identification & managemement of swallowing problems after laryngectomy
DESCRIPTION
Identification & Managemement of Swallowing Problems After LaryngectomyTRANSCRIPT
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IDENTIFICATION &
MANAGEMEMENT OF
SWALLOWING PROBLEMS
AFTER LARYNGECTOMY
KUNNAMPALLIL GEJO JOHN
BASLP,MASLP
KUNNAMPALLIL GEJO JOHN
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OVERVIEW
Dysphagia and Stages of Swallowing
Signs & Symptoms of Mechanical
Dysphagia
Dysphagia in Laryngeal Cancer
Guidelines for Therapy
Management by Swallowing Therapist
KUNNAMPALLIL GEJO JOHN
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DYSPHAGIA
Greek word- disordered eating
Difficulty or pain while swallowing
Greater time and effort to move food or
liquid from mouth to stomach
Types- Mechanical and Neurogenic
KUNNAMPALLIL GEJO JOHN
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SWALLOWING MECHANISM
KUNNAMPALLIL GEJO JOHN
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STAGES OF SWALLOWING
1. Sensory stage
2. Oral preparatory stage
3. Oral stage
4. Pharyngeal stage
5. Esophageal stage
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SENSORY STAGE
Pre-oral Anticipatory Stage
Suggested by Leopold & Kagel (1997)
Encompasses interaction of pre-oral:
Motor
Cognitive
Psychosocial
Somatoesthetic elements KUNNAMPALLIL GEJO JOHN
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ORAL PREPARATORY STAGE
Bolus is formed by mastication involving rotary
lateral movements of the mandible and tongue
Upper and lower teeth crush the material which
falls medially toward the tongue
Tongue moves the material back onto the teeth as
the mandible opens
KUNNAMPALLIL GEJO JOHN
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…CONTD
The tongue mixes food with saliva
The cycle is repeated numerous times before
initiating the swallow
Movement patterns vary depending on
consistency of material being chewed
KUNNAMPALLIL GEJO JOHN
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…CONTD
Labial seal is maintained to ensure no
spillage
Velum is pulled anteriorly and rests against
the slightly elevated back of the tongue
Larynx and pharynx are at rest and nasal
breathing may continue till voluntary
swallow is initiated. KUNNAMPALLIL GEJO JOHN
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…CONTD
Bolus is held between the anterior tongue
and the palate
Tongue cups around the bolus and seals it
against the hard palate, laterally and
anteriorly
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ORAL STAGE
Initiates with stripping action of the tongue
It sequentially squeezes the bolus
posteriorly against the hard palate
Central groove is formed for bolus to move
posteriorly
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…CONTD
When bolus passes the anterior faucial
arches, oral stage is terminated
This stage takes about 1 sec to
complete
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PHARYNGEAL STAGE
Begins with triggering of swallowing reflex
Both voluntary and reflex components are
involved
Triggering of swallowing reflex leads to:
(1) Elevation and retraction of velum
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…CONTD
(2) Initiation of pharyngeal peristalsis
(3) Elevation and closure of larynx at 3
sphincters- epiglottis, false vocal folds and
true vocal folds
(4) Relaxation of the cricopharyngeal
sphincter
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ESOPHAGEAL STAGE
UES relaxes to let the bolus pass
Bolus sequentially passes by:
Striated constrictor muscles of the pharynx
Peristalsis
Relaxation of LES
Normal transit time varies form 8 to 20 seconds.
