Voice therapy to treat voice disorders, basics , different techniques, methods advantages and disadvantages, where and what method to choose? otorhinolaryngology ent
ECochG is a variant of brainstem audio evoked response (ABR) where the recording electrode is placed as close as practical to the cochlea. We will use the abbreviation ECOG and ECochG interchangeably below. ECOG is preferable to us as it is shorter.
ECOG is intended to diagnose Meniere's disease, and particular, hydrops (swelling of the inner ear). ECOG may also be abnormal in perilymph fistula, and in superior canal dehiscence. The common feature connecting these illnesses is an imbalance in pressure between the endolymphatic and perilymphatic compartment of the inner ear.
ECOG can also be used to show that the cochlea is normal, in persons who are deaf. The cochlear microphonic of ECOG may be normal in auditory neuropathy (Santarelli and Arslan 2002) as well as other disorders in which the cochlea is preserved but the auditory nerve is damaged (Yokoyama, Nishida et al. 1999).
Finally, ECOG's have also been used to as a indicator of the temporary threshold shift that may follow noise injury (Nam et al, 2004).
VEMP testing provides a method to evaluate otolith function in the inner ear by measuring electromyographic responses from the sternocleidomastoid (cVEMP) and inferior oblique ocular muscles (oVEMP) elicited by sound stimulation. cVEMP assesses the saccule and vestibular nerve pathway while oVEMP assesses the utricle pathway. VEMP testing is useful in clinical diagnosis of various vestibular disorders including neuritis, Meniere's disease, vestibular schwannoma, and more. Standardization of stimulation and recording methods is still needed for VEMP to be effectively utilized in clinical practice.
This document discusses the auditory steady-state response (ASSR), an auditory evoked potential used to estimate hearing thresholds. The ASSR uses modulated tones and statistical analysis to determine thresholds. It can be recorded from sleeping children and those without measurable auditory brainstem responses. While similar to ABRs, ASSRs analyze amplitude and phase in the frequency domain rather than waveform amplitude and latency. ASSRs also use repeated, modulated stimuli rather than clicks or tones. They provide more frequency-specific information and can estimate thresholds in more severe hearing losses than ABRs.
Auditory neuropathy spectrum disorder (ANSD) is characterized by normal outer hair cell function but abnormal or absent auditory brainstem response, despite mild to profound hearing loss. A 27-year-old female presented with right-sided hearing loss, vertigo, and tinnitus for several years. Testing found normal outer hair cell function but abnormal auditory brainstem responses, consistent with progressive ANSD. Treatment options for ANSD are limited but may include hearing aids, cochlear implants, or speech therapy depending on the severity and progression of the hearing loss.
This document discusses voice disorders and their diagnosis and treatment. It covers the basics of normal voice production and the glottal cycle. Key aspects of stroboscopic examination are described, including amplitude of vibration, mucosal wave, symmetry, periodicity, and glottic closure patterns. Common voice disorders like tension dysphonia, laryngitis, vocal nodules, and vocal fold paralysis are mentioned. The document emphasizes taking a thorough history and examining the oral cavity, larynx, breathing, and voice quality during diagnosis of voice disorders. Stroboscopy aids in detecting subtle vocal fold abnormalities. Voice hygiene and lifestyle modifications are important aspects of treatment.
Voice therapy to treat voice disorders, basics , different techniques, methods advantages and disadvantages, where and what method to choose? otorhinolaryngology ent
ECochG is a variant of brainstem audio evoked response (ABR) where the recording electrode is placed as close as practical to the cochlea. We will use the abbreviation ECOG and ECochG interchangeably below. ECOG is preferable to us as it is shorter.
ECOG is intended to diagnose Meniere's disease, and particular, hydrops (swelling of the inner ear). ECOG may also be abnormal in perilymph fistula, and in superior canal dehiscence. The common feature connecting these illnesses is an imbalance in pressure between the endolymphatic and perilymphatic compartment of the inner ear.
