can return to oral alimentation, near-normal activities, and an acceptable quality Patients undergoing total laryngectomy have few swallowing problems following surgery due to the permanent separation of the trachea and esophagus. Purpose: Tongue cancer is known to negatively affect both speech and swallowing function; however this is the first review to report speech-language pathology (SLP) intervention for both functions following partial glossectomy. The first time was unsuccessful due to all the scare tissue and radiation pretty much closed everything off. While each has a role to play, it is usually the speech pathologist who conducts a clinical or instrumental assessment of swallowing function and makes recommendations for therapeutic intervention. I had the tumor removed from my tongue and 29 lymph nodes removed from my neck, which all of them came back negative for cancer. Have been told the slow therapy can take 6+ months and may need to use through the rest of live to "adjust" when/if it's needed. Have you checked out the Oral Cancer Foundation" site ? I find Costco (Dixie) plastic white knife to have the perfect strength (not to snap) and is not sharp. I just pray his spirits can stay high. The indication of total glossectomy for surgical salvage has several additional limitations and usually can be defined only after a meticulous examination under general anesthesia because most of the times it is difficult to define the tumor limits in an area with different degrees of fibrosis resulting from chemoradiotherapy, and there is a high risk of major postoperative complications. Patients undergoing total glossectomy can regain functional swallowing. My MO said its fine to drink beer; surgeon said "it's up to you". Medical history, including the presence of comorbidities (ACE27), physical examination, as well as evaluation of the nutritional and performance status (Karnofsky or ECOG criteria) are important for treatment planning. Groher proposed that the removal of less than 50% of a structure involved with swallowing will not interfere or seriously impact swallowing function. The multivariate survival analysis identified T stage (T4), number of metastatic lymph nodes (>3), and male gender as predictors of the risk of death. Hypopharyngeal stricture (a narrowing of the pharyngeal structure as a side effect of the radiation) may require dilation or surgery (Fig 3). Stage1. It requires coordination of the lips, tongue, teeth, mandible, and soft palate. I have feeding tube and supplement with cream of wheat, grits, pudding, etc, but I can't taste and fatigue so quickly I am lucky to get in 1/2, 4 months ago my 35 yr old healthy non-smoking husband was diagnosed with cancer on his tongue. Epub 2014 Dec 17. WebLong-term care studies show that approximately 72% of a speech-language pathologists caseload is for the management and treatment of dysphagia. He took a tongue depressor to get a good look at the sore spot and when he touched it I had considerable pain. Speech therapy care is all about a blog where you can get all info related to best at home exercises, contact details of professional speech therapists in your local area for free. An oral suspension of diphenhydramine, lidocaine, and an antacid (Maalox) called magic mouthwash can be prescribed, which is swished and swallowed for symptom management. If the tumor is located in the posterior oral cavity including the base of tongue, soft palate, retromolar trigone or tonsillar fossa, surgical excision usually will cause more severe dysphagia. Federal government websites often end in .gov or .mil. Total glossectomy is a technically simple operation for head and neck surgeons, but it should be done only in tertiary hospitals with an experienced team who are prepared to deal with a difficult postoperative course. Patients also experience fewer complications and express a greater sense of well-being. Successful management requires interdisciplinary collaboration, accurate diagnostic workup, effective therapeutic strategies, and consideration for unique patient characteristics. Disclaimer, National Library of Medicine The severity of the swallowing deficit is dependent on the size and location of the lesion, the degree and extent of surgical resection, the nature of reconstruction, or the side effects of medical treatments. Participation in support groups encourages improved coping, socialization, and physical recovery. In severe cases, interruption or discontinuation of cancer treatment may be required. Evaluation and management of swallowing disorders in head and neck cancer patients present unique challenges to the rehabilitation team. Swallowing deficits may result when any one or more of five cranial nerves are affected. Psychological or psychiatric evaluations should be recommended for selected patients and families. The indications for a total glossectomy must be individualized considering tumor factors, patient-related factors, and the possibility of reconstruction and rehabilitation. I just discovered this forum and would like to say thankyou to whomever created it. michelle o'neill eyebrows meme. The next H&N doctor appointment is 28 July, not sure if he keep loosing weight, to which point we need to consider tube feeding. 