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SYMPTOMS OF
MECHANICAL DYSPHAGIA
Inability to control food or saliva in mouth
Coughing before, during or after a swallow
Effortful and labored swallowing
Increased time taken
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…CONTD
Stringy/ copious secretions
Gurgly voice quality
Recurring pneumonia
Weight loss
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SIGNS OF MECHANICAL
DYSPHAGIA Residue
Penetration
Aspiration
Spiked fever
Backflow
Regurgitation
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ASSESSMENT
IMAGING STUDIES NON-IMAGING
STUDIES
Ultrasound Electromyography
Videoendoscopy Electroglottography
Videofluoroscopy Cervical Auscultation
Scintigraphy Manometry
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BEDSIDE SWALLOW
EXAMINATION
CHART EXAMINATION
Medical history
Time of onset
Duration
Severity
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…CONTD
Pulmonary function
Tracheostomy tube
Nutritional status
Presence of feeding tube
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…CONTD
GENERAL FUNCTIONAL STATUS
Alert
Awake
Sensitive to symptoms
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…CONTD
MEETING THE PATIENT
Posture
Respiratory status
Oral-motor function examination
Laryngeal function examination
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SWALLOW ASSESSMENT
Spontaneous Swallow
Secretion management
Coordination with respiration
Dry Swallow
Timing
Laryngeal elevation
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…CONTD
Chewing
Gauze pad dipped in liquid
Bolus swallow
Consistency
Posture
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…CONTD
During trial swallow, observe:
Patient’s reaction to food
Oral movements in chewing
Coughing, throat clearing
Changes in secretion
Duration of meal and total intake
Coordination of breathing and swallowing
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MANAGEMENT BY
SWALLOWING THERAPIST
POSTURE CONSISTENCY MANEUVERS ENVIRONMENT
MANAGEMENT OF
MECHANICAL DYSPHAGIA
KUNNAMPALLIL GEJO JOHN
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GUIDELINES FOR THERAPY
Counseling prior to treatment
Awareness regarding change in voice and
swallowing
Radiated patients should begin ROM
exercises before or at beginning of RT
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Review patient’s chart to determine extent of
resection and nature of reconstruction
Exercise program begins with surgeon’s
approval
Entire team of professionals should interact
and cooperate
…CONTD
KUNNAMPALLIL GEJO JOHN
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THERAPY TECHNIQUES
Range of motion (ROM) exercises
Extent of movement
Bolus control exercises
Lingual control
LOGEMANN 1998
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Adduction exercises
Laryngeal closure
Tongue base exercises
Tongue base ROM
Falsetto exercise
Laryngeal elevation
…CONTD
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POSTURAL TECHNIQUES
DISORDER POSTURE RATIONALE
Inefficient oral
transit
Head back Utilizes gravity
to clear oral
cavity
Delay in
triggering
pharyngeal
swallow
Chin down Widens
valleculae to
prevent bolus
entering airway,
narrows airway
entrance
DISORDER POSTURE RATIONALE
Inefficient oral
transit
Head back Utilizes gravity
to clear oral
cavity
Delay in
triggering
pharyngeal
swallow
Chin down Widens
valleculae to
prevent bolus
entering airway,
narrows airway
entrance
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DISORDER POSTURE RATIONALE
Reduced
posterior motion
of tongue base
Chin down Pushes tongue
base backward
Unilateral
pharyngeal
dysfunction
Head rotated to
damaged side,
chin down
Places extrinsic
pressure on
thyroid
cartilage,
increasing
adduction
…CONTD
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…CONTD
DISORDER POSTURE RATIONALE
Reduced
laryngeal closure
Chin down,
Head rotated to
damaged side
Puts epiglottis in
more protective
position,
narrows
laryngeal
entrance
Reduced
pharyngeal
contraction
Lying down on
one side
Eliminates
gravitational
effect
KUNNAMPALLIL GEJO JOHN
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…CONTD
DISORDER POSTURE RATIONALE
Unilateral
pharyngeal
paresis
Head rotated to
damaged side
Eliminates
damaged side
from bolus path
Unilateral oral
and pharyngeal
weakness
Head tilt to
stronger side
Directs bolus
down stronger
side
Cricopharyngeal
dysfunction
Head rotated to
damaged side
Pulls cricoid
away from
posterior
pharyngeal wall KUNNAMPALLIL GEJO JOHN
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CONSISTENCY CHANGES
CONSISTENCY EXAMPLES
Thin liquid Milk, fruit juice
Thick liquid Soup, milkshake
Puree Yogurt, custard
Soft solid Mashed potato, idli
