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SPCH3206 > Head and Neck Cancer > Flashcards

Head and Neck Cancer Flashcards

1
Q

Provide some information about head and neck cancer

A
  • most commonly squamous cell carcinoma
  • squamous cells form part of epithelium - cancer presents as thickening of epithelial surface

Head and neck cancer is largely a locoregional disease
- metastases less common in early stages
- not yet invaded into lymph and blood stream
- cancer cell travel via lymph system - poor lymphatic drainage from vocal folds assists in minimising the spread of the cancer from larynx in the early stages

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2
Q

What are the causes of head and neck cancer?

A
  • smoking (and chewing carcinogenic substances)
  • drinking
  • viral causes
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3
Q

What are the two demographics of head and neck cancer patients?

A

Type 1:
- middle aged
- male: female 8:1
- heavy smoker and moderate-heavy drinker

Type 2:
- younger
- HPV+

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4
Q

What are the main cancer sites?

A
  • oral and oropharnygeal
  • laryngeal
  • nasopharyngeal
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5
Q

The head and neck cancer MDT comprises the . . .

A
  • ENT surgeon
  • Plastic surgeon
  • General surgeon
  • Oral surgeon
  • Nursing staff
  • Radiation oncologist
  • Medical oncologist
  • Dentist
  • Prosthodontist
  • Radiotherapist
  • Speech pathologist
  • Physiotherapist
  • Social Worker
  • Nutrition & Dietetics
  • Audiologist
  • Palliative care staff
  • Laryngectomy support visitor
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6
Q

What is the speech pathologist’s role in the MDT?

A
  • input into treatment decisions regarding potential speech and swallowing outcomes and patient suitability to manage these
  • speech and swallowing management
  • pre, during and post- treatment
  • patient advocacy
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7
Q

What are the presenting signs and symptoms of head and neck cancer?

A
  • vocal changes (hoarseness most common)
  • cough, sore throat
  • pain - on swallowing
  • dysphagia/chest infection
  • weight loss
  • halitosis
  • sore in the mouth that won’t heal
  • swelling/thickening
  • blocked nose
  • trismus (inability to open mouth)
  • otalgia (pain in ear)
  • dyspnoea and stridor
  • visible tissue changes
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8
Q

How is head and neck cancer medically diagnosed?

A
  • visual examination, direct palpation
  • lymph node examination
  • nasendoscopy
  • panendoscopy
  • ultrasound + fine needle aspiration cytology
  • imaging: CT, MRI, PET, Ultrasound
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9
Q

Discuss TNM classification

A
  • used to define extent and severity of cancer + used to assist treatment planning
  • ‘T’ = location of primary tumour
  • T0 - no tumour, T4 - massive tumour in structure examined
  • ‘N’ = identifies involvement of lymph nodes in immediate region
  • N0 - no nodal region, N3 - nodal metastes
  • ‘M’ = indicates extent of tumour spread or metastasis
  • M0 - no metastasis, M1 - distant metastasis present
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10
Q

What are the treatment modalities for H&N cancer?

A

Non-surgical techniques:
- radiotherapy
- combined chemo-radiotherapy (C-RT)
- immunotherapy

Surgical techniques:
- laser and robotic surgery
- surgery +/- reconstruction
- +/- non-surgical management

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11
Q

What factors influence the treatment choice?

A
  • tumour site, type and extent
  • patient suitability - health and social factors
  • either a) radical/curative treatment of b) palliation
  • research evidence
  • personal preference/skills of surgeon/equipment/support teams available
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12
Q

Radical vs. palliative treatment?

A

Radical: aim is to achieve cure, therefore complex, time consuming and unpleasant treatments are considered to be justified

Palliative: aim to alleviate symptoms, so intervention should not produce side effects worse than the cancer is causing

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13
Q

How does radiotherapy kill cancer?

