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316 The Voice and Voice Therapy
of phonation. This was due to a more or less uniform bilateral stiffness of the entire vocal fold
area. The effect is very much like that produced by surgical stripping of the vocal fold to remove
vocal fold cancer.
A third case illustrates another role of the SLP in the follow-up and management of patients
treated for laryngeal cancer. A 26-year-old female was seen for evaluation of voice following
surgical removal of superficial squamous cell cancer. The patient is a nonsmoker, does not use
alcohol, and is a vegetarian and marathon runner. She is in excellent shape but has cancer of the
larynx. The cancer has returned three times in less than 2 years and has been removed three times.
The decision of a team of otolaryngologists (ear, nose, throat [ENT] physicians) is to continue
to monitor the return of the cancer and remove it before it becomes deeply embedded in the
vocal folds. The speech pathology clinic is to evaluate the patient every 4 to 6 months, along with
evaluations by the ENT team. The SLP provides videostroboscopic monitoring of the larynx
and acoustic evaluation of the voice as a means of tracking the cancer regrowth. Figure 9–2 is a
picture of the larynx of this young adult female patient with laryngeal cancer. In addition, the
SLP provides ongoing voice management so the patient is using the larynx optimally and does not
FIG URE 9 2. Four views of the larynx of a 26-year-old female with recurring squamous
cell carcinoma, followed over a 2-year period.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 317
engage in vocal abuse, which may make the voice poorer in quality and contribute to edema, a
condition that can make obtaining an accurate status of the cancer more difficult (see Video9–2).
While this is a very unusual case, the monitoring role of the SLP is not unusual and has been
applied in cases of contact ulcer, papilloma, and polyps and polypoid cord degeneration.
Video 9–2. We use glottal fry as a diagnostic
probe for patients who need to reduce laryngeal
hyperfunction and increase the opportunity for
relaxed vocal fold vibration. In the case of irregular vocal fold vibration due to scarring, glottal
fry encourages easy and relaxed vibration while
reducing demands on breath support. Note
on the video segment that glottal fry is used
as a diagnostic probe for patients presenting
with vocal hyperfunction for reasons ranging
from vocal overuse to spasmodic dysphonia
(see Differential Diagnosis of a Complex Voice
Disorder, Chapter 6). Grand Rounds: What is
the average frequency of glottal fry?
We cannot overstate the important role of laryngeal endoscopy in the case of differentially
diagnosing laryngeal cancer. For example, a 72-year-old man was referred to our clinic for voice
therapy to treat hypophonia because of Parkinson’s disease. Because this patient had been diagnosed with Parkinson’s disease years before, he was referred to our clinic without an imaging
study of the larynx. Instead of revealing bowed vocal folds bilaterally, rigid endoscopy at our clinic
revealed a unilateral space-occupying lesion that was whitish and irregular at the edges. A referral
to an ENT physician and subsequent biopsy rendered a diagnosis of T1 glottic cancer; this patient
was successfully treated with laser surgery and radiation.
Voice Facilitating Approaches
Our clinical experience with postsurgical and postradiotherapy treatment of dysphonia has
demonstrated some success using the following approaches, which were discussed in Chapter 7
(see Videos 9–1, 9–2, and 9–3):
●
inhalation phonation using the vowels /i/, /u/, and /o/
●
pitch shifts upward and downward based on the patient’s vocal response
●
glottal fry if vocal fold stiffness is not too great
●
nasal-glide stimulation
●
head turned to the side and lateral digital pressure applied to the thyroid cartilage
●
loudness change, usually lower
●
tongue protrusion /i/
●
glottal fry to tone
318 The Voice and Voice Therapy
Patients with postsurgical and/or postirradiation dysphonia are a challenging vocal population. The critical factor in success with voice therapy is the degree to which the mucosal wave has
been preserved. More often than not, we have been able to improve the voice of these patients
through voice therapy, but we have not always been successful due to too much vocal fold stiffness
or scarring or the absence of tissue (postsurgically), creating irregular vocal fold medial edges.
These patients may also have difficulty swallowing and thus may benefit from swallowing therapy
(Deschuymer et al., 2018).
Video 9–3. Tongue protrusion /i/ appears
bizarre on the video, but it is an effective
voice technique. When protruded, the
back of the tongue is pulled out of the oral
pharynx, and the pharynx and laryngeal
aditus are open to produce easy, clear voice.