Hard solid Biscuits KUNNAMPALLIL GEJO JOHN
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…CONTD
DISORDER EASIEST DIFFICULT
Reduced range
of tongue
motion
Thick liquid Thick foods
Reduced tongue
contraction
Thick liquid Thick foods
Reduced tongue
strength
Liquid Thick foods
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DISORDER EASIEST DIFFICULT
Delayed
pharyngeal
swallow
Thick liquids
and thicker
foods
Thin liquids
Reduced airway
closure
Pudding and
thick foods
Thin liquids
Reduced
laryngeal
movement-
cricopharyngeal
dysfunction
Liquid Thicker, high
viscosity foods
…CONTD
KUNNAMPALLIL GEJO JOHN
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…CONTD
DISORDER EASIEST DIFFICULT
Reduced
pharyngeal
contraction
Liquid Thick, high
viscosity foods
Reduced tongue
base posterior
movements
Liquid High viscosity
foods
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SWALLOWING MANEUVERS Maneuver Problem Rationale
Supraglottic
swallow
Reduced or late
vocal fold
closure
Delayed
pharyngeal
swallow
Voluntary breath
hold closes vf
before and
during
swallowing
Super
supraglottic
swallow
Reduced closure
of airway
entrance
Effortful breath
hold, tilts
arytenoids
forward, closing
airway entrance KUNNAMPALLIL GEJO JOHN
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…CONTD
Maneuver Problem Rationale
Effortful
swallow
Reduced
posterior
movement of
tongue base
Effort increases
posterior tongue
base movement
Mendelsohn
maneuver
Reduced
laryngeal
movement
Laryngeal movt
opens UES,
prolonging
laryngeal
elevation
prolongs UES
opening KUNNAMPALLIL GEJO JOHN
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ENVIRONMENTAL
MODIFICATIONS
Thick straw while drinking liquids
Pillow behind patient's head during
feeding
Reducing distractions like turning off
the TV, no talking during feeding
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DYSPHAGIA IN
LARYNGEAL CANCER
DYSPHAGIA
TUMOR LOCATION SURGICAL RESECTION RADIOTHERAPY
SUPRAGLOTTIC
UNILATERAL
LARYNGEAL TUMOR
MORE THAN ONE REGION
SUPRAGLOTTIC LARYNGECTOMY
HEMILARYNGECTOMY
TOTAL LARYNGECTOMY
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SUPRAGLOTTIC TUMORS:
SUPRAGLOTTIC
LARYNGECTOMY
1. HORIZONTAL/
SUPRAGLOTTIC
LARYNGECTOMY
Small lesions involving
epiglottis, aryepiglottic
fold or false vocal fold
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…CONTD
Protection spared - Base of tongue,
arytenoids and true vocal folds
Reconstruction surgery- larynx elevated and
tucked under tongue base
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…CONTD
To relearn swallow patient must completely
occlude airway entrance
Retract tongue base- contact anteriorly
tilting arytenoid
Laryngeal elevation- airway protection-
arytenoid closer to tongue base affected
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…CONTD
Removal of hyoid- affects laryngeal
suspension
MANAGEMENT
Super-supraglottic swallow
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…CONTD
2. SGL EXTENDED INTO
BASE OF TONGUE
More precipitous drop-off
into airway
Reduced lingual movement
and control of bolus
Management
ROM
Bolus control exercises
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…CONTD
3. SGL EXTENDED
INFERIORLY
Include part of 1 vocal
fold or arytenoid
cartilage
Reduced chances of
recovery of normal
swallow KUNNAMPALLIL GEJO JOHN
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…CONTD
One of the criteria for selection of SGL-
Ability to relearn swallow sequence
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UNILATERAL LARYNGEAL
TUMORS:
HEMILARYNGECTOMY
1. HEMILARYNGECTOMY
Physical removal of vertical
1/2 of the larynx
When tumors located on
free margin of 1 vocal fold
with local extension
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…CONTD
Resection- false vocal fold, ventricle and true
vocal fold
Spared structures- Arytenoid, thyroid, hyoid
and epiglottis
Typical HL- few difficulties postoperatively
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…CONTD
Some bulk tissue reconstructed against
which un-operated side can attain normal
laryngeal closure
MANAGEMENT
Chin down position
If aspiration persists, head rotation to the
operated side KUNNAMPALLIL GEJO JOHN
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…CONTD
2. FRONTOLATERAL
LARYNGECTOMY
Lesion located anteriorly
on a vocal fold
Includes part or all of
anterior commisure of
the larynx
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…CONTD
Reconstruction- some bulk muscle of tissue
taken from strap muscles
Patients with FLL rehabilitated 2-3 weeks
postoperatively
More of them need chin-down head posture
than those with lesser resection
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…CONTD
3. 3/4 LARYNGECTOMY
