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Rehabilitation after laryngectomy


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Rehabilitation after laryngectomy

  1. 1. DR ROOHIA
  2. 2. Introduction • Total Laryngectomy is still the preferred management modality in advanced laryngeal malignancies • TEP (Tracheo-oesophageal puncture) is considered gold standard among various voice rehabilitation procedures • The current 5 yr. survival rate of patients following total Laryngectomy is about 80%
  3. 3. QUALITY OF LIFE Establish and maintain an acceptable quality of life.
  4. 4. Functional alterations following total Laryngectomy • 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
  6. 6. Swallowing rehabilitation • Swallowing rehabilitation for patients dependent on tube feeding after treatment for head and neck cancer usually takes about three months, according to a Dutch study. • although about 20% need help for six months or more. • Patients with transport problems fared better than those with aspiration.
  8. 8. • Disconnection between upper & lower respiratory tract. • Conditioning of inspired air not occur • Heat-moisture exchanger humidifies,filter,inspired air • It reduces sputum production,cough, shortness of breathing,forced expectoration.
  11. 11. • In laryngectomised pt breathing occur through stoma • Anosmia is due to not reaching odour molicules to olfactory epithelium • Leads to reduced taste,reduced food intake,reduced quality of life.
  12. 12. NAIM • Nasal Airway Induced Manoeuver • Repeated extended yawning • Lowering jaw,floor of mouth,tongue,bot,soft palate while closing the lips. • Polite yawning/closed mouth yawning • Induces negative pressure in oral cavity,oropharynx which generate airflow in nasal cavity. • Need single intervention session.
  14. 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. 15. Methods of speech following Laryngectomy • Also known as alaryngeal speech • Esophageal speech • Electro larynx • TEP (Tracheo-oesophageal puncture)
  16. 16. ESOPHAGEAL SPEECH Alaryngeal speech
  17. 17. 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 procedures
  18. 18. 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 speech
  19. 19. 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 speech
  20. 20. Pumping air into cervical oesophagus • Injection method • Inhalational method
  21. 21. 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
  22. 22. 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 speech
  23. 23. 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 voice
  24. 24. 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 frequencies
  25. 25. Esophageal speech development causes 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 patient
  26. 26. Cricopharyngeal spasm • Cricopharyngeal myotomy • Botulinum toxin injection – 30 units can be injected via the tracheostome over the posterior pharyngeal wall bulge
  27. 27. 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 surgery
  28. 28. Electrolarynx - Types • Pneumatic • Neck • Intraoral type
  29. 29. 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 one
  30. 30. 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 generated
  31. 31. Electrolarynx - advantages • Can be easily learnt • Immediate communication is possible • Additional surgery is avoided • Can be used as a measure till the patient masters the technique of esophageal speech or gets a TEP inserted
  32. 32. Electrolarynx - Disadvantages • Expensive to maintain • Speech generated is mechanical in quality • Difficult while speaking over telephone
  33. 33. Types of voice restoration surgeries • Neoglottic reconstruction • Shunt technique
  34. 34. Neoglottis procedure • Performing trachea hyoidopexy • This can restore voice function in alaryngeal patients • Abandoned due to increased incidence of complications like aspiration
  35. 35. 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 esophagus
  36. 36. Types of Prosthesis
  37. 37. Indwelling versus Non indwelling prosthesis Indwelling prosthesis Non indwelling prosthesis Can be left in place for 3-6 months Should be removed and cleaned every couple of days Requires specialist to do the job Pt. Can do it themselves Less maintenance Periodical maintenance Stoma should be greater than 2 cms Stoma should be greater than 2 cms Oesophageal insufflation test should be positive Oesophageal insufflation test should be positive
  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
  39. 39. Types of TEP • Primary TEP – Performed during total laryngectomy • Secondary TEP – Performed 6 months after surgery
  40. 40. 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 used
  41. 41. 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 immediatly
  42. 42. 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 space
  43. 43. 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 intelligible
  44. 44. 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 wall
  45. 45. 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 wall
  46. 46. 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 irradiation
  47. 47. Problems with TEP insertion • Leak through the prosthesis • Leak around the prosthesis • Immediate aphonia / dysphonia • Hypertonicity problems • Delayed speech
  48. 48. 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”
  49. 49. Insufflation test interpretation • Fluent voice on minimal effort – normal • Breathy voice indicating hypotonic cricopharyngeal muscle • Hypertonic voice – “Cricopharyngeal spasm” • Spasmodic voice – “Extreme cricopharyngeal spasm”
  50. 50. Management of leak through the prosthesis Cause Solution Valve in contact with posterior wall of esophagus Replace prosthesis with different length and size Prosthesis length too short for the puncture “Pinched valve” Remeasure the puncture and replace with appropriate size prosthesis Valve deterioration Replace valve Fungal colonization of valve with yeast Treat with nystatin Back pressure High resistant prosthesis Mucous / food lodgment Prosthesis to be cleaned
  51. 51. Management of leak around the prosthesis Cause Solution TEP location Remove prosthesis allow puncture to close and repuncture Unnecessary dilatation during valve placement To be avoided Thin trachea-esophageal wall 6 mm or less Choose custom prosthesis Prosthesis of incorrect length and size Choose correct length Poor tissue integrity due to irradiation Custom prosthesis