A
  • Radiation causes damage to DNA in both normal & tumor cells
  • If cells are unable to repair this damage in time for the next cell division then they die in mitosis (the process of cell division)
  • Cancer cells, however, divide more frequently, and repair less efficiently - therefore the chances of radiation killing a malignant cell are > than for healthy cells
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14
Q

How is radiotherapy treatment delivered?

A
  • if primary treatment: typically initiated as soon as possible post diagnosis
  • or around 4-6 weeks post surgery once tissues healed
  • daily doses delivered over 2-7 weeks
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15
Q

How is radiotherapy treatment dosed?

A
  • SCC are less radiosensitive than other tumours - therefore requires a high dose for cure
  • typical dose for laryngeal cancer is ~60Gy (Gy = gray, cGy = hundredths of gray) delivered in 30-35 fractions over 6 weeks
  • dose and delivery change with tumour type
  • more extensive tumours need more irradiation, longer time and sometimes need combination radiation and chemo
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16
Q

How do you plan for radiotherapy treatment?

A
  • pre-treatment planning
  • ‘shell’ planning - usually 2-3 weeks prior to starting: moulded plastic shell created to maintain patient positioning for daily radiotherapy
  • some patients require dental/maxillofacial consult - removal of dental caries prior to treatment
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17
Q

What is chemotherapy?

A
  • the use of cytotoxic drugs administered orally or intravenously - reach tumour (and normal tissues too!) via the bloodstream
  • cytotoxic drugs are designed to interfere/disrupt and prevent DNA synthesis - therefore preventing tumour growth
  • used to reduce chance of residual tumour cells from re-establishing
  • chemotherapy alone has little impact
  • chemotherapy used in conjunction with radiotherapy for: wide spread disease, large tumour with risk of metastasis/presence of metastasis
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18
Q

How is chemotherapy administered?

A
  • in weeks prior to and/or during radiotherapy
  • multiple chemo drugs may be combined
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19
Q

Explain, including the use of, the ‘Cetuximab’ immunotherapy treatment

A
  • Epidermal Growth Factor (EGFR) inhibitor
  • Cetuximab seeks out cancer cells, binding to EGFR, stopping uncontrolled growth in cancers with EGFR mutations

Use?
- in combination with platinum-based chemotherapy treatment for locally advanced disease
- treatment of recurrent and/or metastatic disease

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20
Q

Explain, including the use of, the ‘Keytruda’ (pembrolizumab) immunotherapy treatment

A
  • helps T-cells in immune system find and fight cancer
  • administered intravenously

Use?
- successful in other cancer types
- may be used either alone, or in combination with chemotherapy medicines for recurrent HNSCC and the tumour tests positive for PD-L1.

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21
Q

List the main surgical interventions for oral and oropharyngeal SCC

A
  • glossectomy (partial, hemi/subtotal, total)
  • floor of mouth (anterior or lateral)
  • tonsillar fossa
  • retromolar trigone
  • palatal (hard, soft)
  • pharyngal resections (anterolateral, lateral posterior)
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22
Q

List the main surgical interventions for laryngeal SCC

A
  • surgery to laryngeal structures
  • partial laryngeal removal
  • supraglottic (removal of all structures above glottis)
  • supra cricoid (removal of all structures above cricoid)
  • total laryngeal removal surgery
  • total laryngectomy
  • pharyngolaryngectomy
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23
Q

What is surgical tumour removal?

A
  • need to remove cancer + ‘safe margins’
  • potential significant impact on function
  • depending on the extent of the cancer spread
  • tumour +/- partial cord removal
  • partial larynx removal, total larynx removal
  • depending on extent of surgery - reconstruction with other tissues may be required
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24
Q

When is laser surgery used?

A
  • for smaller tumours
  • use of a laser as the cutting tool
  • needs a skilled user
  • heals faster, less blood loss
  • enhanced ability to manage smaller laryngeal tumours without typically managed by XRT
  • eliminates added effects of XRT on tissues
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25
Q

When can you use Transoral robotic surgery (TORS)?