HL extending along anterior
commisure to include 1/2 of
other side of the larynx
Intact arytenoid cartilages,
epiglottis, hyoid and tissue
bulk placed on operated
side→ Prevent aspiration
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…CONTD
MANAGEMENT
Chin-down position
Head rotated postures
Adduction exercises
Super-supraglottic swallow
KUNNAMPALLIL GEJO JOHN
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…CONTD
Major problem in extended PL→ preventing
aspiration
Aspiration controlled by reconstructing
narrow glottic chink- airway compromised
Functional tradeoff for elimination of
aspiration is permanent tracheostomy
KUNNAMPALLIL GEJO JOHN
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LARGE LESIONS: TOTAL
LARYNGECTOMY
Total laryngectomy- Lesions involving more
than one region of larynx
Physical separation of gastrointestinal tract
from respiratory tract→ no aspiration
However, swallowing problems do exist in
TL
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…CONTD
1. Nature of closure of surgical defect
Postoperatively, fold of tissue at base of
tongue- pseudo-vallecula
During swallowing, contraction of
pharyngeal constrictor muscles pulls
pseudo-vallecula posteriorly
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…CONTD
Gap widens at base of tongue, forming large
Greater struggle reaction→ greater widening
of pocket
Some restricted to liquid consistency
Treatment- surgical resection of tissue fold
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…CONTD
2. Tightness of surgical closure
Scar tissue strictures in esophagus after
surgery
Narrows esophagus, prevents large
amount of material of thick consistency
from passing
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…CONTD
MANAGEMENT
Dilatation- gave temporary success
Pharyngoesophageal myotomy- release scar
tissue stricture
Changing head positions- head rotation
stretch and open a stricture
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…CONTD
Pharyngectomy, esophagectomy with
reconstruction by distal flap, stomach pull-
up, or jejunal graft- backflow of food
MANAGEMENT
Postural changes like extending neck
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…CONTD
TEP- Most successful surgical prosthetic
procedure
Prosthesis placed in puncture wound prevents
backflow
Trachealus muscle forms a tight seal at puncture
site around prosthesis
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SUMMARY
SURGERY MANAGEMENT
Horizontal or supraglottic
laryngectomy
Super-supraglottic swallow
SGL extended into base of
tongue
ROM and bolus control
exercises
Typical hemilaryngectomy Chin down, Head rotated
to operated side
Frontolateral
laryngectomy
Chin down posture
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…CONTD
SURGERY MANAGEMENT
3/4th laryngectomy Chin down posture, Head
rotated Adduction
exercise, Super-
supraglottic swallow
Total laryngectomy Dilatation,
Pharyngoesophageal
myotomy, Head rotation,
Head back posture,TEP
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RADIOTHERAPY
Following side effects may arise :
Redness or skin irritation
Swelling
Mucositis
Xerostomia (dry mouth) or thickened saliva
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…CONTD
Bone pain
Nausea
Fatigue
Dental problems
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…CONTD
Changes in voice
Loss of appetite, due to altered taste
Dehydration
Fibrosis (scarring)
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…CONTD
Very small changes in salivary flow in T1 or
T2 stage tumor
If all salivary glands in field of radiation-
xerostomia, edema and mucositis
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…CONTD
Xerostomia
Reduced tongue speed
Delay in oral transit time
Delay in triggering pharyngeal swallow
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…CONTD
Fibrosis → Damage to capillaries in radiated
area
If pharynx in the field of radiation- reduced
laryngeal elevation, reduced pharyngeal wall
motion
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…CONTD
Effects may begin during course of RT or
years thereafter
Impairs efficiency and safety of swallow
Severity varies
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…CONTD
MANAGEMENT
ROM exercises before RT begins and
continue to prevent fibrosis
Falsetto exercise
Mendelsohn maneuver
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CONCLUSION
Swallowing therapist needs to combine
many techniques
Patient may have developed some
compensatory strategies
Need to assess and determine if they benefit
If not, then teach appropriate techniques
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“The art of dining well is no slight art, the pleasure not a slight pleasure.”
