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Cancer ↔ malignant growth

Communication Rehabilitation . Characteristics with People Treated for Oral . Cell growth that is • Ongoing • Purposeless • Unwanted Jeff Searl, Ph.D., CCC-SLP, ASHA-F • Uncontrolled Associate Professor • Damaging Department of Communicative Sciences and Disorders . Cells that Michigan State University • Differ structurally • Differ functionally

Several types of cancer Formation of Cancer Squamous cell = we see most often in oral cavity . NORMAL: Genes in DNA = controlled division, growth, and cell death

. CANCER

. Genetic control lost or abnormal

. Abnormal cell divides again and again

. Mass of unwanted, dividing cells continues to grow

. potential damage other cells/tissues in body

. Controls that stop continued division lost/impaired

Anatomy Lip & Oral Cavity Anatomy Review Regions for designating cancer location Regions for designating cancer location

. Following six slides have Trivandrum Oral Lip (vermilion) = images from Cancer Screening reddish hued area, Project. International Agency for Research on Cancer (IARC) “A digital manual for the early diagnosis of oral Labial mucosa = Retrieved 05/28/2017 from neoplasia.” thin(ner) lining of the inside of the lips http://screening.iarc.fr/atlas oral.php?lang=1 IARC link to Trivandrum screening

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Lip & Oral Cavity Anatomy Review Regions for designating cancer location Lip & Oral Cavity Anatomy Review Regions for designating cancer location

Buccal mucosa = lining of cheeks.

Alveolar ridge = bony ridge that holds the teeth Stensen duct opening

Retromolar trigone= Gingiva = tissue covering the neck of the teeth small triangular area behind And alveolar ridge. the last lower molar on each side.

Lip & Oral Cavity Anatomy Review Lip & Oral Cavity Anatomy Review Regions for designating cancer location Regions for designating cancer location

foliate papillae = Anterior 2/3 of tongue = leaf shaped, where side of tongue mobile portion of tongue meets palatoglossal fold, minor salivary glands, lymphoid follicles

Filiform papillae = many, fine, pointed, cone shaped, (blue arrow) Ventral tongue surface = yellow arrow

Median lingual frenum = white arrow Fungigorm papillae = Circumvallate papillae = mushroom-shaped, nodular appearing, Wharton duct opening = blue arrow reddish, dorsum of tongue, posterior 1/3 of tongue, (yellow arrow) (#8-10)

Lip & Oral Cavity Anatomy Review Practice Time Regions for designating cancer location

Floor of mouth = horsehoe-shaped, between ventrum of tongue and gingivae of mandibular teeth, extends to palatoglossal folds posteriorly

Hard palate = roof of oral cavity, contiguous with alveolar ridge of the maxilla and with the soft palate

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Head & Neck Cancer by the Numbers Incidence Rate Data

Incidence? cases in a population • Incidence rate: new cases within specified period of time . Worldwide: 405,000 new case per year • Incidence proportion: proportion of initially disease free population that develops the disease Highest rates: Sri Lanka, India, Pakistan, Bangladesh, Hungary, France Prevalence? actual number of people alive with the disease • Period Prevalence: during a particular period of time . United States: 53,000 • Point Prevalence: at a particular date in time

Mortality? # deaths in certain time period within a certain population

IARC Lip, Oral Cavity Worldwide Incidence Oral Cancer stats for the USA Rates

SEER is a good place to look for all kinds of data for the USA

(Surveillance, Epidemiology and End-Results Program)

Oral Cancer – USA incidence Oral Cancer – MI incidence

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Currently in the US – some general conclusions for Oral Cavity and Pharynx . AND OTHERS . DevCan – National Cancer Institute . . Men 2x > Women Alliance: http://www.headandneck.org/ site/c.8hKNI0MEImI4E/b.628 . Death rates declining 1%-2% past decade 1225/k.BDD9/Home.htm . Survival deteriorates moving from lips to larynx . Support for People with Oral and Head and Neck Cancer: http://www.spohnc.org/ . 10%-15% have other head & neck tumors

Increasing Incidence of HNSCC Primary reason for this increase - HPV

Increased incidence of some types of oral, head . Very common virus and neck squamous cell over the last 3 decades. . 50% sexually active adults with HPV infection in their lifetime Despite decreasing smoking rates

