Transcript Laryngectomy

Voice therapy of
laryngectomy
周谢玲、邵帼珺、关娇
Topics
• Laryngectomy
* when
* how
* acoustics characters
• Voice theropy
* different means
• Comparation
Laryngectomy
Laryngectomy——when
We alredy know that:
* Larynx is an important organ
* Latyngectomy is traumatic
So:
*Laryngeal cancer (type &location & extent)
*life threatening condition
* “Salvage” surgery after failure of
nonsurgical treatment
Such as: radiation
chemotherapy
……
Laryngectomy——when
* 声带癌已浸及前连合或同侧声带后
1/3处，使声带运动受限或已累及对
侧声带。
* 声带以外部位如假声带、会厌、杓
会厌皱襞及环后等处癌肿。
* 声门下区癌肿。
* 喉部其他恶性肿瘤，如肉瘤等
Laryngectomy——how
1.Laryngeal cancer
* Incidence rate:
1~2%of all cancer; 20% of head and
neck cancer; the ratio of male to female
is 13 to 1
* predisposing factor:
cigarette smoke, alcohol, and noxious
fumes
* Locations:
the supraglottis, the subglottis, and
the glottis
Laryngectomy——how
2.Two kind of larygectomy
* Total laryngectomy
The larynx, containing the vocal
* Hemilaryngectomy ( partial
folds, has been removed, usually
laryngectomy )
at the level of the first
The extent
tracheal
ring and location of the
tumor will diratate the extent of
the surgery
Laryngectomy——how
Tumor location
Kind of laryngectomy
Crosses the midline
Total laryngectomy
Only on one side of
the larynx
Hemilaryngectomy
and other partial
laryngectomy
Laryngectomy——how
图1 切口
图3 分离舌骨周围诸肌
图2 剪断舌骨中段
图4 暴露甲状软骨翼板，切断其上角
Laryngectomy——how
图5 分离切断
甲状腺峡部
图7 于环状软
骨下缘切断气管
图6 缝扎甲
状腺峡部
图8 将喉体向上翻起，
与食管前壁分离
Laryngectomy——how
图9 自杓状软骨后
缘进入喉咽腔
图10 沿杓状会厌皱襞，分离、剪
开会厌舌面粘膜，由下而上剥离喉体
图11 分离会厌前
间隙，暴露会厌
Laryngectomy——how
图12 剪开会厌边缘粘
膜，自上而下截除喉
体
图13 自两侧外上方
缝合喉咽粘膜
图14 “y”形缝
合喉咽粘膜
Laryngectomy——acoustics
1. partial laryngectomy
Because of the tumor excise (a
tissue deficit ),there will be some
changs:
*stiffness due to scarring
*a gap in the glottal area when the
folds are approximated
Laryngectomy——acoustics
* air wastage → a breathy voice & short
phonation time
* Inadequate medial compression → reduced
loudness level
* Unequal mass between the right and left VF ,
an irregular vocal fold vibration
an attempt to compensate for the excessive
glottal gap by hyperactivity of false VF → a
rough voice
Laryngectomy——acoustics
2. Total laryngectomy
Laryngectomy——acoustics
the
trachea
attached
to the
neck, sounds
the patient
he
can
make
only certain
voiceless
that
RPRAP
mode
doesproduced
not breathe
throughcheek,
his nose
are
by tougue,
andor
lipmouth,
The
of
voice
the airlose
column
diverted
away
the
compressed
of is
the
air filling
hisfrom
mouth
or
resonators aand
throat.not
realartculators
whisper
Voice therapy
Voice therapy
The importance of speech:
* If you lose your voice, you can’t argue
with your wife; you don’t have to bother with
telephone pests; and you’ll never talk yourself
out of a job or into trouble
* Speech is the primary means whereby
social relationships are achieved and
maintained ,and its loss seriously threatens a
person’s sense of security, adequacy ,and
acceptance.
