2.4%

about 1/3 die

1%

.41 ratio death to survival

the 6th decade 45/100000

(more males) 70/100000

the 7th and 8 decades highest risk (65/100000)

males alone 100/100000

tobacco (lips, oral, cavity, pharynx, larynx)

alcohol (tongue, buccal mucuosa, tongue base and hypopharynx, esophagus)

poor oral hygiene

- Other - tertiary syphilis, human papilloma virus 16, extended exposure to wood and metal dusts, extended exposure to fumes and chemicals, genetic disposition may contribute

HPV 16 seems to play a role in the dev of a sig number of cancers of the mouth and throat (tonsils too)

Oral sex inc risk of acq HPV infections in mouth and throat

(these are very tentative associations!)

Tongue (esp lateral edges)

Floor of the mouth 

Retromolor Trigone (behind molars)

Buccal Mucosa (rare)

HArd Palate

Lip

Gingiva 

errors in cell growth, differentiation, movement and decay

NO

lots of mistakes happen in DNA, cause it's splitting all the time. Usually the mistakes just die off though.

The diff with cancerous ones is they're mistakes that live and then take over

G0 -- resting cell

M -mitosis (cell div)

G2 - premitotic period (RNA/protein synth)

S- Synthesis (DNA)

G1- Postmitotic Period (RNA/protein synth)

benign tumours can squish other structures and push on nerves

but they dont spread to other structures

if you remove them they're fine

grows fast

invades surrounding tissue

alters tissues

metastasis

bloodstream

lymphatic system

a primary tumour is the original tumour

 and  a secondary tumour is the result of metastasis

absorption of excess fluid

return of excess fluid to the bloodstream

absorption of fat

immune function

5 is bottom port of the SCM

4 is behind all of SCM

3 - mid portion SCM 

2 - top port SCM

1- Geniohyoid area

submental nodes

submandibulan nodes

sub digastric nodes

histological analysis is the only definitive diagnosis

blood and urine analysis

Imaging

Visual exam

neoplastic lesions

pain

persistent ulceration, resistant to antibiotic treatment

weight loss

leukoplatia (white spots on the mucous membrane of the tongue and inside the mouth)

Actinic keratoses (scaly or crusty bumps that arise on the mucosa surface)

-surgical resection

-photodynamic therapy (controlled sunburn)

-cryotherapy (freezing)

-electro-coagulation (burnn)

-laser vaporization

squamous cell carcinomas

verrucuous carcinomas

malignant melanoma

lymphoma

undifferentiated tumours

pleomorphic adenomas

adenoid cystic carcinomas

T - tumour size (in reln to site) (0-4)

N - degree of lymph node affection (0-3)

M - distant metastases (0-1)

T1, NO, MO

small primary tumour, no lymph involvement, no metastases

T2, N0, M0

med primary tumour, to lymph, no met

T3, N0, M0 

OR

T1,2 or 3, N1, MO

Large primary but nothing else aff

or any size primary and some lymph involvement

T4, N1, M0

OR

Any T, N2 or 3, M0

OR

Any T, Any N, M1

Metastases in stage 4

chemo

surgery

radiation

palliatvie treatment

(best is to get it precancerous)

-emphasis on early det

- sound management of precancerous lesions

- effective therapeutic measures that are least disabling and disfiguring

-early app of measure to achieve max feasable rehab

- effective palliation for those who cannot be cured

-Active therapy (for curing)

-Combined active/supportive (ease pain/discomfort AND cure)

-Combined palliative and symptomatic (fight ther health probs cuase by cancer or tx of cancer, goal no longer to cure)

- Supportive care (tx to reduce pain and distress and increase feeling of well being)

surgical resection, with sometimes radiation too.

