Presented in Rehabilitation Conference Islamabad organized by ISRA University in affiliation with HEC in Nov. 2015

1. 18 January 2016
1

2. POST LARYNGECTOMY VOICE
REHABILITATION EDUCATION IN
PAKISTAN
Dr. Ghulam Saqulain
M.B.B.S., D.L.O., F.C.P.S
Head of Department of ENT
Capital Hospital, Islamabad

3. Famous Composer, Giacomo Puccini

4. One of the best
known composers
of all times
Died in 1924

5. Giacomo’s quotes
“I am being crucified like a Christ! I
have a collar around my throat that is
like torture.”
“I am having external X-Ray Treatment
at present and then they will put crystal
needles into my neck and make a hole,
again in my neck so that I can breathe
……”
“The thought of that hole, with a
rubber or silver tube in it terrifies me….
What an ordeal!. God Help Me”

6. LARYNGEAL CANCER
It is the most common head & neck cancer.
Male: female = 4:1
>90% squamous cell cancer.

7. Presentation:

10. TOTAL
LARYNGECTOMY
Goal of every clinician is
organ preservation
A total laryngectomy is
often unavoidable.
The current 5 yr. survival
rate of patients following
total Laryngectomy is
about 80%
10

12. 12

13. Devastation
Functional
alterations
• 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 lost

14. Requirements for
normal phonation
• Active respiratory support
• Adequate glottic closure
• Normal mucosal covering of vocal
cord
• Adequate vocal cord length and
tension control

15. Role of the
Speech-Language
Pathologist in
Voice Restoration
After Total
Laryngectomy
• The devastation created by these
changes can be reduced through
the support of a strong
rehabilitation team.
• A Speech-Language Pathologist
has a pivotal role to play

16. • Fortunately the quality of life following a total
laryngectomy is very good provided surgical
and rehabilitation efforts are optimal.
• Over the last several decades considerable
progress in voice, pulmonary and olfaction
rehabilitation of the total laryngectomy
patient has been made.

17. Methods of
speech following
Laryngectomy
• Non Surgical:
o Esophageal speech
o Electro larynx
• Surgical:
o TEP (Tracheo-oesophageal puncture)
o Neoglottis reconstruction
o Artificial larynx

18. Esophageal
Speech
Till 1970’s this was the
gold standard
The vibrating muscles and
mucosa of cervical
oesophagus and
hypopharynx cause
speech

20. Electrolarynx
20

21. • 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

22. Intraoral artificial
larynx

23. Types of voice
restoration
surgeries
• Neoglottic reconstruction (Trachea
hyoidopexy)
• Shunt technique

24. Types of shunts
• High trachea-esophageal shunt
(Barton)
• Low trachea-esophageal shunt
(Stafferi)
• TEP shunts (Guttmann)

25. 25
Tracheo
Oesophageal
Puncture

27. 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 patient

28. 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 introduced

29. 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 esophagus
• It is an indwelling prosthesis can be
left in place for 3 months
• This prosthesis is available in
varying lengths

30. Provox prosthesis
• Indwelling low air flow pressure
prosthesis
• It has extended life time. Can last a
couple of yeas if used properly
• Insertion is easy

31. Laryngeal
Implant
STRASBOURG,French researchers have developed a
titanium implant that can replace a human larynx,
providing new hope for laryngeal cancer patients.
The implant was successfully implanted in 2012 in a
laryngectomy patient

32. • The method of speech rehabilitation used
after total laryngectomy should be the
informed choice of the patient himself/
herself.
• However how is that choice to be made if the
clinician who is advising the patient is ill
informed and or has a bias towards only one
method of rehabilitation?

33. Knowledge & skills of speech
language pathologists/
therapists
A Survey

34. Educational Level
77%
8%
15% 0%
PGD
MSc
Mphil
PhD
n = 21

35. Training
50%50%
Received Training
Didn't Receive
Training
n = 21

36. Handling
Laryngectomized
patients.
43%
57%
Pre laryngectomy
cases
Post laryngectomy
cases
n = 9

37. Familiarity with
Voice Rehab
Procedures.
60%
40%
Familiar
Not Familiar
n = 21

38. Voice Rehab
practicing pattern
40%
20%
20%
20%
Swallowing
Esophageal speech
Electrolarynx
Tracheo esophageal
fistula
n = 21

39. Conclusion
Recommendations
• We have not incorporated post
laryngectomy rehab education in
the syllabi of different training
programs properly
• Practical training is lacking.
• Post laryngectomy rehab
education be imparted in form of
mandatory workshops for all
training programs in speech
language pathology.
• These workshops should focus on
practical training as well.

41. Abstract
• Total laryngectomy or laryngopharyngectomy is still the
treatment of choice for advanced laryngeal/hypopharyngeal
carcinoma. However, the procedure is associated with loss of
normal voice over and above the loss of nasal function,
swallowing difficulties and lung function changes.
Rehabilitation of these patients has long been a major
challenge. In the last few decades there has been significant
development in the speech rehabilitation of these patients.
• The methods employed to reestablish voice after extirpation
of the larynx may be grouped into the categories of:
esophageal speech, surgical methods of creating competent
tracheo-pharyngeal shunts, "near-total" resection of the
larynx with dynamic phonatory shunt, and the use of external
pneumatic or electrical devices to create sound.
• In this article, the post laryngectomy voice rehabilitation
education status in Pakistan among the speech language
pathologists is discussed.