Identification & Managemement of Swallowing Problems After Laryngectomy

IDENTIFICATION &

MANAGEMEMENT OF

SWALLOWING PROBLEMS

AFTER LARYNGECTOMY

KUNNAMPALLIL GEJO JOHN

BASLP,MASLP


OVERVIEW

Dysphagia and Stages of Swallowing

Signs & Symptoms of Mechanical

Dysphagia

Dysphagia in Laryngeal Cancer

Guidelines for Therapy

Management by Swallowing Therapist


DYSPHAGIA

Greek word- disordered eating

Difficulty or pain while swallowing

Greater time and effort to move food or

liquid from mouth to stomach

Types- Mechanical and Neurogenic


SWALLOWING MECHANISM


STAGES OF SWALLOWING

1. Sensory stage

2. Oral preparatory stage

3. Oral stage

4. Pharyngeal stage

5. Esophageal stage


SENSORY STAGE

Pre-oral Anticipatory Stage

Suggested by Leopold & Kagel (1997)

Encompasses interaction of pre-oral:

Motor

Cognitive

Psychosocial

Somatoesthetic elements KUNNAMPALLIL GEJO JOHN

ORAL PREPARATORY STAGE

Bolus is formed by mastication involving rotary

lateral movements of the mandible and tongue

Upper and lower teeth crush the material which

falls medially toward the tongue

Tongue moves the material back onto the teeth as

the mandible opens


…CONTD

The tongue mixes food with saliva

The cycle is repeated numerous times before

initiating the swallow

Movement patterns vary depending on

consistency of material being chewed


…CONTD

Labial seal is maintained to ensure no

spillage

Velum is pulled anteriorly and rests against

the slightly elevated back of the tongue

Larynx and pharynx are at rest and nasal

breathing may continue till voluntary

swallow is initiated. KUNNAMPALLIL GEJO JOHN

…CONTD

Bolus is held between the anterior tongue

and the palate

Tongue cups around the bolus and seals it

against the hard palate, laterally and

anteriorly


ORAL STAGE

Initiates with stripping action of the tongue

It sequentially squeezes the bolus

posteriorly against the hard palate

Central groove is formed for bolus to move

posteriorly


…CONTD

When bolus passes the anterior faucial

arches, oral stage is terminated

This stage takes about 1 sec to

complete


PHARYNGEAL STAGE

Begins with triggering of swallowing reflex

Both voluntary and reflex components are

involved

Triggering of swallowing reflex leads to:

(1) Elevation and retraction of velum


…CONTD

(2) Initiation of pharyngeal peristalsis

(3) Elevation and closure of larynx at 3

sphincters- epiglottis, false vocal folds and

true vocal folds

(4) Relaxation of the cricopharyngeal

sphincter


ESOPHAGEAL STAGE

UES relaxes to let the bolus pass

Bolus sequentially passes by:

Striated constrictor muscles of the pharynx

Peristalsis

Relaxation of LES

Normal transit time varies form 8 to 20 seconds.


SYMPTOMS OF

MECHANICAL DYSPHAGIA

Inability to control food or saliva in mouth

Coughing before, during or after a swallow

Effortful and labored swallowing

Increased time taken


…CONTD

Stringy/ copious secretions

Gurgly voice quality

Recurring pneumonia

Weight loss


SIGNS OF MECHANICAL

DYSPHAGIA Residue

Penetration

Aspiration

Spiked fever

Backflow

Regurgitation


ASSESSMENT

IMAGING STUDIES NON-IMAGING

STUDIES

Ultrasound Electromyography

Videoendoscopy Electroglottography

Videofluoroscopy Cervical Auscultation

Scintigraphy Manometry


BEDSIDE SWALLOW

EXAMINATION

CHART EXAMINATION

Medical history

Time of onset

Duration

Severity


…CONTD

Pulmonary function

Tracheostomy tube

Nutritional status

Presence of feeding tube


…CONTD

GENERAL FUNCTIONAL STATUS

Alert

Awake

Sensitive to symptoms


…CONTD

MEETING THE PATIENT

Posture

Respiratory status

Oral-motor function examination

Laryngeal function examination


SWALLOW ASSESSMENT

Spontaneous Swallow

Secretion management

Coordination with respiration

Dry Swallow

Timing

Laryngeal elevation


…CONTD

Chewing

Gauze pad dipped in liquid

Bolus swallow

Consistency

Posture


…CONTD

During trial swallow, observe:

Patient’s reaction to food

Oral movements in chewing

Coughing, throat clearing

Changes in secretion

Duration of meal and total intake

Coordination of breathing and swallowing


MANAGEMENT BY

SWALLOWING THERAPIST

POSTURE CONSISTENCY MANEUVERS ENVIRONMENT

MANAGEMENT OF

MECHANICAL DYSPHAGIA


GUIDELINES FOR THERAPY

Counseling prior to treatment

Awareness regarding change in voice and

swallowing

Radiated patients should begin ROM

exercises before or at beginning of RT


Review patient’s chart to determine extent of

resection and nature of reconstruction

Exercise program begins with surgeon’s

approval

Entire team of professionals should interact

and cooperate

…CONTD


THERAPY TECHNIQUES

Range of motion (ROM) exercises

Extent of movement

Bolus control exercises

Lingual control

LOGEMANN 1998


Adduction exercises

Laryngeal closure

Tongue base exercises

Tongue base ROM

Falsetto exercise

Laryngeal elevation

…CONTD


POSTURAL TECHNIQUES

DISORDER POSTURE RATIONALE

Inefficient oral

transit

Head back Utilizes gravity

to clear oral

cavity

Delay in

triggering

pharyngeal

swallow

Chin down Widens

valleculae to

prevent bolus

entering airway,

narrows airway

entrance


Inefficient oral

transit

Head back Utilizes gravity

to clear oral

cavity

Delay in

triggering

pharyngeal

swallow

Chin down Widens

valleculae to

prevent bolus

entering airway,

narrows airway

entrance



Reduced

posterior motion

of tongue base

Chin down Pushes tongue

base backward

Unilateral

pharyngeal

dysfunction

Head rotated to

damaged side,

chin down

Places extrinsic

pressure on

thyroid

cartilage,

increasing

adduction

…CONTD


…CONTD


Reduced

laryngeal closure

Chin down,

Head rotated to

damaged side

Puts epiglottis in

more protective

position,

narrows

laryngeal

entrance

Reduced

pharyngeal

contraction

Lying down on

one side

Eliminates

gravitational

effect


…CONTD


Unilateral

pharyngeal

paresis

Head rotated to

damaged side

Eliminates

damaged side

from bolus path

Unilateral oral

and pharyngeal

weakness

Head tilt to

stronger side

Directs bolus

down stronger

side

Cricopharyngeal

dysfunction

Head rotated to

damaged side

Pulls cricoid

away from

posterior

pharyngeal wall KUNNAMPALLIL GEJO JOHN

CONSISTENCY CHANGES

CONSISTENCY EXAMPLES

Thin liquid Milk, fruit juice

Thick liquid Soup, milkshake

Puree Yogurt, custard

Soft solid Mashed potato, idli

Hard solid Biscuits KUNNAMPALLIL GEJO JOHN

…CONTD

DISORDER EASIEST DIFFICULT

Reduced range

of tongue

motion

Thick liquid Thick foods

Reduced tongue

contraction

Thick liquid Thick foods

Reduced tongue

strength

Liquid Thick foods



Delayed

pharyngeal

swallow

Thick liquids

and thicker

foods

Thin liquids

Reduced airway

closure

Pudding and

thick foods

Thin liquids

Reduced

laryngeal

movement-

cricopharyngeal

dysfunction

Liquid Thicker, high

viscosity foods

…CONTD


…CONTD


Reduced

pharyngeal

contraction

Liquid Thick, high

viscosity foods

Reduced tongue

base posterior

movements

Liquid High viscosity

foods


SWALLOWING MANEUVERS Maneuver Problem Rationale

Supraglottic

swallow

Reduced or late

vocal fold

closure

Delayed

pharyngeal

swallow

Voluntary breath

hold closes vf

before and

during

swallowing

Super

supraglottic

swallow

Reduced closure

of airway

entrance

Effortful breath

hold, tilts

arytenoids

forward, closing

airway entrance KUNNAMPALLIL GEJO JOHN

…CONTD

Maneuver Problem Rationale

Effortful

swallow

Reduced

posterior

movement of

tongue base

Effort increases

posterior tongue

base movement

Mendelsohn

maneuver

Reduced

laryngeal

movement

Laryngeal movt

opens UES,

prolonging

laryngeal

elevation

prolongs UES

opening KUNNAMPALLIL GEJO JOHN

ENVIRONMENTAL

MODIFICATIONS

Thick straw while drinking liquids

Pillow behind patient's head during

feeding

Reducing distractions like turning off

the TV, no talking during feeding


DYSPHAGIA IN

LARYNGEAL CANCER

DYSPHAGIA

TUMOR LOCATION SURGICAL RESECTION RADIOTHERAPY

SUPRAGLOTTIC

UNILATERAL

LARYNGEAL TUMOR

MORE THAN ONE REGION

SUPRAGLOTTIC LARYNGECTOMY

HEMILARYNGECTOMY

TOTAL LARYNGECTOMY


SUPRAGLOTTIC TUMORS:

SUPRAGLOTTIC

LARYNGECTOMY

1. HORIZONTAL/

SUPRAGLOTTIC

LARYNGECTOMY

Small lesions involving

epiglottis, aryepiglottic

fold or false vocal fold


…CONTD

Protection spared - Base of tongue,

arytenoids and true vocal folds

Reconstruction surgery- larynx elevated and

tucked under tongue base


…CONTD

To relearn swallow patient must completely

occlude airway entrance

Retract tongue base- contact anteriorly

tilting arytenoid

Laryngeal elevation- airway protection-

arytenoid closer to tongue base affected


…CONTD

Removal of hyoid- affects laryngeal

suspension

MANAGEMENT

Super-supraglottic swallow


…CONTD

2. SGL EXTENDED INTO

BASE OF TONGUE

More precipitous drop-off

into airway

Reduced lingual movement

and control of bolus

Management

ROM

Bolus control exercises


…CONTD

3. SGL EXTENDED

INFERIORLY

Include part of 1 vocal

fold or arytenoid

cartilage

Reduced chances of

recovery of normal

swallow KUNNAMPALLIL GEJO JOHN

…CONTD

One of the criteria for selection of SGL-

Ability to relearn swallow sequence


UNILATERAL LARYNGEAL

TUMORS:

HEMILARYNGECTOMY

1. HEMILARYNGECTOMY

Physical removal of vertical

1/2 of the larynx

When tumors located on

free margin of 1 vocal fold

with local extension


…CONTD

Resection- false vocal fold, ventricle and true

vocal fold

Spared structures- Arytenoid, thyroid, hyoid

and epiglottis

Typical HL- few difficulties postoperatively


…CONTD

Some bulk tissue reconstructed against

which un-operated side can attain normal

laryngeal closure

MANAGEMENT

Chin down position

If aspiration persists, head rotation to the

operated side KUNNAMPALLIL GEJO JOHN

…CONTD

2. FRONTOLATERAL

LARYNGECTOMY

Lesion located anteriorly

on a vocal fold

Includes part or all of

anterior commisure of

the larynx


…CONTD

Reconstruction- some bulk muscle of tissue

taken from strap muscles

Patients with FLL rehabilitated 2-3 weeks

postoperatively

More of them need chin-down head posture

than those with lesser resection


…CONTD

3. 3/4 LARYNGECTOMY

HL extending along anterior

commisure to include 1/2 of

other side of the larynx

Intact arytenoid cartilages,

epiglottis, hyoid and tissue

bulk placed on operated

side→ Prevent aspiration


…CONTD

MANAGEMENT

Chin-down position

Head rotated postures

Adduction exercises



…CONTD

Major problem in extended PL→ preventing

aspiration

Aspiration controlled by reconstructing

narrow glottic chink- airway compromised

Functional tradeoff for elimination of

aspiration is permanent tracheostomy


LARGE LESIONS: TOTAL

LARYNGECTOMY

Total laryngectomy- Lesions involving more

than one region of larynx

Physical separation of gastrointestinal tract

from respiratory tract→ no aspiration

However, swallowing problems do exist in

TL


…CONTD

1. Nature of closure of surgical defect

Postoperatively, fold of tissue at base of

tongue- pseudo-vallecula

During swallowing, contraction of

pharyngeal constrictor muscles pulls

pseudo-vallecula posteriorly


…CONTD

Gap widens at base of tongue, forming large

pocket

Greater struggle reaction→ greater widening

of pocket

Some restricted to liquid consistency

Treatment- surgical resection of tissue fold


…CONTD

2. Tightness of surgical closure

Scar tissue strictures in esophagus after

surgery

Narrows esophagus, prevents large

amount of material of thick consistency

from passing


…CONTD

MANAGEMENT

Dilatation- gave temporary success

Pharyngoesophageal myotomy- release scar

tissue stricture

Changing head positions- head rotation

stretch and open a stricture


…CONTD

Pharyngectomy, esophagectomy with

reconstruction by distal flap, stomach pull-

up, or jejunal graft- backflow of food

MANAGEMENT

Postural changes like extending neck


…CONTD

TEP- Most successful surgical prosthetic

procedure

Prosthesis placed in puncture wound prevents

backflow

Trachealus muscle forms a tight seal at puncture

site around prosthesis


SUMMARY

SURGERY MANAGEMENT

Horizontal or supraglottic

laryngectomy


SGL extended into base of

tongue

ROM and bolus control

exercises

Typical hemilaryngectomy Chin down, Head rotated

to operated side

Frontolateral

laryngectomy

Chin down posture


…CONTD

SURGERY MANAGEMENT

3/4th laryngectomy Chin down posture, Head

rotated Adduction

exercise, Super-

supraglottic swallow

Total laryngectomy Dilatation,

Pharyngoesophageal

myotomy, Head rotation,

Head back posture,TEP


RADIOTHERAPY

Following side effects may arise :

