Sei sulla pagina 1di 54
Evaluation and management of glossectomy
Evaluation and management of
glossectomy
Evaluation and management of glossectomy KUNNAMPALLIL GEJO JOHN BASLP, MASLP
Evaluation and management of glossectomy KUNNAMPALLIL GEJO JOHN BASLP, MASLP

KUNNAMPALLIL GEJO JOHN BASLP, MASLP

Evaluation and management of glossectomy KUNNAMPALLIL GEJO JOHN BASLP, MASLP
Evaluation and management of glossectomy KUNNAMPALLIL GEJO JOHN BASLP, MASLP
Evaluation and management of glossectomy KUNNAMPALLIL GEJO JOHN BASLP, MASLP
Oromotor exercise
Oromotor exercise
Oromotor exercise
Oromotor exercise
Oromotor exercise
“The inability to eat or to drink is not an acceptable way of living” Buset

“The inability to eat or to drink is not an acceptable

way of living”
way of living”
“The inability to eat or to drink is not an acceptable way of living” Buset and

Buset and Cremer

1992.
1992.
“The inability to eat or to drink is not an acceptable way of living” Buset and
“The inability to eat or to drink is not an acceptable way of living” Buset and
“The inability to eat or to drink is not an acceptable way of living” Buset and
The speech therapist perspective
The speech therapist
perspective

Swallowing - vegetative basic biological

Speech function of life -a necessity for survival - an overlaid function - necessary for
Speech
function of life
-a necessity for survival
- an overlaid function
- necessary for social
communication
The organs serving the two function is the
oral cavity associated with respiratory
and laryngeal systems
communication The organs serving the two function is the oral cavity associated with respiratory and laryngeal
communication The organs serving the two function is the oral cavity associated with respiratory and laryngeal
Swallowing rehabilitation –a recent development !
Swallowing rehabilitation –a
recent development !
 Understanding swallowing physiology  Evaluation of disability in objective terms Viz OPSE video fluoroscopy
 Understanding swallowing physiology
 Evaluation of disability in objective terms Viz
OPSE video fluoroscopy – mod. Ba swallow
 Swallowing Rx – Speech pathologists’ domain
 Preventing/pre-empting of Aspiration
Learning from Quality of life perspectives .
Speech pathologists’ domain  Preventing/pre-empting of Aspiration Learning from Quality of life perspectives . 
Speech pathologists’ domain  Preventing/pre-empting of Aspiration Learning from Quality of life perspectives . 
Disability- post resection An appraisal Impact swallowing Bolus preparation Bolus propulsion Bolus residue
Disability- post resection
An appraisal
Impact swallowing
Bolus preparation
Bolus propulsion
Bolus residue
Inadequate nutrition
Aspiration

Oropharynx oral cavity

Base of tongue

Tonsils

Vallecula

Mobile tongue

Oropharynx – oral cavity • Base of tongue • Tonsils • Vallecula • Mobile tongue
Swallowing physiology Four Impt phases Voluntary phase oral preparatory phase oral phase Involuntary phase
Swallowing physiology
Four Impt phases
Voluntary phase
oral preparatory phase
oral phase
Involuntary phase
pharyngeal phase
esophageal phase
Oral & Pharyngeal Phases- Scope for Intervention
Oral & Pharyngeal Phases- Scope
for Intervention
Swallowing process
Swallowing process

Food

Swallowing process F o o d Pharyngeal phase Tongue movement Bolus passing through esophageal area

Pharyngeal

phase

Swallowing process F o o d Pharyngeal phase Tongue movement Bolus passing through esophageal area

Tongue

movement

Bolus passing through

esophageal

area

Swallowing process F o o d Pharyngeal phase Tongue movement Bolus passing through esophageal area
Swallowing process F o o d Pharyngeal phase Tongue movement Bolus passing through esophageal area

Lateral tongue

lesion
lesion
Posteior tongue lesion

Posteior

tongue

lesion

Oral cancer surgical resection
Oral cancer surgical resection
Structural deviation Functional deficits
Structural deviation
Functional deficits
resection Structural deviation Functional deficits  Constant flow of saliva  Facial altered counter 

Constant flow of saliva Facial altered counter Impaired speech Mastication affected Interrupted airway temporarily

Surgically related Dysphagia  Dependent upon 1. Which anatomic structures are removed 2. Extent of
Surgically related Dysphagia
Dependent upon
1. Which anatomic structures are
removed
2. Extent of tissue removed
3. Presence of nerve damage
4. Type of reconstruction
(flap/repair/sutures)
are removed 2. Extent of tissue removed 3. Presence of nerve damage 4. Type of reconstruction
are removed 2. Extent of tissue removed 3. Presence of nerve damage 4. Type of reconstruction
Effect of glossectomy on swallowing
Effect of glossectomy on swallowing
 Reduced oral control with delayed oral transit times  Sensory loss resulting in unwarned
 Reduced oral control with delayed oral
transit times
 Sensory loss resulting in unwarned of
position of food in mouth
 Reduction in lip closure leading to loss of
material from the mouth
 Reduction in range , flexibility and
strength of tongue movements
leading to loss of material from the mouth  Reduction in range , flexibility and strength
leading to loss of material from the mouth  Reduction in range , flexibility and strength
 Difficulty in transferring food from the front to back of oral cavity  Loss
 Difficulty in transferring food from the front
to back of oral cavity
 Loss of bolus into pharynx prior to trigger of
the swallow, leading to aspiration
 Reduced or absent chewing action resulting
in 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 in
propelling the bolus into pharynx
Incoordination of swallow due to swelling and reduced sensation in pharynx Damage to cranial nerve
Incoordination of swallow due to
swelling and reduced
sensation in
pharynx
Damage to cranial nerve 9, 10, 12.
11 th nerve
Failure of the larynx to elevate fully
sensation in pharynx Damage to cranial nerve 9, 10, 12. 11 th nerve Failure of the
sensation in pharynx Damage to cranial nerve 9, 10, 12. 11 th nerve Failure of the

