Structural Disorders - Midterm

0.0(0) Reviews
Report Flashcard set

Spaced Repetition

spaced repetition





Practice Test



109 Terms
😃 Not studied yet (109)
OHNC effects
voice articulation resonance swallowing
OHNC causes
- primarily squamous cell carcinoma - smoking - HPV (human papilloma virus) - alcohol - smoking + alcohol (synergistic effect) - chewing tobacco - environmental exposure - age - radiation exposure - asbestos, wood dust, nickel alloy dust, and silica dust - gastroesophageal Reflux Disease (GERD)
OHNC locations
- larynx - oral cavity - nasal cavity - nasopharynx - orophraynx (maxilla and sinuses, tonsils) - hypopharynx - cervical esophagus - neck
additional concerns
- metastasis to lymph nodes (requires a radical neck dissection) - side effects of treatment: radiotherapy and chemotherapy
care addresses
- physical - physiological - social - psychosocial
counseling OHNC
- be consistent - be clear - be empathetic
impact of OHNC
- physically - most detrimental to personal and social
surgical procedure where all or part of the larynx is excised - (1) total = entire - (2) partial = excision of less than total - supraglottic = excision of less than total - hemi = sagittal cut (left or right)
changes from laryngectomy
- entire larynx is removed - lose laryngeal elevation (makes swallowing harder) - lose phonatory (taste and smell) - lose part of airway
esophageal speech
speech is produced by forcing air into the esophagus, forcing it through the narrow constriction of the pharyngoesophageal (PE) segment to produce vibration for sound
advantages of ES
- no external devices necessary - more natural than an electrolarynx (listeners prefer) - can somewhat manipulate pitch and loudness - hands-free
disadvantages of ES
- may take a long time to learn (many patients never do) - articulation must be excellent - hard to speak above background noise - most patients are potential esophageal speakers - cannot match pitch, loudness, rate, inetll (lower, softer, slower)
contraindications for ES
- neck scar tissue - extensive resection of the PE segment - esophageal stenosis (narrowing) (not a good candidate)
benefits of ES
- sound is preferred to EL - no equipment - not mechanical - hands free - don't need batteries
drawbacks to ES
- hard to learn - hard to teach - not a lot of people know how to teach - quieter - no pitch or loudness variations - difficulty being understood in social settings - struggle to be understood or inability to speak
what makes successful ES
- extent of surgery (less extent to be good) - positive attitude - psychosocial adjustment (support group) - frequency of tx - family support
what makes unsuccessful ES
- lack of motivation - limited physical strength - radiotherapy - dysphagia - limited speech therapy - effect of TEP (more popular)
not appropriate for ES
- extensive pharyngeal surgery (involving tongue, esophagus, or mandible, radical neck disection) - coexisting medical problems - those with hearing loss
injection for ES
- closing the lips, pushing tongue back, squeezing pharyngeal space, forcing air through PE segment, into the esophagus - build up oral pressure to force PE segment open - use air that's currently in the oral cavity - swallowing, forcing, piston-ing
inhalation for ES
- forcing/opening PE segment - take big breath through the stoma, changes pressure in the lungs (negative pressure) - thoracic pressure change pulls the PE segment open - increase negative pressures below PE segment to "suck" air into esophagus - air rushes in on it's own - harder to learn/teach
tracheoesophageal speech
- puncture is made through the tracheal wall into the esophagus (surgically created fistula) - prosthesis is inserted as a one way valve to the esophagus - air supply from the lungs - stoma must be occluded (digitally - finger over OR adjustable valve) - air enters the prosthesis into the esophagus - air continues up through the PE segment where sound is produced - sound enters the oral cavity where it is articulated and shaped into words
difficulties/differences to TE
- no VF - can't voluntarily close or open PE segment - need 2.5-3x higher amount of pressure - can be a lot more challenging for those with respiratory problems
advantages to TE
- can provide the most rapid restoration of "near normal" speech - uses patient's own air supply (own pulmonary air supply) - speech path sizes and places prosthesis - little bit of pitch change, good pauses, louder - pitch is still too low for females
disadvantages to TE
- surgery always carries risk - fistula may stenosis - (slight) risk of aspiration - stoma stenosis - infection (high risk) - radiation-induced fistula closure - granulation buildup - prolapse - leakage around the prosthesis with subsequent aspiration - candida