A
  • Used for T1/T2 cancer of the oropharynx & larynx
  • Benefits over traditional surgery?
  • IMMEDIATE:- Faster healing, shorter stay in hospital, faster return to oral intake
  • LONG TERM: If need C/RT….then….similar issues ongoing
  • The angled telescopes and hypermobile operating
    arms give enhancement to traditional laser surgery
    Techniques
  • Equipment costly and training required
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26
Q

What is reconstruction?

A
  • one tumour is removed, the deficit can be repaired with either primary closure of using a tissue flap
  • primary closure
  • remaining tissues can be pulled together
  • possible for small sections of lip, tongue, soft palate

Flaps or grafts:
- required for larger deficits or when the natural movement of tissue would cause breakdown of a primary closure

Different types:
- pedicle - skin/tissue moved from one part of the body to gill deficit. Called ‘pedicle’ as one part of the flap remains attached to its original vascularisation

  • microvascular - tissues, with venous and arterial supply are transplanted elsewhere in body
  • composite free flaps - tissue + bone
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27
Q

What are some possible complications following surgery?

A
  • slow or poor wound healing
  • fistulae
  • failure of tissue grafts
  • recurrence
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28
Q

What are some possible complications following nonsurgical management?

A
  • pain
  • speech/voice
  • dysphagia
  • weight loss
  • saliva loss
  • taste
  • lymphedema
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29
Q

Discuss treatment toxicities, in both the early and ongoing/late stages

A
  • Acute/Subacute reactions
  • Usually begin approx. 2nd 3 rd week of treatment & continue 2-3 weeks post treatment
  • The subacute up to 3 months post treatment
  • due to the decreased production of new cells in normal tissues – slow healing – slow resolution of damage
  • Chronic / Late / Long term reactions
  • Ongoing changes in the long term post treatment
  • Issues that persist after 3 months post Tx
  • OR new issues that develop late on at 1,2,3…. etc years post care
30
Q

Discuss sickness/reduced appetite/fatigue in head and nek cancer treatment

A
  • treatment induced effects
  • early impacts of chemo: nausea, vomiting
  • fatigue - ongoing - can last months/years post C-RT
  • worsened by addition of chemotherapy
  • thus impacts willingness/capacity to comply with therapy and therapy adherence
31
Q

What are some skin/tissue changes?

A
  • external red/sore, blistering of tissues
    Temporary difficulty experienced during and for a few weeks post treatment
  • creams can assist in reducing pain and discomfort
32
Q

Describe some early skin/tissue changes and some associated effects

A

ACUTE OEDOMA/SWELLING OF TISSUES:
- issues for voice and swallowing
- swelling in oral regions can compromise tongue mobility and articulation
- impacts laryngeal and pharyngeal movement and function
- voice change, some articulatory issues

MUCOSITIS (sores in mouth/throat):
- inflammatory response of mucosal epithelial cells to radiotherapy
- mucosal cells are rapid replacing cells - RT impacts ability to repair and replace
- patients experience pain, pain on swallowing, burning and discomfort
- to minimise, maintain good oral hygiene, regular saline rinses and sodium bicarb solution
- topical numbing agents - oral rinse prior to meals

33
Q

What are some specific side-effects of cetuximab therapy?

A
  • acne-like rash
  • rarely leads to dose reductions or termination of therapy - it is generally reversible
  • cheilitis (lip swelling)
34
Q

Describe some late skin/tissue changes and their effects

A

LYMPHODEMA:
- external
- internal
Swelling caused by fluid accumulation - resulting from damage to the lymphatic system and its transportation of fluids
- presence of the tumour
- damage from the radiotherapy
- damage from surgery

SCARING + FIBROSIS:
- scaring and hardening of tissue
- limits movement of structures
- long term persistent change - can continue for years

DYSFUNCTION:
- post HNC care, cricopharyngeal dysfunction is proposed to be due to relaxation failure, resulting from decreased muscle compliance caused by progressive fibrosis
- major contributor to dysphagia

