SRD Final Exam Study Guide PDF

**[SRD Final Exam Study Guide]** - 28.2% of deaths per year are related to cancer - 43% lifetime probability that you will be diagnosed with any cancer types (44% in males 43% in females) - Incidence of head and neck cancer in males → 4.6% - Incidence of esophageal cancer in males →...

**[SRD Final Exam Study Guide]** - 28.2% of deaths per year are related to cancer - 43% lifetime probability that you will be diagnosed with any cancer types (44% in males 43% in females) - Incidence of head and neck cancer in males → 4.6% - Incidence of esophageal cancer in males → 1.6% - Incidence of head and neck cancer in females → 1.8% - Incidence of esophageal cancer in females → 0.5% - Ages 50-69 and ages 70-84 are most commonly afflicted with head and neck cancer - Head and neck cancer risk for both sexes → 2% - Esophageal cancer risk for both sexes → 0.5% - New head and neck cancer cases in 2021 → 7400, mostly male - New esophageal cancer cases in 2021 → 2400, mostly male - Mortality of head and neck cancer: 2100/7400 cases will die within 5 years of first diagnosis - Mortality of esophageal cancer: 2300/2400 cases will die within 5 years, it is difficult to treat and is often found quite late - If you survive the cancer for more than 5 years → you are considered cured - Oral cancer → 80% survival rate - Further back we go in vocal tract → survival rates go down - Etiology of head and neck cancer: multifactorial; tobacco, alcohol, poor oral hygiene, other factors - \(a) Tobacco: increases toxicity in the oral cavity which stresses the tissue, this tissue can then mutate and become cancerous - Tobacco can cause cancer of the lips, oral cavity, pharynx and larynx - Includes tobacco chewing, cigar smoking, marijuana smoking, etc. - \(b) Alcohol: increases toxicity in oral mucosa, especially when consuming strong alcohol without cleaning teeth, creates an environment where cancer can form - Alcohol can cause cancer of the tongue, buccal mucosa, tongue base and hypopharynx, and esophagus - \(c) Poor oral hygiene: leaving bacteria behind without cleaning it causes cancer risk - \(d) Other factors: HPV, syphilis, exposure to wood, metal dusts, fumes, chemicals, and genetics - Human papillomavirus 16: less of a cancer factor now due to widespread HPV vaccinations - Tertiary syphilis: some strains of syphilis are resistant to antibiotics, and it can lie dormant for decades and come back in old age - Extended exposure to wood and metal dusts: oak dust is especially known as an oral carcinogenic - Extended exposure to fumes and chemicals: carcinogenic that applies to people who work in chemical factories or labs - Genetic disposition to head and neck cancer: higher incidence in some families, cannot explain why - HPV 16 and oropharyngeal cancer: HPV can lead to development of cancers of the mouth and throat (tonsils), especially in younger and middle aged patients - Oral sex → increases risks of HPV infection in mouth and throat - Exact relationship between HPV and oral cancer → not fully understood - Where do cancers occur? → usually in the mucosa - Over 80% of cancers are squamous cells carcinomas - Squamous cells: surface cells of the mucosal lining (epithelial cells), that can be prone to developing carcinomas - Lip tumor: if the cancer is located on the white part of the lip, this is skin cancer, whereas the red of the lip is squamous carcinoma - Cancers can also occur on gingiva and hard palate → less common - Cancer occurs most commonly on the tongue and floor of mouth - Retromolar trigone: triangle behind the molars, also a spot where tumors can form - Buccal mucosa: tumor in the cheek, this has a different etiology, not a squamous carcinoma - Cancer of the lower lip: keratoses - Keratoses: open wound that looks like a sore with crusty bits (yellow and white), it looks like someone was bit in the lip and it never healed  - Cancer of the floor of the mouth: consists of keratoses, and leukoplakia - Leukoplakia: permanent white discolouration in tissue, it changes before a cancer starts growing (little white sores and/or inflamed spot) - Usually when a person has leukoplakia → they wait for it to go away naturally, but it is malignant and will not go away on its own - Cancer of the tongue: bumpiness on outer side of the lateral free margin of tongue, the tissue changes over time, it can also cause craters in the tongue - Ulcerating tumors of the tongue: noticeable tissue changes, can be painful, have an odor, and things may get into the tumor, making it harder to remove - Oropharyngeal carcinomas: usually affects the anterior pharynx and faucial arches, can look similar to cold sore - Carcinoma: the lesion itself may look like a granuloma or polyp, but it has leukoplakia - Laryngeal cancer: cancer on the larynx, surgeon will need to remove larynx or part of it depending on the severity - In the image → lesion is around the anterior commissure, it is bloody, and the patient will feel pain and irritation - Tumorigenesis: formation of cancer, where normal cells are turned into cancer cells - Basics of life: zygote forms with combined DNA → which forms the blastocyst and morula → embryonic differentiation → 3 germ layers (ectoderm, endoderm, mesoderm) → mesoderm has stem cells that turn into muscles, bones, etc. - This process continues throughout the lifespan - Cells always retain potential for differentiation (seen when broken bones heal themselves) - Constant factors that keep us alive: cell growth, division, differentiation, movement, decay and apoptosis - \(1) Cell growth and division: cells are formed via division and they get nutrients, develop their own metabolism, build their own proteins and fulfill their tasks - \(2) Cell differentiation: occurs more in embryonic gestation, but can still happen later - \(3) Cell movement: when a cell splits, they can move out of each other's way and use