Rehabilitation after laryngectomy

types.TEP

1. DR ROOHIA

2. 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%

3. QUALITY OF LIFE
Establish and maintain an acceptable quality of life.

4. 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

5. SWALLOWING
REHABILITATION

6. 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.

7. PULMONARY
REHABILITATION

8. •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.

9. •AUTOMATIC HANDS
FREE SPEEKING
VALVE.

10. OLFACTORY REHABILITATION

11. •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.

12. 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.

13. VOCAL REHABILITATION

14. Requirements for normal
phonation
•Active respiratory support
•Adequate glottic closure
•Normal mucosal covering of vocal cord
•Adequate vocal cord length and tension
control

15. Methods of speech following
Laryngectomy
•Also known as alaryngeal speech
•Esophageal speech
•Electro larynx
•TEP (Tracheo-oesophageal puncture)

17. ESOPHAGEAL SPEECH
Alaryngeal speech

18. 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

19. 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

20. 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

21. Pumping air into cervical
oesophagus
•Injection method
•Inhalational method

22. 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

23. 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

24. 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

25. 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

26. 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

27. Cricopharyngeal spasm
•Cricopharyngeal myotomy
•Botulinum toxin injection – 30 units can be
injected via the tracheostome over the
posterior pharyngeal wall bulge

29. 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

30. Electrolarynx - Types
•Pneumatic
•Neck
•Intraoral type

31. 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

32. 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

33. 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

34. Electrolarynx - Disadvantages
•Expensive to maintain
•Speech generated is mechanical in quality
•Difficult while speaking over telephone

36. Types of voice restoration
surgeries
•Neoglottic reconstruction
•Shunt technique

37. Neoglottis procedure
•Performing trachea hyoidopexy
•This can restore voice function in alaryngeal
patients
•Abandoned due to increased incidence of
complications like aspiration

38. 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

39. Types of Prosthesis

40. Indwelling versus Non
indwelling prosthesis
Indwelling prosthesis Non indwelling prosthesis
Can be left in place for 3-6
months
Should be removed and cleaned
every couple of days
Requires specialist to do the jobPt. 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

41. 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

43. Types of TEP
•Primary TEP – Performed during total
laryngectomy
•Secondary TEP – Performed 6 months after
surgery

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. Problems with TEP insertion
•Leak through the prosthesis
•Leak around the prosthesis
•Immediate aphonia / dysphonia
•Hypertonicity problems
•Delayed speech

52. 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”

53. Insufflation test interpretation
•Fluent voice on minimal effort – normal
•Breathy voice indicating hypotonic
cricopharyngeal muscle
•Hypertonic voice – “Cricopharyngeal spasm”
•Spasmodic voice – “Extreme cricopharyngeal
spasm”

54. Management of leak through
the prosthesis
Cause Solution
Valve 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

55. 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