IMPAIRED SALIVA PRODUCTION:
- xerostomia
- salivary glands in XRT field - rapid and largely irreversible loss of salivary fluid production
- early: thick, tenacious secretions
- late: chronic dryness
- medications to stimulate saliva flow + artificial saliva products available

DYSGEUSIA:
- result of direct damage to tastebuds + reduced saliva production
- taste may be reduced and/or altered. Foods may taste metallic, salty

DAMAGED/LOSS DENTITION:
- pro active
- teeth with suspected dental caries are removed prior to radiotherapy
- long term
- remaining teeth can become damaged by persistent xerostomia causing dental caries at gumline causing teeth to break
- patients must be vigilant with oral care

TRISMUS:
- impaired jaw function
- long term issue
- can occur if TMJ and muscles of mastication in field of treatment or involved in surgery
- require minimum amount of mouth opening for hygiene and safety
- cleaning teeth, intubation for functional eating/chewing

NEUROPATHY:
- long term effects of radiotherapy can include cranial nerve neuropathy
- typically occurs as a late effect in the years post treatment
- mostly associated with patients who receive high dose of chemoRT
- addition of chemo enhances damage to nerves

35
Q

Discuss the nature of swallow impairment post non-surgical management

A

Compounded effects:
- presence of the tumour pre and during therapy
- during and post radiotherapy - combined effects of the treatment toxicities
- early impacts (acute and first 3 months)
- long term impacts from 3 months onwards
- late effects - late radiation induced dysphagia (Late-RAD) - can present from 3 - >10 years post

36
Q

Discuss the clinical presentation of early, late and late-RAD dysphagia

A

Early:
1. prehab
2. responsive diet modifications
3. active rehab

Post-acute -> long term:
- residual long term changes to physiology of swallow structures impacting efficiency and safety of swallow. Active rehab
- often trace aspiration persists - decision for ‘risk feeding’

37
Q

What are the surgical impacts?

A
  • multifactorial
  • loss of key structures
  • other tissue/function/nerve damage from surgical approach
  • learning to compensate/manage tissue flaps
  • areas of desensitisation
38
Q

What does recovery/rehab post surgery look like?

A
  • need to wait until surgical healing is complete
  • potential impacts to speech and swallowing
  • impact of surgery
  • early oedema, swelling
  • other problems caused by ‘open’ approach
  • short term tracheostomy tubes
  • depends on what structures have been removed
  • will depend on if they have flaps/other tissue transplanted in to fill the deficit of the tissue removed
    . . . added effects of RT or CRT post surgery
39
Q

List some factors impacting on swallowing and speech

A
  • loss of key structures required for normal swallow - amount of oral and BOT resected correlates with severity of speech/swallow function
  • increased bulk by flap
  • pockets/pouches created by surgical grafting and repair
  • loss of sensation - both graft and area of surgery
  • reduced ROM of tongue and jaw - surgical anastomosis, scar tissue
  • additional difficulties associated with any subsequent radiotherapy/chemotherapy
40
Q

What are the dysphagia therapy techniques involved in this population?

A
  • education, support, counselling of patients and carers/families
  • implement compensatory strategies
  • diet modification - often liquid puree diet in early stages, then progressing to soft foods
  • some patients may benefit from an intraoral prosthesis
  • to ‘lower’ hard palate - patients with 50% or more tongue resection can benefit from palatal re-shaping
41
Q

What are some rehabilitation techniques?

A
  • oromotor exercises to improve ROM
  • postural changes (head tilt)
  • manoeuvres to protect airway
  • manoeuvres to improve bolus clearance
  • change sensory input
42
Q

What are some therapy techniques for speech?

