SLM112 Biomed Lecture 1 - 11 PDF

Anatomy & physiology of the head & neck Louise Occomore-Kent Senior Lecturer SL2012 / SLM11...

Anatomy & physiology of the head & neck Louise Occomore-Kent Senior Lecturer SL2012 / SLM112 Biomedical Science Honorary Clinical Lead SLT (Head and Biomed ENT Lecture 1 Neck/ENT) [email protected] Biomedical Science [SLM102/SL2012] Module Leader: Dr Rachel Holland [email protected] ENT component of Biomed: 1. Anatomy and physiology of the head & neck 2. Overview of head and neck cancers 3. Laryngectomy and voice restoration 4. Tracheostomy Lecture 1 Basic Anatomical terms Skull & face Nasal cavity Oral Cavity Pharynx Larynx Cranial Nerves (brief) Physiology of Swallowing (intro) Physiology of Speech (intro)  If you only read one thing to accompany my four lectures, I recommend this: Feel free to colour along! Colouring pages are on Moodle.  By the end of this lecture (with some self-directed study to consolidate) Today’s I can: learning 1. Describe the key features of the: outcomes: Skull & face Nasal cavity Oral cavity Pharynx Larynx 2. Have a basic understanding on which to build in subsequent lectures 3. Begin to understand some of the more detailed elements of the anatomy of the head and neck  Structural landmarks (anatomy) Functions (physiology) Why learn Changes in anatomy and/or physiology anatomy & can impact on speech, voice and physiology? swallowing Crucial for diagnosis and management of speech, swallowing and voice disorders Allows dynamic reasoning and problem solving Gives us a shared vocabulary when working with other professionals  Your right or mine? Before we begin…..  Term Meaning Prone/ supine Frontal/ coronal plane Transverse/ horizontal plane Anatomical orientations Saggital plane and planes Mid/ para saggital plane Abduction Adduction  Term Meaning Anterior/ Posterior Ventral/ dorsal Basic Lateral/ Medial Anatomical Proximal/ distal Terms Superior/inferior (coronal/caudal) Superficial/deep (extrinsic/intrinsic) Ipsilateral/contralateral Bones of the head & neck Colouring along? Section 35  Muscles of the face Colouring along? Sections 33/34 Key muscles of the face for chewing/speaking CNV: Masseter – elevates mandible Temporalis – elevates & retracts mandible Medial pterygoid – elevates & protrudes mandible, lateral mandible movement. Lateral pterygoid – protrudes mandible, depresses mandible, lateral mandible movement ______________ CNVII: Orbicularis oris – closes and protrudes lips (kissing), compresses lips against teeth, shapes lips for speech) Buccinator – Presses cheeks against teeth (sucking/whistling/blowing), keeps food between teeth Key muscles of the face for chewing/speaking Zygomaticus major – Angle of mouth superiorly and lateral (smiling) Zygomaticus minor – elevates upper lip Lavator labii superioris – elevates upper lip Depressor labii inferioris – depresses lower lip Depressor anguli oris – angle of mouth laterally & inferiorly (opening mouth) Levator anguli oris - angle of mouth superiorly and laterally (smiling) Risorius Mentalis - angle of mouth laterally (grimacing) Key regions Nasal cavity Pharynx Oral cavity Larynx  SLM112/SL2012 Lecture 1, part 2 Anatomy and physiology of the head and neck The basics! Nasal cavity Nasal cavity Functions: ▪ Air filtration ▪ Air warming and humidification ▪ Olfaction ▪ Resonance for speech Nasal turbinates or conchae increase surface area within the nose Heats air to within 1 degree of body temperature & humidifies Nasal cavity Vibrissae (short, coarse hairs) filter the air, removing dust and other particles Tiny cilia line the nasal cavity, covered in a layer of mucous Cilia transport the mucous posteriorly into the pharynx, where it is swallowed and digested Passage of air through the nasal cavity facilitates sense of smell, contributing greatly to taste Oral Cavity Oral Cavity Speech and Swallowing Lips: Spoon stripping, cup edge contact, etc. Prevent loss of saliva, food and fluid during eating/drinking. Involved in articulation of consonants and vowels Maxilla (upper jaw) & hard palate: Separates oral and nasal cavities. Passive structure involved in swallowing and speech. Oral Cavity Speech and Swallowing Soft palate (‘velum’): Muscles – tensor veli palatini (tenses to lower) and levator veli palatini (tenses to raise) Opens/closes the nasal cavity during speech and swallowing; affects resonance/nasality of speech and prevents nasal regurgitation Mandible (lower jaw) & floor of mouth: Opens and closes oral cavity Active structure in swallowing and speech Tongue (‘Lingual/glossal’) Anterior belly of digastric Muscles of the Tongue Intrinsic muscles – change the shape: Inferior longitudinal muscle (curls tip down) Superior longitudinal muscle (curls tip and sides up) Transverse muscle (makes narrower and deeper shape) Vertical muscle (flattens shape) Extrinsic muscles – move the tongue: Genioglossus (protrusion) Styloglossus (raises sides & aids retraction) Palatoglossus (elevates posterior tongue) Hyoglossus (depresses and retracts tongue) Check in! Nasal cavity Pharynx Oral cavity Larynx Pharynx (‘Hypopharynx’) Pharynx Muscles of the pharynx pull the bolus through the pharynx via a ‘stripping’ action: Inferior constrictor Middle constrictor Inferior constrictor Laryngeal Regions- mid saggital view Supraglottis: Area above the vocal folds Epiglottis Aryepiglottic folds False vocal folds (also called ventricular or vestibular folds) Ventricle/vestibule Glottis: Vocal folds and space between them Cricopharyngeal sphincter Subglottis: Area below vocal folds, entrance to trachea Laryngeal Structure Bones and Unpaired Cartilages Hyoid Bone Epiglottis (leaf shaped) Thyroid cartilage Cricoid Anterior View cartilage Posterior View Thyroid Endocrine gland in the neck Produces thyroxine (T4) and triiodothyronine (T3) Regulates metabolic rate Can become overactive (hyperthyroid) or underactive (hypothyroid) More info here: http://www.btf-thyroid.org/information/your-thyroid-gland Larynx https://www.youtube.com/watch?v=xAtiJTLBvlI Arytenoids Larynx (cont) Arytenoid cartilage Inspiration Phonation Laryngeal Anatomical Landmarks Cricopharyngeal Pyriform Fossa sphincter Interarytenoid Space Arytenoids False Vocal Folds Aryepiglottic Fold True Vocal Folds Valleculae Epiglottis Anterior Commissure Laryngeal cartilages TOTAL: 9 3 Unpaired: Thyroid cartilage Cricoid cartilage Epiglottis (trapdoor) 3 Paired: Arytenoid cartilages (triangular, responsible for moving vc’s, at posterosuperior border of cricoid cartilage) Corniculate cartilages (horn-shaped, sit at apex of artytenoids) Cuneiform cartilages (club shaped, anterior to corniculate) Laryngeal Cartilages - Paired Paired cartilages (arytenoids, corniculates and cuneiforms) can slide together, rotate together and apart and tilt forward and backward. Extrinsic Laryngeal Extrinsic muscles move Muscles the entire larynx Suprahyoid The suprahyoid muscles pull the hyoid bone forward and upward which elevates the larynx. Extrinsic Laryngeal Extrinsic muscles move the entire larynx Muscles Infrahyoid The infrahyoid muscles depress the hyoid bone and larynx. Intrinsic Laryngeal Muscles Move the laryngeal cartilages in relation to each other. Control voice production (phonation) by altering the length, tension and shape of the vocal folds. Adduct and abduct the vocal folds for respiration and phonation. Intrinsic Laryngeal Muscles Thyroarytenoid (Vocalis) - Forms most of the structure of the vocal folds. - On contraction, reduces distance between thyroid and arytenoid cartilages and shortens vocal folds and increases bulk. - Involved in control of low pitch phonation. - Contributes to adduction of the vocal folds. Intrinsic Laryngeal Muscles Posterior Cricoarytenoid - Abducts the vocal folds. - Only muscle that abducts the vocal folds - Sometimes referred to as the ‘safety muscle’ of the larynx. Intrinsic Laryngeal Muscles Lateral Cricoarytenoid - Main adductor of the vocal folds - Pull the back edge of the arytenoids apart, thus front edge of the arytenoids (and therefore the vocal cords) together Intrinsic Laryngeal Muscles Cricothyroid - Tilts thyroid cartilage towards cricoid cartilage. - Lengthens and tenses vocal folds. - Important in increasing pitch. Intrinsic Laryngeal Muscles Interarytenoid Muscles - Pull the arytenoids together. - Contribute to vocal fold adduction. Intrinsic Laryngeal Muscles Ventricular Folds / False Vocal Folds - Also referred to as ‘Vestibular Folds’. - Superior and lateral to true vocal folds - Important for airway protection - Can become inappropriately involved in voice production in some voice disorders Larynx – Vocal Folds Larynx – Vocal Folds Epithelium: Stratified squamous cells Lamina Propria – Superficial Layer Also called ‘Reinke’s space’ Contains loose fibrous and elastic tissue (less than deeper layers) Lamina Propria – Intermediate Layer Densely packed elastic fibres Lamina Propria – Deep Layer Contains mainly collagenous fibres Less elastic than the intermediate layer Vocalis (Thyroarytenoid): Forms the body of the vocal fold Check in! Nasal cavity Pharynx Oral cavity Larynx Knowledge review: By the end of today’s asynchronous lecture (with some reading and consolidation) I can: 1. Describe the key features of the: Skull & face Nasal cavity Oral cavity Pharynx Larynx 2. Have a basic understanding on which to build in subsequent