. >130 strains or genotypes Base of tongue, tonsil in particular – and particularly for white men . Most of these strains are harmless, treatable, and or noncancerous

Head Neck Oncol. 2009 Oct 14;1:36. www.headandneckoncology.org/content/1/1/36

HPV – Oral Cancer Sexual Transmission of HPV

. behavioral epidemiologists → changing sexual behaviors in the 1960s led to increased HPV . Fastest growing oral and oropharyngeal cancer exposure. population

. Otherwise healthy . Several studies = oral HPV infection is likely to be sexually acquired. . Non-smoking

. 35-55 years old E.g., D'Souza and colleagues found that a high (26 or more) number of lifetime vaginal-sex . More males than females (4:1) partners and 6 or more lifetime oral-sex partners were associated with an increased . HPV usually manifests in oropharynx, but also for more risk of HNSCC anterior oral sites

D’Souza et. al. N. Engl J Med 2007 May 10; 356(19): 1944-56

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Etiologic agents and risk factors E-cigarettes

Tobacco Products: Chemicals: . 2014 FDA Regulations applied – relative sales to minors; only . Smoking Tobacco . Asbestos nicotine containing liquids . Cigarettes . Chromium . Nickel . Cigars . 2017 National Youth Tobacco Survey . Arsenic . Middle school – 3% in last 30 days . Pipes . Formaldehyde . High School – 11.7% in last 30 days . Chewing Tobacco . Snuff Other Factors: . Health risk studies – few . Ionizing Radiation . The liquids keep changing Ethanol Products . Epstein-Barr Virus . NEJM (2015) and FDA – formaldehyde in vapor; other . Human Virus Laryngopharyngeal . Vitamin vaping!? Reflux

And more Reminder of synergistic impact of smoking and drinking

. Genetic factors . Diet low in fruits and . Doing both is worse than doing either one veggies individually . Sun exposure (lips) . Most who smoke also drink alcohol (reverse not . Areca nut, betel nut, true) . Wind exposure (lips) betel leaf; paan, pan . OR of heavy drinking + heavy smoking masal, supari significantly increased vs either behavior alone

CDC definition of ‘heavy drinking’: Men = 15/week, Women = 8/week

Staging Staging & Surgical-Oncological Tx • Clinical vs. pathologic • Stage 0, I, II, III, IVA, IVB, (surgical) IVC . Clinical guidelines available – based heavily on . Size, local spread, distant spread (i.e., staging) • AJCC for Lip, Oral Cavity, . Patient wishes • American Joint p16 neg OP Cancer . Comorbidities Committee on Cancer – T – size (AJCC) – N – lymph node spread – M – distant spread

. Briefly… staging

30

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AJCC Staging for Lip & Oral Cavity: T AJCC Staging for Lip & Oral Cavity: N and M

31 32

AJCC Staging by TNM Surgery, Radiation & Chemotherapy for Oral Cancer

OVERALL Approach . Surgical resection as 1o . Particularly with early stages (T1/T2, N0) . +/- reconstruction . +/- elective neck dissection; sentinel node biopsy

. Radiotherapy or Chemoradiation as Adjuvant

[Note: Oropharyngeal = more nonsurgical, and minimally invasive surgery] 33

Resection - more pics later Reconstruction Ladder - more later

. Removal of tissue . Healing by secondary intention . Primary closure

. Tumor size & location dictates removal volume . Skin grafting (split or full thickness)

. E.g., Tongue . Composite grafts . Partial (<40%) . Locoregional flaps . Hemi (40%-60%) . Subtotal (>60% - almost all) . Free tissue transfer . Total (100%)

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Primary and Secondary Intention Flaps - local, regional  examples Pedicle flap (converts to free flap)

Submental Island Flap

Pectoralis Major Myocutaneous Flap

Free Flaps – also various  Neck Dissection – also various extents

Neck Dissection Neck Dissection

. >50% pts with OSCC = lymph metastases . Treating the person with “N0” neck

. Most important prognostic factor = lymph mets . Elective Neck Dissection . 3 RCT = advantages for survival . 50% reduction in 5yr survival of regional nodes involved . Most offer it – stil some controversy