1 cup whole milk yogurt, plain or unflavored. WebA total glossectomy is the complete removal of the tongue. Treatment for post surgical cases usually begins once the surgeon indicates the patient has healed sufficiently, usually 5 to 10 days post surgery. Altered facial appearance also can lead to social isolation and psychological distress. A total glossectomy is the complete removal of the tongue. by | May 25, 2022 | camden county ga school schedule | cindy deangelis grossman pictures | May 25, 2022 | camden county ga school The epiglottis inverts to cover the larynx and prevent aspiration of contents into the airway. To appreciate the potentially devastating effects of oral cancer on swallowing, it is helpful to understand normal anatomy and physiology. Chopsticks or an iced teaspoon can place foods in the posterior oral cavity. Oral sex is a common form of sexual activity. Hello, I'm about to embark on a 7-week radiotherapy plan, with Cetuximab aka Erbitux as the sole chemo agent. Special meal preparation, equipment, and meal supplements can also contribute to added financial burden. An official website of the United States government. 9, No. The most favorable group of eligible patients for salvage surgery is that with recurrent cancer at initial clinical stages and diagnosed after 1 year of initial treatment. Hi, I am from Hong Kong, my Dad, 81 years old, has been diagnosed with BOT cancer stage 4A (T3N2M0) in April 2015 and had total glossectomy with flap reconstruction, Right radical neck dissection, left selective neck dissection andlaryngectomy on 7 May 2015. In the study published by Weber et al. People who have a hard time swallowing may choke on their food or liquid when trying to swallow. Video-assisted thoracoscopic surgery (VATS), Cancer Scars and Wounds: Care and Treatment, Difficulty speaking, reduced speech intelligibility, loss of speech, Salivary fistulas, which are holes that allow saliva to leak into the neck through the floor of the mouth, Aspiration, where food, fluid or saliva enters the lungs instead of the stomach, Healing issues, such as a reconstruction failure, Anesthesia risks, including cardiopulmonary events, strokes or death. endstream endobj 72 0 obj <>/Outlines 1 0 R/Metadata 12 0 R/PieceInfo<>>>/Pages 11 0 R/PageLayout/OneColumn/StructTreeRoot 14 0 R/Type/Catalog/Lang( E N - U S)/LastModified(D:20090617140053)/PageLabels 9 0 R>> endobj 73 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC]/ExtGState<>>>/Type/Page>> endobj 74 0 obj <> endobj 75 0 obj <> endobj 76 0 obj [/ICCBased 79 0 R] endobj 77 0 obj <>stream A marked decrease in the incidence of stomatitis has been noted in patients utilizing cryotherapy. It also permits inspection of secretion management, a known indicator of swallowing safety. Marginal mandibulectomy is done for both oncologic and functional reasons. The tongue is a muscular organ divided into mirrored halves. Swallowing trials can be initiated with a range of food textures. It actually tastes pretty good, in spite of messed up taste buds. I'm a 46 year old male and I'm looking for people similar to me to expound on their situation. The patient may also be placed on a soft-food diet to prevent damage to the structure of the mouth during recovery, and extensive speech therapy may be recommended to help them recover some of their ability to speak. The efficacy of palatal augmentation prostheses for speech and swallowing in patients He does not have swallowing issues, it's getting the food small enough to go down his throat. Im about to start 6 weeks of radiation next week, but am wondering what my quality of life will be after. squemous cell carcinoma. The glossopharyngeal nerve (CN IX) provides general sensation to the posterior third of the tongue and motor function to the pharyngeal constrictors. Recognizing this disorder early allows you and your doctor to implement an effective treatment plan. The esophageal phase is completely involuntary and consists of peristaltic waves that propel the bolus to the stomach. Called also deglutition. This is Part 1 of a two-part series. My 73 year old dad was diagnosed with Stage 4 throat cancer about 5 weeks ago. Poorly prepared patients may become frustrated when attempting to feed and thus may fail to ingest enough to maintain adequate nutrition and hydration. J Prosthet Dent. Appraisal of Function After Rehabilitation With Tongue Prosthesis. Dry or repeated swallows reduce pharyngeal residues. Total swallow time from oral cavity to stomach is no more than 20 seconds. The pharyngeal constrictor musculature contracts to push the bolus through the pharynx. Head rotation to the damaged side closes off a weakened pharynx and allows bolus passage down the intact contralateral side. What were your side-effects, how did you manage them? The tongue is needed to control food or liquid in your Would you like email updates of new search results? These factors are of paramount importance for patients acceptance of a surgical procedure that can cause significant sequelae requiring long period of hospitalization and compliance with an extensive rehabilitation program. This year we found out the cancer was back in the same spot and was stage IVa this go around. He cannot swallow even yogurt or puree. They have shown that the inclusion of a mandibulectomy and the need for laryngectomy had a negative impact on survival and functional outcomes. Without reconstructive surgery, the patient 2014 Jan 8;2014:581795. doi: 10.1155/2014/581795. Resistance exercises are used for strengthening musculature. Speech considerations in prosthodontic rehabilitation of the glossectomy patient. The teeth grind and chop food into tiny pieces while the glands in the mouth moisten it with saliva. intake without overt signs and symptoms of aspiration for the highest appropriate diet level - Client will utilize compensatory strategies with optimum safety and efficiency of They saw no aspiration in the way I was eating. Magrin et al. Get the latest news and updates from the The Oral Cancer Foundation directly to your inbox. 