ECOG can also be used to show that the cochlea is normal, in persons who are deaf. The cochlear microphonic of ECOG may be normal in auditory neuropathy (Santarelli and Arslan 2002) as well as other disorders in which the cochlea is preserved but the auditory nerve is damaged (Yokoyama, Nishida et al. 1999).
Finally, ECOG's have also been used to as a indicator of the temporary threshold shift that may follow noise injury (Nam et al, 2004).
VEMP testing provides a method to evaluate otolith function in the inner ear by measuring electromyographic responses from the sternocleidomastoid (cVEMP) and inferior oblique ocular muscles (oVEMP) elicited by sound stimulation. cVEMP assesses the saccule and vestibular nerve pathway while oVEMP assesses the utricle pathway. VEMP testing is useful in clinical diagnosis of various vestibular disorders including neuritis, Meniere's disease, vestibular schwannoma, and more. Standardization of stimulation and recording methods is still needed for VEMP to be effectively utilized in clinical practice.
This document discusses the auditory steady-state response (ASSR), an auditory evoked potential used to estimate hearing thresholds. The ASSR uses modulated tones and statistical analysis to determine thresholds. It can be recorded from sleeping children and those without measurable auditory brainstem responses. While similar to ABRs, ASSRs analyze amplitude and phase in the frequency domain rather than waveform amplitude and latency. ASSRs also use repeated, modulated stimuli rather than clicks or tones. They provide more frequency-specific information and can estimate thresholds in more severe hearing losses than ABRs.
Auditory neuropathy spectrum disorder (ANSD) is characterized by normal outer hair cell function but abnormal or absent auditory brainstem response, despite mild to profound hearing loss. A 27-year-old female presented with right-sided hearing loss, vertigo, and tinnitus for several years. Testing found normal outer hair cell function but abnormal auditory brainstem responses, consistent with progressive ANSD. Treatment options for ANSD are limited but may include hearing aids, cochlear implants, or speech therapy depending on the severity and progression of the hearing loss.
This document discusses voice disorders and their diagnosis and treatment. It covers the basics of normal voice production and the glottal cycle. Key aspects of stroboscopic examination are described, including amplitude of vibration, mucosal wave, symmetry, periodicity, and glottic closure patterns. Common voice disorders like tension dysphonia, laryngitis, vocal nodules, and vocal fold paralysis are mentioned. The document emphasizes taking a thorough history and examining the oral cavity, larynx, breathing, and voice quality during diagnosis of voice disorders. Stroboscopy aids in detecting subtle vocal fold abnormalities. Voice hygiene and lifestyle modifications are important aspects of treatment.
Stroboscopy is a technique used to visualize vocal fold vibration during phonation using synchronized flashing light. It allows observation of vibration in slow motion, providing real-time information about vibration and detection of vocal pathology. The flashing light is synchronized to the frequency of vocal fold vibration, producing a clear still image of the same portion of the vibratory cycle using the principles of persistence of vision and correspondence. Stroboscopy is essential for planning surgery and improving subtle laryngeal diagnoses. Key diagnostic findings include asymmetry of vibration with lesions like polyps and compromised glottic closure with nodules.
Tinnitus retraining therapy (TRT) is a treatment for tinnitus that involves counseling and sound therapy to retrain connections between the auditory, limbic, and autonomic nervous systems. It categorizes patients based on factors like hearing loss and sound sensitivity and prescribes different sound therapy devices at appropriate levels. Counseling teaches patients about tinnitus mechanisms and helps reduce reactions. Studies show TRT improves tinnitus handicap in 78-96% of patients after 8-18 months of treatment.
This document discusses various tests used to evaluate cochlear and vestibular function, including OAEs, VEMPs, and CCG. It provides details on:
- How OAEs are generated by healthy cochlea and the different types of OAE tests (TEOAE, DPOAE).
- How VEMPs record electrical potentials from neck and eye muscles in response to sound to evaluate vestibular pathways. Details are given on cervical and ocular VEMP procedures.