. SO  treating the neck is critical . Biopsy . Therapeutic – Opportune -- Elective

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Radiation Therapy Briefly – external beam

NCI Resource on Radiation Therapy . ‘Simulation’ . planning . Detailed imaging (CT, could be MRI, PET, ultrasound) . 3 ways to deliver . External beam radiation therapy – common for oral . Mask - stabilize head . Brachytherapy (internal radiation therapy) . Systemic radiation . Computer + MD - determine dose, area of exposure, safest paths of radiation delivery, schedule of treatment intensity/duration . Mode of impact = damages cell DNA; damaged cells stop dividing or die

External beam - delivery Last on external beam

. IMRT = intensity-modulated radiation therapy . Various schedules and approaches now . “beam shaping” . Varied radiation intensity to different areas/depths . Reverse planning . Historically - 5 days/week for 6-7 weeks

. Other fractionation schedules in use . 3D-CRT = 3-dimensional conformal radiation therapy . Hyperfractionation – smaller dose more than 1x day . IGRT…Tomotherapy…Stereotactic radiosurgery . Hypofractionation – larger dose 1 day or less . Accelerated fractionation – larger daily or weekly doses

Side Effects – some impacting speech Chemotherapy – briefly

. Drugs - slow or stop growth of cancer cells . Mucositis . Xerostomia . Candida, other . Combo with radiation Tx in head and neck . Lymphedema cancer in many instances . Fibrosis . To make a tumor smaller . Destroy cancer cells remaining after XRT or surgery . Enhance other treatments . Kill cancer cells that recur

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Side Effects – some impacting speech Chemotherapy

Cisplatin – standard treatment for H&N SCC

. Dysgeusia . Intravenous

. Dermatitis . Common side effects

. Dental decay • Nausea, vomiting

. osteoradionecrosis • Low blood count

• Renal toxicity • Ototoxicity

• Altered blood test results (magn, calcium, potassium)

. Less common side effects: Peripheral neuropathy, Decreased appetite, Taste sensation change, Hair loss

Oral Cancer Impact on Speech Oral Cancer Impact on Speech Before any treatment

. N=172 (125M/47F) . 12% lower Word Recognition . Dx: . Cancer impact (automatic) . maxillary alveolar ridge – 9 . Buccal mucosa – 12 . Female>Male (OSCC) . Cancer treatment impact – surgery, radiation . Margin tongue – 42 . Palate – 8 . Age and gender  WR . Oral floor – 50 . Location of tumor mattered . Mandibular alveolar ridge - 51

Oral Cancer Impact on Speech Oral Cancer Impact on Speech Before any treatment – self-report Before any treatment

Controls WR = 75.81 + 7.15% . N=21 . Detection of Speech . Oral cancers + 1 BOT Changes?

. Interviews + thematic analysis

p.481

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Big Picture Intelligibility Oral Cancer Treatment - Impact on Speech Articulatory Precision / clarity Understandability This is primarily what we deal with. Communication Articulation Acceptability Speaker Impacts from Naturalness Listener Oral Cancer Reconstruction Treatment Resonance •Type Nasal (hyper) •Size •Mobility Voice(?) Oral (altered) Resection Radiation‐ •Location chemo •volume •Acute impacts Hearing F0? males only? •Latent impacts Quality? Cognition Sensorineural HL Lymphedema CommunicationSpeech

Cog‐Language Difference

Tongue Subset of tumor locations considered here

. Tongue These 2 cause the most trouble for . Palate (hard/soft) speech . Lips

A few details on each of these with links to speech.

Degrees of Tongue Resection Lingual cancer

• Partial Glossectomy

• Hemiglossectomy

• Sub-total of Near-total glossectomy

• Total glossectomy

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Partial Glossectomy Hemiglossectomy and Near-total Glossectomy

• Free tissue reconstruction usually preferred – Can match flap to defect in terms of size/volume Radial forearm free flap – Large defects can be filled – Possibility for microneurorrhaphy procedure – Flap tissue not exposed Primary closure to XRT

Total glossectomy Total glossectomy

• Tongue “pull through” technique unless tumor invades mandible

• May require rectus abdominis or anterior lateral thigh flap rather than forearm due to need for increased bulk Pectoralis flap Anterolateral thigh flap

