumatic – Dutch speech aid, Tokyo artificial speech aid Neck Intraoral typeAn initiative of drtbalus otolaryngology online
  28. 28. Electrolarynx - Contd  Neck type is commonly used  Hypoesthesia of neck during early phases of post op period can cause difficulties  If neck type cannot be used intraoral type is the next preferred oneAn initiative of drtbalus otolaryngology online
  29. 29. Intraoral artificial larynx  Intraoral cup should form a tight seal over the stoma. There should not be any air leak  Oral tip should be placed in the oral cavity  Pts exhaled air rattles the cup placed over the stoma  Changes in exhaled pressure can vary the quality of sound generatedAn initiative of drtbalus otolaryngology online
  30. 30. Electrolarynx - advantages Can be easily learnt Immediate communication is possible Additional surgery is avoided Can be used as a interim measure till the patient masters the technique of esophageal speech or gets a TEP insertedAn initiative of drtbalus otolaryngology online
  31. 31. Electrolarynx - Disadvantages Expensive to maintain Speech generated is mechanical in quality Difficult while speaking over telephoneAn initiative of drtbalus otolaryngology online
  32. 32. Types of voice restoration surgeries Neoglottic reconstruction Shunt techniqueAn initiative of drtbalus otolaryngology online
  33. 33. Neoglottis procedure Performing trachea hyoidopexy This can restore voice function in alaryngeal patients Abandoned due to increased incidence of complications like aspirationAn initiative of drtbalus otolaryngology online
  34. 34. Shunt technique Developed by Guttmann in 1930 Involves creation of shunt between trachea and esophagus Lots of modifications of this procedure is available, Basic principle is the same Aim is to divert air from trachea into the esophagusAn initiative of drtbalus otolaryngology online
  35. 35. Types of shunts High trachea-esophageal shunt (Barton) Low trachea-esophageal shunt (Stafferi) TEP shunts (Guttmann)An initiative of drtbalus otolaryngology online
  36. 36. Causes of failure of shunt procedure Aspiration through the fistula Closure of the fistula To avoid these problems prosthesis was introducedAn initiative of drtbalus otolaryngology online
  37. 37. Types of ProsthesisAn initiative of drtbalus otolaryngology online
  38. 38. TEP Was first introduced by Blom and Singer in 1979 One way silicone valve is introduced via the fistula This valve served as one way conduit for air into esophagus while preventing aspiration This prosthesis has two flanges, one enters the esophagus while the other rests in the trachea. It fits snugly into the trachea-esophageal wound Indwelling prosthesis have more rigid flanges when compared to that of non indwelling ones A medallion ring is attached to the non indwelling prosthesis to prevent aspirationAn initiative of drtbalus otolaryngology online
  39. 39. Types of TEP Primary TEP – Performed during total laryngectomy Secondary TEP – Performed 6 months after surgeryAn initiative of drtbalus otolaryngology online
  40. 40. Anatomical structures TEP TEP is performed in midline (Less bleeding) Structures that are penetrated during TEP - membranous posterior wall of trachea, esophagus and its 3 muscle layers and esophageal mucosa Interconnecting tissue in the trachea-esophageal spaceAn initiative of drtbalus otolaryngology online
  41. 41. Advantages of TEP Can be performed after laryngectomy / irradiation / chemotherapy / neck dissection Fistula can be used for esophago-gastric feeding during immediate PO period Easily reversible Speech develops faster than esophageal speech High success rate Closely resembles laryngeal speech Speech is intelligibleAn initiative of drtbalus otolaryngology online
  42. 42. Disadvantages of TEP Pt should manually cover the stoma during voicing Good pulmonary reserve is a must Additional surgical procedure is needed to introduce it Posterior esophageal wall can be breached Catheter can pass through the posterior wallAn initiative of drtbalus otolaryngology online
  43. 43. TEP – Patient selection Motivated patient Patient with stable mind Patient who has understood the anatomy & physiology of the process Patient should not be an alcoholic Good hand dexterity Good visual acuity Positive esophageal air insufflation test Patient should not have pharyngeal stricture / stenosis Stoma should be of adequate depth and diameter Intact trachea-esophageal wallAn initiative of drtbalus otolaryngology online
  44. 44. Contraindications of TEP Extensive surgery involving pharynx, larynx with separation of trachea- esophageal wall Inadequate psychological preparation Patient with doubtful ability to cope up with prosthesis Impaired hand dexterity Suspected difficulty during PO irradiationAn initiative of drtbalus otolaryngology online
  45. 45. Primary - TEP Hamaker first performed in 1985 Primary TEP should be attempted where ever possible In this procedure puncture is performed immediately after laryngectomy and prosthesis is inserted Prosthesis of sufficient length should be usedAn initiative of drtbalus otolaryngology online
  46. 46. Primary TEP - Advantages Risk of separation of trachea – esophageal wall is minimized Tracheo – esophageal wall is stabilized to some extent by the prosthesis Flanges of prosthesis protects trachea from aspiration Stomal irritation is less Patient becomes familiar with prosthesis immediately following surgery Post op irradiation is not a contraindicationAn initiative of drtbalus otolaryngology online
  47. 47. Primary TEP - Procedure Because of exposure following laryngectomy it is easy to perform Ideally performed before pharyngeal closure Puncture is performed through pharyngotomy defect Ryles tube can be introduced via the fistula to provide gastric feeding in the post op periodAn initiative of drtbalus otolaryngology online
