INTRODUCTION OF PROVOX INTRODUCTION OF PROVOX VOICE PROSTHESIS VOICE PROSTHESIS

IMPLATATION IN PAKISTANIMPLATATION IN PAKISTAN

DR. GHLAM SAQULAINM.B.B.S,D.L.O,F.C.P.SHead of Department of

OtorhinolaryngologyCAPITAL HOSPITAL

Islamabad.

DEVELOPMENT OF DEVELOPMENT OF ASSISTIVE TECHNOLOGY ASSISTIVE TECHNOLOGY

FOR POST LARYNGECTOMY FOR POST LARYNGECTOMY SPEECH REHABILITATIONSPEECH REHABILITATION

INTRODUCTIONOF PROVOX VOICE PROSTHESIS IN PAKISTAN

ABSTRACTABSTRACT Laryngectomy is a recognized mode of treatment

offered for a variety of laryngeal tumors all over the world including Pakistan. The Physical changes associated with laryngectomy amount to a complex impairment. Speech Impairment being the most dreaded.

Development and use of Assistive Technology is the only promising chapter for these speech Impaired Individuals.This article outlines the procedure and results of the first implants of Provox Voice Prosthesis and subsequent speech therapy results in Pakistan. A Ray of Hope for Thousands

INTRODUCTIONINTRODUCTION

Normal Anatomy & Physiology Anatomy and Physiology after Laryngectomy Total Laryngectomy removes:

Function of SPEECHNOSE.

This means that there is neither HEATING, nor HUMIDIFICATION of inhaled air, no FILTERATION & no BREATHING RESISTANCE.

PULMONARY PULMONARY REHABILITATIONREHABILITATION

Pulmonary rehabilitation is required because due to the laryngectomy there is :Excessive mucus productionCoughingForced expectorationDecreased pulmonary function which leads to a number of pulmonary problemsSuboptimal prosthetic speechPsychosocial Problems.Provox Pulm. Rehab system significantly reduces these symptoms and problems.

SPEECH REHABILITATIONSPEECH REHABILITATION

Methods of Communication after TL include:

Expressions & lip movements Oesophageal speech Surgical Options Prosthetic valve system with TE fistula:

– Provox

MATERIAL METHODSMATERIAL METHODS

PROVOX VOICE PROSTHESIS SYSTEM

CASECASE RECORDSRECORDS Two patients were implanted with

Provox 2 VoiceProsthesis followed by speech therapy for the first time in Pakistan

One case was operated and rehabilitated at NIHd and the other Capial Hospital

CaseNo: 1 Mr. Sharif, an adult male of 51 and resident of

Rawalpindi presented to us with no speech development two years after laryngectomy and was given an implant.

Case No: 2 Mr. Hameed, an adult male of 60 had

laryngectomy 3 months back and presented to us for voiceprosthesis implantation.

Preparation: Routine Gen, systemic and E.N.T

examination with emphasis on the pharynx

Insufflation test Assessment by Speech Therapist Fitness for General Anaesthesia.

VOICE PROSTHESIS VOICE PROSTHESIS IMPLANTATIONIMPLANTATION

The first case was operated at NIHd in September, 2002 and the other at Capial Hospital in Dec. 2002

RESULTSRESULTS

CASE RECORDS

CASE - IPuberfonia/ Mutational falsetto

• PERSONNEL DATA:– Name: Mr. Ijaz

Hussain– Sex: Male

– Aged 32 years– Resident of Islamabad.

– OPD Case

• COMPLAINTS:– Voice of female

character

•HISTORY:

•Typhoid at the age of 16 Years.

•Recurrent URTI.

•No Voice changes at Puberty.

•Frustration.

•Withdrawal.

PATIENT DATA

EXAMINATION

General Physical Examination: – Normal Physical development.

Systemic Examination: – NAD

E.N.T Examination:– Normal E.N.T Examination. ILD: Normal

mobile vocal cords.

SPEECH THERAPISTS ASSESSMENT

VOICE CHARACTERS:VOICE CHARACTERS:– FEMALE‘S LIKEFEMALE‘S LIKE– HIGH PITCHEDHIGH PITCHED– CREAKYCREAKY– UNPLEASANTUNPLEASANT– ABNORMAL VOICE TONEABNORMAL VOICE TONE

•SPEECH THERAPY MANAGEMENT:

•ENVIROMENTAL MANIPULATION:

•COUNSELLING:

•VOICE TRAINING:

•VOCAL EXCERCISES

•VOCAL PITCH TRAINING

•LARYNGEAL MANIPULATION

•VOICE MENTAINENCE

•THERAPY DURATION: 15DAYS

•PROGNOSIS:95%

TREATMENT

CASE - IIProvox Voice Prosthesis Implantation

for Voice Rehabilitation

Provox Voice Prosthesis Implantation for

Voice Rehabilitation– Name: Mr. Mehboob– Sex: Male – Aged 61 years– Resident of Rawalpindi– D.O.A: 25.10.2002 – D.O.D:

COMPLAINTS:– Voice loss after having

laryngectomy on 17.6.2002.

