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Laryngectomy 1.

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Presentation on theme: "Laryngectomy 1."— Presentation transcript:

1 Laryngectomy 1

2 Cancer of the Larynx Any age; infrequent in children
Males most vulnerable Laryngeal cancer- less than 2% Use of tabacco and heavy alcohol use Radical or conservative surgery

3 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 3

4 Carcinoma Primary Voice Symptom: Description & Etiology:
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

5 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

6 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

7 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

8 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

9 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



12 Treatment 1) Surgery 2) Radiation Therapy 3) Chemotherapy

13 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 4

14 Early Lesion Treatment
Radiation therapy Endoscopic microsurgery Laser excision (CO2) 5

15 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 8

16 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

17 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 6

18 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)

19 Cordectomy Procedure

20 Cordectomy Procedure Excision Area

21 Cordectomy Procedure

22 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

23 Hemilaryngectomy Procedure
Excision Area

24 Hemilaryngectomy Procedure
A. Thyrotomy B. Excision area identified

25 Hemilaryngectomy Procedure
G. Closure of strap muscles & neck

26 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

27 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

28 Total Laryngectomy Procedure
Excision Area

29 Total Laryngectomy Procedure

30 Total Laryngectomy

31 No passage of air from mouth, nose & pharynx into the lungs
CO2 CO2 Speech Normal Exhalation Laryngectomy Exhal. No passage of air from mouth, nose & pharynx into the lungs 7

32 Rehabilitation team Physicians Nurses Physical therapists
Speech Pathologists Social Workers Family members Self-help groups 9

33 Preoperative Visit: Advantages
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

34 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

35 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 10

36 Esophagus Stoma Altered breathing mechanism, removal of larynx 11

37 Pre- & Post Operative Review changed breathing mechanism Grieving
Counseling Physical changes Hygiene concerns Safety concerns 12

38 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

39 Care of tracheostomy, cannula and/or stoma button
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 13

40 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

41 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

42 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

43 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)

44 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

45 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

46 Artificial Larynges Tube in mouth (Cooper Rand
Neck Type (Western Electric) Dental Appliance Type (Speechmaster) Pneumaticall powered (Tokyo)

47 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

48 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

49 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

50 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

51 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 words per minute Good intelligibility

52 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” 16

53 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

54 Esophageal Speech: Glossopharyngeal Press

55 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

56 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 17

57 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 & stenosis 5) One-way valve allowing pulmonary air to enter the esophagus when stoma is occluded while exhaling 6) Automatic valve available

58 Types of Prothsesis Blom-Singer Panje- Voice Button Prosthesis
Passy-Muir Speaking Tracheostomy Valve

59 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 22

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