main failure of TE
- candida - created a pathway from the esophagus to the lungs, any problems with swallowing or the valve, food or candida may come through the prosthesis - put things in the prosthesis to ward of candida
issues for alaryngeal speech
- pulmonary issues (COPD) - radical neck dissection - radiation
when prosthesis is going bad
wet, gurgly voice - something is getting through or around the prosthesis - can lead to infection
heat and moisture exchanger - foam filter captures humidity - creates warm and humid air going into the lungs - IMPROVES RESPIRATORY HEALTH
complications TE
- esophageal perforation (most significant) - secondary mediastinal infection - cervical osteomyelitis (disk degeneration) - rare, pharyngocutaneous leakage (aka, fistula) - drainage, antibiotics, flap surgery - stenosis, narrowing (use of laryngectomy tube) - necrosis (tissue dying) - granulation tissue (cautery, growth on/around stoma)
candidacy for TE
- motivated - willing to undergo surgery - willing to maintain prosthesis (hygiene) - can occlude (digital) - good dexterity, good vision - respiratory health
contraindications for TE
- cognitive issues (in-dwellings have helped this issue) - chronic alcoholism (poor decision making, poor health, candida) - radiation (exceeds 70Gy - range normally 40-80, worried about tissue health) - small stoma (makes difficult to breathe and produce speech)
primary hole for TE
- made during the laryngectomy - depends on the ENT/physician - benefits: done all at once, don't need another surgery
secondary puncture for TE
- done after the laryngectomy - benefit: good for letting everything heal
candidates for TE
- motivated - willing to undergo surgery - willing to maintain prosthesis - can occlude
insufflation testing
adequacy of PE segment for voicing - how to determine if someone can produce tracheoesophageal speech - catheter inserted about 25 cm past PE segment - air is introduced into esophagus to vibrate PE segment - > 8 seconds = ok - if high-pitched, strained = failure
failure with insufflation testing
- fibrosis - misplacement - radiation-induced edema - hyper-hypo tonicity of the PE segment
hypertonicity of PE segment treatment
- myotomy (muscle clipping, makes it easier to release airflow, surgical procedure) - plexus neurectomy (oblate portions of the nerve signal going to the PE segment) - botox (into PE segment musculature, paralyzes receptors site, lasts 3-6 months, results in relaxation, only 1 injection usually does it, PREFER)
time of placement
when the physician tells us to
patients need to know
- need to understand how voice is produced - what to do in case of dislodgment (need red rubber catheters if they can't fish it out) - know the indications of failure (wet, gurgly voice, leakage around and through - prosthesis or sizing failure, strained voice)
prosthesis is leaking around
sizing problem, need a larger one TE
prosthesis is leaking through
need a brand new prosthesis TE
why laryngectomy
- presence of a malignant tumor - depends on: size, location, invasiveness, spread of tumor - necessary due to: trauma (MVA, gunshot, stab, blunt force), nonfunctional larynx w/ aspiration, irreparable supraglottic stenosis
laryngectomy impacts
- communication - psychological - family - economic
laryngectomy procedure
- entire larynx is removed, including the hyoid bone - trachea is connected to a stoma in the anterior part of the neck - esophagus and airway are subsequently separated - radiation or chemotherapy is often necessary to eliminate any small traces of cancer
produced by electrical devices that vibrate the air in the oral cavity for use in articulation - place against the neck - transfers resonance into the neck - requires no phonatory system - need optimal placement to get the best resonance
problems with electrolarynx
- struggle being heard in a loud environment - leathery tissue caused from surgery and radiation (prohibits effective transfer of resonance) - in loud environment, struggle to be heard, drowns out/masks the voice - females don't prefer - too low frequency
TNM system
- T: tumor size - N: nodes involved - M: numbers of organs involved (metastasized)
confined to one site, normal fold mobility
more than one site in supraglottic larynx, normal fold mobility
immobile TVF or extension into postcricoid, medial pyriforms, or pre-epiglottic areas - large tumor, total laryngectomy
invasion of cartilage or tissue beyond the larynx - very large, may obstruct airway - total laryngectomy
nodes cannot be assessed
no regional lymph node involved - total laryngectomy
single, ipsilateral node (3 cm or less)
single, ipsilateral node (3-6 cm) or contralateral nodes no greater than 6cm