pseudopodia to move (not very far, but some movement) - \(4) Cell decay: cells replicate over and over to stay new, older cells decay - \(5) Cell apoptosis: programmed cell death to control cell numbers - Errors in cell growth, differentiation, movement or decay result in neoplasias (tumors) - Benign tumor: does not metastasize, but can still be quite bothersome, can get large and start suppressing other structures but prognoses is better than malignant - Benign tumors are 'fat, dumb, and happy' - Malignant tumor: cancerous tumor that metastasizes and can spread cancer cells through the body via bloodstream and lymphatic system, poorer prognosis than benign - Life cycle of a cell: G1, S, G2, M - G1: growth, cell grows and acquires nutrients and material - S: synthesis, DNA is replicated or this is where bits of DNA are assembled - G2: growth in preparation for mitosis, critical mass is gained - M: mitosis, DNA is transcribed, cells split up and process is continuous and ongoing - Errors or changes can occur with mitosis → usually T-cells in immune system keeps body safe from this - Some mutations are not found easily by T-cells → overtime the mutation can replicate again and again and cause problems - Characteristics of tumors: growth, invasion and infiltration of surrounding tissue, and metastasis - Growth: benign tumors grow slowly, malignant tumors grow more aggressively - Invasion of surrounding tissue: benign or malignant tumor displaces and impacts on tissue - Infiltration of surrounding tissue: malignant tumor alters the tissue - Tumors can grow excessively and they do not stop growing, can get larger than the organ that it is growing in/on - When tumor runs out of space → surrounding spaces gets pressed on and it can infiltrate surrounding tissue - Metastasis: malignant tumor cells travel through the body to create multiple cancer sites, can spread through bloodstream or lymphatic system - Bloodstream: cells travel through the bloodstream - Lymphatic system: tumor can go into lymph nodes and then it can get anywhere else in the body - Primary tumor: original tumor, where the cancer starts - Secondary tumor: metastasis sites - Field cancerization: generalized, diffuse carcinogenic tissue alterations - Sometimes when a person with tongue cancer gets treated, that same patient will get cancer on the tongue again in a different location → tissue on both sides of mouth may be predisposed - Even if you remove one cancer, another cancer might grow in another location → this is considered a separate cancer - Lymphatic system: composed of lymph vessels, lymph nodes, and organs such as bone marrow, spleen, thymus gland, tonsils, appendix, etc. - Function of lymphatic system: absorption of excess fluid, return of excess fluid to the bloodstream, absorption of fat, and immune function - Lymph vessels mirror the circulatory system, functions similarly (but no heart), lymphatic fluid is only displaced when muscles are moving - Lymph drainage: passive, muscle contractions move the fluid through the lymphatic ducts - Swelling of lymph nodes: they will become hard and indurated → sign of inflammation - Hemiparesis in stroke patients → pain can be caused lymph node swelling, can be treated with lymphatic drainage massage - Lymphatic drainage massage is massaging the face downwards towards lymph nodes - When lymph ducts are resected → over time, they reform and lymphatic fluid will drain, but sometimes this can leave scarring - Lymphedema: fluid filled lymph, hard and painful, can occur frequently with neck dissections - Waldeyer's ring: ring around the throat, consists of adenoids, tubal tonsils (on ET, palatine tonsil (on faucial arches), and lingual tonsil (on tongue) - Waldeyer's ring is a good way for nasopharyngeal tumor to get around the throat and into the neck → then downwards into the lungs - How head and neck cancer is diagnosed - Patients complain of pain, lump in throat, something changing, etc. - CT or MR scans, scintigraphy, and ultrasound - Blood and urine analysis can show endocrinological changes that may be associated with head and neck cancer - Visual examination and lymph node palpation → see if lymph nodes feel smooth and soft to the touch or indurated - Definitive diagnosis of cancer: histological analysis of biopsy is needed - Biopsy: needle is poked into the tumor and a bit of tissue is removed to analyze and look for squamous cell carcinoma in the tissue - Typical complaints → neoplastic lesions, pain, persistent ulceration, resistant to antibiotic treatment, and weight loss - Neoplastic lesions: little neoplasias, mole or wart where there was not one before (could be benign), cancerous lesions are usually bigger and take up more space - Ulceration: lesion looks inflamed and bloody, does not respond to antibiotics - Weight loss: rapid and unintentional weight loss, tumor is feasting and taking the patient's nutrients - Deferred otalgia: tooth or ear pain can be a sign of a lesion, symptom of oropharyngeal tumor - Vagus nerve → connection to ear canal - Mandibular branch of trigeminal → combo of pain in inner and outer ear because there may be something sitting under the tongue - Glossopharyngeal nerve → middle ear pain - Deferred otalgia is not a strong diagnostic sign, but could help - Treatment of precanceroses → aggressive treatment to remove leukoplakia, it is not a squamous carcinoma yet but it can be - Surgical resection: take off superficial layer of lesion - Photodynamic therapy: controlled sunburn, UV light used to burn the tissue for new skin to develop - Cryotherapy: using a cold probe, to freeze tissue off and it dies - Electrocoagulation: short circuit to generate heat in certain spots to cauterize tissues during surgery, it stops the bleeding to easily remove tissue - Laser vaporization: shoot tissue, tissue goes from solid to vapor, it is suctioned out - Squamous cell carcinomas → most