lectures 3. Begin to understand some of the more detailed elements of the anatomy What’s next? Synchronous session We know what the structures are, now we need to learn what they do Focus more on applying physiology to the anatomy we have learned References General head and neck anatomy: Seikel, J. A., King, D. W., & Drumwright, D. G. (2005). Anatomy and physiology for speech, language and hearing. Thomson Delmar Learning: New York. Fuller, D. R., Pimental, J. T., & Peregoy, B. M. (2012). Applied anatomy and physiology for speech-language pathology and audiology. Lippincott Williams & Wilkins: Philadelphia. Hutchinson, M., Mallatt, J., Marieb, E. & Wilhelm, P. (2010) A Brief Atlas of the Human Body (2md ed.) Pearson: Harlow (warning: photographs of cadavers!) Gardner, M. (1992) Basic anatomy of the head & neck. Lea & Febinger: Philadelphia. Atkinson, M. and McHanwell S. (2018) Basic Medical Science for Speech and Language Therapy Students 2018: 2nd edition. J & R Press. Laryngeal anatomy: AnatomyZone video – laryngeal cartilages - https://www.youtube.com/watch?v=Z3S2dD9BrSY Sapienza, C., & Hoffman Ruddy, B. (2009). Voice disorders. Plural Publishing: San Diego. Greene, M. C. L., & Mathieson, L. (2001). The voice and its disorders (6th edition). Whurr: London. SLM112/SL2012 Lecture 1 Part 3: The larynx Laryngeal Regions- mid saggital view Supraglottis: Area above the vocal folds Epiglottis Aryepiglottic folds False vocal folds (also called ventricular or vestibular folds) Ventricle/vestibule Glottis: Vocal folds and space between them Cricopharyngeal sphincter Subglottis: Area below vocal folds, entrance to trachea Laryngeal Structure Bones and Unpaired Cartilages Hyoid Bone Epiglottis (leaf shaped) Thyroid cartilage Cricoid Anterior View cartilage Posterior View Thyroid Endocrine gland in the neck Produces thyroxine (T4) and triiodothyronine (T3) Regulates metabolic rate Can become overactive (hyperthyroid) or underactive (hypothyroid) More info here: http://www.btf-thyroid.org/information/your-thyroid-gland Larynx Arytenoids Larynx (cont) Arytenoid cartilage Inspiration Phonation Laryngeal Anatomical Landmarks Cricopharyngeal Pyriform Fossa sphincter Interarytenoid Space Arytenoids False Vocal Folds Aryepiglottic Fold True Vocal Folds Valleculae Epiglottis Anterior Commissure Laryngeal cartilages TOTAL: 9 3 Unpaired: Thyroid cartilage Cricoid cartilage Epiglottis (trapdoor) 3 Paired: Arytenoid cartilages (triangular, responsible for moving vc’s, at posterosuperior border of cricoid cartilage) Corniculate cartilages (horn-shaped, sit at apex of artytenoids) Cuneiform cartilages (club shaped, anterior to corniculate) Laryngeal Cartilages - Paired Paired cartilages (arytenoids, corniculates and cuneiforms) can slide together, rotate together and apart and tilt forward and backward.  Larynx – Vocal Folds Epithelium: Stratified squamous cells Lamina Propria – Superficial Layer Also called ‘Reinke’s space’ Contains loose fibrous and elastic tissue (less than deeper layers) Lamina Propria – Intermediate Layer Densely packed elastic fibres Lamina Propria – Deep Layer Contains mainly collagenous fibres Less elastic than the intermediate layer Vocalis (Thyroarytenoid): Forms the body of the vocal fold Extrinsic Laryngeal Extrinsic muscles move Muscles the entire larynx Suprahyoid The suprahyoid muscles pull the hyoid bone forward and upward which elevates the larynx. Extrinsic Laryngeal Extrinsic muscles move the entire larynx Muscles Infrahyoid The infrahyoid muscles depress the hyoid bone and larynx. Check in! Nasal cavity Pharynx Oral cavity Larynx Knowledge review: By the end of today’s asynchronous lecture (with some reading and consolidation) I can: 1. Describe the key features of the: Skull & face Nasal cavity Oral cavity Pharynx Larynx 2. Have a basic understanding on which to build in subsequent lectures 3. Begin to understand some of the more detailed elements of the anatomy What’s next? Synchronous session We know what the structures are, now we need to learn what they do Focus more on applying physiology to the anatomy we have learned References General head and neck anatomy: Seikel, J. A., King, D. W., & Drumwright, D. G. (2005). Anatomy and physiology for speech, language and hearing. Thomson Delmar Learning: New York. Fuller, D. R., Pimental, J. T., & Peregoy, B. M. (2012). Applied anatomy and physiology for speech-language pathology and audiology. Lippincott Williams & Wilkins: Philadelphia. Hutchinson, M., Mallatt, J., Marieb, E. & Wilhelm, P. (2010) A Brief Atlas of the Human Body (2md ed.) Pearson: Harlow (warning: photographs of cadavers!) Gardner, M. (1992) Basic anatomy of the head & neck. Lea & Febinger: Philadelphia. Atkinson, M. and McHanwell S. (2018) Basic Medical Science for Speech and Language Therapy Students 2018: 2nd edition. J & R Press. Laryngeal anatomy: AnatomyZone video – laryngeal cartilages - https://www.youtube.com/watch?v=Z3S2dD9BrSY Sapienza, C., & Hoffman Ruddy, B. (2009). Voice disorders. Plural Publishing: San Diego. Greene, M. C. L., & Mathieson, L. (2001). The voice and its disorders (6th edition). Whurr: London.  Anatomy & Physiology of the head & neck Louise Occomore-Kent SL2012 / SLM102 Biomedical Science Lecturer (Voice/ Head & Neck) Biomed ENT Lecture 1 Honorary Clinical Lead SLT (Head and Neck/ENT) Synchronous lecture slides [email protected] Today’s learning outcomes: By the end of today’s lecture (with some reading and consolidation) I can: 1. Describe the functions of the: Skull & face Nasal cavity Oral cavity Pharynx Larynx 2. Briefly explain how voice and speech are produced 3. Briefly explain the swallowing process Let’s recap the anatomy with a video: https://www.youtube.com/watch?v=xAtiJTLBvlI Cranial Nerves I Olfactory II Optic III Oculomotor IV Trochlear V TRIGEMINAL VI Abducens VII FACIAL VIII Vestibulocochlear IX GLOSSOPHARYNGEAL X VAGUS XI ACCESSORY XII HYPOGLOSSAL  FACIAL (VII) Motor – facial expression GLOSSOPHARYNGEAL (IX) TRIGEMINAL (V) and some suprahyoid muscles, sublingual and Motor – stylopharyngeus, Motor – muscles of submandibular salivary parotid salivary gland mastication glands Sensory – soft palate, Sensory - face Sensory – taste anterior pharynx, posterior 2/3 1/3 of tongue tongue VAGUS (X) Motor – palate, ACCESSORY (XI) HYPOGLOSSAL (XII) pharyngeal constrictors, Motor – muscles that Motor – intrinsic and intrinsic laryngeal muscles control head and shoulder most extrinsic muscles of Sensory – glottis and movement the tongue laryngeal vestibule Function 1: functions of the nose Nasal cavity Functions: ▪ Air filtration ▪ Air warming and humidification ▪ Olfaction ▪ Resonance for speech Nasal turbinates or conchae increase surface area within the nose Heats air to within 1 degree of body temperature & humidifies Nasal cavity Vibrissae (short, coarse hairs) filter the air, removing dust and other particles Tiny cilia line the nasal cavity, covered in a layer of mucous Cilia transport the mucous posteriorly into the pharynx, where it is swallowed and digested Passage of air through the nasal cavity facilitates sense of smell, contributing greatly to taste Why does this matter to SLTs? Keep this in mind for our laryngectomees who no longer breathe through their nose……. Function 2: Speech Physiology of Speech Resonance Articulation Phonation (see 4) Respiration Oral anatomy Lips: Involved in articulation of consonants and vowels Maxilla (upper jaw) & hard palate: Separates oral and nasal cavities. Passive structure involved in swallowing and speech. Soft palate (‘velum’): Opens/closes the nasal cavity during speech; affects resonance/nasality of speech Mandible (lower jaw) & floor of mouth: Opens and closes oral cavity Active structure in swallowing and speech  Muscles of the Tongue for speech Dynamic interplay between intrinsic and extrinsic muscles for articulation of consonants and vowels. Subtle movements in lingual position and tension significantly affect articulation Intrinsic muscles – change the shape: Superior longitudinal muscle (curls tip and sides up) Transverse muscle (makes narrower and deeper shape) Vertical muscle (flattens shape) Extrinsic muscles – move the tongue: Genioglossus (protrusion) Styloglossus (raises sides & aids retraction) Palatoglossus (elevates posterior tongue) Hyoglossus (depresses and retracts tongue) Tongue Speech MRI of speaking: https://www.youtube.com/watch?v=qjJ-IcCbN6s MRI of opera: https://www.youtube.com/watch?v=f5SUhhfwxEI MRI of rapping: https://www.youtube.com/watch?v=PLTWtf6CTDM MRI of beat boxing: https://www.youtube.com/watch?v=yGV8az8npZU Function 3: swallowing Physiology of Swallowing Oral Phase Bolus formed Bolus moved posteriorly ready for swallowing Voluntary; breathing possible Pharyngeal Phase Swallow reflex triggered Pharyngeal constrictors contract to pull bolus through pharynx Soft palate raises to close off nasal cavity (and prevent food entering nose) Larynx elevates and moves anteriorly, epiglottis tips to close off airway like a trapdoor Laryngeal elevation and excursion pulls cricopharyngeal sphincter open Involuntary; breathing not possible Oesophageal Phase Bolus moves down oesophagus to stomach. Oral anatomy Lips: Spoon stripping, cup seal etc. Prevent loss of saliva, food and fluid during eating/drinking. Maxilla (upper jaw) & hard palate: Separates oral and nasal cavities Passive structure involved in swallowing Soft palate (‘velum’): Closes the nasal cavity during swallowing; prevents nasal regurgitation Mandible (lower jaw) & floor of mouth: Opens and closes oral cavity Active structure in swallowing ‘Floor of mouth’…….. …. or ceiling of larynx?! Tongue Taste (alongside olfaction and vision too) Tongue covered in small bumps (papillae), each containing 100s of taste buds, each containing taste receptor cells. 