A
  • education support counselling of patient and carers/families
  • oromotor ROM exercises
  • articulation drills
  • compensatory strategies
43
Q

Discuss the structures involved in supraglottic laryngectomy

A
  • excision of laryngeal structure above level of true vocal folds
  • entire ventricular folds, epiglottis and part of thyroid
  • can also involve hyoid bone
  • used for tumours of the epiglottis and false vocal folds
  • preservation of vocal folds during the primary difference between this procedure and a total laryngectomy
44
Q

Discuss the effects of supraglottic laryngectomy on swallowing

A
  • due to loss of supraglottic structures - significant initial risk of aspiration of both saliva + food/fluids
  • extension of resection to include base of tongue or the arytenoid cartilages increases aspiration risk
  • risk of aspiration post-operatively is somewhat reduced by including laryngeal suspension as part of procedure
  • most able to recommence an oral diet by 1-3 months with rehab
  • but if slightly more extensive surgery - can be much longer rehab (6-12 months)
45
Q

What does swallow therapy for supraglottic laryngectomy involve?

A
  • patient needs intensive intervention
  • need to assess patients suitability to therapy prior to surgery
  • teach supraglottic swallow prior to surgery
  • use both compensatory strategies and active swallowing manoeuvres
  • techniques that encourage early stronger glottic closure and post swallow airway clearance
46
Q

What are the speech/voice outcomes for patients with supraglottic laryngectomy?

A
  • typically good voice outcomes
  • need to assess patients suitability to therapy prior to surgery
  • teach supraglottic swallow prior to surgery
  • use both compensatory strategies and active swallowing manoeuvres
  • techniques that encourage early stronger glottic closure and post swallow airway clearance
47
Q

What is Supracricoid Partial Laryngectomy (SCPL)?

A
  • removal of all structures above cricoid cartilage
  • including entire thyroid cartilage, true and false vocal folds bilaterally, whole epiglottic space, part/all of epiglottis, and often arytenoid cartilage on affected site
48
Q

What are the types of Supracricoid Partial Laryngectomy (SCPL)?

A

(depends on structures invaded by the cancer and type of reconstruction)

  1. Cricohyoidopexy (SCPL-CHP):
    - removal of all structures above cricoid: only cricoid and hyoid remain
  2. Cricohyoidepiglottopexy (SCPL-CHEP):
    - preserves superior 2/3 of epiglottis (which gets reattached), in addition to cricoid cartilage and hyoid bone
49
Q

What are the swallowing outcomes in Supracricoid Partial Laryngectomy (SCPL)?

A
  • significant dysphagia for saliva and fluids is experienced as a SCPL involves the removal of vital airway protective structures
  • aspiration of saliva expected in days following surgery
  • with the hyoid bone sutured to the cricoid cartilage, instant and permanent elevation is provided allowing the tongue base to help shield the exposed airway
  • swallowing rehab may take up to 6 months
  • ‘functional’ swallowing of modified consistencies usually achieved by 2 months
50
Q

What does SPCL swallow therapy involve?

A

Patient needs intensive intervention
- need to assess patients suitability to therapy prior to surgery

Pre-operative therapy:
- tongue base retraction exercises, controlled swallow + effortful swallow

Post-surgery, ‘airway closure’ is achieved from the approx. of the remaining arytenoids, tongue base and if present, the epiglottic remnant
- effortful swallow, supraglottic swallow

51
Q

What are the voice outcomes for SPCL?

A
  • vocal cords no longer present
  • vibrations for speech are made between the two arytenoids (if both preserved) or between arytenoid cartilage/s and epiglottis
    ‘neoglottis’
52
Q

What are some features of neoglottic speech?