  48. 48. Secondary TEP Usually performed 6 weeks following laryngectomy This allows pt time to develop esophageal speech Area of fistula identified using rigid esophagoscope Prosthesis can be inserted immediatlyAn initiative of drtbalus otolaryngology online
  49. 49. Modified secondary TEP procedure Performed under local anesthesia Patient placed in recumbent position with mild extension of neck with a shoulder roll Tracheostomy tube is removed 12 0 clock position of tracheostoma visualized and infiltrated using 2% xylocaine with 1 in 100,000 adrenaline Yanker’s suction tube is inserted into the oral cavity till it hitches against 12-0 clock position of tracheostome This area is incised using 11 blade and widened using curved artery forceps Blom singer prosthesis is then introduced through this fistulaAn initiative of drtbalus otolaryngology online
  50. 50. 12 – 0 clock position of tracheostomaAn initiative of drtbalus otolaryngology online
  51. 51. Yanker’s suction tube insertedAn initiative of drtbalus otolaryngology online
  52. 52. TEP - IncisionAn initiative of drtbalus otolaryngology online
  53. 53. TEP - widenedAn initiative of drtbalus otolaryngology online
  54. 54. Prosthesis introducedAn initiative of drtbalus otolaryngology online
  55. 55. Prosthesis used in TEP Blom-Singer prosthesis Panje button Gronningen button Provox prosthesisAn initiative of drtbalus otolaryngology online
  56. 56. Panje voice button  Biflanged tube with one way valve  Can be inserted through the fistula created for this purpose  It is supplied with an introducer which makes insertion simple  Should be removed and cleaned every two days  Can be removed, cleaned and reinserted by the patientAn initiative of drtbalus otolaryngology online
  57. 57. Gronningen button  Introduced by Gronningen of Netherlands in 1980  Its high airflow resistance delayed speech in some patients  Now low air flow resistance tubes have been introducedAn initiative of drtbalus otolaryngology online
  58. 58. Blom-Singer prosthesis  Introduced by Blom and Singer in 1978  Commonly used prosthesis  This prosthesis acts as one way valve allowing air to pass into the esophagus and prevents aspiration  This prosthesis is shaped like a duck bill hence known as “Duck bill prosthesis”  The duck bill end should reach up to oesophagus  It is an indwelling prosthesis can be left in place for 3 months  This prosthesis is available in varying lengthsAn initiative of drtbalus otolaryngology online
  59. 59. Provox prosthesis  Indwelling low air flow pressure prosthesis  It has extended life time. Can last a couple of yeas if used properly  Insertion is easyAn initiative of drtbalus otolaryngology online
  60. 60. Indwelling versus Non indwelling prosthesis Indwelling prosthesis Non indwelling prosthesisCan be left in place for 3-6 months Should be removed and cleaned every couple of daysRequires specialist to do the job Pt. Can do it themselvesLess maintenance Periodical maintenanceStoma should be greater than 2 Stoma should be greater than 2cms cmsOesophageal insufflation test Oesophageal insufflation testshould be positive should be positive An initiative of drtbalus otolaryngology online
  61. 61. Problems with TEP insertion Leak through the prosthesis Leak around the prosthesis Immediate aphonia / dysphonia Hypertonicity problems Delayed speechAn initiative of drtbalus otolaryngology online
  62. 62. Oesophageal insufflation test Should be performed before TEP Assesses cricopharyngeal muscle response to esophageal distention A catheter is placed through the nostril up to 25 cm mark. This indicates probable site of puncture Pt is asked to count numbers or vocalize “Ah”An initiative of drtbalus otolaryngology online
  63. 63. Insufflation test interpretation Fluent voice on minimal effort – normal Breathy voice indicating hypotonic cricopharyngeal muscle Hypertonic voice – “Cricopharyngeal spasm” Spasmodic voice – “Extreme cricopharyngeal spasm”An initiative of drtbalus otolaryngology online
  64. 64. Common problems with TEP Improper location of puncture Inappropriate size of puncture Presence of cricopharyngeal spasm Leakage through and around the prosthesisAn initiative of drtbalus otolaryngology online
  65. 65. Location of TEP 12-0 clock position of stoma About 1-1.5 cms from trachea-cutaneous junction If located superiorly pt may find it difficult to occlude If located deep into the trachea then it becomes difficult to introduce the prosthesisAn initiative of drtbalus otolaryngology online
  66. 66. Management of leak through the prosthesis Cause SolutionValve in contact with posterior Replace prosthesis with differentwall of esophagus length and sizeProsthesis length too short for the Remeasure the puncture andpuncture “Pinched valve” replace with appropriate size prosthesisValve deterioration Replace valveFungal colonization of valve with Treat with nystatinyeastBack pressure High resistant prosthesisMucous / food lodgment An initiative of drtbalus otolaryngology online Prosthesis to be cleaned
  67. 67. Management of leak around the prosthesis Cause Solution TEP location Remove prosthesis allow puncture to close and repuncture Unnecessary dilatation during To be avoided valve placementThin trachea-esophageal wall 6 Choose custom prosthesis mm or lessProsthesis of incorrect length and Choose correct length size Poor tissue integrity due to Custom prosthesis irradiation An initiative of drtbalus otolaryngology online
  68. 68. An initiative of drtbalus otolaryngology online

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