- How CCG uses lights on the head and shoulders with video recording to quantify vestibular-spinal reflexes during tests like Unterberger or Romberg maneuvers.
1. Flaps are used in reconstructive surgery to repair structural defects following procedures like cancer surgery. They involve transferring tissue from one part of the body to another while maintaining or reconnecting its blood supply.
2. There are many types of flaps classified by their blood supply, tissue type, and location. Common flaps used in head and neck reconstruction include local flaps like nasolabial and advancement flaps as well as regional and distant flaps like pectoralis major and radial forearm flaps.
3. Proper flap selection and design is important to replace tissue "like with like" and adhere to anatomical borders and units for optimal cosmetic and functional outcomes.
the ppt includes the anatomy of larynx, the physiology of sound production and pathology of vocal cords explaining the myoelastic aerodynamic theory and bernoulli effect in phonation
Pure tone audiometry is a test used to evaluate hearing thresholds across different frequencies. It involves presenting pure tones to a patient through headphones and determining the lowest volume they can detect at each frequency. Key information obtained includes the type, degree, and configuration of any hearing loss. PTA requires patient cooperation and provides an objective measure of hearing sensitivity. Proper testing conditions and techniques are important for accurate results.
This document discusses various techniques and approaches used in voice therapy, including relaxation, respiration training, elimination of vocal abuses, and vocal function exercises. It emphasizes that successful therapy requires a holistic approach combining behavioral, cognitive, and counseling techniques tailored to the individual client. Progress is measured through pre- and post-therapy voice recordings, instrumentation, and tracking improvement across specific criteria.
1. Behavioral tests are used to evaluate hearing in infants and young children, including behavioral observation audiometry for infants under 6 months and condition orientation reflex audiometry (CORA) for children 6 months to 1 year old.
2. CORA uses operant conditioning to teach the child to orient towards a sound source to receive a visual reinforcement from a lighted toy.
3. Visual reinforcement audiometry (VRA) and tangible reinforcement operant conditioning audiometry (TROCA) build on CORA principles to test older children using reinforcement strategies.
4. Conditioned play audiometry (CPA) teaches children ages 2-4 to perform tasks after hearing tones to make the
The document discusses middle ear implants as a type of hearing aid for patients with mild to severe hearing loss. It describes two main types of transducers used in middle ear implants - electromagnetic and piezoelectric. Several implant devices are discussed, including the Vibrant Soundbridge, Middle Ear Transducer (MET), Carina, and Esteem. Clinical trial results for some devices show significant improvement in functional gain and patient satisfaction compared to conventional hearing aids.
This document discusses acoustic reflex and tone decay testing. It defines acoustic reflex as a decrease in tympanic membrane compliance in response to sound stimulation that is measured using immittance testing. Acoustic reflex can be tested ipsi-laterally, stimulating and measuring the same ear, or contra-laterally, stimulating one ear and measuring the opposite ear. Tone decay measures the relaxation of the stapedius muscle between contractions in response to sustained tones and can help localize lesions. Abnormal decay at low frequencies suggests lesions of the auditory nerve or brainstem while decay at high frequencies suggests cochlear lesions.
Videostroboscopy is a useful technique for evaluating the larynx. It uses synchronized flashing light passed through an endoscope to visualize vocal fold vibration in slow motion. This allows examination of vocal fold biomechanics, laryngeal mucosa, and mucosal vibration. Videostroboscopy can detect vocal fold lesions and other pathologies, helping to plan surgery and treatments for voice problems. The procedure involves calibrating a microphone, inserting a rigid or flexible endoscope, and having the patient phonate so vocal fold vibration can be observed. Common findings include vocal cysts, polyps, and nodules, which impact mucosal wave and glottic closure.
This document provides information about masking techniques used during audiometric testing. It defines masking and explains that the goal is to prevent the non-test ear from participating. Interaural attenuation values are discussed as well as when masking is needed for air and bone conduction tests. Types of masking noise, appropriate levels of noise, and risks of undermasking and overmasking are covered.
