What is the 5th most common cancer worldwide?
head and neck cancer
- global cases of laryngeal cancer are approximately 160,000
where do the highest rates of H&N cancer occur?
Southeast Asia and central and southern Europe
H&N cancer account for _____% of all cancers in the U.S.
3%
what are the statistics for a man developing cancer over his lifetime?
For a woman?
one in two
one in three
H&N cancer is diagnosed most often in people over the age of
50
what accounts for approximately 75% of oral, oropharyngeal, and laryngeal cancer.
- alcohol and tobacco
- the combined effects of these two agens substantially increases the risk
modes of treatment for Head and Neck cancer
- radiation
- surgery
- chemo
- each treatment modes presents some complications to the voice
the surgical advancement of H&N cancer is evolving secondary to the introduction of
robotic assisted surgery, less invasive endoscopic procedures, and laser microsurgery.
robotic surgery paired with advances in radiation therapy and chemo have resulted in fewer
total laryngectomies being performed. making it possible to preserve the organ in many cases
what is the most common procedure for advanced laryngeal cancer?
total laryngectomy
during a total laryngectomy what cartilages are removed?
What bones are removed?
What muscles?
- the laryngeal and hypopharyngeal cartilages
- the hyoid bone
- all intrinsic and extrinsic muscles of the larynx
- upper rings of the trachea
what occurs during a total laryngectomy surgery
- the cartilages, muscles, and hyoid bone is removed
- the uppermost portion of the trachea is brought forward and fit flush with the neck.
- an external stoma is created, which permanently serves as the patient's new airway
laryngectomY =
the surgical procedure
LaryngectomEE =
a person who has undergone the surgery
what does a laryngectomy procedure alter
- respiration
- swallowing
- speech
3 methods of alaryngeal speech
- artificial larynx device (electrolarynx)
- Esophageal Speech
- Tracheoesophageal prosthesis
Artificial larynx device (Electrolarynx) pros
- relatively easy to learn
artificial larynx device cons
- mechanical sound quality
- battery dependence/device malfunction
- ties up use of one hand
Esophageal speech pros
-hands free
- no maintenance required
esophageal speech cons
can be difficult (or impossible) to learn, often due to p-E segment tonicity issues (hypertonic/hypotonic)
- Volume and pitch limitations
tracheoesophageal prosthesis (TEP) pros
- optimal volume and pitch capacity, resulting in a more "natural" sounding voice
- easy to learn
TEP cons
may require additional surgery
- may tie up use of one hand
- requires follow-up/maintenance/replacement
When are AL deviced typically introduced?
at the time of surgery and are used as the patient's initial post-op means of communication
- as recovery and healing occur the patient may choose to pursue a different option for their permanent communication mode
2 basic categories of AL devices
- intraoral devices
- neck type devices
intraoral devices
sound is generated and transferred into the oral cavity by means of a tube
- cooper-Rand
- Pneumatic devices
Neck-type devices
the instrument is placed against the neck and electronically-generated sound transfers through the neck muscles into the pharynx.
- Servox
- NuVois
- TruTone
the development of TEP speech has made
esophageal speech less frequent
- the SLP should know something about this form of speech and how to teach it if the need arises
what does esophageal speech involve?
- the insufflation (charging) of air into the esophagus and its subsequent controlled expulsion
what is charging caused by?
the vibration of the muscles located in the pharyngoesophageal (PE) segment.
what is the vibration that occurs from charging used as?
a replacement for the phonation previously produced by the vocal folds
esophageal speech can be learned
easily by some but impossible for others.
what is the key factor for esophageal speech?
tonicity of the PE segment
what does a hypertonic PE segment cause
difficulty in charging and results in strained vibration (Botox may help)
what does a hypotonic PE segment results in
easy charging but poor vibration/weak sound quality (digital pressure or altered head position may help)
2 methods of charging
- injection method
- inhalation method
injection method
uses a tongue pump action to force air from the oral cavity and pharynx past the PE segment and into the esophagus
what is a variation of the injection method
consonant injection
- pushes small amounts of air into the esophagus during the production of pressure-dependent speech sounds
what is the consonant injection primarily used for?
