rehabilitation after laryngectomy

DR ROOHIA

Introduction

• Total Laryngectomy is still the preferred management modality in advanced laryngeal malignancies

• TEP (Tracheo-oesophageal puncture) is considered gold standard among various voice rehabilitation procedures

• The current 5 yr. survival rate of patients following total Laryngectomy is about 80%

QUALITY OF LIFE

Establish and maintain an acceptable quality of life.

Functional alterations following total Laryngectomy

• 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

SWALLOWING REHABILITATION

Swallowing rehabilitation

• Swallowing rehabilitation for patients dependent on tube feeding after treatment for head and neck cancer usually takes about three months, according to a Dutch study.

• although about 20% need help for six months or more.

• Patients with transport problems fared better than those with aspiration.

PULMONARY REHABILITATION

• Disconnection between upper & lower respiratory tract.

• Conditioning of inspired air not occur

• Heat-moisture exchanger humidifies,filter,inspired air

• It reduces sputum production,cough,

shortness of breathing,forced expectoration.

• AUTOMATIC HANDS FREE SPEEKING VALVE.

OLFACTORY REHABILITATION

• In laryngectomised pt breathing occur through stoma

• Anosmia is due to not reaching odour molicules to olfactory epithelium

• Leads to reduced taste,reduced food intake,reduced quality of life.

NAIM• Nasal Airway Induced

Manoeuver• Repeated extended yawning • Lowering jaw,floor of

mouth,tongue,bot,soft palate while closing the lips.

• Polite yawning/closed mouth yawning

• Induces negative pressure in oral cavity,oropharynx which generate airflow in nasal cavity.

• Need single intervention session.

VOCAL REHABILITATION

Requirements for normal phonation

• Active respiratory support• Adequate glottic closure• Normal mucosal covering of vocal cord• Adequate vocal cord length and tension

control

Methods of speech following Laryngectomy

• Also known as alaryngeal speech• Esophageal speech• Electro larynx• TEP (Tracheo-oesophageal puncture)

ESOPHAGEAL SPEECHAlaryngeal speech

Contd…• All pts. Develop some

degree of esophageal speech following Laryngectomy

• All alaryngeal speech modalities are compared with this modality

• Till 1970’s this was the gold standard for all other post Laryngectomy speech rehabilitation procedures

Esophageal speech - Physiology

• Air is swallowed into cervical esophagus

• This swallowed air is expelled out causing vibrations of pharyngeal mucosa

• These vibrations along with articulations of tongue cause speech to occur

• The exact vibrating portion of pharynx is the pharyngo-oesophageal segment

• The vibrating muscles and mucosa of cervical oesophagus and hypopharynx cause speech

Oesophageal speech – PE segment

• This segment is made up of musculature and mucosa of lower cervical area (C5-C7 segments).

• Vibration of this segment causes speech in pts. Without larynx

• Cricopharyngeal area is important

• Cricopharyngeal spasm in these pts. Can lead to failure in developing Oesophageal speech

• Cricopharyngeal myotomy may help these pts. in developing Oesophageal speech

Pumping air into cervical oesophagus

• Injection method• Inhalational method

Injection method

• Enough positive pressure is built inside oral cavity to force air into cervical oesophagus

• Lip closure and tongue elevation against palate causes increase intraoral pressure

• Air is injected into the cervical oesophagus by voluntary swallowing

• This method is also known as tongue pumping / glossopharyngeal press / glossopharyngeal closure

Inhalational method• Uses the negative pressure used in normal breathing to

allow air to enter cervical oesophagus• Air pressure in the cervical oesophagus below

Cricopharyngeal sphincter is the same negative pressure as that of thoracic cavity

• Pts. Learn how to relax Cricopharyngeal sphincter during inspiration allowing air to flow into cervical oesophagus as it enters the lungs

• Pts. Are encouraged to consume carbonated drinks which facilitates air entry into cervical oesophagus helping in generation of Oesophageal speech

Esophageal speech - Advantages

• Patient’s hands are free• No additional surgery / prosthesis needed.

Hence no extra cost for the pt.• Pts. Get easily adapted to esophageal voice

Esophageal speech - Disadvantages

• Nearly 40% of pts fail to develop esophageal speech• Quality of voice generated is rather poor• Pt. may not be able to continuously speak using

esophageal voice without interruption. They will be able to speak only in short bursts

• Significant training is necessary• Loudness / pitch control is difficult• Fundamental frequency of esophageal speech is 65 Hz

which is lower than that of male and female frequencies

Esophageal speech development causes for failure

• Presence of cricopharyngeal spasm• Presence of reflux esophagitis• Abnormalities involving PE segment – like

thinning of muscle wall in that area• Denervation of muscle in the PE segment• Poorly motivated patient

Cricopharyngeal spasm

• Cricopharyngeal myotomy• Botulinum toxin injection – 30 units can be

injected via the tracheostome over the posterior pharyngeal wall bulge

Electrolarynx• 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

• Initial training to use this equipment should begin even before surgery

Electrolarynx - Types

• Pneumatic • Neck• Intraoral type

Electrolarynx - Contd

• Neck type is commonly used

• Hypoesthesia of neck during early phases of post op period can cause difficulties