frequent form of head and neck cancer (80% of cases, and 95% of laryngeal cancer) - Squamous cells are mucosal cells, very active, replicate all the time, it heals quickly - Verrucous carcinoma: wart-like carcinoma, more raised, circumscribed, stays in place (can still be dangerous) - Verrucous carcinoma → subtype of squamous cell carcinoma (results from chew tobacco or betel nut use) - Malignant melanoma: skin cancer, can affect lips - Lymphoma: starts from the lymph nodes - Anaplastic tumors: odd variety of other tumors → multifactorial - May see salivary gland tumors after surgery because of facial nerve (goes through salivary gland) → many patients end up with hemifacial paralysis or facial nerve paralysis from the tumor resection - Tumor staging and classification: TNM system → tumor (T), node (N), and metastasis (M) - T: 0-4, size of the tumor in relation to the site - 0 = cannot find it, 4 = very large - N: 0-3, degree of lymph node involvement - 0 = no lymph involvement, 3 = significant lymph node involvement - M: 0-1 distant metastases - 0 = no metastasis, 1 = metastasis - Tumor staging → depending on results for the TNM dimensions, it guides treatment strategies and is the basis for survival prognosis - TNM system does not make a prediction about functional outcome - Multidisciplinary team to determine cancer treatment: surgery, chemotherapy, radiation, immunotherapy, and palliative treatment - Surgery: remove tumor with a safety margin, and fix any defects after - Surgery most used on anterior lesions → tumor sitting on lips, tongue, flour of mouth → due to accessibility - Further into neck and larynx is harder to access and reconstruct → instead do radiation with or without chemo - Radiation: radiate the tumor by shooting beams at it, makes the tumor small or makes it go away - Pseudopodia: local tumor cell clusters, may miss some after surgery resection, radiation removes the rest - Adjuvant radiation therapy: radiation therapy after surgery (combo) - Chemotherapy: more for generalized cancer, less appropriate for head and neck cancer, because it is more localized, cytotoxic agents put in bloodstream to suppress tumor cell reproduction - Chemotherapy in head and neck cancer: cysplatinum towards start and end of radiation → quite toxic → makes cells more vulnerable to radiation - Palliative chemotherapy can be done in incurable cases → chemo can subside the tumors and allow patient to live a little longer - Radiation with a little bit of chemotherapy can be done to soften up the tissues for radiation to be more effective - Chemoradiotherapy: radiation treatment effect is increased with adjuvant chemo with cisplatinum → BUT this increases treatment side effects - Chemoradiotherapy can cause ototoxicity (hearing loss) - Possible side effects of chemotherapy: hair loss, fatigue, nausea, vomiting, mouth sores, bladder irritation, low blood counts, diarrhea/constipation, decreased sexual drive - Immunotherapy: gives the immune system medications to help it attack the tumor, if successful, immune system remembers antibodies and suppresses tumor recurrence - Immunotherapy is done when radiation does not work the first time around → it is newer and experimental treatment - Palliative treatment: some patients cannot be saved, treatment is stopped and patients will receive medication to be more comfortable and prolong life as much as possible - Alternative treatment methods: cryotherapy, electrocoagulation, laser - Cryotherapy: freezes the tumor → tissue dies on mucosa → peels off → hopefully healthy tissue replaces it - Electrocoagulation: fry tissue with cauder/soldering iron → surface tissue is burned off and removed - Laser: transforms tissue into vapor, for precancerous or small lesions - Surgical intervention vs organ preservation: high-dose radiation can reduce or eliminate the need for surgery and preserve the organ - Advantage to organ preservation → undergo radiation and chemo, cancer will hopefully be cured, and organs are preserved - Disadvantage to organ preservation → more intense radiation side effects - Goals of cancer treatment: early detection, management of precancerous lesions, effective therapy, and effective palliative care, early application of measures - Early detection: find the cancer as quick as possible, sometimes hard, there is a delay between noticing a bump/bruise and getting a diagnosis - Management of precancerous lesions: when leukoplakias and keratoses are spotted, it is not yet a squamous cell carcinoma, if removed in time, there is a good chance that the patient will not develop the squamous cell carcinoma - Effective therapy: therapeutic measures that are the least disabling and disfiguring - Important to consider survival and quality of life - Patient can always add more radiation therapy or remove more safety margins surgically → but patient will be unhappy with permanent damage - Effective palliative care: for those who cannot be cured - Early application: applying these measures early for optimal rehabilitation - Active therapy: treatment meant to cure the cancer - Supportive care: treatment meant to reduce pain and distress to increase well-being - Combined active therapy and supportive care: treatment meant to ease pain and discomfort while also aiming to cure the cancer - Combined palliative and symptomatic therapy: treatment meant to fight other health problems caused by cancer or cancer treatment, cancer itself is not the treatment goal, but the effects of the cancer treatment are the goal - Treatment strategy selection depends on site of lesion - Oral cancer: usually surgical resection with possible adjuvant radiation therapy - Pharyngeal and laryngeal cancer: usually radiation therapy, surgical access is difficult here - Side effects of treatment: structural, functional, psychological, and social changes - Structural changes: anatomical defects, neurological sensory