2-5,000 taste buds on tongue, as well on roof, back & sides of mouth and in pharynx Note the importance of olfaction (smell) in taste also – see ‘the nose’ Swallowing Assists in preparing food for swallowing, including chewing and cleaning the mouth afterwards of residue. Forms and moves the bolus posteriorly ready for swallowing Base of tongue elevates during chewing, then ramps, retracts and drives food/fluids into the oropharynx & pharynx Muscles of the Tongue for swallowing Intrinsic muscles – change the shape: Inferior longitudinal muscle (curls tip down) Superior longitudinal muscle (curls tip and sides up) Transverse muscle (makes narrower and deeper shape) Vertical muscle (flattens shape) Extrinsic muscles – move the tongue: Genioglossus (protrusion) Styloglossus (raises sides & aids retraction) Palatoglossus (elevates posterior tongue) Hyoglossus (depresses and retracts tongue) Function 4: functions of the larynx Larynx - Airway protection Biological - - - Strain/ bear down Respiration Sniff, cough etc Phonatory - Voice production - Pitch - Intonation - Loudness Emotional - - Voice quality Vegetative sounds & emotional vocalization (e.g. laugh, cry, gasp, sigh) Intrinsic Laryngeal Muscles Move the laryngeal cartilages in relation to each other. Control voice production (phonation) by altering the length, tension and shape of the vocal folds. Adduct and abduct the vocal folds for respiration and phonation. Intrinsic Laryngeal Muscles Thyroarytenoid (Vocalis) - Forms most of the structure of the vocal folds. - On contraction, reduces distance between thyroid and arytenoid cartilages and shortens vocal folds and increases bulk. - Involved in control of low pitch phonation. - Contributes to adduction of the vocal folds. Intrinsic Laryngeal Muscles Posterior Cricoarytenoid - Abducts the vocal folds. - Only muscle that abducts the vocal folds - Sometimes referred to as the ‘safety muscle’ of the larynx. Intrinsic Laryngeal Muscles Lateral Cricoarytenoid - Main adductor of the vocal folds - Pull the back edge of the arytenoids apart, thus front edge of the arytenoids (and therefore the vocal cords) together Intrinsic Laryngeal Muscles Cricothyroid - Tilts thyroid cartilage towards cricoid cartilage. - Lengthens and tenses vocal folds. - Important in increasing pitch. Intrinsic Laryngeal Muscles Interarytenoid Muscles - Pull the arytenoids together. - Contribute to vocal fold adduction. Intrinsic Laryngeal Muscles Ventricular Folds / False Vocal Folds - Also referred to as ‘Vestibular Folds’. - Superior and lateral to true vocal folds - Important for airway protection - Can become inappropriately involved in voice production in some voice disorders  Vocal fold movement (WAVE) 1. VFs approximate. 2-7. VFs resist airflow from the 1. 2. 3. 4. 5. lungs until subglottal pressure builds enough to cause the VFs to start to open. VFs open from bottom to top and anterior to posterior. 8-10. Natural elasticity of the VFs 6. 7. 8. 9. 10. causes them to start to return to their resting position. The lower border starts to close first. This repositioning of the vocal folds causes negative pressure between the VFs and an inward pull, which closes the VFs completely. This describes just ONE vibratory cycle of the VFs. Depending on the pitch of the voice being produced, this can happen hundreds of times per second. Videostroboscopy of the mucosal wave cycle can be viewed here: https://www.youtube.com/watch?v=mJedwz_r2Pc Knowledge review: By the end of today’s lecture (with some reading and consolidation) I can: 1. Describe the key features and functions of the: Skull & face Nasal cavity Oral cavity Pharynx Larynx 2. Briefly explain how voice and speech are produced 3. Briefly explain the swallowing process 4. Have a basic understanding on which to build in subsequent lectures 5. Begin to understand some of the more detailed elements of the anatomy and physiology References General head and neck anatomy: Seikel, J. A., King, D. W., & Drumwright, D. G. (2005). Anatomy and physiology for speech, language and hearing. Thomson Delmar Learning: New York. Fuller, D. R., Pimental, J. T., & Peregoy, B. M. (2012). Applied anatomy and physiology for speech-language pathology and audiology. Lippincott Williams & Wilkins: Philadelphia. Hutchinson, M., Mallatt, J., Marieb, E. & Wilhelm, P. (2010) A Brief Atlas of the Human Body (2md ed.) Pearson: Harlow (warning: photographs of cadavers!) Gardner, M. (1992) Basic anatomy of the head & neck. Lea & Febinger: Philadelphia. Atkinson, M. and McHanwell S. (2018) Basic Medical Science for Speech and Language Therapy Students 2018: 2nd edition. J & R Press. Laryngeal anatomy: AnatomyZone video – laryngeal cartilages - https://www.youtube.com/watch?v=Z3S2dD9BrSY Sapienza, C., & Hoffman Ruddy, B. (2009). Voice disorders. Plural Publishing: San Diego. Greene, M. C. L., & Mathieson, L. (2001). The voice and its disorders (6th edition). Whurr: London. Next week… Introduction to Head & Neck Cancers (*warning re: images and content) Make sure you are familiar with the basic anatomy (e.g. key regions and anatomical items, key elements of the mouth, larynx, physiology of speech and swallow) Suggested exercise for knowledge consolidation: Using the diagram on the title slide, explain the swallow and speech production processes to a friend, partner or relative, as if they are a patient. No need for jargon or infinite detail but point out relevant structures and explain basic functions. Head and Neck Cancer 2: Treatment options Louise Occomore-Kent SL2012/SLM102 By the end of this session, we’ll be able to:  Identify the different treatment options for head and neck cancer and their impact on speech and swallowing Treatment options  Radiotherapy  Chemotherapy  Chemoradiation  Surgery  Surgery + radiation/ chemotherapy  Treatments may be curative or palliative Effects of treatment on speech and swallowing iatrogenesis healer originating from Surgery Can be partial, hemi or total Depends on tumour size, location and function Surgical aims: ❑ Tumour excision with clear margins (≥ 5mm) ❑ Maintenance of function Surgery Vs. Primary Closure Reconstruction Tumour extracted Led by Plastic Surgery team, in and surrounding conjunction with treating team tissue pulled Involves importing tissue, usually across to cover containing a blood supply, from a wound ‘donor’ site, and ‘plumbing’ it in Effective only for to help reconstruct (microscopic small tumours anastomosis) Quicker healing time Blood supply is vital so that tissue Much less risk of remains ‘alive’ in new site healing complication Pedicled flaps vs free flaps (FF)  Surgery Blood supply and donor tissue measured by Doppler signal Flaps can ‘fail’ (die), usually requiring further surgery with new donor tissue Common donor sites include: Radial forearm (inner forearm) (RFFF) ALT (antero-lateral thigh) (ALTFF) Pectoralis major (chest) (PMPF) Scapula (back/shoulder) (SFF) Different tissues suited to different reconstructions. Donor tissue retains original properties, e.g. skin colour, texture, hair growth, tattoos etc. Effects of treatment on speech and swallowing: surgery  Change in anatomy  Loss of function  Swelling  Pain  Tracheostomy  Psychosocial issues Radiotherapy (RT) Can be given as a primary treatment or as an adjuvant treatment Kills cancerous cells using high-energy radiation; cells then regenerate with healthy tissue Also kills off many healthy cells, hence nasty side effects (‘toxicity’) Advancements in Radiotherapy (e.g. IMRT) have increased accuracy of RT treatment fields, so less healthy surrounding tissue affected. You can only have RT to the same area once. Effects continue after treatment has stopped Radiotherapy (RT) Usually delivered daily, 5 days per week over a period of several (e.g. 4-6) weeks if curative or ‘radical’ intent May be shorter and less frequent dose if palliative intent Dose measured in Gray (Gy), split into many treatments (fractions, #), e.g. 60Gy in 30# (6 weeks) Treatment accuracy is improved by use of a custom- created mask, which secures pt in stationary position Effects of treatment on speech and swallowing: radiotherapy  Mucositis  Pain  Erythema  Xerostomia/ altered saliva  Oedema  Fatigue  Fibrosis  Psychosocial issues Chemoradiotherapy (CRT) Chemotherapy is the use of cytotoxic drugs to destroy cancer cells In head and neck cancer, chemotherapy is used:  In combination with radiotherapy (‘concurrent chemotherapy’)  Before surgery to shrink a tumour (‘neoadjuvant’ chemotherapy)  To relieve symptoms and improve quality of life (palliative) Chemotherapy is not commonly used on its own as a primary treatment for head & neck cancers  However, is sometimes used alongside RT to increase the sensitivity of the tumour to RT (i.e. Radiosensitiser) Chemoradiotherapy (CRT) Usually delivered for one day per week, intravenously (e.g. on chemo day unit) Not associated with the hair loss - often accompanied by nausea Only usually used with relatively young, fit patients (typically age P propulsion Positioning Placement of bolus Textural mods Fluid flushes Lip closure Positioning Placement of bolus Digital assistance Nasal regurgitation Positioning, textural mods Therabite Types of intervention: dysphagia Possible problems Intervention suggestions (pharyngeal stage) Reduced airway protection/ Manoeuvres late or incomplete vocal fold Head position closure Reduced base of tongue Positioning, textural retraction modification Reduced hyolaryngeal Manoeuvres elevation and excursion Head position Pooling/ residue Head position, digital removal, positioning of bolus, fluid flush, textural modification Odynophagia Texture modification Medical mgmt.  