The production of the voice with the tongue
protruded is sufficiently novel to break
maladaptive (bad) vocal habits often associated with hyperfunction.
Vocal Hygiene
In addition to the techniques listed previously to improve the voice, we also noted the need
for additional attention to vocal hygiene, such as avoiding excessive strain when trying to talk
over noise and increasing water intake. Increased hydration is a key component in these often
dry patients. Reduction of alcohol intake, which also is dehydrating, and substitution of silent
cough and sniff swallow for voiced coughing and throat clearing, respectively, are crucial for these
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patients. Because their anatomy and physiology are often altered by treatment of the disease, these
patients have less latitude or tolerance for vocal abuse, and their mode of vocal fold vibration is
less robust.
Laryngectomy
Understanding the profound changes and adaptations necessary following a total laryngectomy is
crucial for health care professionals, patients, and their families. This procedure, which entails the
complete removal of the larynx along with associated structures, fundamentally alters the patient’s
anatomy and respiratory function. Such a significant surgical intervention not only impacts the
physical aspects of breathing but also has deep psychological and social implications. The creation
of an external stoma as a new airway necessitates adjustments in daily living and communication,
highlighting the importance of comprehensive postoperative care and rehabilitation. Through
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 319
detailed examination of the pre- and postlaryngectomy anatomy, as illustrated in figures, we gain
insight into the extensive nature of these changes and the innovative solutions, such as the stoma
heat and moisture exchange (HME) system, designed to mitigate the adverse effects of losing
natural upper airway functions.
A total laryngectomy involves removal of the entire larynx. The laryngeal and hypopharyngeal
cartilages are removed, along with the hyoid bone, all extrinsic and intrinsic muscles of the larynx,
and the upper rings of the trachea. The uppermost portion of the trachea is brought forward and
fit flush with the neck. An external stoma (mouth) is created, which permanently serves as the
patient’s new airway.
Figures 9–3 and 9–4 show pre- and postlaryngectomy head and neck anatomy. Now that
the patient inhales and exhales through the stoma, the patient no longer experiences the natural
filtering, humidifying, and warming functions that the upper airway once served. Therefore,
a stoma HME system is recommended. The short- and long-term beneficial effects of HME
FIGU RE 93. Normal vocal tract anatomy.
320 The Voice and Voice Therapy
FIGU RE 9 4. Vocal tract anatomy after a total laryngectomy.
use by laryngectomees are well described in the literature (Longobardi et al., 2022). The heated
and moistened air from the exhalation phase of respiration is collected in the HME and reused
during the inhalation phase. This tends to reduce the potential for thickened mucus and subsequent coughing.
The journey of recovery and adaptation for individuals undergoing a total laryngectomy is a
testament to the resilience of the human spirit and the advancements in medical technology. The
stoma HME system exemplifies how engineering and health care can collaborate to improve the
quality of life for patients facing life-altering surgeries. By providing a means to mimic the natural
humidifying, filtering, and warming functions of the upper airway, this system plays a pivotal role
in managing the complications associated with a permanent stoma. As health care professionals,
our role extends beyond the technical aspects of care to encompass the support and guidance
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 321
needed to navigate this new way of living. Through education, empathy, and ongoing research,
we can continue to enhance the outcomes and quality of life for laryngectomy patients, ensuring
that they lead fulfilling lives despite the challenges they face.
Tumor Staging
Tumor staging plays a pivotal role in the management of cancer, serving as a foundation for
determining the extent of disease, guiding treatment decisions, and predicting patient outcomes.
The tumor, node, metastasis (TNM) clinical staging system is a universally recognized framework
used across various cancer types, including breast, colon, lung, liver, prostate, and head and neck
diseases. This system’s application to HNC is particularly crucial due to the anatomical complexity
and functional significance of the affected regions. For SLPs, understanding the TNM criteria is
essential for comprehending the scope of patient management. By integrating information from
physical examinations, radiographic studies, and operative findings, health care professionals,
including SLPs, can ensure accurate staging, which is instrumental in selecting optimal treatment
strategies and improving patient prognoses.