single ipsi node
multiple ipsi nodes
ipsi or contra node involvement - spread, radical neck dissection
lymph node involvement anywhere > 6cm - spread, radical neck dissection
distant metastasis cannot be assessed
no distant metastasis
distant metastasis
location of laryngeal tumor
- supraglottic: raised edges and ulcerations - glottic: irregular thickening w/ possible white, cauliflower appearance - subglottic: diffuse and white or reddish-brown - transglottic: crosses the glottis, weblike
symptoms of laryngeal cancer
- hoarseness (prolonged) - unproductive cough - dysphagia - coughing up bloody mucus - pain - neck mass - airway obstruction (stridor) - weight loss - tenderness in laryngeal area
goals with electrolarynx
- correct/consistent placements (sweet spot) - slowed speech and over-articulation - device on-off control during speech (make appropriate pauses, attention to non-verbal behaviors
advantages of electrolarynx
- easily learned - portable - can be used against the neck or orally with an adapter - doesn't require pulmonary support
disadvantages of electrolarynx
- mechanical sound - requires use of one hand - limited pitch inflection - operating costs such as batteries and repairs
intelligibility with electrolarynx
- on-off problems - lack of pitch - lack of loudness - less sound energy <500Hz
acceptability with electrolarynx
- listeners find it mechanical - how the quality of voice is perceived - do they like their voice and how others think of it - may be a great speaker but they don't like it (could cause social withdrawal)
placement of electrolarynx
- need greatest resonance - vibrating section needs to be flush with neck tissues - oral-tube requires exploration by clinician for best location - trail and error - use a mirror for feedback, mark sweet spot with tape - want to use their dominant side
candidacy for ES
NOT appropriate: - extensive pharyngeal surgery: involving tongue, esophagus, or mandible - coexisting medical problems - those with hearing loss - damaged PE segment
function of ES
an individual's ability to produce "esophageal speech that is sufficiently intelligible, fluent, and comfortable to support resumption of the communication functions assumed prior to laryngectomy" - failure rate: 40-74%
use phonemes with high interval pressures when starting out
- helps force air into esophagus - hard to make voice/voiceless distinctions
vowel choice importance
no tongue position
primary PE segment
done at the same time as the laryngectomy - depends on the ENT/physician - don't need another surgery
secondary PE segment
done after the laryngectomy after everything has healed - requires more healing time - not worried about the tissue as much
insufflation testing
tests adequacy of PE segment for voicing - catheter inserted about 25 cm past PE segment - air is introduced into esophagus to vibrate PE segment - > 8 seconds = ok - if high-pitched or strained = failure - DOES NOT tell you how much effort that took
insufflation failing
- fibrosis - misplacement - radiation-induced edema - hypertonia (too much tightness, can still dilate/work with esophagus) - hypotonia (not enough tone is PE segment)
preoperative counseling
- abundant and competent support from SLP - critical role to success - volunteer alaryngeal speaker
3 things necessary for preoperative counseling
1. larynx will be lost = no voice 2. there is oral speech after a laryngectomy 3. establish a communication method for post-surgery
responsibilities of SLP pre-op
- provide information regarding alaryngeal speech options - determine functional communications needs by discussing with patient, spouse, family, friends - build your relationship with the individual based on trust - monitor and empathize - monitor and facilitate overall rehabilitation - become their advocate
postoperative counseling
- is the patient medically stable? - what is the radiation/chemotherapy plan? - reassess oromotor function - reassess speech-language - determine anatomical changes - attempt to schedule a visit from another alaryngeal speaker
affects of radiation
- first 1-2 weeks will feel great - 4-6 weeks after will feel not good - leads to leathery tissue (struggle finding sweet spot) - sensitive, burning sensation
essentials to explain post-op
- explain the laryngeal excision affects on crying, laughing, humming, etc. - trachea connected to stoma in front of the neck (coughing, crusting) - loss of taste and smell - no voice early in post-op period (writing, gestures, communication board) - alaryngeal speech options are available - SLP will assist them - make sure that you are clear as possible and that they know what to expect (often times they do not)