The Core HNC Team Clinical Nurse SLT Specialist Dietitian Clinical Oncologist Person with H+N HNC and Radiologist Therapeutic their family Radiographer Palliative Restorative care team Surgeons Dentist (ENT/OMFS/ plastics) Improving Outcomes in Head and Neck Cancer, NICE, 2004 Summary of what we have learned today A typical pathway  Which professionals we work with  When we may assess  When we may intervene  Examples of interventions Before next week  Consolidate your knowledge with some self-directed learning  Some ideas:  Take the quiz on Moodle for week 2 to check your knowledge (optional)  Work through the glossectomy case study on week 2 of Moodle  Watch the videos on Moodle of service-users talking about their experience of HNC if you haven’t already  Head and Neck Cancer 1: risk factors, staging and tumour sites Louise Occomore-Kent Senior Lecturer SL2012/SLM102 By the end of this session, we’ll be able to:  List the risk factors for head and neck cancers  Describe the staging system and typical pathway  Outline different types of head and neck cancer and briefly how they impact on speech and swallowing Risk factors for head and neck cancer but also:  Epstein-Barr Virus (EBV)  Sex (more common in men)  Age (more common over the age of 40)  Environmental/ occupational e.g. wood dust  Nutrition e.g. Salted fish  GERD and  Weakened immune system  Exposure to radiation incl. sun exposure  Previous history of head and neck cancer  Human papillomavirus (HPV) Anatomic sites  Lip  Tongue  Base of tongue  Floor of mouth  Salivary glands  Nasal cavity  Nasopharynx  Oropharynx  Hypopharynx  Larynx (supraglottic/ glottic/ subglottic) Staging of tumours T N M Primary Node Metastasis Tumour involvement 0/1 1-4 0-3 - Note: x may be used to signify that one part of the staging is currently unknown - Note: letters such as ‘r’ or ‘p’ may precede the staging. This tells us how the tumour was staged e.g. radiologically or pathologically Lymph nodes  Lymph nodes are part of the body’s lymph system  Several groups of nodes (small bean/grape-shaped nodes) positioned around our body in areas such as neck, armpit, groin, chest  Part of the immune system  Help to fight infection and inflammation An example of patient journey Pt notices persistent ‘red flag’ symptom such as hoarseness of voice/dysphagia/pain on swallow/non-healing ulcer/lump/neck lump GP refers under 2 week wait cancer pathway http://www.nice.org.uk/guidance/ng12 Examined by OMFS (visual inspection) or ENT (visual or nasendoscopy), may take FNA at same time Sent for EUA +/- biopsy if clear lump to sample > Biopsy is positive Usually sent for CT with contrast and/or PET to confirm size & location, and establish ?metastases Clinical presentation + histopathology + radiology are discussed at multidisciplinary meeting Treatment (surgery and/or radiotherapy OR palliative care (comfort approach) 5 year follow up If any signs of recurrence A word about brain tumours…  Glioblastoma  Neuroblastoma  Astrocytoma  Meningioma  Metastases (e.g from lung Ca, breast Ca) Cause neurological speech, language and swallowing difficulties. These are not HNC and would be seen by a neuro oncology multi-disciplinary team. Effects of tumour on speech/ swallowing  Structural changes to articulators  Structural changes to resonance chambers  Structural changes to swallowing mechanism  Space-occupying lesions may disrupt the breathing/ swallowing/ phonation process  Pain, appetite, weight, etc. Summary  Sites and stages of tumours  Risk factors for head and neck cancers  Patient pathway  Potential effect of tumour on speech and/ or swallowing Laryngectomy Louise Occomore-Kent and surgical voice [email protected] SLM102/SL2012 Biomed Lecture 3 restoration (SVR) Part 1: what is a laryngectomy?  Laryngeal cancer T1, T2 (or sometimes T3) T3 or T4 Radiotherapy or Chemoradiotherapy Laryngectomy No recurrence Recurrence Post-op RT or CRT No post-op RT or CRT What is laryngectomy? A surgical treatment for laryngeal cancer May be the first (‘primary’) choice of treatment (e.g. for large laryngeal tumours, e.g. T3 or T4) OR May be used if there is recurrence after a primary treatment (e.g. RT). This would be called ‘salvage surgery’ OR May be used if there is recurrence after a primary treatment (e.g. RT). This would be called ‘salvage surgery’ May be used in the case of a ‘non-functioning larynx’ Is carried out by an ENT Surgeon (with Plastic Surgeon if reconstruction is required) Understanding the anatomical changes You need to be clear on: Normal laryngeal anatomy Key changes after laryngectomy The impact of these changes on function Respiratory Olfactory Voicing Swallowing Key anatomical changes - 1 Removal of the entire larynx, including: hyoid bone thyroid cartilage cricoid cartilage epiglottis true and false vocal cords arytenoids (and sometimes thyroid gland) Neck dissection is also often performed at the same time Key anatomical changes - 2 The trachea is brought forward A tracheal ring is sutured to the anterior neck (in the clavicular notch), which forms the basis of the permanent neck stoma (hole), which pt breathes through The ‘neopharynx’ is stitched up to form one continuous tube from mouth to oesophagus (i.e. no connection to airway) Total separation of the breathing and swallowing systems Key anatomical changes - 3 May or may not require flap reconstruction to rebuild the new pharynx (depending on what needs to be excised) Creation of a pulmonary-oesophageal (PE) segment (a narrowing) somewhere between C4 and C7 (approx 1 vertebrae in length) Myotomy (cutting) of the cricopharyngeal sphincter (see later slides) Myotomy of the sternocleidomastoids to create flat neck profile Part 2: Communication options after laryngectomy Communication options after laryngectomy Summary: https://www.youtube.com/watch?v=Qdbg_DZqe3g Tracheoesophageal speech Electrolarynx (voice prosthesis) Oesophageal speech Mouthing/silent articulation Gesture/Writing/AAC  Electrolarynx Electronic device Battery operated (rechargeable) Has a vibrating membrane Membrane placed against skin of neck, under chin or on cheek Vibration passes into pharynx/oral cavity and is shaped into speech Does NOT require breath support  Electrolarynx Intelligibility depends on: Good placement, Good seal against skin Tissue quality Articulation Reduction of stoma blast One hand and charged batteries required! Quite electronic sound, monotone, limited volume Different models available (some with pitch and volume control functions) https://www.youtube.com/watch?v=AYydnhu6NbU  Oesophageal speech Air is injected purposefully into the new pharynx via the mouth ( via tongue/lip movement/ negative pressure) Air is brought back up, causing vibration in pharynx In simplistic terms, a bit like burp speech (but air does not pass down into oesophagus, only into neopharynx) https://www.youtube.com/watch?v=6KIAb58WhV0 https://www.youtube.com/watch?v=kyN_NFoBfiw https://www.youtube.com/watch?v=UTLg-2N4hyw  Oesophageal speech Takes time and practice to build up phrase length and to inject air quickly enough Some people can inject air very subtly and quickly Not dependent on pulmonary air support Requires good articulation Difficult to achieve good volume Handsfree and does not require batteries! Can’t eat and speak at the same time Tracheoesophageal (TE) speech  The ‘gold standard’ for voice restoration  A puncture (hole) is made in the party wall between trachea and oesophagus.  This hole is called a tracheoesophageal ‘tract’, ‘puncture’ or ‘fistula’ or TEP  A small silicone voice prosthesis (often called a ‘valve’) is inserted into the tract  Tracheoesophageal (TE) speech To speak: 1. Breathe in 2. As you breathe out cover stoma with finger (or press in HME cassette 3. Air is diverted through valve 4. Air vibrates behind valve (in pulmonary-oesophageal segment) 5. The vibration travels up into the mouth where it is shaped into speech sounds The voice prosthesis  Made of silicon  Has a flange (disk) on the front and back.  These flanges lay flat on the posterior tracheal wall and anterior oesophageal wall, acting as ‘stoppers’ to keep the valve in place and prevent it becoming dislodged.  