A
  • good intelligibility, minimal prosodic insufficiency
  • vibrating surfaces of neoglottis are greater in mass than true vocal folds and vibrating mucosa is stiffer due to oedema and fibrosis - therefore slightly lowered fundamental frequency can occur
  • roughness correlates with irregularity of neoglottic vibration
  • patients perceive vocal strain and feelings of fatigue from needing to bear down to achieve voice
53
Q

Discuss SCPL voice outcomes once healing is complete

A

A voice therapy program needs to be tailored to the individual but may include:
- gentle pushing exercises
- the implementation of appropriate vocal hygiene strategies
- strategies to assist vocal projection

54
Q

Discuss total laryngectomy surgery

A
  • entire larynx removed including hyoid
  • extension into pharynx may be conducted dependent on size of tumour
  • airway re-directed to anterior neck - creation of stoma for airway
  • pharyngeal constrictor muscles used to re-create connection from mouth to oesophagus
  • used for extensive T3 or T4 tumours
55
Q

Discuss pharyngolaryngectomy surgery

A
  • involves removal of both the larynx and pharynx - therefore more extensive than a laryngectomy
  • used for larger hypopharyngeal tumours
  • airway is brought forward to create stoma - as in laryngectomy
  • however pharynx needs to be reconstructed - different ways this is done:
    • free jejunal graft
    • stomach pull up
    • thigh or radial forearm flap
      reconstruction
56
Q

What is the impact of the stoma on the pulmonary system?

A
  • Absence of breathing through upper airway
  • open airway
  • cleaning and care
57
Q

What does dysphagia arise from in this population?

A

NOT at risk of aspiration - but dysphagia from:
A - problems created by the surgical closure
B - reduced BOT to posterior pharyngeal wall
C - effects of radiotherapy
D - function/movement of the graft (pharyngolaryngectomy only)

58
Q

Discuss A - problems caused by the surgical closure

A
  • tight surgical closures - creates small lumen and impacts swallowing solids
  • manage by soft/liquid diet
  • scar tissue can form and create strictures - these narrow the oesophagus and prevent large or solid boluses from passing through
  • managed by dilation - using rubber catheters which are used to dilate and stretch the stricture. May need many repeat procedures
  • can get folds of tissue at surgical anastomosis that can form a pocket which collects food/liquids - sometimes can fully occlude opening and prevent foods/fluids
  • managed by surgical removal
59
Q

Discuss B - reduced BOT to posterior pharyngeal wall

A
  • reduced BOT to posterior pharyngeal wall at initiation of swallow impairs efficient delivery of bolus into the graft (if PL) or surgical reconstruction (in TL)
  • therapy techniques that target improved BOT movement - e.g. masako, lingual strengthening
60
Q

Discuss C - effects of radiotherapy

A
  • reduced saliva
  • loss of taste appetite
  • manage symptoms with diet modification
61
Q

Discuss D - function of the graft (PL patients only)

A

Strictures of the top and bottom anastomoses of the graft

Contractile quality (jejunal transplants only) - leading to:
- graft being closed temporarily to delivery of food
- reverse peristalsis
- nasal regurgitation
- SP management: compensatory techniques: soft/liquid consistencies, small boluses, flushing with water after each swallow, multiple swallows
- contractile activity tends to reduce over time and post XRT

62
Q

What are some communication options for when all laryngeal structures are removed?

A

Non-speech: writing & mouthing, computer speech output devices

Electrolarynx: majority get one as ‘backup’ communication device

Oesophageal speech:
- effortful and long to learn

Tracheoesophageal speech (TES):
- primary mode of voice rehabilitation

63
Q

What are some things to factor in to selecting the mode of communication?

A

Patient suitability:
- necessary basic skills (e.g. residual articulation, adequate eyesight, manual dexterity, hearing)
- ability to learn new skills
- attitude and motivation

Support structures:
- carers, adequate available post-surgical support
- accessibility of treatment services post surgery e.g. rural patients

Patient preference

Economic/financial issues

Surgical limitations

64
Q

How does the electrolarynx work?