Accessability is good so that's why

radiation therapy

surgery is second option b/c pharynx is difficult to access and reconstruct

structural changes (anatomatical defects, neurological sensory deficits)

Functional changes (speech/swallowing issues, reduced or altered saliva, olfaction, sensation)

Psychological changes (internal and external)

When the cell divides, the DNA is vulnerable to radiation. Tumour cells divide faster than healthy cells. Therefore you have a better hange of killing malignant cells then healthy cells when giving radiation

BUT... healthy cells divide too and this does also kill them

- the damage is instant, but doesnt show up til the cell divides  (short in mucous, years in bone)

- cells with high sensitivity get damaged (skin, mucosa, hair, salivary glands, lymphocytes)

- low sensitiviy (nerves, muscles, bone, CNS)

external beam (conventional and most common)

brachytherapy (loaded gold pellets implanted to target site)

easy to access areas

good for nasopharyngeal cancer 

masseter scars over time and mandible will break over time

(lock jaw and eventually broken jaw)

an acute side effect of radiation therapy

- painful inflammation of the mucosa

-erythema (redness) and edema (swelling)

- v uncomfortable but goes away quickly

an acute side affect of radiation therapy

-it affects the salivary glands

- more bacteria in mouth

-frequent rinsing with water

-added baking soda to inc pH

-impregnate oral mucos  with butter or oil

-artificial saliva

submandibular gland transfer

relocating one of the submandibular gland to the submental space which is shielded during radiation

(good or tumours in the retromolar trigone)

distortion of taste perception

often increases sweetness

Dysgeusia

Xerostomia

Candida

Mucositis

Dermatitis 

inflammation of the skin in the radiation field

skin looks red, burned, cracked

can have lesions

(tx is dermatological or pain management)

1) dermatitis (2-3wks)

2.) mucositis (4 wks)

3.) dysgeusia (12 wks)

4) Xerostomia (can resolve but tends to persist)

xerostomia

fibrosis

dysgeusia

atrophy

osteoradionecrosis (bone-radiation-die)

trismus

hypertroph

reduced or absent sensation

hypersensitivity

incoordination

What is osteoradionecrosis?

what are management options?

-bc bone cells are late responding to radiation damage

- irradcation can weaken bone leading to fractures

- mandible esp at risk

Management:

-hyperbaric oxygen

-surgical management

-but healing potention of bone not good

when the teeth are damaged /fall out due to radiation

-fibrosis of the temporalis and masseter (lock jaw)

Management:

- training with jaw excerciser (therabite oral excerciesr)

- surgical management

-high does radiation can reduce or elim the need for surgery, thus preserving the organ

BUT.. loss of function following such a hi intensity tx may actually be worse in the end than a surgical resection

- poisonous cytostatica are intro'd into bloodstream, designed to kill tumour cells

- continous chemo would kill a patient, cyclic application allows for recovery

- side affects in H and N cancer outweigh benefits

- In H and N, only used for palliative reasons

hair loss

fatigue

vomiting

mouth sores

bladder infections

low blood counts

diarrhea/constipation

dec sex drive

1) disease related (has the cancer been removed/contained)

2) functional (what functional impairments does the patient now have)

3) Psychological (what are teh effects of the cancer Tx on the patient and his/her environ)

-lump in the throat feeling

- persistent throat clearing

-persistent coughing

-sense of discomfort in the throat

-sore throat

-diffs breathing

- burning sensation on swallow

-pain on swallowi

-referred pain from larynx to ear

-weight loss

trachea and esoph are entirely separated and its no longer possible to breathe through the mouth

(surgeon then does deliberate botch job to create stable scar tissue)

no aspiration (unless fistulas)

BUT.

neg pressure pump lost, basically just have to shove food through the UES which can get quite tight

hyoid not moving forwards and upwards at all

the removal of the laryngeal strap muscles can destabilize the hyoid and decrese tongue motility during a swallow

(leading to inc transit time, poor bolus propulsion and dec UES opening)

for the pharyngeal wall

pretty jiggly 

intraoral electolarynx

pneumatic artificial larynx

pharyngeal

buccal

-air sent into oral cavity with tube

-not hands free

-lungs activate it

-acceptable voice

-high maintenance

can be hard to find sweet spot

robotic sounding

for client with dentures anyways

- remote controle activated

pitch and loudness can change

-prob - sounds source in mouth, gets attenuated

-overarticulation (make it non visible)