Videonystagmography is also known as VNG, is a most advanced diagnostic test for a balance disorder. Individuals who feel dizzy and face difficulty in maintaining their balance and equilibrium should undergo the videonystagmography diagnostic test.
Superior semicircular canal dehiscence is a disorder where the bone between the superior semicircular canal and middle cranial fossa is absent, causing sound and pressure induced vertigo and oscillopsia. It is usually congenital or developmental and bilateral. Patients experience vestibular symptoms like vertigo when exposed to loud sounds, coughing, sneezing or straining. Diagnosis involves a CT scan and audiogram showing an air-bone gap with intact reflexes. Treatment options include avoiding triggers or surgically resurfacing the superior semicircular canal.
This document discusses phonosurgery techniques including vocal fold injection and laryngeal framework surgery. It provides details on the intrinsic laryngeal musculature and the expansion of phonosurgery over the last 50 years to primarily improve or restore the voice. Type I thyroplasty for vocal fold medialization is described in detail, including indications, surgical technique of making a window in the thyroid cartilage and placing different types of implants, advantages, complications, and pitfalls. The goal of type I thyroplasty is to improve voice and prevent aspiration by medializing the vocal fold to mimic the function of the thyroarytenoid muscle.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA), AUDIOTORY BRAINSTEM RESPONSE (ABR)Girish S
Neurologic objective, noninvasive test of auditory brainstem function in response to auditory (click) stimuli. It’s a set of seven positive waves recorded during the first 10 milli seconds after a click stimuli. They are labeled as I - VII. Also called Jewet bumps.
Mucosal folds and ventilation of middle ear AlkaKapil
The document discusses the anatomy and embryology of the middle ear spaces and mucosal folds.
1. The middle ear develops from the tubotympanic recess which buds into sacs including the saccus anticus, medius, superior and posterior. Remnants of mesenchyme become ligaments and blood vessels.
2. The middle ear is divided into several compartments by mucosal folds including the protympanum, mesotympanum, epitympanum, hypotympanum, and retrotympanum.
3. The epitympanum or attic is further divided by mucosal folds into the upper unit above
Superior Semicircular Canal Dehiscence SyndromeAde Wijaya
Superior semicircular canal dehiscence syndrome is caused by a thin or missing bone over the superior semicircular canal. This allows abnormal transmission of sound and pressure into the inner ear, causing symptoms like vertigo, dizziness, autophony, and pressure- or sound-induced vertigo. Diagnosis is based on clinical presentation and imaging evidence of a dehiscence. Treatment options include avoiding triggering environmental factors or surgical repair of the dehiscence. It is an uncommon but important cause of vestibular symptoms that requires consideration in patients with dizziness or auditory symptoms.
QUICK REFERENCE FOR DYSPHAGIA REHABILITATION
GENERAL THERAPEUTIC GUIDELINES FOR PROFESSIONALS. KUNNAMPALLIL GEJO JOHN, SPEECH LANGUAGE PATHOLOGIST / THERAPIST PREPARED THIS REFERANCE BOOKLET FOR SPEECH THERAPIST AND OTHER PROFESSIONALS.
Stroboscopy is a technique used to visualize vocal fold vibration during phonation using synchronized flashing light. It allows observation of vibration in slow motion, providing real-time information about vibration and detection of vocal pathology. The flashing light is synchronized to the frequency of vocal fold vibration, producing a clear still image of the same portion of the vibratory cycle using the principles of persistence of vision and correspondence. Stroboscopy is essential for planning surgery and improving subtle laryngeal diagnoses. Key diagnostic findings include asymmetry of vibration with lesions like polyps and compromised glottic closure with nodules.