– Excessive mucous production

– Coughing

PATIENT DATA

• PAST SURGICAL/MEDICAL

HISTORY: – Developed Supraglottic

S.C.Carcinoma of Larynx and Laryngectomy was performed on 17.6.2002

– Diabetic

WORKUP: GENERAL PHYSICAL EXAMINATION:

– Average built individual with a opening in the neck (tracheostoma) and bringing out sputum frequently.

– BP:150/90– Pulse: 84/ min– Resp: Rate: 20 per minute.

SYSTEMIC EXAMINATION:– Respiratory System: Adequate air entry with conducted

sounds. – CVS: Both Heart Sounds were audible in all four areas.– CNS: Intact– GIT: NAD

LOCAL EXAMINATION:Portex tracheostomy tube in place in the stoma with slight

inflammation of skin close to tying ends of the T tube.

A detailed E.N.T Examination was carried out with special emphasis on:

– Inspection of the pharynx for stenosis or webs at base of tongue: No stenosis or webs seen.

– Checking of stomal size: Stomal size was adequate.

– Speech Therapists Evaluation: Including Insufflation test

To predict outcome of PVP Implantation12 Fr Nasogastric catheter introduced to PE segment

and air was blown to obtain speech.

WORKUP: E.N.T Examination

Radiological:– X-Ray Chest PA view: NAD

Laboratory:– Blood CP & ESR

• N : 68%• L : 30%• M: 01%• E : 01%• ESR: 87 mm 1st Hr.

– Urine RE: NAD– RBS : 170 mg/dl

Anaesthetic Opinion: Stop the morning dose of Daonil on operation day.

WORKUP:

Keeping in view the problems of the patient after total laryngectomy ie., – Loss of Voice and inability to develop oesophageal

speech due to the poor pulmonary function. – Loss of functions of the nose ie., there is neither

HEATING nor HUMIDIFICATION of inhaled air & no Breathing Resistance as a result patient has problems :Excessive mucus productionCoughingForced expectorationDecreased pulmonary function which leads to a

number of pulmonary problems

TREATMENT

TREATMENT

Patient was offered to develop a TE fistula and fit it with ProvoxII, Voice prosthesis and Pulm. Rehab system which not only significantly reduces these symptoms but also provides excellent speech results.

SURGERY & SPEECH THERAPY SURGERY:

– Preoperative preparation• NPO after midnight.• Consent: Patient was

explained the procedure and the possible hazards and benefits.

– Surgery:29.10.2002• T-E fistula was developed

and Provox II Voice prosthesis implanted

SPEECH THERAPY:2 Weeks

FOLLOW UP:– Patient dev. Near normal speech– Symptoms of cough and

expectoration diminished significantly.

DEVELOPMENT

OF TRACHEO-ESOPHAGEAL FISTULA AND

PROSVOX II VOICE PROSTHESIS IMPLANTATION

AND

SUBSEQUENT SPEECH THERAPY

RESULTS.

SURGERY

Anaesthesia:

General Anaesthesia with intubation through the stoma was used.

Operation Procedure

With the patient in supine postion and a small sandbag under the neck, drapes are placed after cleaning the area.

Small size scope passed into the pharynx.

Operation Procedure

Scope end palpated and through superior wall of

stoma.

Trocar and cannula used to make a standard size

T-E fistula.

Operation Procedure

Size of prosthesis to be used assessed using a provox measure guage.

Prosthesis Implanted using a guide wire.

Operation Procedure

RESULTS

Mr. Sharif was able to count up to 8 after 24 hrs after surgery and speak fluently after 1 week.

Mr. Mehboob had lot of secretion and coughing preoperatively and was able to count up to 6 after 2 days and improved significantly afterwards.

PROVOX VOICE PROSTHESIS

IMPLANTATION

Pre-Operative Esophageal Speech

Provox assisted post speech therapy results:

CONCLUSION

Provox 2 Voice Prosthesis implantation is a simple procedure with excellent

results.

PROVOX VOICE PROSTHESIS

IMPLANTATION