Tongue Cancer Surgery – what changes? Example: Partial Glossectomy +

. Mass . Besides speech Case 1. DH . Mobility . Saliva issues Age at video = 65 . Oral cavity space . Eating/chewing Smoker who quit at 57 . Appearance Dx with FOM, lingual cancer . Volume at 59

. Contour TX sequence 1. 48 radiation treatments soon . Sensation after Dx 2. 5yrs later (age 64) cancer returned aggressively 3. FOM+lingual resection; radial forearm flap 4. Some SLP follow-up for swallow, not speech

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Partial Glossectomy: Case 2 Partial Glossectomy

Case 2.

Female

early 20’s

Non-smoker

link to immediate post surgery Partial Glossectomy: Case 2 Partial Glossectomy: Case 2

Partial Glossectomy: Case 2 Partial Glossectomy: Case 2

Catherine's story through radiation

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Partial Glossectomy: Case 2 HemiGlossectomy: Robert (w/flap)

Robert at 2 months

Palatal tumors Near-Total glossectomy: Case example

ODE TO THE PRESENT.

This moment as smooth as a board 1 month post and fresh This hour, this day as clean as an untouched glass. Not a single spiderweb from the past We touch the moment with our fingers We cut it to size, we direct it's blooming It's living, it's alive, it brings nothing from yesterday that can't be redeemed 10 month post nothing from the lost past. This is our creation It's growing this very instant, kicking up sand or eating out of our hand.

Palatal Malignancies – a bit more variety Palatal Cancers . Not very common . Soft palate > hard palate

. Soft palate causes – as before

. Hard palate – . perhaps as before; reverse smoking; syphilis; irritation from dentures? . Often late presentation (months to years)

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Hard Palate Resection Hard Palate - Obturation

. Approach based on size . Small lesion = transoral, partial maxillectomy . Larger = partial maxillectomy  lateral rhinotomy, mid face degloving . Large extending through palate  total maxillectomy

. Palate is midline structure . Neck treated bilaterally –END

. Combo Surgery + XRT for most

Hard Palate – Obturation = historical gold Hard Palate – standard Reconstruction = new comer in past 15-20 yrs

. Radial forearm (Jeong et al., 2017)

. Rectus abdominus flap (Ogino, et al., 2019)

. Anterolateral thigh; latissimus dorsi, fibula osteocutaneous, etc. (Hanasono et al., 2012)

Soft Palate Resection - obturation Lip Cancer

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Lip Cancer - Treatment Lip Cancer – surgical examples

. Really depends on staging, regional node involvement, distant

. Often caught early so local excision with no, or minor, reconstruction Excision with primary closure

Lip Cancer - surgery Excision with lip reconstruction

. Lip flap . Remove tumor from top lip . Raise flap from lower lip . Close upper lip defect

Lip Cancer: Case Study (all lower lip) Projected Problems

. 40 yr old . Smoker for 20+ years Intelligibility Tongue . Lip cancer dx at age 38 Articulatory Precision / clarity . Sequence of Tx Understandability . Radiation (38) and chemo Hard Palate Articulation Acceptability (16) Speaker . Naturalness Listener Cancer returned quickly (2 Soft Palate weeks) Resonance . Resection (lower lip, FOM, jaw) w/ Nasal (hyper) Lips reconstruction (multiple) Oral (altered)

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The literature?  speech intelligibility Sampling of others regarding SI

Details Results Chien et al. (2006) 39; total & near total; 1 yr post ‐ 8% = unintelligible ‐ 92% = intelligible ‐ SI task/rating unclear Carvalho et al. (2008) 36; hemi & near total, wearing ‐ 22% = normal SI . N=27 . “intelligible” after partial palatal augmentation ‐ 31% = mild impairment ‐ 25% = moderate (12) ‐ 22% = severe . 3 groups ‐ Better with vs w/o pros. . Ratings of SI, other Borggreven et al. (2007) 80; oral and oropharyngeal; 1 yr ‐ 71% = deviant SI (rating) . “partially intelligible” post; flap recon measures after subtotal (9) Romer et al. (2019) 81; T1/T2 oral SCC, no reconstr ‐ “excellent” speech . At 6 months post outcomes Steltzle et al. (2013) 71; tongue, FOM, mandib alveolar ‐ WR at 12 months 28% surgery . “intelligible with ridge lower for all vs control attention” after total Lee et al. (2014) 63; oral tongue, most T1; partials ‐ Mean “understandability rating” = 88%