deficits - Anatomical defects: structures were removed, other tissue brought in → structure is not the same anymore, or radiation stiffened the tissue, etc. - Neurological sensory deficits: could have changes in sensation, lack of sensation, tingling, facial paralysis, phantom pain - Functional changes: speech and swallowing problems, reduced or altered saliva, sensation and olfaction - Psychological and social changes: falling into slump after cancer diagnosis, may not be possible for patient to lead their normal life anymore - How radiation works: when a cell divides → DNA info is vulnerable to high energy radiation, tumor cells divide more than normal cells, radiation has a higher chance of killing malignant cells than surrounding healthy cells under radiation - Radiation disrupts cell's metabolism by knocking out the DNA's amino acids → DNA breaks preventing the cancer from undergoing further mitosis - Double sigmoid curve: both malignant and healthy cells undergo mitosis and are vulnerable to radiation or chemo - Cancer cells are attacked first by radiation, then followed by healthy cells - At the start of radiation → nothing happens - After a lot of radiation → cells start slowly dying - Radiation mainly gets the cancer cells, but can also attack the healthy cells - Exact balance of radiation is key → too lenient (cancer recurrence risk), too harsh (patient is unhappy and left with major functional changes) - Tissue damage through radiation therapy: damaging effect of radiation is instant, but manifestation is delayed by the cycle of cell proliferation - Early responding cells with high sensitivity: skin, mucosa, hair, salivary glands, lymphocytes - Late responding cells with low sensitivity: nerves, muscles, bone, CNS - Types of radiation therapy: external beam, brachytherapy - External beam: most common type, conventional radiation therapy → IMRT, VMAT - Intensity modulated radiation therapy (IMRT): take the radiation source at different angles from the patient → allows for minimal effects on surrounding tissues and maximal radiation dose delivered to the tumor - Volumetric modulated arc therapy (VMAT): radiation beam or cannon does not stop, it goes fluidly and sends radiation - Brachytherapy: less common, radiation source is placed into sealed container (gold pellet) and implanted in the target site, prevents excessive exposure of radiation to brain - Effective for hard to access sites such as the nasal cavity - Nasal cavity is right next to brain → external beam can cause brain damage - Positioning for radiation treatment: radiation masks are individually made and molded over patient's anatomy, patient is screwed onto the table (can be traumatizing) - Acute side effects of radiation: dermatitis, mucositis, dysgeusia, xerostomia - Dermatitis: inflammation of the skin in the radiation field, skin looks reddened, burned, cracked, may have lesions - Management of dermatitis: dermatological treatment, pain management - Mucositis: painful inflammation of mucosa (internal equivalent of dermatitis), patients may reduce food intake due to pain and discomfort, may have erythema (redness) and edema (swelling) - Management of mucositis: adjustment of diet (less spices and softer textures), pain management, mucositis is largely reversible - Dysgeusia: distortion of taste perception (increased sweetness, metallic taste, no taste, etc.), this can be annoying and interferes with patient's eating - Xerostomia: dry mouth, decreased salivary flow, decreased intraoral pH leads to more bacteria and caries, can also cause reduced taste sensation and dysphagia - Caries: extensive damage to teeth, removing teeth can be done to prevent this, or shield teeth with a mouthguard and fluoride → this doesn\'t always work on the whole tooth - Salivary glands get inflamed from radiation, they go into overdrive and patients start to drool and overproduce saliva, continued damage → causes xerostomia - Parts of saliva: serous and mucous - Serous: watery component, produced by salivary glands - Mucous: snotty component produced by other structures - With xerostomia → serous production is affected, but mucous is still produced and is not being diluted → leads to bacteria in the oral cavity - Management of xerostomia: frequent rinsing with water, artificial saliva, baking soda to increase pH - Time frame for acute side effects → varies - Acute dermatitis: occurs within 2-3 weeks of radiation - Acute mucositis: occurs within 4 weeks of radiation - Acute dysgeusia: occurs within 12 weeks of radiation - Acute xerostomia: can resolve within 6 months after radiation but may persist - Long term chronic effects of radiation: up to 6 months later, xerostomia, fibrosis, dysgeusia, atrophy, osteoradionecrosis, trismus, hypertrophy, reduced/absent sensation, hypersensitivity, incoordination - Fibrosis: thick or scarred tissue (hardened) - Dysgeusia: in long term effects, it leads to a more permanent loss of smell and taste - Atrophy: structure may contract and waste if there is nerve damage - Osteoradionecrosis: damage to bone after radiation, especially the mandible - Bone cell cycle is slow → long term effect, radiation can weaken the bone leading to fractures, healing potential here is poor, self repair is lessened - Treatment of osteoradionecrosis: hyperbaric oxygen, surgery - Hyperbaric oxygen: done in pressure chambers, air pressure is increased and more oxygen is delivered to the cells and the hope is to stop the osteoradionecrosis - Surgical management of osteoradionecrosis: cut out the damaged part bone and keep as much of the healthy bone as possible - Trismus: muscle fibrosis of temporalis and masseter → reduced mandibular movement and mouth opening, speech and eating are affected - Treatment of trismus: jaw exercises and surgery - Training with a jaw exerciser: stretch jaw using exercisers - Therabite oral exerciser: hand operated device to