clinical evaluation
know premorbid function (what they could do before) and how that might influence treatment
COPD/emphysema rate
80% or 4/5 people will have history of COPD or emphysema in a total laryngectomy - need to have a pulmonary function test done before and after (SLP advocates)
patient history
helps determine what type alaryngeal speech option may be best - how are they communicating now? - read/write? - comprehension? - social life (how isolated/extroverted are they) - overall medical condition (know right away if total laryngectomy/RND) - pulmonary test (SLP advocates for) - employment history (based on what their job is and if they'll be returning)
- hygiene - emotional stability - hearing evaluation - oral mech (not being able to open the jaw, etc.) - TNM staging (where they are in their treatment process) - imaging - pain - necrosis (dying of tissue)
assessing for EL speech
- articulation - placement of EL (use mirror) - avoid excessive expiration (hear stoma noise, masking) - phrase length, appropriate pauses, etc. - work on +v, -v sound distinction (voiced and voiceless)
assessing for ES speech
- require reduced respiratory support (should not be difficult, don't strain/force air out through esophagus) - good articulation? needs to be excellent - can they 'burp' (importance: can set the PE segment into vibration, can create enough air pressure to release it through PE segment) - motivation - your ability (SLP)
assessing for TE speech
- healing complete? - respiratory health? - radiation (and chemo if present) complete? (wait till done) - disease-free - medically stable - stoma > 1.5-2.0 cm in size? - healthy TE wall? - can't start until the doctor says you can
what client needs for TE speech
- motivation - eyesight - dexterity - hygiene - alertness - post-surgical anatomy - mentally stable - understand how the prothesis works - positive insufflation test results (say 'ah' for 8 seconds)
considerations for TE speech
- how is tissue integrity? - thickness of TE wall - check published resistance of each prosthesis - WHY: want to have the lowest resistance prosthesis, larger diameter = better flow, want to prevent leaks through the prosthesis, start with 16 low resistance prosthesis
TE speech simpleness
- careful candidate selection - patient education - careful follow-up
TE problems
- TEP - TEP prosthesis and tract - PE segment (can have spasm) - if problem with voice, take the prosthesis out and have them phonate through an open tract (if can now, problem with prosthesis - if can't now, problem with PE segment)
effortful speech TEP
- to troubleshoot, ask them to phonate through open fistula (open tract) - if they can, check prosthesis - stuck? - gelcap? - overfitting? - forceful digital occlusion
delayed aphonia or dysphonia
- may be prosthesis problem - closure of tract? - prosthesis was too short - granulation build-up (not so much) - false tract created? (not so much) - stenosis?
reduce PE spasm
- myotomy - plexus neurectomy - botox (botox best, only need one time)
- through: problem is prosthesis (debris, candida, gelcap) - around: sizing issue, could lead to . . . (pistoning - prosthesis will slide back and forth)
prostheses deteriorate
- normal - 3-9 months depending on nystatin and cleaning - directly related to candida
- intelligibility - articulation (over) - timing - prosody - marking voiced and voiceless
EL goals
- functionality - communicating wants and needs - proficiency: optimal placement, on-off control, artic, rate, phrasing
ES goals
- terminal goal = maximal intelligibility with minimal effort (don't use a lot of respiratory effort, better if they relax and don't force air out) - consistency vs quality vs latency (how long to inject and eject) - most important: consistency
ES subgoals
- artic - rate (slowed) - phrasing (short phrases, going to want to say as much as they can in one breath) - intonation - loudness - in either injection or inhalation methods - don't hurry into longer utterances (less air in the esphogus) - distractions (non-verbals)
TE goals
- valving (correctly) - artic - rate - phrasing - nonverbal behaviors (distractions)
lesson plans
- baseline - stimuli - instruction and feedback - consistent vs variable practice - speed or accuracy
group therapy
- often very beneficial - patient can open up with people who understand exactly what the patient is feeling - not everyone is a good fit with a support group
difference in spontaneous speech in TE speakers vs laryngeal speakers
TE speakers will take a breath when it is grammatically correct but will only say about 2/3 of a regular laryngeal speaker
little in the literature that details criteria for termination - intelligibility vs acceptability