Q1 = quality of speech Q9 = clarity of Q10 = difficulty Q15 = Q18 = makes it difficult to be articulation as being strain unpredictable understood an issues understood in to speech noisy room speak intelligibility

Q20 = great deal of effort to speak

. 17 OC & 38 OPC . Various stages

. Subsites . Primary surgery

. Tongue 15 . All with AV RT/ChemoRT . BOT 15 . 2yr -12 yr follow up . Tonsil 22 . Speech Handicap Index . FOM 2

. SP 1

Dwivedi et al – other findings

. Overall Speech Quality . More severe speech-related (self-report) psycho-social impairment -OC . 238 OC, 34 OPC, 6 . PREDICTORS of Speech 1. Feelings of incompetence bc outcomes (on UW-QOL) at 12 of speech maxillary sinus mos: . OC: 35% good-excellent . UW – QOL pre, 6-mos, 1 . Tumor size (smaller = better) 65% ave – poor 2. Avoidance of groups bc of year, longer speech . XRT (none = better) . OPC: 76% good-excel . Closure/reconstruction 3. Feeling tense while talking 24% ave/ - poor because of distorted speech (primary = better) . Neck dissection (less . OC and OPC – speech worse 4. Avoidance of going out bc of extensive = better) in evening  fatigue speech

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Zyudam et al - Results What to make of it all? – some nuggets

. Greater resection volume = worse speech (Bohle et al., 2005; Furia et al., 2001; Ji et al., 2017) . Importance of speech . Activity (8) function to survivors at . Appearance (7) . Increased tongue mobility & strength = higher SI [partial & hemi] (Kreeft 1yr – relative to other . Anxiety (6) et al., 2009; Lazarus et al., 2013) choices . Taste (6) . Saliva (14) . Mood (5) . Highly variable SI after total and subtotal (Kreeft et al., 2009) . Chewing (13) . Pain (5) . Speech (13) . Shoulder (4) . Correlation bulk and contours of reconstructed tongue (Kimata et al., 2003; Seikaly et al., 2003) . Swallowing (10) . Recreation (2) . Maxillectomy reduces speech function & SI  but generally well managed prosthetically (Futran et al., 2002)

Lymphedema – speech? More Nuggets

. Patient reported speech outcomes = lower than clinical measures (Rinkel et al., 2015)

. Radiation Therapy Impact? . RT as primary: variable outcomes . RT as adjuvant: tends to worsen speech outcomes (Keeft et al., 2009) Negative Impact No Significant Impact Stelzle, et al. (2013 Laaksonen et al. (2010, 2011) Bozec et al. (2009) Pauloski et al. (1998) Nicoletti et al. (2004)

. Soft palate involvement = worse speech outcomes (Bohle et al., 2005)

More.. SLP Roles: Pre-operative/Pre-XRT

. Lymphedema impact? . Acute and latent impacts on speech reported (Deng et al., 2013; Jackson et al., . Baseline: . Phoneme inventory 2016; Payakachat et al., 2013) . “my tongue swelling, it impacted my speech… it impacted my ability to . Speech production – . Oral mech exam eat” (Deng et al., 2016, p.1271) characteristics, deficits . “At times I feel my tongue is too big for my mouth and my speech is then very slurred and much worse than what it is now… very difficult . Intelligibility to understand” (Jeans et al., 2018, p.5) . Communication needs . “I’m not talking normal because of the swelling of the tongue” (Jeans . Speech-Com QOL et al., 2018, p.5) . Cognitive-Comm

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SHI SLP Roles: Pre-operative/Pre-XRT

Baseline Tasks/Tools Communication needs & Interview, self‐report wishes

Speech impact Speech Handicap Index (Rinkel et al., 2008; Dwivedi et al., 2011))

Communication Participation Inventory Bank (CPIB) (Yorkston et al., 2013)