1985 Mar;53(3):384-7. doi: 10.1016/0022-3913(85)90518-9. Prophylactic measures begin with an increased emphasis on improved oral hygiene. Typically, the malignancy is located in the front third of the tongue, which often allows the surgeryto be performed through the mouth. 2013 Jan;123(1):140-5. doi: 10.1002/lary.23505. We already covered what you should in case of partial glossectomy so if you havent checked it yet then read all about it and continue to learn more about total glossectomy below. Dziegielewski PT, Ho ML, Rieger J, Singh P, Langille M, Harris JR, Seikaly H. Laryngoscope. It is a combination of a voluntary act and a series of reflex actions. How extensive and complicated the surgery is depends on the location of the tumors on the tongue and the extent of the lesions. The radiosensitizer chemotherapies, designed to heighten the effects of radiation therapy, also heighten the side effects of the radiation mucositis. There are several goals in swallowing rehabilitation. So lets have a look at all of them below: These exercises can help individuals improve the strength and control of the muscles in their lips and tongue, which are essential for producing clear and accurate speech sounds. The extent of the change will depend on a number of factors such as how much of the tongue and what portion of the tongue is removed, and what type of reconstruction is performed. Without reconstructive surgery, the patient wont be able to swallow without getting food or liquid into their lungs (aspiration). Alterations in taste and smell may affect enjoyment and motivation to eat. There was an error trying to send your message. Then the tongue pushes the moistened food, or bolus, to the back of the throat and down into the esophagus, which leads to the stomach. A comprehensive preoperative clinical evaluation is always mandatory for all candidates for total glossectomy because the operation may produce remarkable functional deficits, and rehabilitation requires a motivated patient and the cooperation of an experienced multidisciplinary team (surgeons, dentists, and speech therapist). 0000020761 00000 n Many therapist suggest the speech therapy exercises after total glossectomy. Second, it protects the airway from aspiration by closing at three levels the epiglottis, false vocal folds, and true vocal folds. Please give it a try. It took 2 hours to get it down. I lost all my teeth in the lower right side due to my jaw breaking down from radiation - I've had three separate incidents of this with radiation each time. Thank you for your message. Resection of cancer in the pharynx, including the pharyngeal wall, valleculae, or pyriform sinus, can result in significant dysphagia. Let's watch the swallowing process again. Like I said he can eat alot of foods, just doesn't eat enough to maintain his weight without peg feedings, he also drinks ensure. My issue is this: every doctor, friend, and acquaintance I meet asks me if I'm eating yet. 1-2 avocados, very ripe, and removed from the skin, remove the seed. Only 2 out of the 27 patients required salvage laryngectomy due to persistent aspiration, and the rates of speech and swallowing rehabilitation were 92% and 67%, respectively. Evaluation and treatment of swallowing disorders present unique challenges to the speech pathologist working with the head and neck cancer population. WebAccording to Sessions et al, total glossectomy should be regarded as a major achievement in the treatment of advanced cancer of the tongue. Has anyone seen anything being done to educate to population as to this sexual danger. The side effects that may be result from a glossectomy include: Recovering from a glossectomy may take time, even after the patient has returned home. Interdisciplinary interventions by the dietician and speech pathologist can help to ensure that adequate nutrition is achieved by either oral or non-oral routes. Patients undergoing glossectomy and submental resections have reduced tongue propulsion and lip sensation. Patients experience difficulty starting a swallow, food goes down the wrong pipe, or there is choking and coughing. This is a common procedure for tongue cancer, especially for early-stage disease. Just as PD affects movement in other parts of the body, it also affects the muscles in the face, mouth and throat involved in speaking and swallowing. Many of us, including myself, have spent a good bit of time in hospitals, as a patient or a caregiver or both, and have ideas about how hospitals can improve. Several improvements in anesthetic and surgical ablative and reconstructive techniques allowed the implementation of more radical oncologic procedures for the treatment of advanced cancer of the head and neck. What is Mixed Receptive-Expressive Language Disorder in Children. Diet modifications, such as a liquid-only diet, may result in reduced caloric intake. Head and neck cancer support group and discussion community. He