• If neck type cannot be used intraoral type is the next preferred one

Intraoral artificial larynx• Intraoral cup should

form a tight seal over the stoma. There should not be any air leak

• Oral tip should be placed in the oral cavity

• Pts exhaled air rattles the cup placed over the stoma

• Changes in exhaled pressure can vary the quality of sound generated

Electrolarynx - advantages

• Can be easily learnt• Immediate communication is possible• Additional surgery is avoided• Can be used as a measure till the patient

masters the technique of esophageal speech or gets a TEP inserted

Electrolarynx - Disadvantages

• Expensive to maintain• Speech generated is mechanical in quality• Difficult while speaking over telephone

Types of voice restoration surgeries

• Neoglottic reconstruction• Shunt technique

Neoglottis procedure

• Performing trachea hyoidopexy• This can restore voice function in alaryngeal

patients• Abandoned due to increased incidence of

complications like aspiration

Shunt technique• Developed by Guttmann

in 1930• Involves creation of shunt

between trachea and esophagus

• Lots of modifications of this procedure is available, Basic principle is the same

• Aim is to divert air from trachea into the esophagus

Types of Prosthesis

Indwelling versus Non indwelling prosthesis

Indwelling prosthesis Non indwelling prosthesisCan be left in place for 3-6 months

Should be removed and cleaned every couple of days

Requires specialist to do the job Pt. Can do it themselves

Less maintenance Periodical maintenance

Stoma should be greater than 2 cms

Stoma should be greater than 2 cms

Oesophageal insufflation test should be positive

Oesophageal insufflation test should be positive

TEP• Was first introduced by Blom and Singer in 1979• One way silicone valve is introduced via the

fistula• This valve served as one way conduit for air into

esophagus while preventing aspiration• This prosthesis has two flanges, one enters the

esophagus while the other rests in the trachea. It fits snugly into the trachea-esophageal wound

Types of TEP

• Primary TEP – Performed during total laryngectomy

• Secondary TEP – Performed 6 months after surgery

Primary - TEP

• Hamaker first performed in 1985• Primary TEP should be attempted where ever

possible• In this procedure puncture is performed

immediately after laryngectomy and prosthesis is inserted

• Prosthesis of sufficient length should be used

Secondary TEP

• Usually performed 6 weeks following laryngectomy

• This allows pt time to develop esophageal speech

• Area of fistula identified using rigid esophagoscope

• Prosthesis can be inserted immediatly

Anatomical structures TEP• TEP is performed in

midline (Less bleeding)• Structures that are

penetrated during TEP - membranous posterior wall of trachea, esophagus and its 3 muscle layers and esophageal mucosa

• Interconnecting tissue in the trachea-esophageal space

Advantages of TEP• Can be performed after laryngectomy / irradiation

/ chemotherapy / neck dissection• Fistula can be used for esophago-gastric feeding

during immediate PO period• Easily reversible• Speech develops faster than esophageal speech• High success rate• Closely resembles laryngeal speech• Speech is intelligible

Disadvantages of TEP

• Pt should manually cover the stoma during voicing

• Good pulmonary reserve is a must• Additional surgical procedure is needed to

introduce it• Posterior esophageal wall can be breached• Catheter can pass through the posterior wall

TEP – Patient selection• Motivated patient• Patient with stable mind• Patient who has understood the anatomy & physiology

of the process• Patient should not be an alcoholic• Good hand dexterity• Good visual acuity• Positive esophageal air insufflation test• Patient should not have pharyngeal stricture / stenosis• Stoma should be of adequate depth and diameter• Intact trachea-esophageal wall

Contraindications of TEP

• Extensive surgery involving pharynx, larynx with separation of trachea-esophageal wall

• Inadequate psychological preparation• Patient with doubtful ability to cope up with

prosthesis• Impaired hand dexterity• Suspected difficulty during PO irradiation

Problems with TEP insertion

• Leak through the prosthesis• Leak around the prosthesis• Immediate aphonia / dysphonia• Hypertonicity problems• Delayed speech

Oesophageal insufflation test

• Should be performed before TEP• Assesses cricopharyngeal muscle response to

esophageal distention• A catheter is placed through the nostril up to

25 cm mark. This indicates probable site of puncture

• Pt is asked to count numbers or vocalize “Ah”

Insufflation test interpretation

• Fluent voice on minimal effort – normal• Breathy voice indicating hypotonic

cricopharyngeal muscle• Hypertonic voice – “Cricopharyngeal spasm”• Spasmodic voice – “Extreme cricopharyngeal

spasm”

Management of leak through the prosthesis

Cause SolutionValve in contact with posterior wall of esophagus

Replace prosthesis with different length and size

Prosthesis length too short for the puncture “Pinched valve”

Remeasure the puncture and replace with appropriate size prosthesis

Valve deterioration Replace valve

Fungal colonization of valve with yeast

Treat with nystatin

Back pressure High resistant prosthesis

Mucous / food lodgment Prosthesis to be cleaned

Management of leak around the prosthesis

Cause Solution

TEP location Remove prosthesis allow puncture to close and

repuncture

Unnecessary dilatation during valve placement

To be avoided

Thin trachea-esophageal wall 6 mm or less

Choose custom prosthesis

Prosthesis of incorrect length and size

Choose correct length

Poor tissue integrity due to irradiation

Custom prosthesis