The middle portion of the valve is a hollow tube, which contains a one way flapper  Flapper opens backward, allowing air from trachea into oesophagus BUT does not open forward, which prevents food, drink or saliva entering the airway (being aspirated)  The voice prosthesis  The voice prosthesis needs to be changed every few months when it ‘fails’ (average 2-6 months)  When it fails, the flapper stops doing its job and fluid leaks forward through the valve Can be due to candida growth on the oesophageal side  Pt phones/emails SLT/CNS – try to change ASAP (i.e. within 24 hours)  OR some patients can change their own valve (depends on the type, and the patient) Tracheoesophageal (TE) speech  Pt may have a plug to insert while eating/drinking to prevent aspiration  Many types of valve available (different properties)  Different diameters and lengths, depending on tract diameter and party wall length. Needs to be a good fit to prevent leak around and/or displacement Common myths: That the valve produces a sound - It does not, it simply transmits air into the reconstructed pharynx, where it vibrates. That ‘pushing the button’ is what makes the sound - Pressing the HME cassette in does not make a sound, it just prevents air escaping from the stoma and sends it back through the valve Tracheoesophageal (TE) speech Requires: Good pulmonary air support Hand to occlude (cover) stoma and good timing of stoma occlusion Good articulation Daily cleaning, good eyesight and dexterity (or supportive caregiver) Handsfree kit available. Requires very good baseplate seal. Tracheoesophageal (TE) speech Voice quality depends on the ‘tonicity’ of the PE segment. Can be: hypotonic (loose – creates wet, rough sounding voice), hypertonic (tight - creates strained-sounding voice) or tonic (in between). ST0PS rating system.  Tracheoesophageal (TE) speech Valve can block with secretions or food. Needs cleaning in order to start speaking again Can’t eat and speak at the same time Can be susceptible to spasm/stricture in the PE segment which interrupts vibration for voicing. May be treated with botulinum toxin, dilatation or laser. The neo-pharynx needs to be healed from surgery before introducing voicing. Pt typically has a water-soluble contrast swallow (x-ray while swallowing dye) on day 7 post surgery. If all healed pt can start voicing. If not, wait and repeat. Usually a feeding tube keeps the puncture open immediately post-operatively Silent articulation No vibratory source Uses only voiceless sounds Relies on consonants Plosives easiest, followed by fricatives Requires exaggeration of articulation and slow rate Usually requires some degree of lip reading by the listener Very difficult against background noise or when not face-to-face  Summary of speech/voice options Electrolarynx Oesophageal speech Tracheo-oesophageal Silent articulation speech (voice prosthesis) Airflow source Vibratory source Articulators (Sound shaper) Additional equipment required Strengths Limitations Identifying type of speech What can you see? Think about: Electrolarynx? What might be the challenges for patients using these Using finger to occlude methods of speech? stoma? How are they similar of different to one another? Handsfree? What strategies might the patient use? Swallowing air? What support might they require from a conversation What can you hear? partner? Electronic? What is it like communicating after laryngectomy? Rough/deep? Watch this video and try to identify each No vibration communication type: https://www.youtube.com/watch?v=R4azcU6i2IE  Louise Occomore-Kent SL2012/SLM102 An introduction to Slides adapted from North West Regional Trache Group (2010) TRACHEOSTOMY TRAINING RESOURCES: A guide to tracheostomy tracheostomy management in Critical Care and beyond. National Tracheostomy Safety Project (NTSP): www.tracheostomy.org.uk Part 1: what is a tracheostomy? Learning outcomes Understand how tracheostomy alters the physiology of Respiration Speech Swallow Understand the key differences between tracheostomy and laryngectomy Gain an overview of how tracheostomies are managed Gain an overview of how a patient would be ‘weaned’ from a tracheostomy What is a trachestomy? (& why) -1 A trachestomy or ‘trache’ (pronounced ‘tracky’) is an artificial opening made in the neck. Usually this is between the second and third tracheal tings. It is performed for the purpose of: 1. Securing and maintaining a safe airway in patients with injuries to the face, head or neck following certain types of surgery to the head and neck (often called a ‘covering trache’) Pharyngeal, laryngeal or tracheal obstruction What is a trachestomy? (& why) -2 2. Establishing a SAFE AIRWAY to allow air passage to lungs e.g. choking, severe anaphylaxis causing obstruction of oral cavity/pharynx/larynx, airway obstructing tumour 3. Enabling long-term mechanical ventilation of patients in an acute ICU setting. 4. Facilitating mechanical ventilation in the longer term 5. Facilitating the removal of respiratory secretions where independent clearance or cough are poor 6. Protecting the airway of patients who are at high risk of aspiration of saliva (i.e. patients with poor laryngeal and tongue movement on swallowing e.g. neuromuscular disorders, unconsciousness, head injuries, stroke etc) Types of trache procedure Temporary vs long term Elective or emergency Surgical or percutaneous (‘bedside’)  Temporary vs long term Temporary: When patients require long/short term respiratory support or cannot maintain the patency of their own airway. E. g. Certain maxillofacial or ENT surgical procedures These tubes will be removed when the patient recovers. Long term/permanent: May be due to: Carcinoma of the nasopharynx or larynx, or long-term laryngeal anatomical changes. Need for long term respiratory support (e.g. ventilation) Long term severe dysphagia (inc aspiration of saliva) In long-term cases, a ’functional’ laryngectomy may be considered (as it is often more straightforward to manage) Elective vs emergency procedure Planned tracheostomy (usually surgically inserted): e.g. to support a safe airway during surgery For planned or expected tracheostomies Emergency tracheostomy (may be percutaneous/’bedside’): Due to a sudden, acute need to establish a safe airway E.g. choking, anaphylaxis Understanding the anatomy Understanding the anatomy Image shows cuffed trache tube with cuff inflated Key points – tracheostomy TUBE The trache is usually inserted between the second and third tracheal rings Nothing is removed with a trachestomy An incision is made into the neck into which a trachestomy tube is placed The tube is usually lightly sutured (stitched) in place The tracheostomy tube is curved and open at both ends One opening sits external to the neck, and the other sits pointing down inside the trachea The trachestomy tube is BELOW the larynx  Key points – anatomy and tube Respiratory secretions will be coughed in to the tube (or out the end of it if good cough strength) Air flows in through the tube, down to the lungs, and back out of the tube No airflow through nose and mouth (see later discussion re: cuff/fenestration) – altered resus protocol Tube is secured with tapes around the neck Usually a square of dressing under the tube Usually a blue box at bedside containing necessary equipment and bed sign alerting staff to trache status Part 2: types of tube  Images left to right: Fenestrated uncuffed outer tube/cannula Inner tube Understanding trache tubes Introducer Lots of different types of tube (different brands) – paediatric and adult Different lengths and diameters Can be one single tube OR (more commonly) have an outer tube and inner tube (tube may be referred to as ‘cannula’) Can be cuffed OR uncuffed (if cuffed, the cuff can be up or down) Can be fenestrated (rarer now in clinical practice esp. for first tube) Inserted with an introducer which is removed immediately on insertion (and usually discarded) Single vs double cannula Single cannula tube – used mainly immediately post insertion. Most patients will changed to a double cannula tube very quickly due to safety Risk: what happens if a single cannula blocks with secretions? Double cannula tube – has an outer tube and an inner tube which fits inside Q: What is the function of the inner tube? Every outer tube (the part that is sutured in place) comes with TWO inner tubes Purpose of inner tube: if fills with secretions, can be easily replaced Always wash inner tube straight away and keep the spare by the bedside Outer tube of cuffed trache tube and 2 x inner tube Uncuffed or cuffed Balloon  Uncuffed tube Uncuffed tube: A little air can travel past the tube on exhalation Requires a safe swallow (on secretions) to tolerate (as aspirated saliva/fluid would go down past the trache) Patient with uncuffed tube may be appropriate for oral intake (if safe swallow ) Cuffed tube Cuffed tube: The cuff is a circular inflatable band which sits around the inferior end of the trache tube It acts as a stopper by creating a full seal with the internal tracheal wall Balloon No air can go past the trache tube Indicated for pressure ventilation OR if risk of aspiration of saliva Aspirated saliva would get caught above the cuff NIL BY MOUTH (due to tight seal of cuff in trachea) DO NOT OCCLUDE TRACHE TUBE (no airflow via mouth or nose) Cuffed tube Cuffed tube: Balloon The cuff can be inflated or deflated Inflated: When the cuff is inflated, the external ‘pilot’ balloon will also be inflated (balloon just acts as a visible sign of cuff status) The cuff pressure must be correct to maintain the right seal but avoid excessive pressure on inner trachea Cuff pressure is measured by a manometer – connect it to the pilot balloon, should read within the green zone Often