The TNM clinical staging system defines the extent of disease, with variations depending on
the location of the cancer (breast, colon, lung, liver, prostate, and head and neck). This section
focuses on head and neck disease and its TNM staging criteria. Tumor staging is critical for
establishing the disease status and patient prognosis and for selecting the most effective treatment paradigm. When staging a head and neck tumor, information gleaned from the physical
examination, radiographic studies (CT scans, MRIs, and positron emission tomography scans),
and operative and pathological findings are included in this process. The SLP should have an
understanding of the TNM criteria in order to appreciate patient management implications.
Correct staging is critical for optimizing treatment and maximizing outcome. TNM staging in the
head and neck may encompass tumors involving the nasal cavity; nasopharynx; paranasal sinuses;
oral cavity; salivary glands; oropharynx; hypopharynx; and supraglottic, glottic, and subglottic
larynx (National Cancer Institute, 2018) The presenting stage of the cancer is the most important
prognostic indicator for patient survival.
●
T (primary tumor: extent, size, invasiveness): Tis = “in situ” small surface lesion,
noninvasive, dysplasia. T1 = small tumor very localized. T2 = more penetrating and
larger tumor. T3 = penetrating lesion of muscle and possibly cartilage, movement of a
vocal fold is impaired because of cartilaginous invasion. T4 = very large, highly invasive
and penetrating tumor. The size and extent of the primary tumor increases from Tis
through T4. The higher the corresponding number, the greater is the risk for local,
regional, and distant spread (Figures 9–5 to 9–8).
●
N (regional lymph node involvement): N0 = no spread to the neck lymph nodes. N1
= spread to one lymph node (ipsilateral). N2 = spread to one lymph node ipsilateral
measuring more than 3 cm, or multiple contralateral or bilateral neck lymph nodes.
N3 = spread to one or more lymph nodes measuring more than 6 cm. Regional spread
equates to a poorer prognosis, and the site of the primary tumor is a major determining
factor in this metastasis.
322 The Voice and Voice Therapy
FIGU RE 9 5. T1 glottic cancer.
FIGU RE 9 6. T2 glottic cancer.
●
M (distant spread): M0 = no evidence of distant spread. M1 = distant spread. Distant
spread of the cancer from the primary tumor in the head and neck to other organ sites
(lung, bone, liver). This is more common in late-stage, advanced cancers and carries a
survival expectancy of 2 to 4 years (American Cancer Society, 2024).
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 323
F I GU R E 9 7. T3 glottic cancer.
FIGU RE 9 8. T4 supraglottic and glottic cancer.
The TNM staging system for HNC underscores the critical importance of accurate disease
characterization in clinical practice. This meticulous process influences every aspect of patient
care, from the initial diagnosis to the formulation of a targeted treatment plan and the evaluation
of prognosis. For SLPs, a thorough understanding of tumor staging enriches their contribution
324 The Voice and Voice Therapy
to the multidisciplinary care team, enabling them to tailor their therapeutic approaches to each
patient’s specific condition and needs. As the most significant prognostic indicator, the initial
cancer stage not only informs treatment decisions but also serves as a beacon guiding the journey
toward achieving the best possible outcomes for patients battling HNC.
Surgical Advances and Organ Preservation Protocols
The landscape of surgical management for HNC is undergoing a significant transformation,
driven by the advent of robotic-assisted surgery, minimally invasive endoscopic procedures, and
laser microsurgery. These innovative techniques represent a paradigm shift from traditional open
surgical methods, such as partial or total laryngectomy, toward approaches that prioritize the preservation of surrounding healthy tissue (collectively described as organ preservation approaches)
(Campbell et al., 2022; Gamez et al., 2020). By utilizing transoral routes or small incisions, these
methods aim to reduce the need for major surgical resections while maintaining oncological
efficacy. This evolution in surgical practices is complemented by advancements in radiation
therapy and chemotherapy, further supporting the goal of organ preservation without compromising patient survival. The move toward less invasive surgical options reflects a broader trend in
HNC management, focusing on improving patient outcomes through technologically enhanced
treatments that offer the promise of reduced morbidity.
While the shift toward minimally invasive surgical techniques and organ preservation strategies marks a promising development in the treatment of HNC, it is accompanied by nuanced
challenges and considerations. Organ preservation, though an appealing concept, does not always
equate to the maintenance of organ functionality and can be associated with significant toxic side
effects (Elicin & Giger, 2020). Despite the advances in treatment modalities, total laryngectomy
remains the most prevalent surgical intervention for advanced laryngeal cancer, underscoring the
complexity of balancing oncological control with the preservation of function and quality of life.
