Speech rehabilitation after

near total laryngectomy

KUNNAMPALLIL GEJO JOHN,

BASLP,MASLP

AUDIOLOGIST

KUNNAMPALLIL GEJO JOHN,

““First duty of a man is to First duty of a man is to

speak that is his chief speak that is his chief

business in this world”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

KUNNAMPALLIL GEJO JOHN,

Diagrammatic representation of NTL speech

KUNNAMPALLIL GEJO JOHN,

Shunt from trachea to pharynx

KUNNAMPALLIL GEJO JOHN,

Speech therapy after NTL

when?

3-4 days after removal of NG

tube

After medical line of treatment

completes

KUNNAMPALLIL GEJO JOHN,

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 KUNNAMPALLIL GEJO JOHN,

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 KUNNAMPALLIL GEJO JOHN,

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 stoma-

exhalation & articulation KUNNAMPALLIL GEJO JOHN,

Factors to keep in mind

Patient should be motivated

Pulmonary reservoir should be

sufficient

Stoma should not be narrow

KUNNAMPALLIL GEJO JOHN,

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

KUNNAMPALLIL GEJO JOHN,

Digital occulusion of stoma

KUNNAMPALLIL GEJO JOHN,

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 KUNNAMPALLIL GEJO JOHN,

Aspiration in NTL cases

Severe ------ Pulmonary complication

Total laryngectomy

Moderate ------Aspiration of liquid

frequently

Manageable with anti-

aspiration methods

Minimal----- Detected occasionally

Transient

KUNNAMPALLIL GEJO JOHN,

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

KUNNAMPALLIL GEJO JOHN,

NTL Speech Achievement Kidwai Study

Laryngeal lesion n= 70

Hypopharyngeal lesion n=112

KUNNAMPALLIL GEJO JOHN,

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,