Speech Production Phoneme Inventory or Artic Test Ratings or measurements of… Speech Intelligibility, SIT test; ratings/scaling Acceptability Oral mech exam Rate, range, speed, coordination; symmetry Hearing Make sure it is not forgotten Cognitive‐Communication

CPIB Hearing Status

. Age-related decline is possible

. Treatment related alteration (chemo) also possible . Cisplatin + radiation = SNHL (e.g., Hitchcock et al., 2009; Zuur et al., 2007)

. Baseline hearing prior to starting radiation-chemo- surgery; period reassessment after

Cognitive Function (CF) Post Surgery

. Bond et al (2012, 2016): CF decrease even before Tx; . Baseline is important 13% with language deficits . What was done? post chemorad . Post . Gan et al (2011): . What structures are left? . Periodic assessment . CF decline in 90% of HNC pts at 16 months post . Degree of CF correlated with . How do they move? thereafter radiation dose . Various memory abilities = most impacted . Further plans? - more surgery; chemoradiation; prosthetics? . Hsiao et al (2010) - similar

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SLP Roles Post: Repeat Lingual and Labial Cancer Patients SLP Roles Post: Specific to Lingual

Baseline Tasks/Tools Communication needs & Interview, self‐report wishes . 2 primary roles Speech impact Speech Handicap Index (Rinkel et al., 2008)

Communication Participation Inventory Bank (CPIB) . Communication rehabilitation (Yorkston et al., 2013)

Speech Production Phoneme Inventory or Artic Test . Participation in prosthetic attempts Ratings or measurements of… Speech Intelligibility, SIT test; ratings/scaling • Palatal augmentation Acceptability • Lingual prosthetic Oral mech exam Rate, range, speed, coordination; symmetry Hearing Make sure it is not forgotten Cognitive‐Communication ?

SLP Roles Post: Specific to Lingual SLP Roles Post: Specific to Lingual Lingual Prosthetics Palatal Augmentation Prosthesis

. 5 studies specific to Oral Cancer only – palatal . 14 studies specific to Oral and Base of Tongue – palatal augmentation augmentation and lingual prostheses • Intelligibility improve for vowels (2 studies), consonants (5), sentences (1), conversation (6) • 3/5 = improved speech intelligibility • Improved resonance (4) • More improvement in those with larger resections • Improved voice quality (3) • 1 other showing vowel formants closer to pre-op

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SLP Roles Post: Lingual & Palatal Augmentation Prosthesis SLP Interventions

. Be on the team . Speech (and swallow) evals . What’s been tried? . Does it work? . Baseline

. Maxillofacial . During construction as Prosthodontist appropriate . You . Post final construction . Head & Neck Surgeon

. Dietetics . Primary speech foci = SI . Etc.

SLP Interventions for Glossectomy SLP Roles Post: Specific to Labial What’s been tried?

. Understand … . Train alternative . Pre-post testing of maxillary and velopharyngeal . Remaining structures productions of prosthetics problematic speech . Movement capabilities sounds . How to . Relation to other . Perceptual structures . Nasometry . Flexible endoscopy . Aerodynamics

Tongue Resections – historically attempted substitutions for consonants and Vowels ? – usually less focus (more so with total and near-total glossectomy) Phoneme Strategy t/d/n sub lower lip for tongue tip Vowels Strategy s/z/ slit btw upper/lower teeth or slit btw tensed/spread lower lips front/back (e/a) mandibular thrust

k/g/ng pharyngeal contact with ? hi/lo (i/ae) mand. Elevation l midpoint lip-lip; buccal? short/long (i/I) duration r vocalic /r/; overlap lips

th draw lower lip down from inside of upper lip and teeth NOTE: Old training lit mostly regarding sh, ch nothing great (try for any fricative) people with laryngectomy + glossectomy

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Does SLP Intervention Help? SLP Roles Post: Specific to Palatal

. Expectations – usually not much . General intelligibility strategies . 10-12 Tx session . N=27 in 3 groups [3-6 months] • Total glossectomy . Rating 0-7 “understandable … (GRP1) vowels, CV, VCV . “Intelligibility” rated (4 pt scale) – spontaneous speech • Subtotal glossectomy (GRP2 – retained BOT)

• Hemiglossectomy (GRP3)

The Results What was the therapy?