stretch masseter - Dynasplint trismus exercise: hand operated device to help with mandibular motion - Surgical management of trismus: cut the masseter, cut through the muscle and sever the masseter so that the patient has more movement (BUT → masseter has a tendency to reattach) - Incoordination: movements don't work effectively anymore - Cervical esophageal stricture: can occur following intensive radiation therapy, bolus has trouble moving down the esophagus effectively and pools halfway down - Treatment success: looks at the disease, functionally and psychologically - Disease-related: has the cancer been removed or contained? - Functional: what functional impairments does the patient have? - Psychological: what are the effects of the cancer treatment on the patient and their environment? - After cancer: acute survivorship, long-term survivorship (1-5 years), and permanent survivorship (considered 'cured') - Challenges with survivorship: physical issues, psycho-emotional issues, social issues - Cancer-related cognitive impairment: multifactorial etiology, originally thought it was pharmaco toxic (after chemoradiotherapy), but also observed in non chemoradiotherapy patients - Cancer-related cognitive impairment is temporary in most patients, resolves after treatment is completed, only partial recovery in 20-30% of patients, these patients may respond to cognitive rehabilitation interventions - Early symptoms of laryngeal cancer: lump in throat feeling, throat clearing, coughing, sense of discomfort in throat, sore throat, difficulty breathing, burning sensation or difficulty or pain during swallowing, referred pain from larynx to ear, unexplained weight loss - Total laryngectomy: removal of laryngeal structures, from the hyoid bone down the first tracheal cartilages - After larynx is removed → patient needs to continue breathing through the trachea, it is bent forward and stitched into an opening in the neck at the level of the sternum - Total laryngectomy procedure: large donut shaped cartilage/scar, so that the tracheostoma stays open, we do not want it to shrink and heal - Total laryngectomy → airway is completely sealed from the esophagus - Possible complications of total laryngectomy: coughing, tasting food, no more speech, no emotional vocalizations, and no air filtration - Coughing with laryngectomy: when coughing, we use glottal opening and closing motion to build up pressure and release it quickly, this does not work anymore, cough happens through tracheostoma → can be compensated by closing off the tracheostoma - Tasting food with laryngectomy: patients will have hard time tasting food, they still have lingual taste but everything will be dull because while eating we breathe through our nose (big taste contributor), after a while, food tastes good again - Emotional vocalizations with laryngectomy: cannot laugh, cry, or make emotional vocalizations, it is inaudible - Air filtration with laryngectomy: everything you inhale goes right into lungs → no nose hairs protecting and filtering air or adjusting air temp, in winter, air can be very cold and dry - Heat and moisture exchanger: can be placed on tracheostoma, moisture exchanger needs to be exchanged as moisture and heat builds up - If we do not have a moisture exchanger → with every exhale heat goes out and risks such as cold air, dust, bugs, microfibers, etc., hit the bronchi directly without protection - Safety cards: must be on laryngectomy patients at all times, explaining that in emergency situations, they require mouth to neck resuscitation - Pneumatic artificial larynx (Tokyo larynx): consists of a housing, and when patient exhales through tracheostoma, it goes into the housing where sound is transmitted into the patient's oral cavity to be used for speech production - Advantage of pneumatic artificial larynx: not battery operated and easier to produce lexical tones since you can vary the air pressure - Disadvantage of pneumatic artificial larynx: must be used with two hands and tube must be held between teeth - Transcervical electrolarynx: press a button, and it makes a low volume buzzing sound to transmit through tissue to get a strong oral signal and produce speech, a seal between electrolarynx and vibrating neck tissue is needed - Advantage of transcervical electrolarynx: pitch can be adjusted, only need one hand to operate - Disadvantage of transcervical electrolarynx: scar tissue from radiation can muffle the sound, robotic voice quality - Cooper-Rand intraoral electrolarynx: sounds clearer than a transcervical electrolarynx → but it is more difficult to position the device intraorally - Cooper-Rand intraoral electrolarynx → is good for patients with scar tissue or hardened/stiff neck tissue - Treatment considerations for artificial larynges: over articulation with exaggerated movements, identifying best coupling spot, larynx-to-skin seal, develop conversational speech, and pragmatic use of the larynx - Over articulation without exaggerated movements: use residual air in vocal tract to make strong articulatory contacts and harmonic sound - Identification of best coupling spot: finding the spot under the neck for best electrolarynx results, hard to find the spot at first - Larynx-to-skin seal: electrolarynx needs to stay put after coupling spot is found and cannot wander while patient is speaking - Develop conversational speech: coordinate e-larynx and articulation by working on phrases, pauses, speech rate, etc. - Pragmatic use of larynx: moving e-larynx off of coupling spot to show turn taking - After a total laryngectomy → artificial larynx is the default choice for speech given to patients - Goals for using artificial larynges: optimal placement, coordination of the 'on' control with speaking, articulatory precision, appropriate rate and phrasing, and attention to nonverbal behaviour - Esophageal speech: air insufflation into upper