Speech Therapist role-

Swallowing disorder

Swallowing disorder
Swallowing disorder
Swallowing disorder
Swallowing disorder
Speech Therapist role- Swallowing disorder
Speech Therapist role- Swallowing disorder
Speech Therapist role- Swallowing disorder

To maximize residual

Speech Therapist role- Swallowing disorder • To maximize residual
disorder • To maximize residual
disorder • To maximize residual

function

• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options

To offer alternative

• To maximize residual function To offer alternative • feeding options
•

•
•
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options

feeding options

• To maximize residual function To offer alternative • feeding options
• To maximize residual function To offer alternative • feeding options
When should dysphagia management begin? Assessment and management should be done when healing is complete
When should dysphagia
management begin?
Assessment and
management should be
done when healing is
complete without
postoperative complications
SWALLOWING REHABILITATION WHEN?
SWALLOWING REHABILITATION
WHEN?

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

sequel Enhance Salivary flow with Sialogogues, Pilocarpine ,

to prevent fibrosis & minimise

for 6-8 months sequel • Enhance Salivary flow with Sialogogues, Pilocarpine , to prevent fibrosis &
for 6-8 months sequel • Enhance Salivary flow with Sialogogues, Pilocarpine , to prevent fibrosis &

Swallowing assessment

informal  Observe how the person handles secretion  Examination of the structure & function
informal
 Observe
how
the
person
handles
secretion
 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
Swallowing assessment vidiofluroscopic analysis Modified barium swallow Consistency of material-
Swallowing assessment
vidiofluroscopic analysis
Modified barium swallow
Consistency of material-
liquid/paste/cookie
Swallow measures----- OPSE
Indicates the efficiency of
swallowing for all the three food

materials

Swallow measures----- OPSE Indicates the efficiency of swallowing for all the three food materials
Treatment timing
Treatment timing
Before radiotherapy During radiotherapy After radiotherapy Little and often practice daily Regular follow up
Before radiotherapy
During radiotherapy
After radiotherapy
Little and often practice
daily
Regular follow up
timing Before radiotherapy During radiotherapy After radiotherapy Little and often practice daily Regular follow up
timing Before radiotherapy During radiotherapy After radiotherapy Little and often practice daily Regular follow up
timing Before radiotherapy During radiotherapy After radiotherapy Little and often practice daily Regular follow up
Deglutitory disorders TONGUE  Mild ---- < 30% resection with tongue mobility  Severe ---
Deglutitory disorders
TONGUE
 Mild ---- < 30% resection with tongue
mobility
 Severe --- >50% tongue resection
 Impairs - lingual peristalsis, antr-postr
bolus movts & pharyngeal phase
 Increased oral phase
 Drooling of saliva
 Reduced/absent chewing action
resulting in long term fluid diet
Deglutitory disorders LIPS
Deglutitory disorders
LIPS
 
Deglutitory disorders LIPS   Minimal oral phase - reduction in lip closure - loss of

Minimal oral phase - reduction in lip closure - loss of material from mouth

Deglutitory disorders LIPS   Minimal oral phase - reduction in lip closure - loss of
Deglutitory disorder MANDIBLE Severe if combined with glossectomy Oral preparatory, oral& pharyngeal phase
Deglutitory disorder
MANDIBLE
Severe if combined with
glossectomy
Oral preparatory, oral&
pharyngeal phase
Difficulty in chewing
Drooling
if combined with glossectomy Oral preparatory, oral& pharyngeal phase Difficulty in chewing Drooling
How to start management? Explanation of surgery and its effect Altered swallowing physiology Food
How to start management?
Explanation of surgery and its
effect
Altered swallowing
physiology
Food consistency for
swallowing
Amount of material
Reconstructed tongue after major surgery
Reconstructed tongue after major
surgery
Total glossectomy
Total glossectomy
Lower jaw cancer operated
Lower jaw cancer operated
Lower jaw cancer operated
Lower jaw cancer operated
Partial glossectomy
Partial glossectomy
Partial glossectomy  Postoperative view

Postoperative view

Partial glossectomy  Postoperative view
Partial glossectomy  Postoperative view
Partial glossectomy  Postoperative view
Partial glossectomy  Postoperative view
Treatment of tongue cancer
Treatment of tongue cancer
Treatment of tongue cancer  Transoral excision