- ident of best 'soft spot'

- larnyx to skin seal

-dev convo speech, phrasing, pauses etc (make it natural)

- pragmatic use (with turn taking)

1)optimal placement

2)coordination of the 'on' control with speaking

3)articulatory precision

4) appropriate rate and phrasing

5)attenuation to nonverbal behaviours

air gets 'shoved' into upper 3rd of esophagus, the air vibrates UES then comes out through vocal tract

-NOT gas from stomach, the airs is just environmental

Injection methods ( plosive consonant injection, glossal compression injection, glossopharyngeal compression injection, 'modified swallow')

Inhalation method (inhale deeply, inc neg resting press on esohp)

1) train air insufflation, injection or inhalation

2) Voice production on demand following insufflation

3) Repeated productions of voice following insufflation

4) Monitor dev of detrimental behs (grimacing, stoma blast)

5) Reduce degree of artic contact assoc with insufflation and voicing

1)get air in and out

2)produce plosives, vowels and diphthongs

3)simple useful monosyll words

4)voice two syll words

5) voice simple phrases

6) practice artic and connected speech

7) achieve stress

8) active conversation

9) conversational speech rate

prolongation of voice

inc intelligibility

minimize assoc noises or beh

maintain rate

improve prosody

(hard to do if its really dry out)

-motivation

-adequate understanding of postsurgical anatomy

-basic understanding of TEP prosthesis

-adquate manual dexterity

-adequate visual acuity

- demonstrated abiltiy to care for prosthesis

- no sig hypophargneal stenosis

-poss air insuffation test

-adequate pulmonary function

-adequate stoma

-mental stability

1)puncture dilation

2)puncture measurement

3)insertion of the gel-capped prosthesis

4)cut insertion strap

1)valving

2)artic

3)phrasing

4)rate

5)attention to nonverbal behavours

an insufflation test

yes if  normal tonus and good voice

no if   spasm, hypertonicity, hypotonicit

basically mimics a TEP

air from stoma, then through nose and into UES

gives client an idea of what speaking with a TEP will be like

-leaky TEP valve

-esophageal leaking though TEP fitula

-opening resistance of TEP valve

- Candida (it loooves silicone)

-persistent spasm of the Pharygo-esophageal segment

-granuloma, scarring, infection, edema of fistula 

- disappreaance of TEP valve under granuloma

-swallowing prosthesis

-aspiration of prosthesis (bad)

small tracheostoma

fistula from radionecrosis

large fistulas (open to outside)

large postoperative edema

large granuloma

airways and breathing safety

swallowing safety (do they have a separate airway/food passage?)

voice quality and quantity

the stripping of an effected vocal fold, complete fold could be removed

Arytenoid usually left in place which helps preserve laryngeal function

What are some cordectomy complications?

What does most therapy focus on?

frequent probs - minor changes to voice and effort, hyperfunctional compensation common

Therefore therapy often aimed at reducing hyperfunctional compensation (pressed/forced phonation

-smooth/easy phonation

-increase utterance length

-control speech rate via phrasing tasks

-'careful pushing'

-visual feedback (visipitch) for loudness and voicing measures

type of partial laryngectomy

tumour on one vocal fold will often have the tendency to spread around the ant commissure

(aryteniods left in place)

 if tumour spread too far posteriorly and interiorly, then they surgeon resects half of the larynx including the aryteniod

(a more confined vertical resection where the aryteniod is left in place is a 'vertical partial laryngectomy'

What are specific problems with vertical partial and hemi-laryngectomies?

what does therapy try to do?

