RU2367485C1 - Method of phonal function recovery in larynx cancer patients underwent conservative surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: there are performed rational psychotherapy, respiratory gymnastics, magnetotherapy and phonal trainings that involves setting a patient's speech signal through a microphone to a rehabilitation complex for phonal function recovery with use of biological feedback. It is ensured by spectral analysis of primarily received speech signal in an algorithm complex that enables to assign a frequency of pitch and phonation duration. The threshold pitch frequency is evaluated to perform phonal trainings. While acquiring speech skill, the threshold is increased to perform the following phonal trainings. Each lesson shall include spectral analysis of speech signal. The phonal trainings are assisted with speech material including syllables, words and 2-3-word phrases with initial phonemes [M] and [N]. Duration of phonal trainings is 10 minutes, twice a day, every 45 minutes. While acquiring the vocal speech, specified time is increased to 15 minutes, 3 times a day every 30 minutes.

EFFECT: method provides self-regulation mechanisms included, allows enhancing compensation abilities of an organism and accelerates forming speech skills.

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Description

The invention relates to medicine, specifically to otorhinolaryngology, and relates to methods for restoring voice function in patients with laryngeal cancer after organ-preserving operations.

Among patients with malignant tumors of the head and neck, the largest group consists of patients with laryngeal cancer from 2 to 4% [1, 4, 6, 13, 14]. The combined treatment method, including radiation and chemotherapy, surgical intervention in various sequences, remains the main and most effective. Surgical treatment of the larynx inevitably leads not only to cosmetic defects, but also to violations of the respiratory and voice-forming functions. In recent years, in order to weaken the depth of functional disorders and the severity of the postoperative period in clinical oncology, organ-preserving and functionally sparing operations have been widely used, which preserve respiratory function, but inevitably lead to voice disturbance from 30 to 100%. New methods of organ-preserving operations on the larynx require new methodological approaches to voice rehabilitation. At present, when the quality of life indicator of cancer patients is considered the second most important criterion for assessing the results of anticancer therapy after survival, the desire of scientists at the modern level at the junction of related disciplines to comprehensively solve the problem of improving the quality of life of patients with laryngeal cancer using high-tech voice rehabilitation methods is completely justified [5, 6, 7, 8, 13, 14, 15].

It is known that the human vocal apparatus has great compensatory capabilities, so with the help of the remaining part of the larynx a voice sufficient for full communication can be developed [3, 5, 7, 9].

Known methods for restoring the voice function of patients after organ-preserving operations of the larynx.

1) “A method for the rehabilitation of patients after subtotal resections and extirpation of the larynx”, where the authors V.V. Dormakov, Yu.S. Vasilenko, O.S. Orlova, E. A. Kirasirova offer a technique that consists of three stages - preparatory, main and final to automate acquired skills. At the preparatory stage, psychotherapy, correction of respiratory function and physiotherapy exercises, articulation gymnastics are performed. The task of the second stage is to educate a new mechanism of voice formation, for this, speech material is used. At the final stage, work is carried out to automate the acquired skills [7].

2) “A method for restoring sonorous speech in patients after resection or removal of the larynx” / Edited by S. L. Taptapova. The method consists in normalizing the ratio of inspiration and expiration, stimulation of movement in the anatomical and physiological structures of the larynx, voice exercises, and vocal exercises [12].

The disadvantage of the methods of voice function restoration proposed by the authors is that during restoration of voice function, activation of the neuromuscular apparatus of the external and internal muscles of the larynx in the postoperative period is not supposed. It is known that after the operation, the muscles are in a state of spasm, and conditioned reflexes cannot appear in the spasmodic muscle, so it becomes necessary to relax them. The authors also do not take into account that in order to prepare the vocal apparatus for phonation, it is necessary to correct phonation and physiological respiration simultaneously with activation of the neuromuscular apparatus of the external and internal muscles of the larynx

Closest to the proposed method is the restoration of sonorous speech in patients with laryngeal cancer after resection, developed at the State Research Institute of Oncology of the Tomsk Scientific Center, which consists in the use of rational psychotherapy, respiratory gymnastics and voice exercises, while magnetic field therapy is additionally carried out before voice exercises without a thermal effect with inductors mounted on the anterolateral surface of the neck region on two sides of the midline, with different poles relative to each other and with centering at the point of entry of the recurrent nerve, for 10 minutes, to a course of 10 procedures. The first five procedures are affected by an alternating sinusoidal field in a continuous mode, and in the next five procedures by a pulsating field in a pulsed mode with a magnetic field induction of 17.5 mT. Voice exercises are carried out by means of pronouncing the sound “M” for a long time, with the head slightly bowed, while simultaneously acting with a vibrator with a flat nozzle at the point of entry of the return nerve, alternately on both sides, the oscillation frequency is 100 Hz [3].