- supplemental air sources
inhalation method uses
differential air pressure to suck in air into the esophagus through a relaxed PE segment during a sudden inhalation of air into the lungs
as pressure in the thoracic cavity increases, what happens
pressure in the esophagus decreases, pulling air in
for a laryngectomy using esophageal speech what are the initial goals of therapy
- consistency
- effective charging
- latency
- duration
- stop and go
- number of syllables per charge
- pitch and loudness changes
- contrasting stress
- exaggerated articulation
- timing mid-sentence charges
consistency
successful charging and sound production 10/10 attempts
effective charging
avoid "double pumping:
latency
no delay between the charge and the sound production
duration
the ability to control air expulsion to result in a tone production of 2.5-3.0 seconds
stop and go
the ability to stop and restart sound production on a single charge
number of syllables per charge
try for 7
contasting stress
switching stress from one syllable to another
exaggerated articulation
pop" the posives
today what are most laryngectomees candidates for
tracheoesophageal puncture and prosthetic approach to alaryngeal speech rehab
in many cases TEP will be performed at the same time as
the total laryngectomy
what may also be performed so that the PE segment does not present excessive resistance to the outward flow of air
cricopharyngeal myotomy
historically TEP was done as a
secondary procedure after the patient healed from the total laryngectomy and some physicians continue this practice
In TEP what is created
- a puncture, or fistula is created between the back wall of the trachea and the esophagus.
Once the fistula has healed (5-7 days) what is done
a silicone prosthesis is placed through the fistula allowing air from the lungs to be diverted into the esophagus and used for voicing via vibration from the PE segment
what is located in the body after a PE segment
a one way valve located in the body of the prosthesis prevents leakage of food/liquid from the esophagus into the trachea
what allows much greater volume and pitch variation and an improved acoustic voice quality
the ability to utilize the large quantity of lung air, as opposed to the small quantity of air available in the oral cavity and pharynx
what qualifies a patient for TEP
- adequate pulmonary support, therefore patients with lung cancer, asthma, or other severe lung diseases may not be a candidate
- must possess the necessary cognitive and sensorimotor skills to occlude the stoma for speech
- must have a P-E segment that v
SLP's role with TEP patients
education of the patient and caregivers about the prosthesis, how it works and how to take care of it
- fitting the prosthesis
- teaching and assessing the patient's ability to occlude the stoma using the appropriate degree of pressure, determine which fi
laryngectomy ADL changes
- Filtration/humidification
- Mucus plugs
- Swimming/water sports
- Smelling
- Nose blowing
- Noisy environments
- Listener factors (e.g., hearing impaired caregivers)
- Post-radiation effects (dental issues, candida fungus, fibrosis)
- Swallowing issues
3 types of resonance disorders
- hypernasality
- hyponasality
- assimilative nasality
hypernasality
an excessively undesirable amount of perceived nasal cavity resonance during the phonation of normally non-nasal vowels and non-nasal voiced consonants
VPD
term for inappropriate transmission of the sound wave into the nasal cavity
VPD may be caused by
- VP incompetence
- VP insufficiency
- VP inadequacy
VP incompetence
impaired motion of VP mech
VP insufficiency
a tissue deficiency
VP inadequacy
a mixture of both
speech characteristics of VPD
- audible nasal air emission
- reduced intraoral air pressure
- hypernasality
hyponasality
reduced or completely lacking nasal resonance for the 3 normal nasalized English phonemes: /m,n,ng/
hyponasality is the result of
anatomical obstructions within the nasal cavity
- may be associated with abnormally large adenoids and tonsils, a deviated nasal septum, an obstructed naris, choanal atresia, nasal turbinate swelling, or allergic rhinitis
assimilative nasality
the speaker's vowels or voiced consonants sound nasal when adjacent to the 3 nasal consonants.
