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What are the components of rehabilitation of the laryngectomized patient (4)?
- -pre op counseling
- -changes that take place posy laryngectomy anatomic, physiologic, psychological implication
- -voice restoration techniques which include electrolarynx, esophageal speech and TEP
- -TEP (sizing, fitting and accessories)
Explain the lymph node distribution:
what lymph node is only for oral caners and which are for head and neck cancers?
- I-submental and submandibular nodes (only for oral cancers)
- II -Upper jugulodigastric group
- III -Middle jugular nodes (draning the naso and oropharynx, oral cavity, hypo pharynx and larynx)
- IV-Inferior jugular nodes (draining the hypo pharynx, subglottic larynx, thyroid and esophagus)
- V-posterior triangle group
- VI -Anterior compartment group
- -when there is evidence of a disease your lymph nodes try and fight it off
Facts about laryngeal cancer:
-how many people are diagnosed with cancer for the larynx each year?
-Laryngeal caner affects ___4x more often than _____.
-In US ______ lesions account for 60% of laryngeal cancers.
- -about 12,000 every year
- -men 4x more than women
- -glottic lesions
What are the predisposing risk factors for laryngeal cancer?
- -tobacco smoking
- -smokeless tobacco
- -HPV (type 16)
What are some symptoms of laryngeal cancer?
- -hoarseness >3weeks: Glottic lesions
- -lump in throat feeling
- -persistent throat clearing
- -persistent coughing
- -throat discomfort
- -sore throat
- -difficulty breathing
- -pain when swallowing
- -referred pain in ear
- -burning sensation in throat
- -weight loss
Supraglottic and hyper pharyngeal lesions are usually at stage ___ or ____ by the time they seek treatment
3 or 4
To make a diagnosis what do you need... (8 things)
- -case history
- -indirect mirror laryngoscopy
- -flexible fiberoptic endoscopy
- -laryngeal stroboscopy
- -direct laryngoscopy (under anesthesia)
- -image studies: CT/MRI/PET
- -fine needle aspiration cytology
What is the only test that tells you if and what type of cancer?
Staging of cancer
What does T refer to?
What does N refer to?
What does M refer to?
- T -primary tumor size and extent
- N-absence or presence and extent of the regional lymph node metastasis
- M-absence or presence od distant metastasis
Stage 1 Cancer would be...
Stage 2 cancer would be...
Stage 3 cancer would be...
Stage 4 cancer would be....
any T4/NO/MO, andy T/N2/MO, any T/N3/MO and anyT/anyN/M1
How do you describe a tumor? (4 things)
- -arytenoid mobility (very important to talk about this)
If arytenoid is immobile, irrespective of the size of the lesion the T stage is marked as a ____ lesion
Survival rates with:
-early localized tumors (T1, T2-NO)
-advanced localized tumors (T3, T4-NO)
-regional lymph node metals for all T stages
- -early localized tumors (T1, T2-NO)- 87.5%
- -advanced localized tumors (T3, T4-NO)72.1%
- -regional lymph node metals for all T stages 46.2%
_________ _________ _________ involvement decreases survival by 50%
regional lymph node
_______ __________ is carried out in case of stage III and stage IV advance laryngeal cancers
_________ _______ ________ constitutes more than 90% of laryngeal cancers.
squamous cell carcinoma
__________ ______ have a higher rate of bilateral lymph node metastasis as compared to glottic primaries.
What is the 5 year survive rate for T1 and T2 glottic cancers.
What is the 5 year survival rate for stage 3 or 4?
- 5 year for t1 and t2 is 90%
- for advanced stage less than 40%
- -prognosis is poorer in cases of recurrences
Explain radiation therapy as a treatment option for laryngeal cancer.
What is the freq? What is the dosage? How many fractions?
- -definitive treatment for early stages of cancer
- -definitive or adjuvant (additional) treatment for advance stages
- -conventional accelerated (daily) 6-7 weeks
- -dosage: 6000cGy
- -fractions: 30-33
- -intensity-modulated radiotherapy
What are some side effects of radiation therapy?
- -dysphagia and odynophagia
- -reduced taste
- -skin irritation
- -tissue swelling
- -breathing problems
- -decrease saliva
- -dry mouth (xerostomia)
- -trisums: decreased mouth opening
- -cytotoxic drugs target cell growth by interfering with the DNA and impugning the cells to reproduce
- -used in conjunction with radiation
- -induction chemotherapy helps debulk the tumor
Chemotherapy can be _________ for patients who cannot receive surgical , more radiation or have unresectable cancers.
What are some side effects of chemo?
- -hair loss
- -sores in mouth
- -weakened immune system
- -allergic reactions
- -damage to organs
What are 4 conservative treatment options?