However, the disadvantage of this method is the lack of effectiveness due to the rather long periods of rehabilitation, which range from 1.5 to 2 months.

A new technical task is to increase the efficiency of restoration of voice function by reducing the rehabilitation time and improving the quality of life of patients.

To solve the problem in a method of restoring voice function in patients with laryngeal cancer after organ-preserving operations, including rational psychotherapy, breathing exercises, magnetotherapy, voice training by introducing a patient's speech signal through a microphone into a rehabilitation complex for restoring voice function using biological feedback, for which conduct a spectral analysis of the initially received speech signal using a complex of algorithms allowing they select the frequency of the fundamental tone of the voice and the duration of phonation and determine the threshold value of the frequency of the fundamental tone of the voice, on the basis of which voice training is carried out, then, as you master the skill of speech, the threshold value is increased and subsequent voice training is performed, spectral analysis of the speech signal is performed for each lesson, for voice training sessions use speech material, including syllables, words and phrases of 2-3 words with initial phonemes [M] and [H], the duration of voice training is 10 minutes, 2 once a day, with a break of 45 minutes, as the patient takes possession of a loud speech, this time is increased to 15 minutes, 3 times a day with a break of 30 minutes.

The authors did not find in the literature analyzed by them the given set of distinctive features leading to the solution of their task. The method has passed a clinical trial in the clinic of the State Research Institute of Oncology, TNC SB RAMS.

Thus, the proposed technical solution meets the criteria of the invention of "novelty", "inventive step", "industrially applicable".

The method is as follows. The way to restore voice function in patients with laryngeal cancer after organ-preserving operations consists of 5 stages: rational psychotherapy, breathing exercises, activation of the neuromuscular apparatus of the external and internal muscles of the remaining part of the larynx, voice training using a rehabilitation complex to restore voice function using biological feedback , automation of the correct phonation.

The biofeedback method (BFB), used in voice recovery, consists in the arbitrary control of the voice-forming function according to electronic devices, which provide real-time recording, signal processing and presentation of the results in a convenient form for learning to control voice parameters. Adaptive biocontrol methods contribute to the early inclusion of self-regulation mechanisms of the body, make better use of compensatory capabilities and accelerate the formation of voice skills [10, 11].

Violation of the voice function is a traumatic fact, since a threat to the professional unsuitability of patients is created. At the first stage of restoration of the patient’s vocal function, it is necessary to convince of the reversibility of violations of the vocal and respiratory functions, to inspire hope for success, to set the condition for active inclusion in the recovery process. Classes must be conscious. Before the start of each stage, it should be explained not only what and how to perform, but why. Psychotherapeutic orientation should be carried out throughout the period of restoration of voice function.

Respiratory gymnastics is performed to correct physiological and phonon respiration [2, 11].

The task of the third stage is to activate the neuromuscular apparatus of the external and internal muscles of the remaining part of the larynx with the help of magnetic field magnetotherapy without a thermal effect. The work uses 2 types of currents: sinusoidal, which makes it possible to create an alternating magnetic field, and pulsating - creating a unidirectional magnetic field. The patient in a sitting position impose two inductors of cylindrical shape, with a diameter of 8 cm each. Inductors are installed on the anterolateral surface of the neck from two sides of the midline, centered in the area of the return nerve entry, relative to each other by different poles. In the first five procedures they are exposed to an alternating sinusoidal field in a continuous mode, in the next five procedures - to a pulsating field in a pulsed mode with a magnetic field induction equal to 17.5 mT. The duration of the procedure is 10 minutes daily. The course of treatment is 10 procedures [2].

At the fourth stage, voice training is performed, which begins by pronouncing the sound “M” for a long time and at the same time is acted upon by a vibrator with a flat nozzle at the point of entry of the return nerve. The oscillation frequency of the vibrator is 100 Hz. Depending on the severity of the disturbance of sonorous speech, the duration of these exercises is from 3 days to 2 weeks.