Transoral excision

Treatment of tongue cancer  Transoral excision
Treatment of tongue cancer  Transoral excision
Treatment of tongue cancer  Transoral excision
Treatment of tongue cancer  Transoral excision
Commandoprocedure
Commandoprocedure
Commandoprocedure
Commandoprocedure
Commandoprocedure
Commandoprocedure

Accumulation

of saliva in the

Accumulation of saliva in the anterior part of the oral cavity Reconstructed area

anterior part of the oral cavity

Accumulation of saliva in the anterior part of the oral cavity Reconstructed area

Reconstructed

area

Accumulation of saliva in the anterior part of the oral cavity Reconstructed area
Accumulation of saliva in the anterior part of the oral cavity Reconstructed area
No ligual /oral tongue to lateral food
No ligual
/oral tongue
to lateral
food
Glossectomy with lip splitting approach

Glossectomy with lip splitting approach

Tongue flap A type of reconstruction of the defect

Tongue flap – A type of reconstruction of the defect
How to start ?
How to start ?
 Baseline data  Medical history – extent and site of resection
 Baseline data
 Medical history –
extent and site of
resection

Type of reconstruction

 Oral cavity – structural and functional deficits
 Oral cavity –
structural and
functional deficits
– extent and site of resection  Type of reconstruction  Oral cavity – structural and
Dysphagia management • Start after decannulation • Oromotor exercise  Compensatory methods postural changes
Dysphagia management
• Start after decannulation
• Oromotor exercise
 Compensatory methods
postural changes
change in food
consistency
 Directional maneuvers
supraglottic
swallow
super supraglottic
swallow
Dysphagia program  Information giving about altered swallowing physiology  Positive, supportive and realistic
Dysphagia program
 Information giving about altered
swallowing physiology
 Positive, supportive and realistic
assurance
 Constant family support
 Assessment of respiratory
problem
Decannulation of tracheostoma
Range of motion exercises  
Range of motion exercises

Start early-as soon as adequate healing Ensure adequate pain control Short frequent practice sessions throughout the day-5-10 min 10 times a day Evaluate progress regularly Potential to improve for up to 3 months

throughout the day-5-10 min 10 times a day Evaluate progress regularly  Potential to improve for

throughout the day-5-10 min 10 times a day Evaluate progress regularly  Potential to improve for
throughout the day-5-10 min 10 times a day Evaluate progress regularly  Potential to improve for
throughout the day-5-10 min 10 times a day Evaluate progress regularly  Potential to improve for

Oromotor exercises tongue

Oromotor exercises tongue
Oromotor exercises tongue
Oromotor exercises tongue
Oromotor exercises tongue
Oromotor exercises tongue
Oromotor exercises tongue
Oromotor exercises tongue
Compensatory methods-5 ‘T’
Compensatory methods-5 ‘T’
  Total  Time  Texture
 Total
 Time
 Texture
Compensatory methods-5 ‘T’   Total  Time  Texture  Temperature Taste

Temperature Taste

Compensatory methods-5 ‘T’   Total  Time  Texture  Temperature Taste
Compensatory methods-5 ‘T’   Total  Time  Texture  Temperature Taste
Swallowing therapy
Swallowing therapy
Swallowing therapy
Compensatory method of feeding

Compensatory

method of

feeding

Feeding aids Helps in bolus placement, manipulation &transport in oral cavity 1. Long handled feeding
Feeding aids
Helps in bolus placement,
manipulation &transport in
oral cavity
1. Long handled feeding
spoon
2. Straw
3. Sippy cup
4. Cup with cut out for
nose
5. Asepto syringe &
catheter

Swallowing therapy session

Swallowing therapy session
Hints & tips on feeding  Pick times when patient is most alert  Ensure
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

side and tilt head to this side Avoid mixed consistencies of food and drink Pay attention
Pay attention to food presentation
Pay attention to food presentation
 
side and tilt head to this side Avoid mixed consistencies of food and drink Pay attention
side and tilt head to this side Avoid mixed consistencies of food and drink Pay attention
Oral hygiene Encourage patient to clear mouth after each swallow Carry put oral hygiene after
Oral hygiene
Encourage patient to clear mouth
after each swallow
Carry put oral hygiene after each
meal
Oral hygiene Encourage patient to clear mouth after each swallow Carry put oral hygiene after each
Oral hygiene Encourage patient to clear mouth after each swallow Carry put oral hygiene after each
Each morning
Each morning
 When awake what will I eat today how will I prepare it how long
 When awake
what will I eat today
how will I prepare it
how long will it take
me to eat
will I have to speak to
anyone
will others understand
my speech
how long to continue
it take me to eat will I have to speak to anyone will others understand my

like this

Physician’s efforts are to bring back an individual from death whereas The rehabilitation professional’s efforts
Physician’s efforts are to bring
back an individual from death
whereas
The rehabilitation professional’s
efforts are to take him\her
towards meaningful life
individual from death whereas The rehabilitation professional’s efforts are to take him\her towards meaningful life
individual from death whereas The rehabilitation professional’s efforts are to take him\her towards meaningful life