Redness or skin irritation

Swelling

Mucositis

Xerostomia (dry mouth) or thickened saliva


…CONTD

Bone pain

Nausea

Fatigue

Dental problems


…CONTD

Changes in voice

Loss of appetite, due to altered taste

Dehydration

Fibrosis (scarring)


…CONTD

Very small changes in salivary flow in T1 or

T2 stage tumor

If all salivary glands in field of radiation-

xerostomia, edema and mucositis


…CONTD

Xerostomia

Reduced tongue speed

Delay in oral transit time

Delay in triggering pharyngeal swallow


…CONTD

Fibrosis → Damage to capillaries in radiated

area

If pharynx in the field of radiation- reduced

laryngeal elevation, reduced pharyngeal wall

motion


…CONTD

Effects may begin during course of RT or

years thereafter

Impairs efficiency and safety of swallow

Severity varies


…CONTD

MANAGEMENT

ROM exercises before RT begins and

continue to prevent fibrosis

Falsetto exercise

Mendelsohn maneuver


CONCLUSION

Swallowing therapist needs to combine

many techniques

Patient may have developed some

compensatory strategies

Need to assess and determine if they benefit

If not, then teach appropriate techniques


“The art of dining well is no slight art, the pleasure not a slight pleasure.”

-Michel de Montaigne (1533-1592)


ACKNOWLEDGEMENTS

Our sincere gratitude to:

Dr. S.N.Oak- Dean of TNMC & BYL Nair Charitable

Hospital

Mrs. G.B.Gore- Professor & Head of AST Dept of TNMC

& BYL Nair Charitable Hospital

Dr. Premalatha for her guidance

Mansi and Priya for their suggestions and co-operation

All the staff members and students


REFERENCES

Dikeman, K. J., & Kazandjian, A. S. (2003). Communication and Swallowing

Management of Tracheostomized and Ventilator-Dependent Adults.

Canada: Thomas Learning Inc.

Jones, B. (2002). Normal and Abnormal Swallowing. Springer Publishing Group.

Kazi, R., Prasad, V., Venkitaraman, R., Nutting, C.M., Clarke, P., Rhys-Evans, P.,

& Harrington K.J. (2006). Questionnaire analysis of the swallowing-related

outcomes following total laryngectomy . Clinical Otolaryngology 31 (6), 525–530.

Logemann, J. A. (1983). Evaluation and Treatment of Swallowing Disorders.

Austin: Pro-Ed Publication.


…CONTD

Logemann, J. A., Pauloski, B. R., Rademaker, A.W., Cook, B., Graner,

D., Milianti, F., Beery, Q., Stein, D., Bowman4, J., Lazarus,

C., Heiser, M. A., & Baker, T. (1992). Impact of the diagnostic

procedure on outcome measures of swallowing rehabilitation in head

and neck cancer patients. Dyshpagia, 7 ( 4), 179-186.

Logemann, J. A., Gibbons, P., Rademaker, A.W., Pauloski, B. R., Kahrilas,

P. J., Bacon, M., Bowman, J., & McCraken, E. (1994). Mechanisms of

recovery after supraglottic laryngectomy. Journal of Speech and

Hearing Research, 37, 965-974.

Logemann, J. A. (1998). Evaluation and Treatment of Swallowing

Disorders. Austin: Pro-Ed Publication.


…CONTD

Murdoch, B. E., Theodoros, D. G. (2001). Traumatic Brain Injury:

Associated Speech, Language, and Swallowing Disorders. San Diego:

Singular Publishing Group, Inc.

Pradhan, S. (2006). Voice Conservation Surgery for Laryngeal and

Hypolaryngeal Cancer. Mumbai: Lloyds Publishing House.

Perlman, A. L. (1997). Deglutition and Its Disorders: Anatomy, Physiology,

Clinical Diagnosis, and Management. San Diego: Singular Publishing

Group, Inc.

Wikipedia, the free encyclopedia. Retrieved on August 12, 2007 from

http://en.wikipedia.org/wiki/Dysphagia


THANK YOU


Identification & Managemement of Swallowing Problems After Laryngectomy

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