-can have higher F0 and shorter duration on sustained vowels (v. variable)

- thearpy needs to identifiy predominant source of voice (glottal or ventricular)

- might need to use supraglottic activity for communication if folds can achieve adeq closure

- ident pt of easiest phonation

-dec utterance length to avoid exhaustion of the pulmonary support

-defect fairly extensive (degree of variability for indiv outcomes is considerable)

- 'vocal noise' is frequent complaint

TX - balance excessive noise and necessary air pressure for driving an often tight sounrce

-posture adjustments 

all laryngeal structures above the Vfolds are removed (epiglottis, vestibular folds, hyoid, thyroid)

leaving the v folds and the aryteniods as the sole protection of the airway

voice quality and quantiy can be poor

also often need tracheostomas

(airway management is big concern)

-high risk of aspiration can lead to over adduction of v folds and hyperfunctional voicing probs

-tx goal is eliminate aspiration and est phonation

variation of supraglottic laryngectomy. The hyoid and epiglottis are preserved though.

So leave better swallow safety and voice quality

temporary trach - stoma not scarred to it can heal later, silver tube inserted to keep airway open

open during normal respriation

it closes when the phonation threshold pressure is reached and allows the patient to phonate

-fills the space bet the tracheostoma tube and the tracheal walls

-prevents air leakage

-can also reduce aspiration but not intended purpose

No

lots of leakage

tracheal irritation and trauma

esophageal trauma (can reduce esophageal motility too)

- some studies found that cuff inflation inc asp by a factor of 2.7

glottal phonation =)

vestibular phonation

aryepiglottic phonation

"to phonate at any cost, reduce airflow and promote an acceptable voice quality"

"improve global communication in which strategies involving overartic, modulation and projection'

1)if patient shows glottic tendency- therapy must follow it (ie not go towards vestibular phonation etc)

2)if patient shows supraglottic tendency - therapy should ephasize strategies which favour the approx and vibration of the supraglottic structures

3) If patient shows mixed sound source - glottic and supra, then therapy must shift to supraglottic level

sonorization level

speech level

vocal plasticity level

promoting phonation at any cost

Techniques:

- humming

- vocal fry (strohbass)

- half swallow boom

- hard vocal attack

- sustained /B/

- mild pushing

improving vocal quality (hoarse voice is acceptable)

ident optimum head and neck posture for phonation

improve speech intellig through overartic

additional techniques - chant, chewing

-emphasize modulation, expand dynamic and frequency range

-singing and reading 

-supra and super glottic swallow

-Mendelson maneuver

- inc laryngeal ventral-cranial excursion

- tongue protrusion may elevate the larynx

-head and neck postural changes

mobility - is passive

motility- active ability to move

-Primary wound healing (defect left open to heal)

-Local closure (surrounding tissue is closed over the defect)

-Local flap/pedicle flap closure (tissue flap is liften close to the defect but retains origicanl blood supply)

-Free flap closure - tissue lifted somewhere else on the body and transplanted

Local flap - is lifted close to defect but keeps own blood supply (Pectoralislappen!)

Free flap - tissue removed from thigh etc and transplanted to other area

-lenghtening of vowel duration

-reduction or increase of vocal intensity

-reduction of rate and intentional use of meaningful pauses

-widening of pitch range and variability

-maximize mobility and motility of residual tissue

-re-establish articulatory targets consistent with the movement capabilities of the structures

-improve the speaker's ability to achieve speech sound differentiation

-bring the palate to the tongue idea for glossectomees

-could be good for swallow too, adequate closure etc

- BUT .. 

not really used that much yet in therapy

Use bilabial closure to approximate /s/ and /z/

-called labial compensation

labial compensation

-seal mid lips and allow lateral movement out sides

-review nutrition mode

-diet mod

-physiological maneuvers (Mendelson supraglottics etc)

-Clearance enhancement

-Inc stimulation vlaue of bolus

-Preparation (dryness relief)

-Precautions (sit upright post meal)

-Inc effort to energy efficency of meals, hi cal per portion in multiple smal meals)

PT excercise for oral structures

ice cream spoon

special feeding spoon

syringe with top removed

closes a maxillary defect

like a retainer

a sort of prosthesis for the face

for removal of different areas after surgery for cancer

an example is a maxillio-oculo-facial epithesis ( ca be attached to glasses to keep it on)

Facial epithesis

Dento-facial epithesis