voice therapy of laryngectomy 周谢玲、邵帼珺、关娇. topics laryngectomy * when * how *...

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——whenWe 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——how1.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——how2.Two kind of larygectomy

* Total laryngectomy

* Hemilaryngectomy ( partial laryngectomy )

The extent and location of the tumor will diratate the extent of the surgery

The larynx, containing the vocal folds, has been removed, usually at the level of the first tracheal ring

Laryngectomy——how

Tumor locationKind of

laryngectomy

Crosses the midline Total laryngectomy

Only on one side of the larynx

Hemilaryngectomy and other partial

laryngectomy


图 1 切口

图 2 剪断舌骨中段

图 3 分离舌骨周围诸肌

图 4 暴露甲状软骨翼板，切断其上角


图 5 分离切断甲状腺峡部

图 6 缝扎甲状腺峡部

图 7 于环状软骨下缘切断气管

图 8 将喉体向上翻起，与食管前壁分离


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


图 13 自两侧外上方缝合喉咽粘膜

图 14 “y” 形缝合喉咽粘膜

图 12 剪开会厌边缘粘膜，自上而下截除喉体

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

RPRAP mode The lose of voice

the trachea attached to the neck, the patient does not breathe through his nose or mouth, the air column is diverted away from the resonators and artculators

he can make only certain voiceless sounds that are produced by tougue, cheek, and lip compressed of the air filling his mouth or throat.not a real whisper

Voice therapy

Voice therapyThe 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 speechTo 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——totalThree 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——totalAdoption 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 structures or inserting a tube or fitted prosthetic electrolarynx into the mouth while speaking.

Neck type: you place it against your throat, push a buttom, and the machine transmits a vibration noise to your throat which you then form into words and sounds with your lips, teeth, and tougn

intraoral type: vibration sound is transmitted directly into your mouth via a small tube, words and sounds are made in a similar manner


* 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)


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

* 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 SpeechThe 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

* 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


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

•easy to have leak Cleaning and flushing

Installed prosthesis



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)

ComparationEsophageal

speechElectrolarynx

(EL)Tracheoesophageal 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 methodEsophageal speech

Surgery Method

• Syrinx Speech• Larynx reproduce technology • Larynx transplant technique

Thank you!

voice therapy of laryngectomy 周谢玲、邵帼珺、关娇. topics laryngectomy * when * how *...

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