Tinnitus retraining therapy (TRT) is a treatment for tinnitus that involves counseling and sound therapy to retrain connections between the auditory, limbic, and autonomic nervous systems. It categorizes patients based on factors like hearing loss and sound sensitivity and prescribes different sound therapy devices at appropriate levels. Counseling teaches patients about tinnitus mechanisms and helps reduce reactions. Studies show TRT improves tinnitus handicap in 78-96% of patients after 8-18 months of treatment.
This document discusses various tests used to evaluate cochlear and vestibular function, including OAEs, VEMPs, and CCG. It provides details on:
- How OAEs are generated by healthy cochlea and the different types of OAE tests (TEOAE, DPOAE).
- How VEMPs record electrical potentials from neck and eye muscles in response to sound to evaluate vestibular pathways. Details are given on cervical and ocular VEMP procedures.
- How CCG uses lights on the head and shoulders with video recording to quantify vestibular-spinal reflexes during tests like Unterberger or Romberg maneuvers.
1. Flaps are used in reconstructive surgery to repair structural defects following procedures like cancer surgery. They involve transferring tissue from one part of the body to another while maintaining or reconnecting its blood supply.
2. There are many types of flaps classified by their blood supply, tissue type, and location. Common flaps used in head and neck reconstruction include local flaps like nasolabial and advancement flaps as well as regional and distant flaps like pectoralis major and radial forearm flaps.
3. Proper flap selection and design is important to replace tissue "like with like" and adhere to anatomical borders and units for optimal cosmetic and functional outcomes.
the ppt includes the anatomy of larynx, the physiology of sound production and pathology of vocal cords explaining the myoelastic aerodynamic theory and bernoulli effect in phonation
Pure tone audiometry is a test used to evaluate hearing thresholds across different frequencies. It involves presenting pure tones to a patient through headphones and determining the lowest volume they can detect at each frequency. Key information obtained includes the type, degree, and configuration of any hearing loss. PTA requires patient cooperation and provides an objective measure of hearing sensitivity. Proper testing conditions and techniques are important for accurate results.
This document discusses various techniques and approaches used in voice therapy, including relaxation, respiration training, elimination of vocal abuses, and vocal function exercises. It emphasizes that successful therapy requires a holistic approach combining behavioral, cognitive, and counseling techniques tailored to the individual client. Progress is measured through pre- and post-therapy voice recordings, instrumentation, and tracking improvement across specific criteria.
1. Behavioral tests are used to evaluate hearing in infants and young children, including behavioral observation audiometry for infants under 6 months and condition orientation reflex audiometry (CORA) for children 6 months to 1 year old.
2. CORA uses operant conditioning to teach the child to orient towards a sound source to receive a visual reinforcement from a lighted toy.
3. Visual reinforcement audiometry (VRA) and tangible reinforcement operant conditioning audiometry (TROCA) build on CORA principles to test older children using reinforcement strategies.
4. Conditioned play audiometry (CPA) teaches children ages 2-4 to perform tasks after hearing tones to make the
The document discusses middle ear implants as a type of hearing aid for patients with mild to severe hearing loss. It describes two main types of transducers used in middle ear implants - electromagnetic and piezoelectric. Several implant devices are discussed, including the Vibrant Soundbridge, Middle Ear Transducer (MET), Carina, and Esteem. Clinical trial results for some devices show significant improvement in functional gain and patient satisfaction compared to conventional hearing aids.
This document discusses acoustic reflex and tone decay testing. It defines acoustic reflex as a decrease in tympanic membrane compliance in response to sound stimulation that is measured using immittance testing. Acoustic reflex can be tested ipsi-laterally, stimulating and measuring the same ear, or contra-laterally, stimulating one ear and measuring the opposite ear. Tone decay measures the relaxation of the stapedius muscle between contractions in response to sustained tones and can help localize lesions. Abnormal decay at low frequencies suggests lesions of the auditory nerve or brainstem while decay at high frequencies suggests cochlear lesions.
