1 Laryngectomy. 2 Cancer of the Larynx Any age; infrequent in children Males 50-70 most vulnerable...

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Laryngectomy

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Cancer of the Larynx

• Any age; infrequent in children

• Males 50-70 most vulnerable

• Laryngeal cancer- less than 2%

• Use of tabacco and heavy alcohol use

• Radical or conservative surgery

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Tumor Location & Symptoms

• Supraglottal, glottal or subglottal

• Tumors on or near the folds = hoarseness immediately

• As tumors increase in size= disturbed breathing & noise during inspiration

• Supraglottal Tumors may result in:– dysphagia– swelling in neck– discharge– pain

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Carcinoma

• Primary Voice Symptom:– Hoarseness ( 1 of the 7 warning signs)

• Description & Etiology:– May effect structures of the oral cavity, pharynx, &

larynx– Incidence; 2 -5% of all malignancies– Etiology: smoking (50-70% of oral & laryngeal

cancers), Synergistic effect with smoking & alcohol consumption

– Severity of malignancy evaluated using TNM system

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TNM System

• T= Primary tumor

• N= Involvement of lymph nodes

• M= Signifies spread of lesion to other parts of

the body (metastasis)

– Low numbers indicate lesser involvement

– Example: T1N0M0= lesion has a local confined

tumor with neither node involved nor any

metastasis

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Classification of Glottal Cancer• T: Location of primary tumor

– Tx Cannot be staged

– T0 No evidence of tumor

– Tis Carcinoma in situ

– T1 Confined to vocal folds

– T2 Supraglottal or subglottal extension, normal or impaired ability

– T3 Confined to larynx but with fixed cord

– T4 Massive tumor

• N: Involvement of regional lymph nodes– Nx Cannot be assessed

– N0 No involvement

– N1 A single small node on one side

– N2 A single large or multiple small nodes on one side

– N3 Massive nodes on one or both sides

• M: Distant Metastasis– Mx Cannot be assessed

– M0 No known metastasis

– M1 Metastasis present

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Carcinoma• Perceptual Signs & Symptoms:

– Hoarseness, lump in neck, broadening of larynx (detected on palpitation), tenderness in the neck, dysphagia, odynophagia, dyspnea

– Acoustic Signs-• Depends on extent of carcinoma

• Frequency & amplitude perturbation will increase

• Lower maximum phonation range

• Slightly higher fundamental frequency

• Spectral noise levels increased

• Lower dynamic range

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Carcinoma• Measurable Physiological Signs:

– Airflows are generally increased– EGG recording reflect reduced time of closure– Subglottal pressure increased (increased stiffens of

vocal folds)

• Observable Physiological Signs:– Laryngoscopy-

• May reveal small undefined tumor to large, diffuse tumor

• Diagnosis requires biopsy & histological analysis

• Most arise from epithelium & are squamous cell

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Carcinoma• Observable Physiological Signs:

– Stroboscopy-• Early cancer can be diagnosed early by strob

– Small lesions that have a marked effect of vibration

– Can help define level of invasion with small cancers

– More invasive- vocal fold becomes fixed, no movement

– Pathophysiology-• Lesions invade tissue & destroy normal behaving cells

• Effects:– Vocal fold closure

– Reduced horizontal excursion

– Restricted or absent mucosal wave

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Treatment

• 1) Surgery

• 2) Radiation Therapy

• 3) Chemotherapy

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Treatment Strategies

• Factors to consider:1) Site of tumor

2) Extent of tumor

3) Node involvement

4) Metastasis

5) Patient’s age

6) General health of the patient

7) Pulmonary status

8) Preservation of laryngeal function

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Early Lesion Treatment

•Radiation therapy

•Endoscopic microsurgery

•Laser excision (CO2)

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Radiation Therapy

• Uses:

1) Early glottic lesions

2) Lesions extending to true vocal folds

3) Often combined with surgery (cordectomy)

4) Advanced supraglottic lesions

• Effects:

1) Edema, fluid build-up, skin redness, necrosisCompComplications (tissue necrosis, skin irritation)

3) Common side-effects

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Chemotherapy

• Used in advanced malignancies

• Used less because of the effectiveness of

radiation therapy & surgical excision

• Also, coexisting illness due to toxicity of

chemotherapy can be avoided

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Laryngectomy

• Removes larynx- “ectomy”

• “Laryngectomee”

• Total or partial removal of larynx

• Conservation surgical procedures– patients best suited

– conservation procedures

• Reconstruction

• Surgery for advanced laryngeal cancer

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Surgery• Partial Laryngectomy Procedures:

– Used for discrete, superficial glottic carcinoma (up to T2) or for those with more extensive T1 lesions

• Cordectomy:

– Tumor well localized to a single vocal fold (lot larger than 5 mm, confined to middle third)

• 1. Entrance into the endolarynx via vertical incision at midline of thyroid cartilage

• 2. Tumor is then resected (includes tissue wedge including tumor & surrounding tissue)

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Cordectomy Procedure

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Cordectomy Procedure

Excision Area

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Cordectomy Procedure

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Surgery• Partial Laryngectomy Procedures:

– Hemilaryngectomy:

