The document discusses rehabilitation after laryngeal surgery. It covers the basics of speech physiology and the assessment and treatment of speech disorders following different laryngeal procedures. Key points include: 1) Speech requires a power source (lungs), sound source (larynx), and sound modifier (vocal tract). After laryngectomy, alaryngeal speech methods are used. 2) Evaluation of speech issues depends on the surgical site and may include videofluoroscopic swallow studies. 3) Treatment includes tracheoesophageal voice using a prosthesis, esophageal speech, or an electronic larynx. Rehabilitation aims to restore normal speech. 4) Complications are addressed and rehabilitation supports recovery of speech and

1. REHABILITATION
AFTER LARYNGEAL
SURGERY
Dr Sujay Susikar
PG in Surgical Oncology
Prof Dr R Rajaraman’s Unit
Department of surgiacl oncology
Govt Royapettah Hospital

2. Physiology of Speech
3 basic elements are necessary:
(1) Power source,
(2) Sound source,
(3) Sound modifier.
For laryngeal speakers
• lung air is the power source,
• larynx is the sound source,
• vocal tract ( pharynx, oral
cavity) is the sound modifier.

3. Speech generation
 Respiration
 Phonation
 Resonance
 Articulation

4. Assessment of speech after treatment
 Depends on site of lesion
 Template of surgical deficit
Respiration
 Insufflation testing
Resonance
 Nasometry
Phonation
 VFSS
 FEES

5. VFSS
The studies are captured using fluoroscopy in video or
digitized format that allows detailed analysis of the
oropharyngeal swallowing and speech process
Penetration
 Contrast enters the airway, remains at or above vocal
folds
Aspiration
 Contrast passes glottis

6. Treatment of post op speech
disorders
Varied depending on the site:
Alaryngeal speech:
 Tracheoesophageal prostheses
 Artificial larynx
 Esophageal speech

7. Rehabilitation after laryngectomy
 After total laryngectomy (TL), the sound source is
removed and the lungs are disconnected from the vocal
tract.
Successful voice restoration following total laryngectomy
(TL) requires identification of an
 Alternative sound source
 Viable power source.

8. Rehabilitation after laryngectomy
 Stoma care
Rehab of speech:
 Tracheo esophageal voice
 Artificial larynx
 Esophageal voice
Experienced speech pathologist essential

9. Esophageal speech
 Principle: Esophageal speech is
produced by insufflation of the
esophagus and controlled egress
of air release that vibrates the
pharyngoesophageal (PE)
segment for sound production.
Anatomic structures for
articulation and resonance are
usually unaltered
 Articulated by the tongue, lips
and teeth
 Speech pathologist teaches
insufflation behavior

10. Esophageal speech
Techniques:
 Injection involves using the articulators to increase
oropharyngeal air pressure, which, in turn, overrides the
sphincter pressure of the PE segment, thereby
insufflating the esophagus.
 Inhalation involves decreasing thoracic air pressure
below environmental air pressure by rapidly expanding
the thorax so air insufflates the esophagus.
Both techniques are based on the pressure differential principle that
air flows from areas of higher pressure to areas of lower pressure.

11. Esophageal speech
Advantage:
 Does not utilize devices
or implants
 No further surgery is
required.
Disadvantage:
 Time intensive learning
 Difficulties with phrasing
and loudness

12. Tracheo esophageal voice
 Preferred modality
 Based on concept of
shunting of tracheal air
to the pharynx thro
fistulous tract during
exhalation to produce
sound thro vibration of
the mucosa of the upper
esophageal segment

13. Tracheo esophageal voice
Principle: A surgical fistula is created in the wall separating
the trachea and esophagus.
 A one-way valved prosthesis is placed in the puncture
tract, allowing lung air to pass into the esophagus.
 The lung air induces vibration of the PE segment for
sound production.
 The mechanics of the one-way valve allow lung air to
pass into the esophagus without food and liquids
passing into the trachea.

14. Tracheo esophageal voice
Selection criteria
 Motivated and mentally stable.
 Adequate understanding of their anatomy, and the mechanics of
the prosthesis.
 Sufficient manual dexterity and visual acuity to care for the
stoma and the prosthesis.
 Should not have significant stenosis of the hypopharynx.
 Be able to produce speech following esophageal insufflation via a
properly positioned esophageal catheter (the Taub test).
 Adequate pulmonary reserve.
 Should have a stoma of adequate depth and diameter to accept a
prosthesis without airway compromise.
 It is worth noting that several of these requirements (1,2,4,5) are also
necessary for good esophageal speech.

15. Tracheo esophageal voice
Advantages:
 The air supply for speech is pulmonary
 Phonation sounds natural, and
 Voice restoration occurs within 2 weeks of surgery.
Disadvantages:
 Additional surgery is required for secondary
punctures,
 The prosthesis must be maintained, and
 Aspiration may occur if liquids leak through a
malfunctioning valve.

