Evaluation and Management of Glossectomy

7/27/2019 Evaluation and Management of Glossectomy

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Evaluation and management of

glossectomy

KUNNAMPALLIL GEJO JOHN

BASLP, MASLP


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Oromotor exercise


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The inability to eat or todrink is not an acceptableway of living

Buset and Cremer

1992.


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The speech therapist

perspective

Swallowing - vegetative basic biologicalfunction of life

-a necessity for survival

Speech - an overlaid function

- necessary for socialcommunication

The organs serving the two function is theoral cavity associated with respiratoryand laryngeal systems


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Swallowing rehabilitationarecent development !

Understanding swallowing physiology

Evaluation of disability in objective terms VizOPSE video fluoroscopy mod. Ba swallow

Swallowing Rx Speech pathologists domain

Preventing/pre-empting of Aspiration..

Learning from Quality of life perspectives .


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Disability- post resection

An appraisal

Impact swallowing

Bolus preparation

Bolus propulsion

Bolus residueInadequate nutrition

Aspiration


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Oropharynx oral cavity

Base of tongue

Tonsils

Vallecula

Mobile tongue


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Swallowing physiology

Four Impt phases

Voluntary phase

oral preparatory phaseoral phase

Involuntary phase

pharyngeal phase

esophageal phase


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Oral & Pharyngeal Phases- Scopefor Intervention


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Swallowing process

FoodTonguemovement

Pharyngealphase

Bolus passing

throughesophagealarea


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Lateral tonguelesion


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Posteiortongue

lesion


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Oral cancer surgical resection

Structural deviation

Functional deficits

Constant flow of salivaFacial altered counter

Impaired speechMastication affected

Interrupted airway

temporarily


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Surgically related Dysphagia

Dependent upon

1. Which anatomic structures areremoved

2. Extent of tissue removed

3. Presence of nerve damage

4. Type of reconstruction(flap/repair/sutures)


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Effect of glossectomy on swallowing

Reduced oral control with delayed oraltransit times

Sensory loss resulting in unwarned ofposition of food in mouth

Reduction in lip closure leading to loss ofmaterial from the mouth

Reduction in range , flexibility andstrength of tongue movements


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Difficulty in transferring food from the frontto back of oral cavity

Loss of bolus into pharynx prior to trigger ofthe swallow, leading to aspiration

Reduced or absent chewing action resultingin long term fluid diet

Nasal regurgitation or leakage, if the soft

palate has been affected Lack of velopharyngeal seal resulting in

insufficient intraoral pressure to assist inpropelling the bolus into pharynx


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Incoordination of swallow due toswelling and reduced sensation inpharynx

Damage to cranial nerve 9, 10, 12.11th nerve

Failure of the larynx to elevate fully

h h i l


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Speech Therapist role-Swallowing disorder

To maximize residual

function

To offer alternative

feeding options


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When should dysphagia

management begin?

Assessment andmanagement should bedone when healing is

complete withoutpostoperative complications


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SWALLOWING REHABILITATIONWHEN?

Healed Wound & no e/o Fistula

Preferably before RT ( Incorporate Amifostine)

Continue until mucositis makes it painful( after 20GY)Maintain Nutrition all the time ( PEG )

Recommence after 4-6 weeks after Last fraction RT

Continue for 6-8 months to prevent fibrosis & minimise

sequelEnhance Salivary flow with Sialogogues, Pilocarpine ,


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Swallowing assessmentinformal

Observe how the person handlessecretion

Examination of the structure &function of the oral structures

Cough reflex

Sign of aspiration Nutritional status of the patient

Interest of the patient for swallowing

Rx


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Swallowing assessment

vidiofluroscopic analysisModified barium swallow

Consistency of material-liquid/paste/cookie

Swallow measures----- OPSE

Indicates the efficiency ofswallowing for all the three food

materials


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Treatment timing

Before radiotherapy

During radiotherapy

After radiotherapy

Little and often practicedaily

Regular follow up


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Deglutitory disordersTONGUE

Mild ---- < 30% resection with tonguemobility

Severe --- >50% tongue resection

Impairs - lingual peristalsis, antr-postrbolus movts & pharyngeal phase

Increased oral phase Drooling of saliva

Reduced/absent chewing action

resulting in long term fluid diet


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Deglutitory disordersLIPS

Minimal

oral phase- reduction in lip closure

- loss of material frommouth


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Deglutitory disorderMANDIBLE

Severe if combined withglossectomy

Oral preparatory, oral&pharyngeal phase

Difficulty in chewingDrooling


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How to start management?

Explanation of surgery and itseffect

Altered swallowingphysiology

Food consistency forswallowing

Amount of material


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Reconstructed tongue after majorsurgery


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Total glossectomy


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Lower jaw cancer operated


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Partial glossectomy

Postoperative view


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Treatment of tongue cancer

Transoral excision


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Commandoprocedure


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Accumulationof saliva in theanterior part

of the oralcavity

Reconstructedarea


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No ligual/oral tongueto lateralfood


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Glossectomywith lip splitting

approach

fl f


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Tongue flapA type ofreconstruction of the defect


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How to start ?

Baseline dataMedical history

extent and site of

resectionType of

reconstruction

Oral cavitystructural andfunctional deficits


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Dysphagia management

Start after decannulation Oromotor exercise Compensatory methods

postural changeschange in foodconsistency

Directional maneuvers

supraglotticswallowsuper supraglottic

swallow


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Dysphagia program

Information giving about alteredswallowing physiology

Positive, supportive and realisticassurance

Constant family support

Assessment of respiratoryproblem

Decannulation of tracheostoma


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Range of motion exercises

Start early-as soon as adequate healing

Ensure adequate pain control

Short frequent practice sessionsthroughout the day-5-10 min 10 times aday

Evaluate progress regularly

Potential to improve for up to 3 months


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Oromotor exercises tongue


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Compensatory methods-5 T

Temperature

Taste

Total

Time

Texture


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Swallowing therapy


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Compensatorymethod offeeding


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Feeding aidsHelps in bolus placement,

manipulation &transport in

oral cavity

1. Long handled feeding

spoon

2. Straw

3. Sippy cup

4. Cup with cut out fornose

5. Asepto syringe &catheter


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Swallowing therapy session


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Hints & tips on feeding

Pick times when patient is most alert

Ensure as upright and comp. position

Allow plenty of time to eat and ensure a relaxed

environment with no distractions is maintained Encourage patient to place food in non operated

side and tilt head to this side

Avoid mixed consistencies of food and drink Pay attention to food presentation


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Oral hygiene

Encourage patient to clear mouthafter each swallow

Carry put oral hygiene after eachmeal


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Each morning When awake

what will I eat today

how will I prepare it

how long will it takeme to eat

will I have to speak toanyone

will others understandmy speech

how long to continue

like this


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Physicians efforts are to bringback an individual from death

whereas

The rehabilitation professionals

efforts are to take him\hertowards meaningful life

Documents

Evaluation and Management of Glossectomy