• One half of larynx is removed; Used for both T2 & T3 lesions or small number of glottic carcinoma cases where vocal fixation is present

• 1. Entrance into laryngeal region through thyroid

–2. Tumor & surrounding tissue resected

–3. Midsection of thyroid cartilage is prepared as a flap

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Hemilaryngectomy Procedure

Excision Area

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Hemilaryngectomy Procedure

A. Thyrotomy

B. Excision areaidentified

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Hemilaryngectomy Procedure

G. Closure of strap muscles & neck

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Surgery• Partial laryngectomy Procedures:

– Vertical partial Laryngectomy:• For tumors involving one-half of larynx, however cancer

can’t restrict vocal fold movement

• Appropriate for:• Tumor has been staged from T1 to early T3

– Antero-Frontal Partial laryngectomy:• Recommended for tumors that involve the glottis

bilaterally (cancer crosses anterior commissure to involve membranous segment of both true vocal folds)

• Must retain normal movement or exhibit only limited reductions in mobility

• Stage T2 lesions

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Surgery• Total Laryngectomy:

– For laryngeal tumors not suitable for conservative surgical approaches

– Advanced tumors T3 lesions or greater• Require a wide field approach

– 1. Removal of entire laryngeal framework (thyroid, cricoid, arytenoid, epiglottis) & all laryngeal membranes & muscles

– 2. Trachea is then brought to midline of the neck

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Total Laryngectomy Procedure

Excision Area

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Total Laryngectomy Procedure

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Total Laryngectomy

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• No passage of air from mouth, nose & pharynx into the lungs

Normal Exhalation Laryngectomy Exhal.

CO2

Speech

CO2

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Rehabilitation team

• Physicians

• Nurses

• Physical therapists

• Speech Pathologists

• Social Workers

• Family members

• Self-help groups

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• 1. Evaluate preoperative speaking skills:– Articulation errors– Speaking rate– Dialectical patterns– Degree of oral opening during speech

• 2. Detailed description of forthcoming surgery:– Pamphlets regarding laryngectomy surgery &

rehabilitation• “Helping Words for the Laryngectomee”• “Your New Voice”

– IAL (International Association of Laryngectomees– American Cancer Society

Preoperative Visit: Advantages

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Preoperative Visit: Advantages

• 2. Provide patient & family emotional support

– Reassure patient and family patient will talk again• Describe methods of speaking without a larynx

– Esophageal speech

– Demonstration of artificial larynx

– Voice therapy following surgery

• 3. Meet and interact with a successful rehabilitated laryngectomee

– Give name, occupation & provide a brief explanation of person’s procedures

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Preoperative Visit• Provision of reassurance and support

• Written materials describing surgery etc.

• Communication methods post surgery

• Demonstration of artificial larynx

• Review changed breathing mechanism (next diagram)

• Physical changes related to swallow, smell, taste & diet

• Grieving period

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• Altered breathing mechanism, removal of larynx

StomaEsophagus

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Pre- & Post Operative

• Review changed breathing mechanism

• Grieving

• Counseling

• Physical changes

• Hygiene concerns

• Safety concerns

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Postoperative Visit• Consult with physician:

– When patient will be able to begin voice therapy

– Any medical considerations preventing from the immediate use of an artificial larynx

• Tube in the mouth device can be used as an option here

• Role of accompanying laryngectomee:– Preoperative & postoperative visit

– Develop motivation & to provide a model

– Answer questions about fears, worries, support groups

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Hygiene Concerns

• Care of tracheostomy, cannula and/or stoma button

• Stoma, cannula & stoma button must be kept clear of mucous

• Stoma covers (gauze, foam rubber or decorative jewelry)

• Excessive mucous

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Stoma Hygiene• Daily cleaning of the stoma

– 1. Wash hands first– 2. Rinse a cotton washcloth with warm water,

gently place the washcloth against stoma & wipe gently

• Don’t use bits of paper or cotton balls

• Do not use soap (irritation or coughing if enters into stoma)

– 3. Lubricate stoma with Vaseline or Abolene cream

• Leave on for about 2 minutes and then wipe off

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Cannula Hygiene• Hospital staff should instruct patient

• Must be cleaned using warm water, soap & brushes– Several cleanings during the course of the day– Outer tube requires less frequent cleaning

• Weaning of cannula begins 6 weeks post surgery (gradual over several weeks)– First: 1hour a day– Second: Gradual increase until the patient does not

wear the cannula in the daytime– Third: Removal for 24 hour periods

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Stoma Covers• Stoma must be covered at all times

• Covers:– Gauze-like bib– Foam rubber– Scarves, jewelry, turtle neck

• Protective Functions:– Creates a warm, insulated space between stoma &

atmosphere– Filter out dust, small insects, lint– Muffles stoma noise during sleeping, absorb

mucous

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Stoma Safety & Other Problems• Precautions while bathing or showering

– Rubber shower shield– Do not stand directly under water– Rubber shower mat to prevent falls– Heavy perfumed soaps should be avoided

(irritation & coughing)

• Problems swallowing, taste & smell and digestion– Postsurgical narrowing of the esophagus– Sense of taste & smell are reduced (no exchange of

air through nose) (limited to sweet & sour)

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Stoma Safety & Other Problems

• Problems swallowing, taste & smell and digestion (cont.)– Digestive problems associated with esophageal speech

• Air trapping poor & air moves lower down causing

– Boating

– Abdominal pain

– Chronic flatulence

• Problems related to trapping air within the lungs– Difficulty in lifting heavy objects

– Difficulty in eliminating body waste

– Difficulty with child birth

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Voice Training: Artificial Larynx• Controversy: Artificial larynx or esophageal

speech first?