Voice therapy
Preoperative care
* Partial laryngectomy
*
*
Total laryngectomy
Voice therapy——Preoperative
* An explanation of operation, an
curable cancer
* Discussion of postoperative
feelings
* Preparation for loss of speech
* Discussion of normal production
of speech
To give the patient some insight
into what is going to happen
Voice therapy——partial
* inhalation phonation using the vowel
/i/ to eliminate the excessive vocal
effort and reduce the false VF
activity
* Use an upward pitch to increase VF
tension and gain better
approximation
Voice therapy——total
* Begins with a review of the
mechanics of speech production
as it occurs when the larynx is
present
* Tell the patient that much of his
speech apparatus has not been
altered and the operation did not
affect many of his speech habits
and skills
Voice therapy——total
Three general communication options:
* Artificial larynx (AL)
* Esophageal speech (ES)
*Tracheoesophageal puncture and
prosthesis (TE)
实质：Learn to substitute other
structure for his missing ones
Voice therapy——total
Adoption rate of the treatment:
Esophageal Speech---------------------6%
Artificial larynx-electrolarynx-------55%
Tracheoesophageal Prosthesis--------31%
Remained nonvocal----------------------8%
——By Hillman and colleagues
Esophageal Speech---------------------42%
Both adopt ES and EL------------------91%
——By Janpanese
Voice therapy——The artificial larynx
* Types：
Mechanical type : a metal cylinder containing a
reed, lead the sound to the mouth by means of
a tube
Electric type : a mechanical box similar to a
flashlight (The neck type; The intraoral type)
* Theory:
Introduces sound for speech by placing the
instrument against the external throat or oral
Neck
type: you
place it aagainst
throat,
structures
or inserting
tube oryour
fitted
intraoral type: vibration sound is
prosthetic
electrolarynx
into the
mouth while
push a buttom,
and the machine
transmits
a
transmitted
directly
into
your
mouth
via
a
speaking. noise to your throat which you then
vibration
small tube, words and sounds are made in a
form into words and sounds with your lips,
similar manner
teeth, and tougn
Voice therapy——The artificial larynx
* Station:
Frequently encouraged during the
first few days following surgery ; A
good alternate mode (other mode
fail ,environmental factor)
* Voice quality:
A monotonic and robotic sounding
(no pitch adjustment options)
Voice therapy——The artificial larynx
The steps in speech therapy:
* find the “sweet spot”
* Learn to hold and operate the EL in
your non-dominant hand since it
frees up your other hand so that
you can write
Voice therapy——Esophageal Speech
* Theory:
Compressing air within the oropharynx
and injecting this denser air into the
more rarefied space of the esophagus
Bring compressed air into the
esophagus ;once the air is in it ,external
forces compress the air within it and
expel it, the esophageal explosion sets up
a vibration of the pharyngoesophageal
(PE) segment
* types:
Injection and inhalation
Voice therapy——Esophageal Speech
* Station:
a traditional therapy method
* Voice quality:
hoarse , low-pitched , and often
belchlike quality
Plosive consonants(/p/, /b/, /d/, /t/,
/k/, /g/)
Affricatives containing plosives(/t∫/,
/dЗ/
Voice therapy——Esophageal Speech
The steps in speech therapy:
* Learn to swallow air into the upper part of
the esophagus and immediately force it back
(as it passes the narrow throat muscles, it is
made to pulsate, and a belchlike sound,
similar to that of a vowel, is produced)
* Imitate the movements voluntarily (drinking
cokes or any carbonated beverage)
* Learn to produce vowels, consonants, and
syllables
* Stresses the development of vocal inflection
* Speech restoration
Voice therapy——Esophageal Speech
* The esophagus functions as a substitute
for the vocal fold
* The removal of the larynx increase the
space in the neck available to the
esophagus and permits it to expand to
accommodate the air necessary for
speech
* Control the air at the upper opening of
the esophagus
* Learn to inhibit breathing while speaking
Levels of esophageal speech
* No esophageal sound production—no speech
* Involuntary esophageal sound production—no
speech
* Voluntary sound production part of the
time—no speech
* Voluntary sound production most of the
time—vowels differentiated, monosyllabic
speech
* Esophageal sound produced at will—single
word speech
* Esophageal sound produced at will with
continuity—word grouping
* automatic esophageal speech
Voice therapy——Tracheoesophageal
• Theory:
makes a small puncture in the
wall between the trachea and
esophagus
Tracheoesophageal continued
How to do the surgery
①makes a small hole in the
rear of the stoma leading to
the esophagus
②Once this puncture heals ,a
prosthesis is fitted and
inserted into the opening
Tracheoesophageal continued
How to speak after the surgery:
occlude the stoma with your thumb or
finger and simply force air through the
prosthesis into the esophagus
This air movement vibrates the walls of
the esophagus and you can create sounds
and words normally with your
lips ,teeth ,and tongue ,etc
Tracheoesophageal continued
• easy to have leak
Cleaning and flushing
Installed prosthesis
Voice therapy——Esophageal Speech
Keep in mind:
Avoid any early attempts at
speech (speech therapy should
not be started until the muscles
and mucous membranes are well
healed and no longer tender)
Esophageal
speech
Comparation
Electrolarynx (EL) Tracheoesophage
al Puncture (TEP)
needs to train
no much needs to train
does not need to train
both hands to be
possible to move freely,
and can work while
speaking
both hands not to be
possible to move freely,
cannot work while
speaking
single-handed to be
possible to move freely,
only can work with
single-handed when
speaking
can speak in everywhere
need mechanism
can speak in everywhere
spoken language is
clarity and good
spoken language is not
clarity and good
Spoken language is
clarity and good
sound not loud
sound loud
sound loud
easy weary
not weary
not weary
not to inhale in wrong
way
not to inhale in wrong way
easy to inhale in wrong
way
Research in voice therapy in China
• Non-surgery method
• Surgery method
Non-surgery Method
• Instrument method
Disposition artificial larynx
Electrolarynx
• Non-instrument method
Esophageal speech
Surgery Method
• Syrinx Speech
• Larynx reproduce technology
• Larynx transplant technique
Thank you!