now an adaptor in place for infection control if manometers are shared between patients Cuff is inflated and deflated using a 10ml syringe with some room air Cuffed tube Subglottic port – a thin tube which allows you to suction any material that has collected above the cuff (should be done regularly and recorded) (note: the subglottic port is above the cuff but below the glottis) Gives a good indication of whether pt is aspirating saliva Before deflating the cuff, you should suction any material from subglottic port (so that it doesn’t drop down into lungs) Note: Long term cuff inflation can reduce laryngeal and upper tracheal sensation (inc reducing cough sensitivity). Also consider laryngeal disuse-dysfunction. Recap Cuff status Indications Uncuffed Can be used if pt is not at risk of aspirating saliva Can often voice (with occlusion or speaking valve) May cough respiratory secretions into tube and/or mouth May be able to eat and drink orally if safe Cuffed Cuff up: Used if pt needing positive pressure ventilation / Low awareness states Used if pt at risk of aspiration on saliva or gastric contents (cuff catches any aspirated material) No airflow through nose or mouth Nil by mouth Cuff down: If able to manage own saliva for short periods Consider move to uncuffed tube when consistently managing this May be able to voice (with occlusion or speaking valve) May be able to eat and drink orally if safe Tracheostomy vs laryngectomy Similarities Tracheostomy Laryngectomy Altered airway – breathe through neck May be unable to speak Resus via neck Chest secretions cleared via neck Require HME system of some kind Vulnerable to water entry Vulnerable to secretion build up and potential block off Poor public and medical awareness!  Tracheostomy vs laryngectomy Differences Tracheostomy tube Laryngectomy tubes Tracheostomy Laryngectomy All structures remain present and Removal of larynx and surrounding structures anatomically intact Needs tube in place 24/7 Most do not need tube use, and some just at night, for example High risk of losing airway if tube removed Permeant stoma No immediate risk if tube removed Likely to need regular suction Can usually cough out of stoma Inner tube inside main tube Single tube (if worn) May achieve airflow through larynx and No airflow through nose and mouth (unless tracheoesophageal speech) mouth/nose (if uncuffed/cuff down) Risk of aspiration No risk of aspiration (unless valve leaking) Voice may be produced by vocal cords No vocal cords; requires alternative vibratory source Common safety & troubleshooting issues Issue Steps Pt struggling to breathe or Change inner cannula +coughing due to Trache tube Ask nurse for suction blocking with secretions Check adequately humidified Nebulisers Chest physio Urgent help if unable to resolve Pt +coughing (not due to secretion Check recommended cuff status block or oral intake) Check cuff is correctly inflated/deflated Trache tube displaced EMERGENCY CALL OUT N.B. trache stoma closes up quickly once tube displaced, unlike laryngectomy Respiratory arrest EMERGENCY CRASH CALL See flowchart in NW Trache Group (2010) doc  SLM112/SL2012 Tracheostomy Lecture 4 - Part 3: Weaning and SLT Functions With thanks to Louise Occomore-Kent for the original content and design of these slides which have been adapted and delivered by Kat Wozniak-Potter [email protected]  Weaning What is weaning? Gradual movement towards decannulation (removing the tube) by: Reducing a patient’s dependence on the cuff Introducing a one-way valve or “speaking” valve SLTs usually lead the wean for ENT traches Critical Care traches/Non-ENT traches are usually jointly managed by the MDT (SLT, Physio, Trache Specialist Nurse and Anaesthetist/Critical Care Consultant) Weaning Key question: how long has the trache been in situ and has the main reason for insertion of the trache improved or resolved? Is the patient generally medically stable/on an upward trajectory? 1. Is the patient managing their own saliva and secretions? e.g. How much suctioning are they requiring? (think oral, subglottic & chest secretions) Are they able to cough into/out of the tube? How much is being suctioned from the subglottic port, if there is one? Weaning 2. Cuff deflation trial (+/- speaking valve trial) Once oral and subglottic secretions are removed… Deflate cuff with 10ml syringe (as shown in video) with simultaneous tracheal suctioning (2 people required). Observe pt +closely (visual, SpO2), are they swallowing their saliva? If they de-saturate, start coughing++, can’t clear secretions or aren’t swallowing saliva, reinflate the cuff. If they stabilise consider progressing to the next stage (one- way valve/speaking valve trial) Weaning 3. Speaking valve trial Before placing the speaking valve, complete digital finger occlusion to assess airflow & patency of the upper airway Can they breathe comfortably if you occlude the tube, do their observations remain stable e.g. SpO2, respiratory rate etc. Are they able to voice? If not, why? (Tube size? Respiratory strength/effort? Laryngeal function? Fatigue?) May tolerate for a certain time then fatigue. Need to start with short periods and work up gradually.  EXAMPLE TRACHEOSTOMY Weaning RECOMMENDATIONS -15 mins cuff down & one-way 4. Set a regimen / weaning plan valve/speaking valve; x 3 daily Are they appropriate to commence a weaning plan? -Please remove the speaking valve (therapeutic vs. wean) and re-inflate the cuff if any of the If so, how many times per day following signs are observed: cuff deflation & speaking valve? Who with? (SLT-led or nurse-led) -Persistent wet upper For how long? airway sounds/wet voice What to look for? (Set limits) and unable to clear What to do if pt not tolerating? -Observations consistently Nighttime? outside of normal limits Oral intake assessment? (e.g. SpO2 20) Consider the benefits & risks of -Patient is visibly all the above uncomfortable or distressed  Fenestrated vs unfenestrated Fenestration is the name for hole(s) on the bend of the tube. Allows more airflow up into the larynx (i.e. through holes in tube not just around tube (if uncuffed/ cuff down)) Two inner tubes: Fenestrated – required to obtain benefits of fenestration (holes align) Unfenestrated – for suctioning; blocks off fenestration function or for cuff up periods) Risk of granulation forming against or into fenestrations Fenestrations need to sit in the right place to be effective Not recommended where cuff inflation is required, as aspirated material can pass through fenestrations. Impact of tracheostomy on respiration Air bypasses nose and mouth when the cuff is inflated Impact on smell Air is not filtered, warmed and humidified Needs external humidification otherwise secretions become very thick, sticky and dry Dry/sticky secretions can block/occlude trache tube and cause TrachPhone respiratory distress. May be fatal if not cleared as secretions can fully plug trache tube or trachea below tube. Need to wear a HME system that fits on to the end of the tube, e.g. Swedish Nose or TrachPhone. Contains foam (NB these are banned in some hospitals due to plugging risk and a trache mask with humidified and sometimes warmed circuit may be used for self-ventilating patients) Swedish Nose Impact of tracheostomy on respiration HME bib is an option but doesn’t sit flush due to proud trache tube Likely to need regular nebulisers (trache not face mask) Likely to need regular suction to clear secretions from bronchi at TrachPhone least initially Some patients with good cough can cough up secretions: into tube (in which case change inner cannula) out the end of the tube (in which case can wipe with tissue) Swedish Nose Nebuliser with trache mask Deep suction Impact on voice Cuffed (cuff up): It is not possible to make voice while cuff is inflated (as no airflow can pass around the tube and through the glottis; all airflow is through tube) DO NOT PUT ON SPEAKING VALVE AS PT WILL BE UNABLE TO BREATHE OUT Uncuffed (or cuff down): Voice may be possible with cuff down or uncuffed tube (as long as air can flow around the tube in the space between the outer tube and the tracheal walls). May be better with fenestrated tube (as air can also flow through tube). Also consider downsizing. Trache tube needs to be occluded to produce voice. Stops air escaping through tube. Air then flows around trache tube and up into larynx and over vocal folds as usual Voice will sound like pt’s usual voice, but may be weaker due to reduced airflow Also consider time that voice has been out of use (disuse atrophy, secretions etc.) Speaking valves Common types are Passy Muir and Rusch valves Allows inspiration through the speaking valve Closes off on expiration to occlude trache tube and force air up around the trache tube and through the glottis DO NOT USE WITH CUFF UP (pt will be unable to breathe out and this will be fatal) Rebalances respiratory and pharyngeal/laryngeal pressures to help improve respiratory and swallow function Will close off on coughing so secretions will come up into mouth (Can sometimes ping off with a strong cough so twist slightly as you put it on!)  