Videostroboscopy is a useful technique for evaluating the larynx. It uses synchronized flashing light passed through an endoscope to visualize vocal fold vibration in slow motion. This allows examination of vocal fold biomechanics, laryngeal mucosa, and mucosal vibration. Videostroboscopy can detect vocal fold lesions and other pathologies, helping to plan surgery and treatments for voice problems. The procedure involves calibrating a microphone, inserting a rigid or flexible endoscope, and having the patient phonate so vocal fold vibration can be observed. Common findings include vocal cysts, polyps, and nodules, which impact mucosal wave and glottic closure.
This document provides information about masking techniques used during audiometric testing. It defines masking and explains that the goal is to prevent the non-test ear from participating. Interaural attenuation values are discussed as well as when masking is needed for air and bone conduction tests. Types of masking noise, appropriate levels of noise, and risks of undermasking and overmasking are covered.
Videonystagmography is also known as VNG, is a most advanced diagnostic test for a balance disorder. Individuals who feel dizzy and face difficulty in maintaining their balance and equilibrium should undergo the videonystagmography diagnostic test.
Superior semicircular canal dehiscence is a disorder where the bone between the superior semicircular canal and middle cranial fossa is absent, causing sound and pressure induced vertigo and oscillopsia. It is usually congenital or developmental and bilateral. Patients experience vestibular symptoms like vertigo when exposed to loud sounds, coughing, sneezing or straining. Diagnosis involves a CT scan and audiogram showing an air-bone gap with intact reflexes. Treatment options include avoiding triggers or surgically resurfacing the superior semicircular canal.
This document discusses phonosurgery techniques including vocal fold injection and laryngeal framework surgery. It provides details on the intrinsic laryngeal musculature and the expansion of phonosurgery over the last 50 years to primarily improve or restore the voice. Type I thyroplasty for vocal fold medialization is described in detail, including indications, surgical technique of making a window in the thyroid cartilage and placing different types of implants, advantages, complications, and pitfalls. The goal of type I thyroplasty is to improve voice and prevent aspiration by medializing the vocal fold to mimic the function of the thyroarytenoid muscle.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA), AUDIOTORY BRAINSTEM RESPONSE (ABR)Girish S
Neurologic objective, noninvasive test of auditory brainstem function in response to auditory (click) stimuli. It’s a set of seven positive waves recorded during the first 10 milli seconds after a click stimuli. They are labeled as I - VII. Also called Jewet bumps.
Mucosal folds and ventilation of middle ear AlkaKapil
The document discusses the anatomy and embryology of the middle ear spaces and mucosal folds.
1. The middle ear develops from the tubotympanic recess which buds into sacs including the saccus anticus, medius, superior and posterior. Remnants of mesenchyme become ligaments and blood vessels.
2. The middle ear is divided into several compartments by mucosal folds including the protympanum, mesotympanum, epitympanum, hypotympanum, and retrotympanum.
3. The epitympanum or attic is further divided by mucosal folds into the upper unit above
Superior Semicircular Canal Dehiscence SyndromeAde Wijaya
Superior semicircular canal dehiscence syndrome is caused by a thin or missing bone over the superior semicircular canal. This allows abnormal transmission of sound and pressure into the inner ear, causing symptoms like vertigo, dizziness, autophony, and pressure- or sound-induced vertigo. Diagnosis is based on clinical presentation and imaging evidence of a dehiscence. Treatment options include avoiding triggering environmental factors or surgical repair of the dehiscence. It is an uncommon but important cause of vestibular symptoms that requires consideration in patients with dizziness or auditory symptoms.
QUICK REFERENCE FOR DYSPHAGIA REHABILITATION
GENERAL THERAPEUTIC GUIDELINES FOR PROFESSIONALS. KUNNAMPALLIL GEJO JOHN, SPEECH LANGUAGE PATHOLOGIST / THERAPIST PREPARED THIS REFERANCE BOOKLET FOR SPEECH THERAPIST AND OTHER PROFESSIONALS.
Use side hand grip for head control, the therapist assist lip close & jaw closer. Use straw when drinking liquid. Place food to unimpaired side. Use cold food / liquid.