A

Electrolarynx devices
Many different types….
* Servox (digital)
* TruTone
* Romet …others (see Ward & van As-Brooks 2007)

  • Device is held against the neck or cheek
  • The sound, generated by the battery powered hand held device, passes through the neck / cheek tissues and then is shaped by the articulators / resonators to produce speech
  • Sound is turn off and on by patient at natural phrase boundaries
  • Settings on device allow some ability to set pitch and volume settings
65
Q

Advantages & Disadvantages of AL

A

Advantages
* Easy to use & learn to use
* Provides functional, intelligible speech
* Relatively inexpensive
* Compact and easy to use

Disadvantages
* Different voice quality (*particularly EL devices)
* Requires good articulation skills
* One hand is occupied during speech
* Although less expensive than ongoing TES equipment – still an expense

66
Q

What is oesophageal speech?

A
  • “Independent” technique – i.e. no devices / equipment required
  • Patient injects air from nose and mouth into esophagus and then expels it
  • The expelled air vibrates the cricopharyngeus muscle of the upper esophagus and the middle and inferior pharyngeal constrictor muscles – these structures are collectively referred to as the pharyngoesophageal (PE) segment
  • Patient then articulates normally using the vibrating noise of the PE segment as the noise source for speech
67
Q

Advantages & Disadvantages of ES

A

Advantages
* No reliance of mechanical or other devices
* Both hands are free when speaking
* More natural sounding than AL devices

Disadvantages
* Time consuming to learn compared to AL & TES
* Need to use shorter phrases
* Vocal intensity sometimes insufficient
* Stoma noise, klunking, & facial grimacing during air injection need to be minimised for “natural” speech

68
Q

Tracheoesophageal speech (TES)

A
  • Primary mode of voice rehabilitation in Australia
  • Most similar to normal laryngeal phonation due to use of pulmonary air supply – allows for normal phrase length
  • But can sound different to normal speech due to the differences between having vocal folds (pre-surgery) versus now having vibrating segment of tissue (the neoglottis!)
    Quality is lower in pitch with minimal ability to vary pitch
    Quality may sound rough
    Pharyngolaryngectomy patients sound wet and deeper due to their jejunal tissue graft

Also get intermittent voice stoppage due to contractile status of the graft

TES is produced using a voice prosthesis placed in a surgically created puncture in the tracheoesophageal party wall (the section of tissue dividing the trachea and oeosphagus)

  • The puncture is referred to as the tracheoesophageal puncture (TEP) or tracheoesophageal fistula (TOF)
  • Made at time of surgery (primary puncture) or later (secondary puncture)
  • When the patient occludes their stoma with their finger/thumb, pulmonary air is diverted up through the prosthesis and into the reconstructed oesophagus where it causes vibrations of the Pharyngo -esophageal (PE) segment (this is the noise generator!) to create sound for speech
  • The prosthesis is NOT a noise generator!!

Finger occlusion – facilitates diversion of pulmonary air into and through prosthesis

69
Q

Tracheoesophageal speech (TES)
Types of Voice Prosthesis

A
  • Key elements
    Retaining flanges at each end
    Safety strap
    One way valve
  • But elements vary between devices
    Low pressure valves, antifungal materials, duckbill valve etc etc
  • ..and vary in how long they are designed to stay in
    Standard/Non-indwelling (change daily/weekly/monthly)
    Indwelling (up to 1 year or more)

The SP determines the valve most suited to an individual

70
Q

Advantages & Disadvantages of TES

A

Advantages
* Most natural of all modes of communication
* Driven by pulmonary air – normal phonatory durations & phrase length possible
* Although less than laryngeal phonation, greater pitch & intensity range is possible than with EL or ES
* Easier to learn than ES

Disadvantages
* Requires a surgical procedure
* Requires ongoing maintenance of prosthesis
* Manual occlusion of stoma required (if not using valve)
* Additional problems with candida, mucous can affect valve function
* Small risk of aspirating the prosthesis (falls out of TEP and down into lungs)

71
Q

Impacts of COVID in HNC care

A
  • At risk population
  • Immunocompromised during treatment
  • Open airway (laryngectomy)
  • Aerosol generating procedures / at risk procedures
  • Proactive management of VPs + Telepractice to help
    minimise travel / hospital visits

SPCH3206 (12 decks)

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