- the VP port is opened too soon and remains open too long, so that vowel or voiced consonant resonance preceding and following nasal consonant resonance is als
assimilative nasality may be a result of
exposure to faulty speech models or exaggerated regional dialect patterns that may normally have subtly nasal characteristics
what type of voice disorder is assimilative nasality
- functional
- voice therapy is considered warranted and very effective
eval of nasal resonance disorders includes
- perceptual analysis of speech
- simple instrumental assessment
- stimulability testing
- artic testing
- oral exam
- laboratory instrumentation testing
treatment of hypernasality
depends largely on whether the problem is due to insufficiency (structural) or incompetence (functional)
treatment for hypernasality secondary to VP insufficiency
- surgical- VP flap for short immobile or stiff soft palates closure of clefts or fistulas
- dental: orthodontics or prosthodontics, with use of palatal lifts or obturators
voice therapy is not recommended for patients with
hypernasality due to VP insufficiency
for individuals who speak with hypernasality for functional reasons
voice therapy can help develop more oral resonance and may be worthwhile
treatment for hyponasality
consists of treatment for whatever is causing the nasal obstruction and is managed medically/surgically
treatment for assimilative nasality
consists of voice therapy, often using a listening tube or see-cape, and is best attempted only by those patients who are highly motivated to develop more oral resonance
when encountering a patient presenting with a voice disorder, the clinician begins a systematic process of
- assessment: collecting relevant data for clinical decision making
- eval: appraisal of the implications and significance of the assessment
- diagnosis: calls for the clinician to make a decision about whether a problem exists and if so, differentiating
a voice assessment should follow
an exam of the patient by a laryngologist
evaluation of voice includes
a questionaire asking about the onset, and quality of voice
what is the most important area of a vocal exam in terms of understanding the cause of a voice disorder and potential treatment
- visual inspection of the larynx
inspection of the larynx is in 2 forms
- mirror laryngoscopy
- endoscopic laryngoscopy
mirror laryngoscopy
a small mirror is placed at the back of the patient's mouth and light is shone of the mirror from the physician's headset
- if angled properly a reflected view of the hypopharynx can be seen
endoscopic laryngoscopy
either fiberoptic scope is placed in the mouth or a flexible fiberoptic scope is passed through one of the nasal passages
components of the comprehensive voice eval
1. review of auditory visual status
2. case history
3. behaviorial observation
4. auditory perceptual ratings
5. voice related quality of life
6. oral mech
7. laryngoscopy
8. acoustic analysis
9. electroglottographic analysis
10. aerodynamic analysis
11.
hearing acuity is important in
monitoring and regulating one's own voice production
visual acuity is an important consideration when assessing
a person with a voice disorder
Case History Overview
- Description of the problem and cause
- Onset and duration of the problem
- Variability of the problem
- Description of vocal demands
- Additional case history information (e.g., previous voice therapy attempts and results, information from family, etc.)
behavioral observations
clinicians must become critical observers, attempting to describe behavior they see rather than merely labeling it.
- writing observations about a patient is one of the few ways clinicians can note what they observe.
GRBAS Scale
uses a 4 point equal appearing rating scale of 0 (normal) to 3 (extreme) to assess grade, roughness, breathiness, aesthenic (weak) and strain
CAPE-V
judges rate six aspects of voice
- (Overall Severity, Roughness, Breathiness, Strain, Pitch, and Loudness)
by placing a tick mark on a 100 mm horizontal line. The instrument includes two unlabeled scales in the event a voice includes other significant fea
voice -related quality of life
2 basic approaches
- generic assessments
- communication- related quality of life
generic assessments
provide a summary of overall health-related quality of life, and specific assessments that focus on specific communication-related quality of life.
Instrumental vs. Noninstrumental assessment of voice
non-instrumental
approach, one relies on behavioral observation of the patient, examination of the patient's oral-peripheral mechanisms, auditory perceptual judgments about various aspects of the voice (e.g., pitch, loudness, quality, respiratory-phonatory control, resona
instrumental approach
one obtains indirect measures of voice production (e.g., visualization of the larynx, acoustic measures of the voice signal, aerodynamic measures of pressure and flow, physiological measurement of laryngeal muscle function, etc.).
the most important skills of the instrumental approach and non-instrumental is
to analyze objectively