1) Oral habits like thumb sucking, tongue thrusting and mouth breathing can cause malocclusion if performed repeatedly over long periods of time.
2) Habits exert pressure on developing teeth and jaws, potentially causing spacing, crowding, open bites or cross bites.
3) Treatment involves identifying the habit, counseling parents and patients, using reminders or appliances to encourage adoption of healthy oral behaviors, and correcting any resulting malocclusion. Managing habits at a young age can prevent long-term dental issues.
This document discusses the process of deglutition (swallowing). It begins with an introduction describing that swallowing involves coordinated activity of the oral cavity, pharynx, larynx, and esophagus muscles. It is partly under voluntary and partly under reflexive control. The document then covers the components, phases (oral, pharyngeal, esophageal), muscles involved, theories of swallowing, and neural control of deglutition. Key points include that swallowing has oral preparatory and oral phases under voluntary control and a pharyngeal phase that is reflexive, propelling the bolus into the esophagus for involuntary transport.
1. Mastication is the process of chewing food to prepare it for swallowing and involves rhythmic movements of the jaw through a chewing cycle.
2. Food characteristics like hardness can influence the masticatory process by affecting forces exerted, muscle activity, and jaw movements during chewing.
3. Both oral physiology factors and food properties may impact the threshold at which chewing triggers the urge to swallow, with harder and drier foods requiring more chewing cycles to reduce size and hydrate before swallowing.
Physiology of swallowing is a complex coordinated activity involving muscles of the oral cavity, pharynx, larynx, and esophagus under both reflex and voluntary control. The document describes the structures involved in swallowing like the tongue, pharynx, larynx, and cricopharyngeal sphincter. It explains the sequence of events in normal swallowing including the oral, pharyngeal and esophageal phases. Key muscles and cranial nerves involved in each phase are identified. Causes, assessment, and management of dysphagia or swallowing difficulties are also discussed.
This document provides information on a child named Ahsan Jamil who is 8 years old and diagnosed with a phonological processing disorder secondary to hearing impairment. He has a cochlear implant and was brought to the hospital one year ago with concerns about his speech clarity and language acquisition. His speech initially had many articulation errors, fast rate, and poor eye contact along with some behavior problems. Currently, he communicates verbally, can speak in 4 word sentences with 90% intelligibility, and his behavior problems are decreasing as his language increases. He is making progress in speech therapy.
The document provides details about the anatomy and physiology of swallowing. It describes the four stages of swallowing as oral preparatory, oral, pharyngeal, and esophageal. Key points include that swallowing involves passage of food from mouth to stomach through coordinated voluntary and involuntary contractions. The pharynx and esophagus are described in terms of layers, segments, nerve supply, and functions during swallowing. Causes and characteristics of dysphagia in the oropharyngeal and esophageal regions are also summarized.
The document discusses the physiology of deglutition or swallowing. It describes how swallowing involves coordinated muscle activity to move food from the mouth to the stomach through three phases - oral, pharyngeal, and esophageal. The oral phase prepares food for swallowing through chewing and mixing with saliva. The pharyngeal phase is a reflex that protects the airway and involves tongue pumping and epiglottis closure. The esophageal phase relaxes the lower esophageal sphincter to allow food passage through peristalsis. Neural control involves both voluntary and involuntary pathways in the brain and medulla to coordinate the complex swallowing process.
Tongue thrust and mouth breathing habits in childrenDr. Harsh Shah
Overview on mouth breathing and tongue thrusting in children leading to ill effects
Presented by : Pratiksha Ahire
Guided by : Dr. Rehan Khan
Dept. of Pediatric Dentistry
SDDCH PArbhani
This document discusses habits like thumb sucking and tongue thrusting and their effects on malocclusion. It defines habits as fixed practices produced by constant repetition of an act. Thumb sucking can cause malocclusion depending on factors like the position of the digit during sucking and the force applied. Preventive measures include proper nursing, use of well-designed pacifiers, and providing kinesthetic activities. Appliances can be used to treat habits and may work by rendering sucking meaningless or changing the tongue's position. Tongue thrusting is also discussed, including its types, causes, effects like open bite, and treatment involving muscle training and appliances with spikes.