As soon as the voice becomes louder, they switch to voice training using a rehabilitation complex to restore voice function using biological feedback. Two types of voice training are used in the work: an increase in the frequency of the fundamental tone and an increase in the duration of phonation.

Before starting voice training, a diagnostic voice recording is performed for spectral analysis and determining the parameters of the fundamental frequency and the duration of phonation for further training. To this end, with the help of a microphone, the patient's speech signal is introduced into the rehabilitation complex for the restoration of voice function. In real time, a spectral analysis of the speech signal is carried out using a set of algorithms, the frequency of the fundamental tone of the voice, typically located in the range from 30 to 150 Hz, is isolated. Speech therapist in an accessible form explains the purpose and course of the upcoming voice training so that they are conscious. Creating a motivational framework is a prerequisite for the exact implementation of the recommendations of a speech therapist.

Voice training is carried out in a sitting position, while the patient's head is slightly tilted down. A microphone is placed at a distance of 10 cm from it.

For training aimed at increasing the frequency of the fundamental tone, determine the threshold value (frequency of the fundamental tone from 30 to 150 Hz) for this training. The threshold value is selected individually for each patient, depending on the degree of impaired voice function and the results of the previous lesson. The patient repeats speech material at a speech therapist. In real time, a spectral analysis of the speech signal takes place and it is evaluated by a given parameter (fundamental frequency). On the monitor screen, the patient sees a spectrum diagram of his voice and has the opportunity to compare it with a threshold value. If the attempt was successful, and the pitch frequency reached a predetermined threshold or was higher, positive reinforcement is performed in the form of an opening picture. Each subsequent attempt can be carried out only after a corresponding assessment of the previous one. At the end of the training, the result is summed up and an average indicator of the frequency of the fundamental tone is determined, this indicator will be a threshold value for the next training. For voice training, speech material is used, consisting of syllables with initial phonemes [M], [H], for example: “Ma, Mo, Mu, Me, Mi”, “Na, But, Well, Ne, Ni”, etc. .

Training aimed at increasing the duration of phonation is carried out depending on the threshold value of the duration of phonation, which is measured in milliseconds (ms). The threshold task is selected for each patient, according to the results of spectral analysis of the diagnostic voice recording or the results of the previous lesson. The patient delivers speech material into the microphone, in real time there is a spectral analysis of the speech signal and its comparison with a given parameter. The duration of the pronounced sound is fixed on a special indicator in the form of a dark strip, which is filled with a light green color as the sound is pronounced. When the indicator is full, it is considered that the sound is pronounced correctly, this leads to the opening of a small part of the picture. Voice training is considered complete when the picture is fully open. For the next workout, the task is complicated, that is, the parameter of the duration of phonation increases. For voice training use speech material, consisting of syllables with initial phonemes [M], [H]. After the patient says these exercises without difficulty, they proceed to pronounce the words "May, Masha, mine, our bridge, our, Nastya, number, night, etc.". Then, phrases of 2-3 words “Masha waves. My bridge. My bridge is small. ”

The duration and interval between classes is determined depending on the general condition of the patient. Initially, the duration of voice training is 10 minutes, 2 times a day with a break of 45 minutes, as the patient learns sound, this time increases to 15 minutes, 3 times a day after 30 minutes.

Automation of the skill of voice formation is carried out in the fifth stage. The patient is offered reading poetry, compiling stories on any topic of interest to him.

The method of biological feedback, which is used in voice rehabilitation, consists in the arbitrary control of the voice-forming function according to electronic devices that record and convert information about the state of sonorous speech of a person into visual signals that are available to the mind in real time. The patient gets the opportunity to control: see, hear, evaluate and purposefully change the parameters of the impaired voice function. Methods of adaptive biocontrol contribute to the early inclusion of self-regulation mechanisms, make better use of the compensatory capabilities of the body and accelerate the formation of speech skills. Initially, the duration of voice training is 10 minutes, 2 times a day with a break of 45 minutes, as the patient learns sound, this time increases to 15 minutes, 3 times a day after 30 minutes. The proposed mode helps to obtain a stable rehabilitation effect in a shorter time (from 2 to 6 weeks), helps to accelerate the process of formation of speech skills due to the fact that conditions are created so that the patient can consciously control the activity of the physiological systems of his body and learn how to manage their parameters.

Example: Patient I. 60 years old (IB No. 12895).