esophagus for phonation, difficult for SLPs to model, fellow laryngectomy patients volunteer to help with esophageal speech - Techniques for air insufflation in esophageal speech: burp, injection method and inhalation method - Injection method: positive pressure, can be done with plosive consonant injection, glossal compression injection, and glossopharyngeal compression injection - Plosive consonant injection: say a strong /k/ sound, instead of releasing the /k/, swallow the air - Glossal compression injection: press back with tongue and try to get air into the esophagus - Glossopharyngeal compression injection: try to swallow air - Inhalation method: negative pressure, esophagus has negative pressure at rest → inhale deeply to widen trachea and esophagus, increases negative pressure, then the relaxed UES allows for air into the esophagus - Training esophageal sound production: start with air insufflation → voice production on demand → repeated productions → monitor development of detrimental behaviors during insufflation and speech (grimacing, stoma blast, etc.) → reduce degree of articulatory contact - Advanced goals for esophageal speech: prolongation of voicing, increasing intelligibility, minimize associated noises or behaviours. Minimize unwanted noises or behaviours, maintain adequate speech rate, improve prosodic features - Problems with esophageal speech: klunking and stoma blast - Klunking: audible charging of the esophagus → voice swallow sound during insufflation - Stoma blast: respiratory noise → patient audible exhaling while speaking - Tracheo-esophageal puncture (TEP): esophageal speech driven by airflow from the lungs by occluding tracheostoma to allow pulmonary air to go into the esophagus, put a valve so that only air goes through UES - TEP provides a different quantity of air → length of utterance be closer to before - Criteria for TEP candidacy: motivation, understanding of postsurgical anatomy, understanding of TEP prosthesis, manual dexterity, visual acuity, ability to care for prosthesis, no significant hypopharyngeal stenosis, positive air insufflation test, adequate pulmonary function, adequate stoma and mental stability - Hypopharyngeal stenosis and TEP: cannot have a tight cricopharyngeal sphincter, or else air has nowhere to go - TEP timelines: primary TEP and secondary TEP - Primary TEP: occurs at the time of the laryngectomy, prosthesis 8-10 days after patient resumes oral diet, speech is deferred 3-4 more days to avoid a fistula - Secondary TEP: after recovery of the laryngectomy, separate procedure where TEP prosthesis is inserted 4 days post-op, and patient starts speaking right away - TEP management: inserted by a qualified medical professional or delegated act for SLPs - Tracheoesophageal puncture: tracheostoma is the bigger opening in the patient's neck, must wear the prosthesis at all time due to tendency of tissue wanting to close - Types of TEP prostheses: non-indwelling and indwelling - Non-indwelling TEP: changed and maintained by patient, lower cost - Indwelling TEP: stays in place, and only comes out if it's broken or has issues → usually 6 months - Indwelling TEP → changed and replaced by clinician, more expensive because it needs to maintained and washed, silver-oxide coating to prevent candida growth - Blom-Singer indwelling voice prosthesis with gelatin capsule: folding device that allows you to fold up the ring so that it sticks up and insertion can be done with gelatin capsule on top of it - Blom-Singer indwelling insertion step 1: puncture dilation → take a plunger to dilate the structure with lubricant and it is inserted to open it to its maximum size - Blom-Singer indwelling insertion step 2: puncture measurement → measure size of opening and determine how long the prosthesis needs to be - Blom-Singer indwelling insertion step 3: insertion of gel-capped prosthesis → T-bar protects prosthesis from falling into the patient's trachea, once device is pushed in, the gel capsule dissolves and device unfolds - Blom-Singer indwelling insertion step 4: cutting of insertion strap → optional step depending on patient's comfort - Blom-Singer indwelling prosthesis: patient can occlude it with their thumb or use a one way valve that shuts when there is enough pressure for speech - Cleaning a TEP: cleaned with a pipette that flushes it out on a daily basis at the minimum, multiple times a day is recommended - Goals for tracheoesophageal speech: valving (occlude TEP), articulation, phrasing, rate and attention to non-verbal behaviours - Insufflation testing: tracheostoma adapter is placed on top of tracheostoma, adapter has a tube connected to the side, and a catheter is put through the patient's nose and down their pharynx and it is swallowed, when in place → patient can occlude adapter and it will go into tube to show air insufflation - Possible outcomes of esophageal insufflation testing: normal muscle tone, spasm, hypertonicity and hypotonicity - Normal muscle tone in insufflation testing: good voice production - Spasm is insufflation testing: complete aphonia → UES is so tight that it does not open at all - Hypertonicity in insufflation testing: reduced voicing → UES is tight but air still comes out, but not enough for sufficient voicing - Hypotonicity in insufflation testing: reduced voicing → UES has too little muscle tone and not enough resistance to muscle tone (flapping sounds) - Myotomy of UES and crico-pharyngeus: surgical treatment of hypertonicity/spasm in UES, cutting the cricopharyngeus muscle to relax the UES - Nonsurgical treatment of hypertonicity/spasm in UES: botox injection - Tracheostoma valve problem: valves need to be retained in body (unnatural), it is difficult to place it and patients cannot wear them for long, it can leak, and device needs to be replaced or taken off - Complications of TEP voice rehabilitation: leaking TEP valve, esophageal leaking