- -laser excision
- -partial laryngectomy
- -organ preservation
Describe laser excision and who this is used for.
-Type I to V, depending on amount of vocal fold resected. Type V cordectomy involves completed removal of VF.
What is a partial laryngectomy? (2 types)
- -supraglottic laryngectomy: involves removal of structures above the glottis including the epiglottis.
- -hemilaryngectomy: involves vertical removal of laryngeal structures. May involve complete removal of one VF and partial removal of structures on contralateral side.
Does a patient have better swallowing outcomes for partial of hemilaryngectomy?
Explain the concept of organ preservation.
- -newer trend
- -combine chemo and radiation
- -aim is to preserve larynx and avoid stoma
- -5 year survival rates still unknown
- -severe swallowing and voice issues after high doses of chemo and radiation
- -just b/c you are preserving the organ doesn't mean you are preserving fx
Explain what a total laryngectomy is.
- -surgical excision of entire cartilaginous larynx including the (epiglottis, hyoid bone, extrinsic strap muscles, may include upper 2 tracheal rings)
- -control of the neck one of the most important factors in successful management of laryngeal tumors
- -radical neck dissection performed only if disease has metastasized to lymph nodes
- -now that strutters are removed the two passages trachea and esophagus need to be separated
- -stoma is created where the trachea is redirected and sutured to external next area
- -stoma now serves as the airway
- -NO connection between the trachea and the pharynx, nose and mouth the person is now a NECK BREATHER
What are some methods of reconstruction?
- -in case of extensive tumor surgical reconstruction is possible
- -this gives support and protection to head and neck area
- -pectoralis major myocutaneous flap (PMMC)
- -Jejunal Free flap
- -gastric pull up (GPU)
what is a pectoralis major myocutaneous flap (PMMC)?
- -taken from chest
- -voice production is generally fx but not as equal to a TE voice
What is a jejunal free flap?
- -used in reconstruction following laryngopharyyngectomy
- -voice quality is wet, gurgle and hypotnic with a decreased intensity
- -pt can present with swallowing problems
What is a gastric pull up (GPU)??
- -used in reconstruction
- -involves transposition of the entire stomach
- -methods beside TEP fitting need to be considered
What do you need to discuss with pt in pre-operative counseling?
- -ask "what has your doctor told you?"
- -educate patient with diagrams or pictures
- -prepare pt and family for immediate post op loss of speech (need to carry white board right after surgery)
- -presence of stoma
- -stress importance of regular follow up
- -explain options of voice rehab
- -tube feeds after surgery (usually 2 weeks)
- -encourage individual to start swallowing own secretions
- -start with ice chips, liquid, soft foods
- Effects of Radiation
- -changes in saliva production and consistency
- -changes in swallowing and important of maintaining adequate nutrition and weight
- -stress importance of team approach.
What test must be done before a patient can start eating again after total laryngectomy.
- -Gastrographing (test for leaks)
- -if you don't see any leaks can move onto MBS
Special considerations: Respiration
- -air is no longer filtered, moisturized or warmed
- -dry air causes mucous buildup with thicker secretion
- -stoma covers: cloth, foam and HME (heat moisture exchanges)
Explain coughing and sneezing post laryngectomy.
- -through stoma
- -need to remind individual to cover stoma not mouth
- -counseling regarding drainage from nose
Explain swallowing following a total laryngectomy
- -generally not affected
- -may need esophageal dilation secondary to narrowing
- -oral feeds start 1-2 weeks post op
- -patients are counseled about feeds deepening on type of reconstructive procedure (gastric pull up)
How is smell and taste impacted post laryngectomy?
- -smell is impaired since the individual can no longer inhale through the nose to activate olfactory nerve
- -since taste is influenced by smell it is also affected
- -olfactory rehab
safety concerns for pt with total laryngectomy
- -TOTAL NECK BREATHER -no VF, breathes only though the neck and not the nose
- -mouth to stoma resuscitation
- -advised to wear medical alert bracelet
- -discuss safety around water
- -use rubber shower shield
- -special considerations for swimming (Larkel)
Inability to regulate the larynx and build pressure may impair _______ and ________.
-lifting and pooping
Psycho social concerns post laryngectomy
- -adjustments to reaction of the disease, physical changes , self confidence, changes to relationships
- -need to maintain independence and not become dependent on another family member
- -personal and sexual relationships also affected
- -need to communicate adequately in work setting.
Modes of communication following Total laryngectomy (6)
- -mouthing and gesturing
- -buccal speech
- -artificial larynx
- -esophageal speech
- -tracheoesphageal speech
Explain artificial larynges. What is the most common type? What are other types?