Diagnosis: Laryngeal cancer T2N0M0. Condition after a radical course of radiation therapy (2003) and surgical treatment in the amount of: tracheostomy, resection of the larynx (2006).

Concomitant pathology: coronary heart disease, atherosclerotic cardiosclerosis, exertional angina FC-I-II, against the background of GB III art.

He entered the Department of Head and Neck Tumors on 05/17/2006 to restore voice function. At admission, the patient in everyday life spoke in a whisper. Free breathing disorganized, exhaled sharply shortened, tracheostomy is not completely closed. Speech exhalation is sufficient to pronounce a phrase of 4-5 words. Speech dyspnea is noted. Speech Therapy Diagnosis: Athony.

In the first lesson, a psychotherapeutic conversation was held about the possibility of restoring sonorous speech, returning to the previous way of life, and working. To this end, they demonstrated a patient who underwent a resection of the larynx and is fluent in sonorous speech. They presented an audio recording testifying to a good degree of mastery of a sounding speech. An important task was to train the skills of proper physiological breathing in combination with the correction of phonon respiration. Breathing exercises began with practicing abdominal (diaphragmatic) breathing while lying down. First, a simple sequence of inhalations and exhalations was carried out, with a gradual lengthening of the exhalation phase. The breath should be short, vigorous, silent. Exhale long slow smooth at the count of one to five, from one to six and so on. Abdominal muscles, diaphragm, inferior muscles should participate in breathing.

1. Inhale by mouth, exhale by mouth.

2. Inhale through the mouth, exhale through the nose.

3. Inhale through the nose, exhale through the mouth (say “C” on the exhale).

4. Inhale through the nose, exhale through the mouth (pronounce “Ш” on the exhale).

5. Inhale through the mouth, exhale through the right half of the nose.

6. Inhale through the mouth, then through the left half of the nose.

7. Inhale through the nose, exhale through tightly compressed lips.

8. Inhale through the mouth, exhale through the nose with tremors (diaphragmatic).

Perform each exercise 5 times in a row.

Activation of the neuromuscular apparatus of the external muscles of the larynx, articulation and pharyngeal muscles was carried out using the apparatus of the alternating magnetic field "Pole-1". On the third day, we started voice training. The patient made the sound "M" for a long time with his head slightly bowed. At the same time, the vibrator acted on the entry point of the recurrent nerve with an oscillation frequency of 100 Hz. On the second day after completing this exercise, a rude, poorly modulated voice appeared. An acoustic voice recording was made. In a spectral study, the frequency of the fundamental tone (FST) [A] is 45 Hz, the instability of the frequency of the fundamental tone (LFET) is 24%, [O] FRE - 51 Hz, LFET - 24%, FER [I] - 40 Hz, LFR - 17% The patient was explained in an accessible form the purpose and course of the upcoming trainings so that the trainings were conscious.

Voice training was carried out in a sitting position, head slightly tilted down. At a distance of 10 cm from it was a microphone. The initial threshold value was 46 Hz. The patient repeated speech material at a speech therapist. In real time, a spectral analysis of the speech signal and its evaluation by the frequency of the fundamental tone took place. On the monitor screen, the patient saw a spectrum diagram of his voice and had the opportunity to compare it with a threshold value. If the attempt was successful and the pitch frequency was 46 Hz or more, positive reinforcement in the form of an opening picture was carried out as an encouragement. At the end of the training, we summed up: the frequency of the fundamental tone averaged 50 Hz. The threshold value for the second voice training is 50 Hz; at the end, the frequency of the fundamental tone was on average 63 Hz. For the third workout, the threshold value is 63 Hz. For the fourth - 70 Hz. For the fifth - 78 Hz. For the sixth - 83 Hz. For the seventh - 88 Hz. For the eighth - 95 Hz. For the ninth - 98 Hz. For the tenth - 100 Hz. For the eleventh - 102 Hz. For the twelfth - 105 Hz. For the thirteenth, -108 Hz. For the fourteenth - 110 Hz. Syllables were included in voice training, then words and phrases from 2-3 words with initial phonemes [M], [H].

Inspection on the 7th day from the beginning of the restoration classes. The patient at home communicated partly in a loud speech. The duration of the phrase is 4-5 words. A voice of medium sound, medium timbre, monotonous, interrupted. Free breathing disorganized. In a spectral study dated 05/25/2006: fundamental frequency (frequency response) [A] - 110 Hz, instability of the fundamental frequency (low frequency) - 3%, [O] frequency - 110 Hz, low frequency - 17%, frequency [I] - 48 Hz, low frequency - 12%. The duration of phonation was 1132 ms.