• Types of artificial laryges:

– Manner in which vibratory source is powered

– Place at which the artificial larynx is positioned in order to deliver sound into the oral cavity

• Tube in the mouth

• Denture Type

• Neck Type

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Artificial Larynges

Tube in mouth (Cooper Rand Neck Type (Western Electric)

Pneumaticall powered (Tokyo)

Dental Appliance Type (Speechmaster)

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Pneumatically Powered Voice Prosthesis

• Utilizes air from lungs

• Pulmonic air enters the voice prosthesis via airtight cover that is fitted to stoma

• To speak, user places mouthpiece end into mouth– Van Humen Artificial Larynx

• Vibrating reed in tube is source, then patient does the articulation

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Electronically Powered Voice Prosthesis

• Battery-operated

• Quality depends on the acoustic characteristics of the device & degree of surgery

• Certain devices generate sound source:– Extrorally with tube method

– Through denture plate introrally

– Tone conducted from external surface of neck to hypopharynx

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Benefits: Artificial Larynx• Immediate and relatively intelligible oral

communication

• Effective if voice therapy is delayed due to healing

• Provides a method of communication– 35% of laryngectomees cant learn esophageal

speech

• Provides a higher intensity level than esophageal speech

• Temporary alternative for fatigue, URI or emotionally upset

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Goals of SLP for Artificial Larynges

• Acquaint patient with types available

• Coordination of hand to mouth movements to synchronize sound source and articulatory onset

• Placement, seal

• Reduce stoma noise

• Normal phrasing

• Explain device to strangers

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Esophageal Speech• Consonant injection method• Glossopharyngeal Press• Inhalation Method• Swallow Method

– Greater air pressure in the oral cavity will flow to a chamber containing less pressure (esophagus)

– Goals:• Patient should reliably phonate on demand

• Patient should use rapid air intake

• Short latency between air intake & phonation

• Produce 4 -9 syllables per air charge

• Speaking rate of 85-129 words per minute

• Good intelligibility

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Esophageal Speech Production

• Consonant Injection:– Most efficient method of getting air into esophagus

– Start with words: pie, tie, cake, stop, scotch, skate

• Allows esophagus to increase in pressure easily

– Phrases that allow the esophagus to become loaded:

• “Pick that skate”; “Take it to heart”; “Put it back”

– Phrases that are mostly vowels are harder (low

pressure):

• “I am well’; “In a house”

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Esophageal Speech Production• Consonant Injection:

• General Instructions-

1)take air into top of esophagus, trap air & release it

2) vibration occurs in P-E segment

3) patients inject or move air by using tongue “pumping”

4) rapid successive productions of sounds such as /p/, /t/ & /k/ in combination with a vowel are practiced first

• Progression-

– Produce intraoral whispers or plosive consonants

– Compress air and explode it through lips: /p/

– Attempt the syllable- /pa/

– Production of other plosives, fricatives or affricates

– Monosyllabic words with plosives: Pie, Tie

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Esophageal Speech: Glossopharyngeal Press

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Esophageal Speech: Problems• Excessive Stoma Noise:

– Forceful movement of air through stoma during exhalation

– Coes tes with esophageal production– Instructions to reduce force of exhalation (“say it

softer”)• Biofeedback: Wear a stethoscope with diaphragm near

stoma; mirror, place piece of tissue paper over stoma

• Klunking:– Noise from attempting to rapidly & forcefully

inject air– Alter head position or reduce force of injection

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Surgical or Prosthetic Methods

• Shunting the pulmonary air into lower esophagus

1) Reconstructive and prosthetic methods (TE approaches)

2) Reduces effort, avoids extraneous movement

3) Phrasing is more natural, smooth & fluent

4) Allows for redirection of exhalation

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Tracheoesophageal Puncture (TEP)

1) Solved problems of shunt (aspiration of saliva, liquids and food into trachea & stenosis of shunt)

2)15-20 minute surgical procedure creating fistula

3) Voice prothsesis or “duckbill” inserted in fistula

4) Prevents aspiration & stenosis5) One-way valve allowing pulmonary air to

enter the esophagus when stoma is occluded while exhaling

6) Automatic valve available

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Types of Prothsesis• Blom-Singer

• Panje- Voice Button Prosthesis

• Passy-Muir Speaking

Tracheostomy Valve

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Readings

• Other Sources:– Salmon, S.J. & Mount, K.H. (1991).

Alaryngeal Speech Rehabilitation. Pro-Ed

– Doyle, P.C. (1994). Foundations of Voice and Speech Rehabilitation Following Laryngeal Cancer. Singular Publishing