A multidisciplinary team should be compiled in advance to assist with both the preoperative and postoperative education and treatment. The functional outcomes of a laryngeal transplantation include breathing, vocal, and swallowing functions. A speech and language pathologist (SLP) will be involved in the swallowing and voicing treatment of the patient. The evaluations completed pre and post operative by the SLP should include the GRABS, Vocal handicap index, basic acoustic analysis, Flexible endoscopic evaluation of swallowing, and a videofluoroscopic swallow study. These evaluations may also be given at regular intervals until the patient’s voice and swallowing functions are stabilized.
Counseling and education prior to the surgery is a crucial role for the SLP. The SLP must explain potential outcomes of voicing, swallowing, and breathing. This includes explaining what the voice could sound like post-surgery, consequences of failed nerve reinnervation, potential need of a tracheostomy for breathing and speaking (including use of a Passy-Muir valve if needed), possible need for a feeding tube, and any speech therapy that may be necessary to return the laryngeal functioning to near-normal.
For swallowing function, the larynx provides glottal closure so that food and liquids do not enter into the trachea. It also allows for the timely opening of the crico-pharyngeal sphincter so that food can easily pass into the esophagus. Research continues to develop comparing normal laryngeal excursion to that of a transplant. Swallowing therapy will likely be needed in order to focus on coordination of laryngeal closure with the pharyngeal stage of the swallow. It should be noted that treatment would be intense, occurring on a daily basis during the recovery period.
Looking at voice function in terms of speaking quality, transplantation allows the vocal folds to phonate again. In theory, the resonating chamber such as the pharynx, nasopharynx, and oral cavity are not changing; therefore the sounds of the vocalizations should not dramatically change. This theory continues to be looked at as new transplants begin to occur. A person’s accent is formed by the articulators (lips, cheeks, tongue, and palate), therefore the patient’s accent will remain the same.
It is not realistic to think that upon transplantation that the larynx will immediately begin functioning normally, allowing for easy speech. Voice therapy to help restore function may work on aspects such as coordination of breathing in conjunction with vibratory phonation. Achieving mastery of pitch and volume can take time (Narula, Bradley, Carding, Hakim, Rumsey & Sokol, 2011).
Dr. Douglas Hicks was the SLP who treated Tim Hiedler, the first patient to receive a laryngeal transplant. Prior to the surgery, Dr. Hicks and other members of the team provided counseling and education regarding the procedure and possible outcomes, especially since this was the first laryngeal transplant. Following the surgery, Dr. Hicks performed voice and swallowing therapy. Hiedler’s vocal folds were paralyzed, so he required a tracheostomy to breath. Dr. Hicks trained Hiedler to use the tracheostomy to speak. In addition, swallowing therapy was performed and Hidler now eats an oral diet. After the surgery, Dr. Hicks continued to conduct subjective and object assessments, aerodynamic tests of airflow and volume, and videoendoscopy to monitor the functioning of the larynx.
Resources:
Narula, T., Bradley, P., Carding, P., Hakim, N., Rumsey, N., & Sokol, D. (2011). Laryngeal transplantation . London: The Royal College of Surgeons of England.
No comments:
Post a Comment