It was planned to begin the second type of voice training - increasing the duration of phonation. The initial threshold value was 1150 ms. Following the speech therapist, the patient repeated the speech material, pronounced vowel sounds for a long time. In real time, a spectral analysis of the speech signal took place and its comparison with a given parameter (phonation duration). The duration of the pronounced sound was demonstrated on the indicator in the form of a dark strip, which was filled with a light green color as the pronunciation of the sound. When the indicator was completely full, it was believed that the sound was pronounced correctly (parameter reached), this led to the opening of a small part of the picture. The lesson ended when the picture opened completely. The threshold value for the second voice training is 1200 ms. For the third workout, the threshold value is -1250 ms. For the fourth - 1350. For the fifth - 1500 ms. For the sixth - 1550 ms. For the seventh - 1600 ms. For the eighth - 1650 ms. For the ninth - 1750 ms. For the tenth - 1900 ms. For the eleventh, 2000 ms. For the twelfth - 2100 ms.

12 lessons were held. After completion of the rehabilitation therapy, the patient in everyday life communicates in a loud speech, speaks freely on the phone. The voice is quite loud, medium timbre, phrase duration 7-8 words. The voice recording was recorded according to the spectral analysis: the fundamental frequency was (BST) [A] - 160 Hz, the instability of the fundamental frequency (LFST) was 1%, the phonation duration was 2150 ms; [О] ЧОТ - 165 Hz, нСОТ - 4%, phonation duration 2300 ms; FER [I] - 165 Hz, wFER - 2%, phonation duration 2100 ms.

Follow-up examination 01/30/07 (6 months after the end of the recovery therapy). In everyday life he communicates in a loud speech. The voice is loud, medium timbre, phrase duration 8-9 words. No difficulty talking on the phone and at home. Acoustic analysis of sonorous speech has been carried out: the fundamental frequency (FER) [A] - 174 Hz, the instability of the fundamental frequency (LFER) - 1%, the duration of phonation is 3150 ms; [О] ЧОТ - 177 Hz, нСОТ - 1%, phonation duration 3950 ms; FER [I] - 182 Hz, wFER - 1%, phonation duration 3550 ms. He continues to work as a trainer. He refused disability. In social and labor terms, the patient is adapted. According to the questionnaire, there is a significant improvement in the quality of life in comparison with the beginning of voice rehabilitation.

Initially, the duration of voice training was 10 minutes, 2 times a day, with a break of 45 minutes. As the patient becomes proficient in sonorous speech, this time increases to 15 minutes, 3 times a day with a break of 30 minutes.

The proposed method was carried out restoration of voice function in 12 patients. The effectiveness of voice rehabilitation was 91.6% in terms of 2 to 6 weeks.

Restoring voice function in patients with laryngeal cancer after organ-preserving operations is an important task and is crucial in terms of quality of life. Lair recovery therapy using a biofeedback technique helps to enable self-regulation mechanisms, accelerate the formation of speech skills due to the fact that the patient can consciously control the activity of the physiological systems of his body and control their parameters. The application of the developed technique allows to increase the effectiveness of log restoration therapy, reduce the rehabilitation time and improve the quality of life of this category of patients.

Information sources

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Claims (1)

A method of restoring voice function in patients with laryngeal cancer after organ-preserving operations, including rational psychotherapy, breathing exercises, magnetotherapy, voice training by introducing a patient's speech signal through a microphone into a rehabilitation complex for restoring voice function using biological feedback, for which spectral analysis is initially performed the received speech signal using a set of algorithms that distinguish the frequency of the fundamental tone voices and the duration of phonation, and determine the threshold value of the frequency of the main tone of the voice, on the basis of which voice training is carried out, then, as you master the speech skill, the threshold value is increased and subsequent voice training is carried out, characterized in that the spectral analysis of the speech signal produces each lesson, for voice training use speech material, including syllables, words and phrases of 2-3 words with initial phonemes [M] and [H], the duration of voice training is 10 minutes, 2 times a day, s a break of 45 minutes, as the patient learns a sonorous speech, this time is increased to 15 minutes, 3 times a day with a break of 30 minutes.