Is a phenomenon of reflex sequence of muscle contractions that propels the ingested materials and pooled saliva from the mouth to the stomach.
PATTERNS
Infantile (visceral) swallow
Adult/mature swallow
ADULT SWALLOWING
Is composed of 4 stages
Voluntary
Preparatory phase
Oral or buccal
Involuntary: Controlled By Medulla and Lower Pons
Pharyngeal
b. Oesophageal
2nd chapter of digestive system from Guyton & HallDrMisba
This document discusses the propulsion and mixing of food in the alimentary tract. It covers topics like the control of food intake by the hypothalamus, the mechanics of ingestion including mastication and swallowing, and the movements that propel and mix food through the small intestine like segmentation and peristalsis. The small intestine uses various movements controlled by the enteric nervous system to thoroughly mix foods with enzymes to aid absorption over a period of 3-5 hours.
This document discusses several functions of the stomatognathic system including mastication, deglutition, speech, and respiration. It provides details on the physiology and mechanics of each function. For mastication, it describes the opening and closing phases, chewing strokes, and forces involved. Deglutition is summarized as a three stage process - oral, pharyngeal, and esophageal. Speech production involves respiration, phonation, resonance, and articulation using various positions of the lips, tongue, and teeth. Respiration is described as the exchange of air between the blood and environment.
This document discusses various procedures related to enteral feeding including nasogastric tube feeding, gastric lavage, and gastrostomy feeding. It provides nursing considerations and steps for NG tube placement and feeding, gastric lavage procedure, and administering feedings via gastrostomy tube. Complications of each procedure are also outlined. The document aims to guide nurses in properly preparing patients and safely assisting with various enteral feeding and gastric procedures.
This document discusses gastrointestinal disorders in children, beginning with an overview of pediatric differences in GI anatomy and physiology. It then covers signs and symptoms of GI disorders in infants and children, assessment techniques, and common GI disorders including structural defects, disorders of motility, and inflammatory disorders. Specific structural defects discussed in depth include cleft lip and palate, esophageal atresia and tracheoesophageal fistula, with details on diagnosis, management, and nursing care for each.
This document provides an overview of dysphagia (difficulty swallowing) including its causes, presentations, investigations, and management approaches. Dysphagia can result from problems in the oral, pharyngeal, or esophageal phases of swallowing. Common causes include strokes, neurological diseases, head and neck cancers. Investigations may include barium swallows, endoscopy, biopsy, and esophageal manometry. Newer techniques like high-resolution manometry and functional luminal imaging probe allow more detailed assessment of esophageal motility and function. Management is tailored to the underlying cause but may include dietary modifications, swallowing exercises, or medical/surgical interventions in severe cases.
Mastication involves chewing food into smaller pieces to prepare it for swallowing. The key processes involved are cutting and grinding food using the teeth, mixing it with saliva, and forming it into a bolus. Several structures are involved including the teeth, tongue, cheeks and muscles of mastication. Chewing involves rhythmic jaw movements in a tear drop pattern with phases of opening, closing and grinding the food. Mastication makes digestion more efficient by increasing the surface area of food particles.
This document provides information on various breathing exercises and their goals, indications, contraindications, and techniques. The main goals of breathing exercises are to improve ventilation, cough effectiveness, strength and endurance of respiratory muscles, chest mobility, and breathing patterns. Exercises include diaphragmatic breathing, pursed lip breathing, and localized expansion techniques. The document describes how to perform each exercise and provides guidance on proper technique and positioning.
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
SWALLOWING AND VOICE REHABILITATION .pptx
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
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 )
4.
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
17.
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
19.
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
22.
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
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
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
48.
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
53.
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
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