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As the field continues to evolve, ongoing research and clinical trials will be essential in refining
these approaches, ensuring that innovations in surgical management translate into tangible benefits
for patients navigating the difficult journey of head and neck cancer treatment.
Preoperative Counseling
Because laryngectomy alters respiration, swallowing, and speech, it is essential that the patient
understands the concept of laryngectomy and details about the surgery and speech rehabilitation. Therefore, a presurgical counseling session is recommended for the patient and their family.
Typically, in larger medical or teaching institutions, counseling would involve an interdisciplinary
team. Members of such a team may include head and neck surgeons, oncologists, plastic surgeons,
gastrointestinal physicians, nurses, social workers, SLPs, prosthodontists, dentists, dietitians, respiratory therapists, and laryngectomees (volunteers with laryngectomy who serve as a resource to the
patient). In a smaller or more rural environment, the SLP may be the sole provider of information. Regardless of the setting or facility, the SLP should illustrate and describe the changes that
occur in the speech mechanism as a result of laryngectomy. Written information, illustrations,
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 325
and films about various alaryngeal communication options should be provided. The SLP should
also demonstrate artificial larynges and address patient concerns and questions. Information may
be accessed through the Internet from organizations such as the International Association of
Laryngectomees (IAL) or WebWhispers. The booklet Self-Help for the Laryngectomee (Lauder,
2001) can be reviewed with the patient. Whenever possible, it is recommended that a laryngectomized patient-visitor, one who has successfully completed medical–surgical treatment and
speech rehabilitation, be included. This provides a unique opportunity for personal contact with
an experienced mentor.
Over the years, we have observed, and it is well reported in the literature, that laryngectomees have psychological profiles similar to amputees. Naturally, their primary concern is their
immediate health prognosis. We address these concerns by explaining that surgical and ancillary
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intervention are state of the art, and that head and neck cancers are among the more curable
cancers. A checklist for pre- and postoperative consultation, in addition to online resources and
medical supply resources, is found at websites of the International Association of Laryngectomees
(IAL), WebWhispers, and ASHA.
Postlaryngectomy Communication Options
As a consequence of total laryngectomy, individuals lose their natural voicing source, making speech
rehabilitation with a substitute sound source a major goal. The laryngectomee has three general
communication options after surgery, none of which is mutually exclusive. The first two, esophageal
speech and tracheoesophageal speech, use the pharyngoesophageal (PE) segment as the new voicing
source. In esophageal speech, air is “inhaled” into the PE segment and then expelled, setting the
tissue of the PE segment into vibration for a voice source. Tracheoesophageal voice restoration
surgery may be performed at the time of the total laryngectomy (primary) or sometime after
surgery (secondary). An opening or puncture is made through the posterior wall of the trachea,
extending through the anterior wall of the esophagus. A prosthesis inserted into the puncture shunts
pulmonary air from the trachea into the esophagus, causing the upper esophageal sphincter and
surrounding tissues to vibrate. This creates the sound that can be used for tracheoesophageal speech.
Option three, the electrolarynx, falls under the general category of artificial larynx (AL). This
method introduces sound for speech through an instrument externally placed against the throat or
oral structures, or through a fitted prosthetic electrolarynx inserted into the mouth while speaking.
As described by Hoffman Ruddy and colleagues (2016), the best communication option
for the patient to use as an alternative mode of communication depends on a number of factors
including age, cognitive status, motor coordination, and cultural and personal preferences
(p.219). A systematic review by van Sluis and colleagues (2018) reported results from 26 studies
reporting on multidimensional voice outcomes after total laryngectomy. Tracheoesophageal speech
was reported to be the method with the best outcomes for fundamental frequency, maximum
phonation time, and intensity. Perceptually, tracheoesophageal speech also was reported to be the
most pleasant and comprehensible to listeners. None of the methods were reported to yield greater
outcomes of self-reported vocal functioning. Tiple and colleagues (2015) examined voice-related
quality of life after total laryngectomy and reported that VHI scores were moderately high for all
patients, with those using tracheoesophageal speech reporting more significant voice handicap
than those using esophageal or electrolaryngeal speech.