-Michel de Montaigne (1533-1592)
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ACKNOWLEDGEMENTS
Our sincere gratitude to:
Dr. S.N.Oak- Dean of TNMC & BYL Nair Charitable
Hospital
Mrs. G.B.Gore- Professor & Head of AST Dept of TNMC
& BYL Nair Charitable Hospital
Dr. Premalatha for her guidance
Mansi and Priya for their suggestions and co-operation
All the staff members and students
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REFERENCES
Dikeman, K. J., & Kazandjian, A. S. (2003). Communication and Swallowing
Management of Tracheostomized and Ventilator-Dependent Adults.
Canada: Thomas Learning Inc.
Jones, B. (2002). Normal and Abnormal Swallowing. Springer Publishing Group.
Kazi, R., Prasad, V., Venkitaraman, R., Nutting, C.M., Clarke, P., Rhys-Evans, P.,
& Harrington K.J. (2006). Questionnaire analysis of the swallowing-related
outcomes following total laryngectomy . Clinical Otolaryngology 31 (6), 525–530.
Logemann, J. A. (1983). Evaluation and Treatment of Swallowing Disorders.
Austin: Pro-Ed Publication.
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…CONTD
Logemann, J. A., Pauloski, B. R., Rademaker, A.W., Cook, B., Graner,
D., Milianti, F., Beery, Q., Stein, D., Bowman4, J., Lazarus,
C., Heiser, M. A., & Baker, T. (1992). Impact of the diagnostic
procedure on outcome measures of swallowing rehabilitation in head
and neck cancer patients. Dyshpagia, 7 ( 4), 179-186.
Logemann, J. A., Gibbons, P., Rademaker, A.W., Pauloski, B. R., Kahrilas,
P. J., Bacon, M., Bowman, J., & McCraken, E. (1994). Mechanisms of
recovery after supraglottic laryngectomy. Journal of Speech and
Hearing Research, 37, 965-974.
Logemann, J. A. (1998). Evaluation and Treatment of Swallowing
Disorders. Austin: Pro-Ed Publication.
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…CONTD
Murdoch, B. E., Theodoros, D. G. (2001). Traumatic Brain Injury:
Associated Speech, Language, and Swallowing Disorders. San Diego:
Singular Publishing Group, Inc.
Pradhan, S. (2006). Voice Conservation Surgery for Laryngeal and
Hypolaryngeal Cancer. Mumbai: Lloyds Publishing House.
Perlman, A. L. (1997). Deglutition and Its Disorders: Anatomy, Physiology,
Clinical Diagnosis, and Management. San Diego: Singular Publishing
Group, Inc.
Wikipedia, the free encyclopedia. Retrieved on August 12, 2007 from
http://en.wikipedia.org/wiki/Dysphagia
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THANK YOU
KUNNAMPALLIL GEJO JOHN