. Vowel differentiation practice – . Maximize residual isolation and combo with bilabials tongue movement . Phoneme inventory review and train consonant replacements as possible

. Adaptive articulation . Pitch and intensity range (vowels?)

. Reduce speaking rate . Reduce negative compensations . Saliva management . Overarticulation training

. Yawn-chewing (for jaw? voice?)

Skelly et al. (1971). Compensatory physiologic phonetics for the What did Skelly do? glossectomee. Journal of Speech and Hearing Disorders, 36, 101-112.

. N=25 (14 totals and 11 partials) . SLP Tx program – 12 months

. Non-speech exercises – “excursion” . SLP Tx for all – started 9mos to 2 years post surgery . “drill for intelligibility” of vowels, consonants

. Speech intelligibility assessed pre- and post-Tx . Exploring compensatory artic with remaining articulators . W-22 PB Word Lists . Identifying those compensations that positively impact . 3 listeners from pool of 27 listeners per subject intelligibility . Also did cinefluoroscopic studies of 5 patients . Functional communication test

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Skelly et al. (1972). Changes in phonatory aspects of glossectomee Skelly et al. (1972). Changes in phonatory aspects of glossectomee intelligibility through vocal parameter manipulation. Journal of Speech and intelligibility through vocal parameter manipulation. Journal of Speech and Hearing Disorders, 37, 379-389. Hearing Disorders, 37, 379-389.

• N = 10 (total glossectomy) plus 10 controls (other cancers of neck • The therapy goals: , mandible) – Reduction of oral and pharygneal noises

• SLP Tx for this study initiated 16 weeks to 9 years post surgery – Adjustment of vowel duration (all had completed articulatory therapy prior to the therapy offered – Elevation of habitual pitch in this study) – Extension of pitch range • SLP Tx designed for 4 months duration, weekly sessions, – Improved resonance of higher harmonics homework

Skelly et al. (1972). Changes in phonatory aspects of glossectomee Skelly et al. (1972). Changes in phonatory aspects of glossectomee intelligibility through vocal parameter manipulation. Journal of Speech and intelligibility through vocal parameter manipulation. Journal of Speech Hearing Disorders, 37, 379-389. and Hearing Disorders, 37, 379-389.

. The therapy approach:

. Various throat relaxation activities (borrowed from singers)

. Yawn-sigh vowels, voicing during rotary chewing

. Vowel duration activities (max, short but loud)

. Pitch practice (habitual:vowels, words, phrases, convo; variation: intonation exercises)

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Takatsu et al (2016) Blythe et al (2015)

. N=62; partial glossectomy, various reconstruction . Systematic review re: SLP intervention . Assessed vowel space area and formant transition outcomes with people who have partial slopes for /a/, /i/, /u/ glossectomy . 1422 articles screened . Vowel space and formant slopes decreased pre-post . 76 reviewed surgery . 7 met criteria for inclusion . All were level III or IV (Oxford) – most were case . Post-SLP, increased space and slopes series, one was quasi-experimental

SLP Roles Post: Palatal Tumor Blythe et al

. Trends . Hard Palate = . Soft Palate =

. Interventions varied maxillary prosthetics velopharyngeal • individually prescribed for compensations prosthetics or flaps • range of motion • Other (some re: rate, voice, etc.)

. Essentially all demonstrated improvement in intelligibility • Study quality generally low • Mixed Tx approaches within same participant

SLP Roles Post: Palatal Tumor SLP Roles Post: Palatal Tumor Be on the Prosthetics Team . Nasal Escape/Resonance . Speech (and swallow) evals . Focus . Perceptual ratings of • hypernasality = vowel phenomenon . Baseline . Nasal Escape/Resonance . During construction as • nasal emission = appropriate . Intelligibility, consonant phenomenon understandability (“audible burst on pressure consonant”) . Post final construction

. Instrumental Assessments • Flexible endoscopy of VP closure • nasometry • Aerodynamic assessment

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SLP Role Post: Labial Cancer surgery Questions

. Literature tells us what…? Essentially no empirical data published about effectiveness or efficacy of any intervention

. Typically limited to no need for SLP involvement unless total labial resection/reconstruction

. Our basis for intervention . Logic and understanding of • normal speech sound production • abilities of remaining articulators

. Expert opinion

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