through TEP fistula into airway, opening resistance of TEP valve, candida biofilm, persistent spasm of PE segment, granuloma, scarring, infection, edema of TEP fistula, disappearance of TEP valve under granuloma tissue, swallowing or aspiration of prosthesis - Candida biofilm on TEP: complication that may clog the prosthesis and could lead to leakage - Pectoralis major flap for fistula closure: may result in a bit of tension if flap tissue contractions or if distance is very far the patient cannot turn head freely after - Enlarged tracheostoma: complication managed with flange adapters, not every patient is motivated to do this - Voice amplifier: can help project TEP voice in social situations → examples are ChatterVox and Handsfree amplifier - Human larynx transplantation: only done on non-oncological patients, due to immune system suppressants needed for the transplant, immune system is needed in cancer patients to fight cancer - Tim Heidler: first patient to have a successful larynx transplant - Partial laryngectomy: partial removal of larynx to effectively remove cancer while maintaining physiological breathing, swallowing and voice production - Potential problems of partial laryngectomy: airway and breathing safety, swallowing safety, voice quality and quantity - Cordectomy: taking out VF or part of VF, scar tissue after tumor removal can help healthy VF to talk, arytenoid is left in place to preserve laryngeal function - Cordectomy variations: can be a superficial stripping of a lesion or total removal - Problems with cordectomy: hyperfunctional voice compensation, post-op soft and insufficient voice - Therapy goals for hyperfunctional compensation: identify anatomical and physiological problems, and identify and prevent maladaptive behaviors, example → ventricular phonation - Strategies to help with hyperfunctional compensation: smooth, easy phonation, increase utterance length, control speech rate with easy onset, chant talk, etc. - Strategies to help with post-op soft and insufficient voice: symptomatic voice exercises, such as → careful pushing, hard vocal onset, speaking more loudly, etc. - Anterior commissure resection: remove tumors located at the anterior commissure, arytenoids are left in place, adam's apple or tip of cartilage is removed and remaining larynx is shorter and smaller → two functioning arytenoids results in glottal phonation source - Hemilaryngectomy: if tumor spread vertically, surgeon can resect half of the larynx, including the arytenoid - Vertical partial laryngectomy: similar to hemilaryngectomy, confined vertical resection where arytenoid is left in place - Problem with hemilaryngectomy: variable voice outcomes, some could be aphonic or have a better voice quality - Therapy goals with hemilaryngectomy: vowel phonation tasks to see if glottal or ventricular voicing is happening, ventricular phonation can be an acceptable alternative, decrease utterance length to manage pulmonary support if needed - Extended frontolateral laryngectomy → variation of hemi-laryngectomy - Extended frontolateral laryngectomy: takes out ¾ of larynx with one arytenoid left to achieve function - Problem with extended frontolateral laryngectomy: highly variable voice outcomes and vocal noise - Therapy goals with extended frontolateral laryngectomy: reduce vocal noise, build up pulmonary pressure for exciting a potentially tight voice source, and posture adjustments (example → head turn) - Supraglottic laryngectomy: radical horizontal procedure, removing structures above the VF but leaving VF and arytenoids in place to protect airway and preserve phonation - Structures removed in supraglottic laryngectomy: epiglottis, ventricular folds, hyoid, and thyroid cartilage - Problems with supraglottic laryngectomy: airway safety, high aspiration risk, sometimes over adduction of VF, and hyperfunctional voice disorder - Therapy goals with supraglottic laryngectomy: eliminate aspiration and re-establish phonation - Supracricoid partial laryngectomy with cricoid epiglottopexy → variation of supraglottic laryngectomy - Supracricoid partial laryngectomy with cricoid epiglottopexy: surgical pull up of cricoid to the hyoid, which results in better swallowing safety and voice quality - Management of compromised airway: permanent tracheostoma or temporary tracheotomy - Permanent tracheostoma: seen in total laryngectomy, stoma is cut into neck at collarbone level, trachea is bent forward into the stoma, edges of stoma are scarred to prevent shrinkage or closure of tracheostoma - Temporary tracheotomy: stoma is not scarred so it can heal later, silver tube is inserted to keep airway open - Tracheostoma (more permanent) and tracheotomy (supposed to be removed) - Tracheotomy tube: keeps airway open, seen in partial laryngectomy → there is an airway opening at the top, air goes through the tube and vocal tract - Speech tubes with fenestration: fenestration allows airflow to larynx so that patient can phonate more easily, if patient has functioning VF and needed a tracheotomy, fenestrated tubes are inserted to speak - Passy-Muir one-way speech valve: speech valve is open during normal respiration and it closes when phonation threshold pressure is reached and allows patient to phonate - Cuffed tracheotomy tube: close off airway in a ventilated patient to prevent air leakage, inflated cuff fills space between the tracheostoma tube and tracheal walls - Complications of cuffs: leakage, tracheal irritation and trauma, esophageal trauma and swallowing with a cuff - Esophageal trauma from a cuff: mechanical pressure from cuff can reduce esophageal motility - Swallowing with a cuff: increase aspiration risk - Oblique mixed phonation: one true VF and one false VF are phonating, can modulate pitch - Glottal phonation: phonation of true VF, glottal phonation is ideal, however ventricular phonation is acceptable in some cases - Ventricular