18 January 2016

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POST LARYNGECTOMY VOICE REHABILITATION EDUCATION IN

PAKISTAN

Dr. Ghulam SaqulainM.B.B.S., D.L.O., F.C.P.S

Head of Department of ENTCapital Hospital, Islamabad

Famous Composer, Giacomo Puccini

One of the best known composers

of all times

Died in 1924

Giacomo’s quotes

“I am being crucified like a Christ! I

have a collar around my throat that is

like torture.”

“I am having external X-Ray Treatment

at present and then they will put crystal

needles into my neck and make a hole,

again in my neck so that I can breathe

……”

“The thought of that hole, with a

rubber or silver tube in it terrifies me….

What an ordeal!. God Help Me”

LARYNGEAL CANCER

It is the most common head & neck cancer.

Male: female = 4:1

>90% squamous cell cancer.

Presentation:

TOTAL LARYNGECTOMY

Goal of every clinician is

organ preservation

A total laryngectomy is

often unavoidable.

The current 5 yr. survival

rate of patients following

total Laryngectomy is

about 80%

10

12

Devastation Functional alterations

• Loss of smell

• Changes in normal swallowing

mechanism

• Changes in the pattern of

respiration

• Most importantly Loss of speech.

The importance of this function is

not realized till it is lost

Requirements for normal phonation

• Active respiratory support

• Adequate glottic closure

• Normal mucosal covering of vocal

cord

• Adequate vocal cord length and

tension control

Role of the Speech-Language

Pathologist in Voice Restoration

After Total Laryngectomy

• The devastation created by these

changes can be reduced through

the support of a strong

rehabilitation team.

• A Speech-Language Pathologist

has a pivotal role to play

• Fortunately the quality of life following a total

laryngectomy is very good provided surgical

and rehabilitation efforts are optimal.

• Over the last several decades considerable

progress in voice, pulmonary and olfaction

rehabilitation of the total laryngectomy

patient has been made.

Methods of speech following

Laryngectomy

• Non Surgical:

o Esophageal speech

o Electro larynx

• Surgical:

o TEP (Tracheo-oesophageal puncture)

o Neoglottis reconstruction

o Artificial larynx

Esophageal Speech

Till 1970’s this was the gold standard

The vibrating muscles and mucosa of cervical

oesophagus and hypopharynx cause

speech

Electrolarynx

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• 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

Intraoral artificial larynx

Types of voice restoration

surgeries

• Neoglottic reconstruction (Trachea

hyoidopexy)

• Shunt technique

Types of shunts

• High trachea-esophageal shunt

(Barton)

• Low trachea-esophageal shunt

(Stafferi)

• TEP shunts (Guttmann)

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TracheoOesophageal

Puncture

Panje voice button• Biflanged tube with one way

valve

• Can be inserted through the

fistula created for this purpose

• It is supplied with an introducer

which makes insertion simple

• Should be removed and cleaned

every two days

• Can be removed, cleaned and

reinserted by the patient

Gronningenbutton

• Introduced by Gronningen of

Netherlands in 1980

• Its high airflow resistance delayed

speech in some patients

• Now low air flow resistance tubes have

been introduced

Blom-Singer prosthesis • Introduced by Blom and Singer in

1978

• Commonly used prosthesis

• This prosthesis acts as one way valve allowing air to pass into the esophagus and prevents aspiration

• This prosthesis is shaped like a duck bill hence known as “Duck bill prosthesis”

• The duck bill end should reach up to esophagus

• It is an indwelling prosthesis can be left in place for 3 months

• This prosthesis is available in varying lengths

Provox prosthesis

• Indwelling low air flow pressure

prosthesis

• It has extended life time. Can last a

couple of yeas if used properly

• Insertion is easy

LaryngealImplant

STRASBOURG,French researchers have developed a titanium implant that can replace a human larynx, providing new hope for laryngeal cancer patients.

The implant was successfully implanted in 2012 in a laryngectomy patient

• The method of speech rehabilitation used

after total laryngectomy should be the

informed choice of the patient himself/

herself.

• However how is that choice to be made if the

clinician who is advising the patient is ill

informed and or has a bias towards only one

method of rehabilitation?

Knowledge & skills of speech language pathologists/

therapists

A Survey

Educational Level

77%

8%

15% 0%

PGD

MSc

Mphil

PhD

n = 21

Training

50%50%Received Training

Didn't ReceiveTraining

n = 21

Handling Laryngectomized

patients. 43%

57%Pre laryngectomycases

Post laryngectomycases

n = 9

Familiarity with Voice Rehab Procedures.

60%

40%

Familiar

Not Familiar

n = 21

Voice Rehab practicing pattern

40%

20%

20%

20%Swallowing

Esophageal speech

Electrolarynx

Tracheo esophagealfistula

n = 21

Conclusion

Recommendations

• We have not incorporated post laryngectomy rehab education in the syllabi of different training programs properly

• Practical training is lacking.

• Post laryngectomy rehab education be imparted in form of mandatory workshops for all training programs in speech language pathology.

• These workshops should focus on practical training as well.

Abstract

• Total laryngectomy or laryngopharyngectomy is still the treatment of choice for advanced laryngeal/hypopharyngealcarcinoma. However, the procedure is associated with loss of normal voice over and above the loss of nasal function, swallowing difficulties and lung function changes. Rehabilitation of these patients has long been a major challenge. In the last few decades there has been significant development in the speech rehabilitation of these patients.

• The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts, "near-total" resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound.

• In this article, the post laryngectomy voice rehabilitation education status in Pakistan among the speech language pathologists is discussed.