Impact on swallow Pt’s usually NBM when cuff up (as swallowing w cuff up may cause trauma in trachea and impede oesophageal dilation, absence of airflow to upper respiratory tract results in reduced sensation) When regularly tolerating cuff down & speaking valve, may be suitable for swallow Ax Aspiration has been reported in up to 85% of tracheostomy patients. (NW Trache group, 2010) Consider dysphagia as product of primary aetiology (e.g. CVA, TBI, spinal injury, H&N ca/Surgery) as well as the impact of trache Can be difficult to effectively palpate larynx May benefit from instrumental swallow Ax such as FEES or sometime Videofluorscopy When thinking about swallow and trache management, consider reason for trache! E.g. CVA w aspiration of fluids vs large glottal tumour causing airway obstruction Impact on swallow Swallowing assessment starts with salivary secretions. Signs of aspiration of secretions may include: Secretions/saliva suctioned from subglottic port Not tolerating cuff deflation due to unmanageable saliva and/or wet voice when cuff deflated Signs of aspiration on oral intake may include: Usual signs of aspiration on/after oral intake – coughing, increased facial colour, wet voice, increased resp rate, decreased SpO2 after oral intake, etc Suctioning of food or fluids via the trache tube directly out of the trachea/bronchi Impact on swallow N.B. ‘Blue dye test’ This used to be implemented to detect aspiration. Pt given fluids which were dyed blue If evidence of blue fluids around trache tube or suctioned, this was seen to indicate aspiration. If no blue, may be considered safe. No longer used due to high false negative rate i.e. just because there is no blue dye, it doesn’t mean there is no aspiration!  SLT role Communication: Trache care: Swallow: Facilitating communication while Joint working with Trache Discussions around unable to voice Team and Physio (esp Chest secretion/saliva management Physio)* E.g. AAC (communication charts, Swallow assessment if cuff alphabet charts, eye gaze, Involvement with weaning down/uncuffed signs/gestures, electrolarynx) (cuff deflation trials, speaking valve trials) Instrumental swallow assessment Speaking valve trials (uncuffed or Patient and relative Swallow rehab cuff down) education Communication support/therapy Patient and relative education Staff education as part of other conditions (e.g. Staff education CVA, TBI, H&N) Patient & relative education Staff education * In head and neck/ENT traches, the physio and Trache Team are rarely involved. The SLT and surgical team manage the wean. References and further reading Great, clear summaries of key features/issues: https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy- guidelines/indications/ National Tracheostomy Safety Project (NTSP) https://tracheostomy.org.uk/resources/documents RSCLT (2014) Tracheostomy Competency Framework https://www.rcslt.org/members/publications/publications2/tracheostomy_comp etency_framework Some videos for more information (NB: these contain videos of invasive procedures with real service-users) Deep suction demo https://www.youtube.com/watch?v=lGpfuHdrUgk SLT deflating a cuff (after suctioning the subglottic port) in a ventilated patient while Nurse performs closed deep suction https://www.youtube.com/watch?v=AZSmiBPZnCY Emergency procedure for tracheostomy https://www.youtube.com/watch?v=Qu7M-LPAufI Above cuff vocalisation (ACV) (using the subglottic port to pass oxygen through the vocal folds in a cuffed and ventilated patient) https://www.youtube.com/watch?v=IAcfufLvM-c Demo of various types of humidification: https://www.youtube.com/watch?v=WuEQt6n_vOU Communication impact after a tracheostomy: https://www.youtube.com/watch?v=1EblS4HSeyE  The Ear Paul Turner City, University of London SL2012 / SLM112 Learning Outcomes At the end of the lecture you should have a basic understanding of: ◼ Auditory anatomy and physiology ◼ Medical and surgical aspects of disorders of the ear and hearing ◼ Prevalence of hearing loss ◼ Hearing testing (audiometry) ◼ Hearing disorders and speech perception 2  General Structure and Function of the Outer, Middle and Inner Ear ◼ The ear can be divided into the outer, middle and inner ears The ear 1. O,M,I 3 2. Wave  Outer Ear Structure: The outer ear consists of the auricle or pinna and external auditory meatus. Acoustic characteristics & function: ◼ Collects sound ◼ Ear canal resonates and so increases the sound level at the tympanic membrane (eardrum) - Question: What is resonance? ◼ Aids sound localisation 4  Tympanic Membrane Structure ◼ The tympanic membrane is made up of a thin fibrous layer covered by skin on the outside and mucosa on the internal surface. ◼ The fibrous layer extends throughout the pars tensa (but not the pars flaccida). The Tympanic Membrane The TM vibrates back and forth with incoming compressions and rarefactions of the sound wave. 6  The Middle Ear ◼ The middle ear is an air-filled chamber situated between the ear canal and the inner ear. ◼ Connected to naso-pharynx via the Eustachian tube. ◼ The auditory ossicles, (malleus, incus and stapes) form a chain which connect the tympanic membrane with the oval window of the cochlea. The ear ME front/back ani, 7 slow/fast, video Three Little Bones 8 Function of Middle Ear ◼ The middle ear serves to deliver sound efficiently to the (fluid filled) cochlea, by reducing the amount of sound energy that is reflected away. ◼ This efficient sound transfer through the middle ear enables us to hear up to about 28dB better, as compared to not having middle ears. 9 The Eustachian Tube Connects the middle ear with the naso-pharynx Diagram to show nasopharyngeal orifice 10  Function of the Eustachian Tube The main function of the Eustachian Tube is to aerate the middle ear so that the pressure in the middle ear remains the same as the atmospheric pressure. (ET blockage is common in children which leads to middle ear problems).  The Inner Ear ◼ The inner ear is called the labyrinth because of the complexity of its shape. ◼ It comprises the balance organs and the hearing organ, the cochlea. 12  Sound Transmission to the Inner Ear ◼ The cochlea is a long, coiled, fluid- filled tube (about 33mm long in humans) that is divided along most of its length into three sections: the scala vestibuli, scala tympani and scala media which contains the basilar Diagram showing movement of membrane and pressure waves through cochlea sensory hair cells. 13  Sound Transmission to the Inner Ear ◼ The stapes pushes against the oval window of the cochlea. ◼ Causes fluid in cochlea to vibrate at the same frequency as the sound and sets up ‘travelling waves’ in the basilar membrane. (The BM runs along the length of the spiral cochlea). ◼ Pressure relieved by bulging round window. 14  Travelling Waves ▪ Each location along the BM responds best to a small range of sound frequencies. The base of the cochlea (near the oval window) responds to high frequencies and the apex to low frequencies. ▪ The travelling wave peaks at the part of the BM which is tuned to the stimulus frequency and then dies away. The ear Inner cutaway, H,M,L,all Travelling Wave and Frequency The main factor which changes the tuning along the basilar membrane is the variation in its width and the related change in effective stiffness from base to apex. 16 Travelling Wave and Frequency ◼ Tuning of the Basilar Membrane ◼ CochleaWeb 17 A Speech Example: Travelling Waves and Vowel Sounds High frequency components are processed at the base, low frequency components at the apex. 18  Cross Section Through a Single Turn of the Cochlea The cochlear duct (1) The scala vestibuli (2) The scala tympani (3) The spiral ganglion (4) The auditory nerve fibres (5) The ear Slice view H,M,L,all 19 Anatomy of the Organ of Corti ◼ The organ of Corti is the sensitive element in the inner ear and can be thought of as the body's microphone (as like a microphone it converts sound waves into electrical signals). ◼ It is situated on the basilar membrane. ◼ It contains rows of hair cells. ◼ Above them is the tectorial membrane. 20  Organ of Corti The ear One turn view wave O of C wave 21 Organ of Corti Showing rows of inner and out hair cells and their associated 22 neurons  Hair Cells ◼ There are two kinds of hair cells in the organ of Corti: inner hair cells (IHC) and outer hair cells (OHC). ◼ Normally there is a single row of IHCs and three rows of OHCs. In humans there are approximately 3,500 IHCs and 12,000 OHCs per cochlea. ◼ IHCs are innervated by afferent neurons. ◼ OHCs are innervated by efferent neurons. 23 Hair Cells Mag ~ 1000x (on handout) 24  Roles of Inner and Outer Hair Cells ◼ When sound waves cause the basilar membrane to move up and down the inner hair cell stereocilia are deflected which causes the hair cell to fire and a signal is sent up the auditory pathway to the auditory cortex – you hear the sound! ◼ Outer hair cells act to fine tune the cochlea's frequency selectivity and increase the dynamic range. ◼ They do this by physically expanding and contracting pulling the basilar and tectorial membranes together and apart and so increasing Inner hair cell the stimulation of the inner hair cells. 25 Innervation of the Whole Inner Ear The afferent and efferent neurons together form the cochlear division of the eighth cranial nerve. 