Laryngectomy – surgical and SLT perspectives

• Mr Hartley SRH• Mr O’Hara SRH• Mr Ragbir RVI

• Lynn Bolden SRH/FH• Sarah Owen FH

Programme

• Options and selection

• Swallowing problems

• Valve complications

• Quiz

History of speech rehabilitation in laryngectomy

• Oesophageal voice

• 1932: Ice pick

• Electro-larynx

• 1980 Secondary SVR

• 1985 Primary SVR

• 2011…..

Surgical and SLT perspectives:

• Communication options – Characteristics, advantages and

disadvantages

• Selection– Surgical/medical/non-surgical/outcome/

evidence

• Measuring outcomes

Electrolarynx Oesophageal voice

Surgical voice restoration (SVR)

Production of voice

Requirement Laryngeal voice SVR OV

Initiator

power

Lungs Lungs Oesophageal air from oro-phayrnx

Vibrator

Sound

Vocal cords PE segment PE segment

Resonator

Quality

Vocal tract Vocal tract Vocal tract

Articulators

Speech

Tongue, teeth

palate

Tongue, teeth

palate

Tongue, teeth

palate

Impact of altered speech

• Verbal – Basic or complex information, telephone, social

exchanges• Non verbal expression

– Power, superiority, trust, seduction, vulnerable, encouragement etc

• Emotional expression– Joy, fear, sadness, anger

• Physical changes– Effort, fatigue, breathing, volume, pitch, intonation– Inconsistent and unreliable (E.L. ex)

Cont.

• Vocal Image– Gender, culture, intelligence, class, personality: kind, warm..

• Reactions from others– Deaf, low intelligence– Left out, avoided – Adverse attention or comments – misunderstandings

• Environmental/situational limitations– Noisy or smoky environments– Telephone– Meal times– Group situations

Communication options and voice characteristics. Exercise 1

• Use exercise 1 sheet to rate/describe voices

• Recordings

• E1, M Scar, OV, MDay

• Next slide valve

• DVD TW

• Then… WLvs D Wil, JMc, N Murph, Len

Communication options - selection

• Exercise 2

• Divide into 3 groups

• Mixture of Senior and junior SpRs

Summary of surgical and SLT considerations/literature

“Primary SVR should be offered to all patients undergoing laryngectomy” (H & N guidelines ‘11)

• Discuss…

Swallowing in laryngectomy

• Swallowing problems and outcomes

• ENT and plastic’s perspectives

• Assessment and management

Exercise 3

• Swallowing is the main concern for your patient. He is making the decision about whether to have treatment, or which treatment option to have, based on the information you give.

• Describe the short and long term swallowing outcomes for your patient. Explain the sorts of problems he may encounter and any future assessments or treatments that may be required.

Clinical presentation

• Increased effort & time to eat• Sticking• Limited consistencies• Weight loss• Regurgitation – nasal/oral• Bloating/belching• Voice and valve problems• Other – upper/lower GI…

ENT perspective

Plastic’s perspective

Assessments

• Which assessment when?– Comprehensive history - may have been

assessed extensively!– EUA– TNO– Ba Swallow/Videofluoroscopy/combined– Other imaging – Valve assessment– Other

Case recordings/images

• Normal swallow, Jej, ALT, pseudo-epiglottis, stricture, multiple problems

• Surgical management

• Other: SLT, lymphoedema, nutrition, psychology/support groups

Which outcomes should we measure?

• Discuss

Outcome measurements

• Multi-perspective– Patient: voice/swallow

related QOL– Voice: quality– Intelligibility – Valve complications– Cost– Dietary intake– WST

• Longitudinal

• Comparison with other methods – Do patients adapt what ever their communication method?

• Primary Vs secondary

What outcomes should we measure?

Multi-perspectivePrimary Vs Secondary SVR???Validated/ratings of voice and swallow function• SRH rating scale• Intelligibility? % use by patient? • Normalcy of diet, WST

Validated questionnaires of patient’s perceptionValve complicationsValve costEnteral feeding