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Speech rehabilitation after near total laryngectomy

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP AUDIOLOGIST

KUNNAMPALLIL GEJO JOHN,

First duty of a man is to speak that is his chief business in this world

KUNNAMPALLIL GEJO JOHN,

Role of speech therapist


-

Important member of the team in head and neck cancer rehabilitation

- Not just speech rehabilitation but involved in total rehabilitation

KUNNAMPALLIL GEJO JOHN,

Speech restorative surgery-goal


Speech

and swallowing sans aspiration Swallowing sans dysphagia

KUNNAMPALLIL GEJO JOHN,

What is near total laryngectomy? (NTL)


Is a surgical procedure where in part of the larynx preserved

Total laryngectomy Near total laryngectomy

Partial laryngectomy
KUNNAMPALLIL GEJO JOHN,

Near total laryngectomy

Surgical intervention to preserve the part of the function of the larynx Between the partial laryngectomy and total laryngectomy Like total laryngectomy-speech is preserved Like partial laryngectomy-nasal breathing is sacrificed
KUNNAMPALLIL GEJO JOHN,

Total laryngectomy
Nasal

breathing sacrificed Permanent stoma Verbal communication is lost


KUNNAMPALLIL GEJO JOHN,

Partial laryngectomy
Nasal

breathing is preserved Verbal communication is present Temporary tracheostoma Stoma will be in situ for only few days

KUNNAMPALLIL GEJO JOHN,

Near total laryngectomy

Nasal breathing is sacrificed Verbal communication is preserved Permanent stoma Patient can speak with preserved larynx

KUNNAMPALLIL GEJO JOHN,

How does speech produced after NTL?


Myomucosal

shunt At the tine of surgery part of the larynx is preserved Preserved larynx - one vocal cord, one arytenoid, one false vocal cord,

KUNNAMPALLIL GEJO JOHN,

NTL(Tracheo pharyngeal shunt speech)


Lung powered speech Left over larynx serves as vibrator Temporal and acoustic parameters are far superior to esophageal speech

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Diagrammatic representation of NTL speech

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Shunt from trachea to pharynx

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Speech therapy after NTL

when?
days after removal of NG tube After medical line of treatment completes
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3-4

Speech rehabilitation technique


Start Rx after swallowing tolerated Breathing and relaxation exercises Occlusion of stoma with clean hand and finger Visual feed back for proper occlusion of stoma

KUNNAMPALLIL GEJO JOHN,

Speech therapy schedule-NTL How ?


30-40

min/session Individual therapy Group therapy Resume sentence level before initiation of post operative RT
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How do we proceed?

Good posture Relaxing exercises for head and neck area Normal inhalation Closing of the stoma Phonation Words beginning with a vowel and sentences Refinement of speech
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Inhalation --occlusion of stoma+ exhalation and production of voice

KUNNAMPALLIL GEJO JOHN,

Patient in conversation

KUNNAMPALLIL GEJO JOHN,

Near total laryngectomy speech

KUNNAMPALLIL GEJO JOHN,

KUNNAMPALLIL GEJO JOHN,

NTL Therapy procedure


Counseling
Therapist make an attempt

Finger to stoma coordination

Proper valving
Inhalation-occlusion of stomaexhalation & articulation
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Factors to keep in mind


Patient should be motivated Pulmonary reservoir should be sufficient Stoma should not be narrow

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Finger to stoma coordination


Not

too much pressure -Strained voice Not too little - Air escape from the stoma Not closing the mouth of the shunt at the tracheal level - air will not pass through shunt
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Digital occulusion of stoma

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Problem one can face -NTL


Severe

cough Short neck Improper closure of stoma Lack of motivation Vaso vagal irritation Inability to understand instruction Short of breath
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Aspiration in NTL cases


Pulmonary complication Total laryngectomy Moderate ------Aspiration of liquid frequently Manageable with antiaspiration methods Minimal----Detected occasionally Transient

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Severe ------

How to prevent aspiration


Cuffed tracheostomy tube Use of digital pressure over the tip of the shunt Use of Dan Kelly pressure band Sensory and motor innervations of one of the arytenoid should be intact Shunt should not be too wide

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NTL Speech Achievement Kidwai Study

Laryngeal lesion n= 70 Hypopharyngeal lesion n=112

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NTL speakers speech proficiency


Larynx n=70 Excellent=13 Good =25 Satisfactory =9 Poor = 23 Hypopharynx n=112 Excellent = 22 Good = 30 Satisfactory =26 Poor =35

KUNNAMPALLIL GEJO JOHN,

If all my possessions were taken away from me, I would like to keep the power of speech, so that I would soon regain the rest Daniel Webster

KUNNAMPALLIL GEJO JOHN,

Thank you
KUNNAMPALLIL GEJO JOHN,