Voice Disorders- Laryngeal Cancer

Esophageal Speech

"burping to talk"- swallow air, let pass down, and burp back up PE segment voice is created by injecting air into the esophagus either through positive or negative pressure voice is elicited as vibration of the pharyngoesophageal segment

What is involved in the pre-operative evaluation?

***Make sure the patient understands what is happening to them. Talk to them about it. Bring a communication board. Discuss stopping addictive habits. Confirm the patient's understanding of diagnosis and surgery. Evaluate communication potential. Social and emotional status Economic status Visual abilities Cognitive abilities Manual dexterity Other things to consider: Get a baseline of their communication potential (read/write, blind, tremor) Consider their support system- who will be caring for them post surgery? Expenses

What are some side effects of surgery?

-tissue deficit can cause stiffness due to scarring -change the vocal cords and prevent complete closure -no vocal folds

Electrolarynx Instruction

1. Finding "sweet spot"- swelling, post radiation often do best with placement to side of mouth- finding where it resonates best 2. Articulation- teach them to over articulate 3. Coordination/timing of on & off - hand placement 4. Phrasing 5. Gestures to supplement communication 6. Volume and Pitch

Electrolarynx Therapy Process

1. Start with known targets (counting, patient's name) 2. 3-5 word utterances -address phrasing, rate and pausing 3. Longer sentences -phrasing and rhythm 4. Recite poems or other familiar recitation- pledge of allegiance, reading 5. Conversational speech "Hierarchical Approach"

What is the total number of laryngectomy completed each year in the US?

3000

How many total laryngectomees are living in the US?

50,000-60,000

What percent of oropharyngeal cancers (especially tongue base and tonsils) are caused by or linked to HPV?

50-70%

What percent does alcohol and tobacco use account for head and neck cancers? (especially in oral cavity, oropharynx, hypopharynx, and larynx)

75%

What is involved in pre-operative counseling?

Discuss communication options: gestures, mouthing, writing, electrolarynx, TEP, Esophageal speech Explanation: vocal cords will be gone, talk about changes in respiratory system, swallowing, taste/smell abilities, and explain anatomy and physiology of the process Bring diagrams to help give a visual of what is going to happen.

What are some risk factors related to day to day activities, exposure, and health?

Occupational exposure- wood dust, asbestos & synthetic fibers, construction, metal, textile, ceramic, logging, food industries Radiation exposure Epstein-Barre Virus Exposure Ancestry- Asian ancestry, chinese

What are the four types of H&N cancers based on location?

Oral Cavity Pharynx Larynx Paranasal sinuses and nasal cavity Salivary Glands

What are some other risk factors related to food intake and hygiene?

Paan (betel quid)- chewing a type of nut; immigrants from southeast Asia Mate- tea-like beverage habitually consumed in South America Preserved or salted foods- certain preserved or salted foods during childhood Oral health- poor oral hygiene and missing teeth; mouthwas with high alcohol content

What is a SLP's role in the entire process?

Pre-operative evaluation and counseling Post-operative evaluation and training

After the removal (total laryngectomy), what is the reconstruction process?

Regional and free flaps: take muscle from pec muscle or other muscles and sew into the throat -required to fill defect -pec major, myocutaneous flap -radial forearm flap -anterolateral thigh flap

What does a total laryngectomy include?

Removal of the entire larynx including: -Larynx- vocal folds, arytenoids, ventricular folds -Hyoid bone -epiglottis -thyroid and cricoid cartilages -intrinsic muscles -1 or more tracheal rings The trachea is sutured anteriorly with permanent stoma- the esophagus and trachea are separated

What are the three treatment modalities of H&N cancer?

Surgery, Chemo, and radiation therapy It could be one of these or a combination approach

How is the heat and moisture exchange different when a person has a stoma?

air moves straight in through stoma and does not become moist and heated through oral cavity like normal breathing

What does chemo and radiation do for laryngeal cancer?

allows for "organ preservation"- without preservation of function (most patients end up with a trach) - typically most patients receive chemo AND radiation therapy

Electrolarynx training

battery powered electromechanical device with vibrating head, which generates a sound- this replicates the vibration of vocal folds Placed under neck, jaw and cheek- It resonants against the tissues of the neck, cheek or in the oral cavity. The sound can then be shaped into speech by speech articulation. Sounds very quiet and robot like. It is controlled by the person's thumb. Research shows that introduction to this early is extremely helpful.

What are some surgery options for Laryngeal cancer?

cordectomy, supraglottic laryngectomy, hemilaryngectomy, partial laryngectomy, laser surgery, TORS (transoral robotic surgery), total laryngectomy

What is involved in post-operative voice rehabilitation?

electrolarynx training, esophageal speech training, tracheoesophageal speech

Supraglottic laryngectomy

everything above the vocal folds (supraglottic area) is removed; might remove false vocal folds, epiglottis- cannot swallow, usually use a feeding tube

Hemilaryngectomy

half of the larynx is removed and reconstructed- are able to use false vocal folds or supraglottic area

Total laryngectomy

is the most invasive procedure

Laser surgery

laser target wherever cancer is; superficial cancer; can leave scars

Squamous cells

line the inside of the mouth and oral cavity; mucosal surfaces inside the head and neck Exposure to harmful chemicals can cause the lining to change.

oral cavity

lips, front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, floor of the mouth under the tongue, hard palate, and small area of the gum behind the wisdom teeth

subglottic larynx cancer

located below the vocal folds

What are some determining factors of treatment for H&N cancers?

location of cancer, what kind of cancer, stage of the tumor, and age and general health of the patient

pharynx

nasopharynx, oropharynx, hypopharynx

Partial laryngectomy

part of the larynx removed in any fashion

Cordectomy

removal of vocal cords- breathy voice, weak, supraglottic voice patterns, major swallowing problems

About 90% of H&N cancers are related to what cells?

squamous cells

Tracheo oesophageal puncture (TEP)- voice prothesis

the door on the end stays shut until air passes through Take a breath in, cover stoma and air travels through device to esophagus, vibrates and creates voice

What are some side effects post radiation?

tissue will be inflamed, soft palate disappears -dryness- changes how saliva glands secrete mucus -inadequate tissue mass -irregular vocal fold edges -stiffness -swelling of vf -permanent change to larynx

What are the risk factors for developing laryngeal cancer?

tobacco (smoking, chewing, etc.), alcohol, Human Papilloma Virus (HPV), Epstein-Barre Virus (Mono)

TORS

uses daVinci Robot

Tracheoesophageal speech

voice is created by shunting air into the esophagus through a one-way valve (TEP) Airflow creates vibration of the pharyngoesophageal segment

What are the general responsibilities of an SLP when working with a laryngectomy (H&N) patient?

voice, and mostly swallowing When working with patients who have had surgeries would focus on artic, resonance, swallowing, and voice (tongue, palate, larynx)

oropharynx

where the oral cavity meets the throat