phonation: phonation of false VF - Aryepiglottic phonation: patient compensates lack of VF by approximating arytenoids, surrounding tissue vibrates for phonation - Goals of therapy in partial laryngectomy: phonation, reduce airflow, promote acceptable voice quality, improve communication with over articulation, modulation, projection and nonverbal communication - Finding best source of voicing in partial laryngectomy: use ears and endoscopy to determine phonation type, restore glottal phonation is possible, if not, make ventricular or mixed phonation acceptable - Levels of partial laryngectomy rehab program: sonorization level, speech level, and vocal plasticity level - Sonorization level: sustained phonation at the sound level (in isolation) - Sonorization level → re-establish effective phonation with techniques such as humming, vocal fry, half-swallow 'boom', hard vocal attack, bilabial li-trill /B/, gentle pushing - Speech level: syllables, words, more coordinated productions - Speech level → improve vocal quality, identify optimum head and neck posture for phonation, use over articulation if needed - Vocal plasticity level: modulating pitch, loudness, dynamic levels, singing, funny sounds, breath management, etc. - Vocal plasticity level → expand dynamic and frequency range, practice prosodic patterns, singing and reading - Oral cancer is the most frequent head and neck cancer type - There are a lot of muscles in the tongue that interdigitate (criss-cross) with one another - Extrinsic tongue muscles: help move the tongue backwards, forward, up and down - Intrinsic tongue muscles: helps with tongue configuration - Muscular hydrostat: muscular structure without a skeleton used to move the organism or manipulate objects, example → tongue - Lingual taste: taste buds for five basic flavours, sweet, salty, sour, bitter, umami (savoury), are distributed evenly across the tongue - Most of taste comes from smell - Screening for oral cancer: fluorescence testing and blue dye testing, oral cancer is not always diagnosed quickly because people wait a long time before going to doctor - Mobility: passive movability, take the tongue and move it around - Motility: active ability to move, ability for tongue to move by itself - Reconstruction of lingual resection defects: primary wound healing, local closure, local flap/pedicle flap closure and free flap closure - Primary wound healing: defect is left open to heal, done via small resection or laser off the tumour → might leave a small scar, for small lesions - Local closure: surrounding tissue is closed over the defect, stitching the margins of the wound together and they will heal → for larger defect - For very large defects → flap tissue is used to replace and reconstruct the defect - Local flap/pedicle flap closure: tissue flap is lifted close to defect but retains its original blood supply - Free flap closure: tissue is lifted somewhere else on the body and transplanted into the defect site, requires reconnection to tiny local blood vessels - Anastomosis: connections of blood vessels of the flap to the recipients - Lingual reconstruction with platysma myocutaneous flap: tongue is reconstructed using platysma → thin muscle that lines skin of neck, it is flexible and can be stretched - Radial forearm free flap: use inside of radial forearm (to avoid hair growing on the tongue), flap is taken from here with blood vessels and tissue is brought into oral cavity - Radial forearm is the more commonly used procedure - Gracilis free flap: lingual reconstruction with inside of thigh - Sometimes a flap may atrophy and get smaller, surgeons oversize the flap a bit - Jejunum free flap for oral reconstruction: peristalsis is preserved here, patients tend to be unhappy with this because something is constantly twitching in their mouth - Mandibular reconstruction: scapula free-flap, fibula transplant, implant-retained prosthesis - Mandible reconstruction with implant-retained prosthesis: bone transplants (fibula) so that patient can chew food and enjoy it - Effect of lingual defect size: cut-off for poorer speech acceptability is at around 20.4% resection of tongue surface - Compensation effects: average tongue velocity increases after surgery - Glossectomy secondary compensatory strategies: lengthening of vowel duration, reduction or increase of vocal intensity, reduction of rate and intentional use of meaningful pauses and widening of pitch range and variation - Secondary compensatory strategies for glossectomy → aims to increase speech intelligibility - Therapy for partial glossectomy: maximize mobility and motility of residual tissue (non-speech oral motor exercises), re-establish articulatory targets based on movement capabilities of structures, and improve speech sound differentiation - Tongue motility exercises: protrusion, retraction, side to side, up and down, etc. - Palatal augmentation prosthesis: useful for food manipulation and swallowing, unclear speech benefits - Glossectomy gravity cup with flow regulator: switch the flow on and off, gets bolus toward back of oral cavity more easily - Feeding syringe: places bolus more posterior, not enjoyable having whole meals in liquids and purees - Maxillary defect: surgeon may take out part of the hard palate, prosthodontist will make an obturator to fill the defect - Implant-retained maxillary prosthesis: usually speech will be restored if the prosthetic is a good fit → SLP role is to look at speech quality, intelligibility, hypernasality, and consult with prosthodontist - Speech bulb lift: removable maxillary prosthesis, separates oropharynx and nasopharynx during speech and swallowing - Epithesis: type of prosthesis for aesthetic purposes - Ocular prosthesis: artificial eye is hand painted, glasses can cover the defect and keep the epithesis in place - Other epithesis: can also do nasal epithesis or epithesis to cover large facial defects