26  The Cochlea to Brain Transmission System ◼ 30,000 nerve fibres form the auditory nerve. ◼ The fibres are grouped by the frequency of the sound signal they carry, the number of fibres a sound requires gives the brain a gauge of its intensity. ◼ The nerve fibres carrying sound signals lead to different parts of the auditory cortex depending on the frequencies they carry. ◼ The auditory cortex lies in a deep furrow in the brain called the Sylvian fissure. The high tones terminate deep within the Sylvian fissure while the low tones end near the outer surface. 27 Auditory Pathway Ear disorders 28 Hearing Loss Conductive v Sensori- neural Hearing Loss ◼ Conductive hearing loss - caused by a problem conducting sound through the outer or middle ear. ◼ Sensorineural hearing loss - caused by inner ear or auditory nerve dysfunction. 29  Conductive Hearing Loss (CHL) Incidence and Prevalence of Conductive Hearing Loss in Children ◼ Conductive hearing loss in children is extremely common: ◼ Cumulative incidence birth to 6yrs is 80%. ◼ Prevalence: up to 20% of children under 6 might be expected to fail a sweep test due to a mild/moderate hearing loss caused by a conductive loss in the winter, 10% in the summer (Haggard et al, 2004). ◼ This is usually temporary and far fewer children require active treatment. Significant conductive hearing losses are likely to persist in 5% of children. ◼ Some children are at an increased risk of conductive loss such as those with Down’s syndrome or cleft palate. 30 CHL / Outer Ear Pathologies – Wax 31  CHL / Outer Ear Pathologies - Otitis Externa (bacterial, viral, fungal) OE is an outer ear pathology, but does not necessarily affect hearing. Viral OE Fungal OE 32  CHL / Middle Ear Pathologies - Glue Ear ◼ Otitis media with effusion, or glue ear, is characterised by the presence of thick sticky, mucoid effusion in the middle ear. Aetiology ▪ Caused by prolonged failure of the Eustachian tube to aerate the middle ear (ET blockage). Often develops after a cold or middle ear infection (acute otitis media), but not an infection in itself. Presentation ▪ Hearing loss, discomfort, a blocked feeling. In children: inattentive, possibly slow speech/language development in chronic cases. 33  CHL / Middle Ear Pathologies - Glue Ear Management ▪ ‘Watchful waiting’ + allergy tests / advice on dust / avoid exposure to cigarette smoke. Can be slow to resolve (40% in 1 month, 65% in 2 months, 75% in 3 months) and may reoccur. ▪ If the problem does not resolve, a myringotomy may be performed, the fluid removed and a grommet inserted. OME otoscopic appearance https://www.nhs.uk/conditions/glue-ear/ CHL / Middle Ear Pathologies – Glue Ear Management Grommets ◼ Keep the middle ear aerated ◼ Prevent recurrence of glue ear ◼ Stay in place for 3-18 months ◼ Spontaneously extrude ◼ Eardrum heals Hearing Aids ◼ For children with chronic glue ear, especially recurrent glue ear after grommets. Classroom Management ◼ Front of class, focussing attention, reducing background noise, checking they have heard, etc. 35  CHL / Middle Ear Pathologies - Acute Otitis Media Acute suppurative otitis media, or acute otitis media, is a bacterial middle ear infection, often from an upper respiratory tract infection. Presentation ◼ Initially a mild hearing loss with slight pain, this can rapidly progress until there is an increased conductive hearing loss and excruciating pain, together with systemic symptoms including fever, nausea, vomiting. ◼ The eardrum is an angry red. In severe cases, creamy white pus in the middle ear cavity causes the TM to bulge. 36  CHL / Middle Ear Pathologies - Acute Otitis Media Management ◼ Antibiotics to kill the infection and analgesics for the pain. In more severe cases, when the TM is bulging due to the presence of pus under pressure, an incision is made in the TM and the pus drained. This will relieve the pain. ◼ If the TM has already ruptured, it is seen with a small perforation and pus in the external canal. The ear canal should be cleaned. The TM normally heals in a few days. ◼ Can lead to a chronic suppurative OM if untreated. The ear dis, middle, suppurative and TM rupture 37  CHL / Middle Ear Pathologies – Chronic Otitis Media Chronic suppurative otitis media, or chronic otitis media, is a disorder of the middle ear characterised by hearing loss and persistent or recurrent discharge via a perforation. Aetiology ◼ CSOM follows an acute infection which does not fully resolve. Presentation ◼ Hearing loss and persistent or CSOM with recurrent discharge. central perforation 38  CHL / Middle Ear Pathologies – Chronic Otitis Media Management ◼ Patient instructed to keep water out of the ear to avoid further infections being introduced via the perforation. ◼ Overt local infections need to be cleaned and treated with antibiotic drops. Small central perfs may close spontaneously, larger perfs Cholesteatomas may require reparative surgery (a myringoplasty). ◼ With marginal perfs, obvious infection needs to be treated as above. Marginal perfs (as well as retraction pockets in the attic region of the TM) can lead to the development of a cyst called a cholesteatoma, which needs to be removed. 39 CHL / Middle Ear Pathologies – Central (Safe) TM Perforations ◼ Can be pinhole to virtually total. ◼ Middle ear may be dry or infected. ◼ In severely infected cases pus drains out through perf. Management: ◼ Keep ear dry ◼ Infection may need antibiotic treatment. ◼ Small perfs heal often, larger perfs require reparative surgery. 40 CHL / Middle Ear Pathologies – Marginal (Unsafe) TM Perforations ◼ Perf involving annulus of TM, can be v. small to large involving most of TM. Further Investigations: ◼ As for safe perfs, plus X- rays and examination with an operating microscope. Management: ◼ Normally surgery with regular follow up. 41  Prevalence of Sensori-neural Hearing Loss (SNHL) ▪ 11 million (1 in 6 of the UK population) are affected by hearing loss. ▪ 8 million of these are aged 60 and over. ▪ 6.7 million could benefit from hearing aids but only about 2 million people use them. ▪ About 900,000 people are severely or profoundly deaf. ▪ Hearing Link 2019 42  Causes of SNHL in Children ◼ SNHLs vary from mild to profound. They tend to be greater in the high frequencies and exhibit discrimination problems. ◼ The large majority of cases of SNHL in childhood are congenital and are either inherited or have pre-natal infectious causes e.g. rubella or cytomegalovirus. ◼ Other causes include peri/postnatal problems e.g. birth asphyxia, prematurity or hyperbilirubinaemia (a build up of bilirubin which may damage auditory neurons). ◼ In addition, a very small number of children will acquire a SNHL as a result of conditions such as meningitis, encephalitis, mumps, measles or head injury. ◼ Uptake of MMR has reduced the incidence of acquired SNHL in children. 43 Causes of Acquired SNHL - Presbycusis ◼ Caused by aging processes in the cochlea, in particular the loss of both inner and outer sensory hair cells. ◼ Hearing loss is bilateral, predominantly high frequency, slowly progressive. ◼ Very common - 1/3 of people at 65 and 1/2 at 75 have a significant hearing loss. 44  Causes of Acquired SNHL - Noise Induced HL ◼ Disruption to stereocilia caused by exposure to loud sounds. ◼ Noise induced HL can be occupational or recreational. Ear disorders 45 Causes of Acquired SNHL - Ototoxic Drugs Death of hair cells and associated neurons 46 Sudden SNHL ◼ There are a number of causes of sudden SNHL such as head trauma, meningitis and viral infections (including flu and coronavirus). ◼ It is thought that the virus enters inner ear cells and brings about cell death and/or causes the body to release inflammatory chemicals which damage the inner ear. ◼ Treatment: steroids to reduce inflammation. 47  Causes of Acquired SNHL - Acoustic Neuroma ◼ An acoustic neuroma is a benign primary intracranial tumour of the myelin-forming (sheath) cells of the vestibulocochlear nerve (CNVIII). ◼ Presentation Progressive unilateral deafness with poor speech discrimination and tinnitus, unsteadiness, headache, facial nerve problems. ◼ Treatment: normally surgery MRI of a large (3cm) left sided neuroma  Hearing Testing – Audiometry Audiogram form Audiogram - example 50  Speech Perception Depends upon: ◼ The clarity of the original signal. ◼ The level of attention of the listener. ◼ The level of the signal v background noise. ◼ Acoustic cues – sound patterns that are markers of specific features of a sound. ◼ Contextual information – knowledge of vocabulary, structure of language, person speaking. ◼ Visual cues – speech-reading. ◼ The hearing acuity and clarity of the listener 51  Speech Perception – with Hearing Impairment Hearing loss causes: ◼ Raised auditory threshold ◼ Poor frequency resolution ◼ https://www.hearinghealthcarecentre.co.uk/hearing -loss-simulation/ 52  Summary ◼ We’ve introduced auditory anatomy and physiology as well as medical and surgical aspects of disorders of the ear and hearing. ◼ We looked briefly at hearing testing and how disorders of the ear affect speech perception. ◼ We will examine these topics in more detail in the Audiology lectures. 53  References ◼ Durrant J D and Lovrinic J H, 1995, Bases of Hearing Science 3rd Edition, Williams and Wilkins ◼ Graham J and Baguley D, 7th edition 2009, Ballantyne’s Deafness ◼ Haggard et al. Otitis Media, Hearing Loss, and Language Learning: Controversies and Current Research Journal of Developmental & Behavioral Pediatrics. 25(2):110-122, April 2004 ◼ Hawke M, Keane M, Alberti P., 1990, Clinical Otoscopy, 2nd Edition, Churchill Livings