- Most common is electrolarynx (neck type device)
- -sound generator is the vibratory surface of the electrolarynx
- -when held against the skin of mandible/neck/cheek converts vibrations into electronic sound.
- Oral devises
- -cooper rand or PO vox -generate sound in a small transducer and transmit through tube
- Intra-oral devises
- -ultra voice -custom built into upper denture or retainer
- -pneumatic artificial larynx -rarely used in US
People using artificial larynges must ________ words.
Advantages to artificial larynges
- -easy to learn
- -equal in intelligibility to esophageal speech
- -easily discriminated in noise than esophageal speech
- -can be easily adapted and changed to intraoral device
Disadvantages to artificial larynges
- -robotic quality
- -cost factor
- -requires one hand for use
- -failure of mechanical breakdown
- -difficult to vary and use pitch
- -limited ability to vary pitch and intensity
Explain the PE segment
- Pharyngoesophageal segment
- -sound generator for individuals using esophageal speech or tracheoesophageal speech. The tonicity of the PE segment greatly influences voice quality
- -source of esophageal phonation is primarily derived through response of cricophayngus muscle.
What is esophageal speech?
- -phonatory source or sound generator is the PE segment
- -based on technique in which pt transports small amount of air into esophagus
- -due to increased pressure, the air is forced back the PE segment to induce resonance
- -rarely get a phonation time more than 4 sec
What are the two methods of air intake for esophageal speech?
- -esophagus is in state of neg pressure and as air is inhaled into lungs, air also enters esophagus. air pressure in lungs and esophagus become equalized. Air can then be expelled to produce vibration of PE segment
- -compressing intraoral air into the esophagus with assistance from the tongue or lips and sometimes the cheeks.
What are advantages to esophageal speech?
- -no mechanical or prosthetic devices used
- -both hands are free while talking
- -more natural sounding than electrolaryngeal speech
What are the disadvantages to esophageal speech?
- -four to six months to learn
- -30% are able to develop this as primary means of comm
- -phonation sustained over a very short period of time
- -low intensity and low pitch
- -limited pitch and intensity modulation
What is a total laryngectomy with TEP? Explain Primary and secondary TEP.
- -primary or secondary procedure for voice restoration
- Primary TEP
- -TE fistula or puncture is created months or at times years after total laryngectomy
- -voice restoration is better after primary TEP
- -creation of a traceoesophageal (TE) fistula between the trachea and esophagus in the superior boarder of the stoma.
the _______ is not the puncture.
Describe voice prosthesis/TE prosthesis
- -a one way valve made of silicone that has a valve at distal end. The anterior end has an opining through which pulmonary air enters .
- -Two types : indwelling and non dwelling
- -Indewlling prosthesis: prosthesis is changed every 3 months in clinical setting
- -Non indwelling: prosthesis is changed and cleaned by patient. has to be trained to remove this
- -a retention collar separates part which is inserted into the esophagus from that which is in the trachea
- -a flange or strap is attached to prosthesis to aid in insertion and secure device once in place
What treatment considerations for TEP?
- -needs to taught to occlude the stoma
- -co ordination b/w breathing-occlusion-phonation
- -amont of pressure pt uses for stomal occlusion has to be regulated
- -care and maintenance of prosthesis
- -make pt aware of what happens if device becomes defective Peri or central TEP leak
what are some advantages of voice prosthesis?
- -major advantage is the use of pulmonary air as the driving force for the PE segment. This allows patent to sustain phonation over a longer period of time
- -privides more natural speech -breathing action and the acoustic characteristics of voice are closer to approx measure for laryngeal speakers.
- -TE speech is easy to acquire and learn
- -hands free prosthesis now available.
What are some disadvantages to voice prosthesis?
- -daily maintenance
- -semi permanent (changed every 3 months)
- -the recurrent leakage of prosthesis after a period of time requires replacement by clinician
- -if perfumed as second procedure, additional surgery
Contraindications to TEP placement
- -inadequate pulmonary reserve
- -inadequate depth and diameter of stoma
- -recurrent disease
- -unresolved fistula
- -bad tissues
- -reduced income
- -poor/no insurance
- -transportation issues
Speaking valves and factors to consider
- -peristomal topography
- -skin type
- -stomal contour
- -pulmonary status
- -manual dexterity
- -stomal symmetry
- -contiguous stomal lip
How to check if TEP is in place?
- -turn TEP 360 degrees to ensure esophageal flange is engaged
- -ask pt to phonate
- -ask pt to sip water -check for leak
What does it mean if patient fails to acquire TE speech?
- -issues with prosthesis
- -cricopharyngeal spasm
- -pharyngeal neurectomy
- -cricopharyngeal myotomy