16. Tracheo esophageal voice
Techniques of tracheo
esophageal puncture:
 Primary
 secondary

17. Primary TEP
 Constructed after stoma before the pharynx is closed
Advantages:
 Avoiding a secondary procedure
 Provides early voice rehabilition
 TEP fistula can be used as a temporary feeding
esophagostomy
Disadvantages:
 Initial sensitive stoma
 Stoma migration with healing
 Delayed speech with post op RT

18. Secondary TEP
Advantages:
 Healing stabilized
 May have developed good esophageal voice
Disadvantages:
 Two operations
 Aphonic much longer
 Myotomy may be necessary
 Secondary TE puncture is considered for patients at
risk of developing a fistula such as those who have
severe radiation sequelae.

19. Tracheo Esophageal Prosthesis
Duckbill
 Size: The prosthesis is 6-28 mm in length and 16F or 20F in
diameter.
 Advantages: It has good durability, can be changed
independently, and is inexpensive.
 Disadvantages: Airflow resistance is increased.
Low resistance/pressure
 Size: It is 6-28 mm in length and 16F or 20F in diameter.
 Advantages: It has decreased airflow resistance, has shorter
esophageal extension, and can be change independently.
 Disadvantages: It has decreased durability and is sensitive to
esophageal pressure changes.
Indwelling
 It is 6-22 mm in length and 20F or 22F in diameter.
 Advantages: It has decreased airflow resistance, increased security
from dislodgement, and a removable strap.
 Disadvantages: It is clinician-dependent and has the potential for
gastric distention from excess air insufflation. It is expensive

20. Hands-free tracheostoma valves
2 primary functions:
 Hands-free speech and
 Housing for heat and moisture filters.
Adhered to the neck, with a valve housing directly over
the stoma.
For speech, the air pressure generated during increased
exhalatory effort closes the tracheostoma valve and
directs air back through the tracheoesophageal
prosthesis

21. Complications of TEP
 Failure of voice restoration
 Bleeding from around the tract
 Air in the stomach
 Salivary leak thro or around the prosthesis
 Aphonia during RT
 Mediastinitis
 Cervical cellulitis
 Cervical spine fracture
 Aspiration of the prosthesis

22. Electronic larynx
 Principle: An external
mechanical sound source is
substituted for the larynx.
Anatomic structures for
articulation and resonance are
usually unaltered.
 External device placed against
the neck or an intraoral type
 Electronically driven
 Sound articulated by tongue,
lips and teeth

23. Electronic larynx
 Neck type - placed flush to the skin on
the side of the neck, under the chin, or
on the cheek. Sound is conducted into
the oropharynx and articulated normally.
 Intraoral devices are used for patients
who cannot achieve adequate sound
conduction on the skin. A small tube is
placed toward the posterior oral cavity,
and the generated sound is then
articulated. The tube has minimal effect
on articulatory accuracy if the patient is
taught properly and learns to use it well.
 A third type of electrolarynx has been
developed using an electromyograph
(EMG) transducer in the strap
muscles to activate a sound source for
hands-free use.

24. Electronic larynx
Advantages:
 Short learning time
 Can be used in
immediate post op
 Relative availability and
low cost
Disadvantages:
 Mechanical soumd
 Dependence on batteries
 Need for maintanence of
intraoral tubes

25. Aphonia following voice prosthesis
placement
Causes:
 Post treatment edema
 Spasm of cricopharyngeus
 Pharyngeal stenosis
Evaluation:
 VFSS
Management:
 Stenosis – dilatation
 Spasm- botulinum toxin injection

26. Treatment of post op speech
disorders
Rehabilitation of velum:
 Optimization of respiratory volume
 Increase precision of articulation
 Increase volume intensity
 Slow the rate of articulation
 Use biofeedback for frequently spoken words
 Use of reconstruction or prosthetic management

27. Treatment of post op speech
disorders
Rehabilitation of oral articulation:
 Maximizing coordination of articulation
 Use of contrastive drills
 Use of intelligibility drills
 Implementing speech strategies

28. Rehabilitation after partial laryngeal
procedures:
 Both comunication and swallowing
 Can result in some compromise of phonation
 Swallowing generally adversely affected only in
short term
 Post op dysphagia- due to decrease in sensation
and altered anatomy
 Risk of penetration and aspiration

29. Support during treatment with
chemoradiation
After treatment issues:
 Stiffness
 Edema Frozen neck
 Fibrosis
 Xerostomia
 Stenosis
Management:
 Good supportive care- management of mucositis
 Adequate analgesia
 Management of depression
 Maintenance of nutrition
 Monitoring by the treatment team

30. Rehabilitation after chemoradiation
 Relief from xerostomia
 Maintanence of mobility
 Reduction of aspiration
 Improvement in voice

31. THANK
YOU !