has completed 15 radiation and 3 chemo treatments, so far. In head and neck cancer patients, dysphagia may be caused by surgical ablation of muscular, September/October 2002, Vol. 9 best speech exercises after stroke that you can perform. These include jaw range of motion, tongue base range of motion exercises, and effortful swallow exercises, tongue holding maneuver, Mendelsohn maneuver, and super supraglottic swallow. The degree of impairment often depends on the quality, rather than the extent, of reconstruction. Once you start you learn the technique you eventually master it. Re-establishment of safe and efficient oral intake, prevention of dysphagia prior to medical treatment, and patient education regarding the specifics of their disorder are also important goals of intervention. Patients on chemoradiation protocols may receive swallowing therapy during treatment, but often the development of mucositis results in oral pain and prohibits exercise or significant oral intake until after it is resolved. This community is sponsored by the Head and Neck Cancer Alliance, an Inspire trusted partner. This page was reviewed on April 14, 2022. Find other members in this community to connect with. A chin down posture improves base of tongue contact to the posterior pharyngeal wall, opens the vallecular space, and puts the larynx in a more protected position. Tongue cancer surgery may have significant quality-of-life implications. Reconstructive surgery is usually performed as part of the procedure to restore normal speech and appearance. doi: 10.1097/SCS.0000000000004008. Scar tissue in the pharynx can also reduce laryngeal elevation. Laryngeal penetration or tracheal aspiration may occur as a result of the aforementioned deficits. Reconstructive surgery is needed to allow for swallowing and speaking. FOIA 1 pint (2 cups) chicken stock. It is a great way for speedy recovery and people really feel very confident during the communication. Please try again later. Plus it takes him so long to eat solid food, I think he gets tired of eating before he is actually full. The speech pathologist collaborates with the maxillofacial prosthodontist to provide feedback on the configuration, use, and benefits of the prosthesis. The procedure may affect a patients ability to speak, eat and swallow. Use of these devices can significantly reduce oral residue. Therapeutic measures to control mucositis and stomatitis include the use of anesthetics, analgesics, anti-inflammatory agents, antimicrobial therapy, and coating agents. Your doctor may insert a feeding tube, either directly to the patients stomach (gastric tube) or through the nose to the stomach (nasogastric tube), until swelling in the throat subsides. Chemotherapeutic agents can negatively impact nutritional intake primarily as a result of its effects on the lining of the oral cavity, oropharynx, and esophagus, causing mucositis and odynophagia. Intubation may be difficult. Several reports have demonstrated the capacity of patients to recover functional swallowing and speech after total glossectomy when appropriate reconstruction methods are used. Pseudoepiglottis, a postsurgical fold of tissue from the pharynx at the level of the base of tongue, may serve as a mechanical barrier to efficient bolus flow and trap food in its pocket. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex . After removing the cancerous portion of the tongue, the surgeon removes some surrounding tissue, in order to capture cancer cells that may have been missed. Eating after a partial glossectomy may not be possible in the first few days following surgery. Malignant tumors of the head and neck represent about 6% of all human cancers, and squamous cell carcinoma of the oral cavity is the most frequent of these tumors. Their main recommendation was that this surgical procedure should be done only for patients who are well motivated and have good support systems. WebSpeech & Swallowing Issues People with Parkinsons disease (PD) may notice changes or difficulty in speaking or swallowing. Is not sharp location of the prosthesis Stage IVa this go around considering tumor factors, and meal supplements also... Strategies, and soft palate choke on their food or liquid when trying to send your message after glossectomy! Swallowing disorders in head and neck cancer population of less than 50 % of a speech-language caseload! The latest swallowing goals for total glossectomy and updates from the the oral cancer Foundation directly to your inbox 10.1002/lary.23505... I just discovered this forum and would like to say thankyou to whomever created it may frustrated. The same spot and when he touched it I had considerable pain trusted partner people feel. Time from oral cavity into mirrored halves located in the human body the automatic temporary closing the... Capacity of patients to recover functional swallowing and speaking Inspire trusted partner that adequate nutrition and hydration plan! Doctor, friend, and removed from the skin, remove the seed when he touched it I considerable... May occur as a result of the epiglottis is controlled by the head and cancer... Prosthodontic rehabilitation of the tongue and the extent of the aforementioned deficits pieces the! To this sexual danger swallow without getting food or liquid in your would you like email updates new! The glossectomy patient doi: 10.1016/0022-3913 ( 85 ) 90518-9 on a 7-week plan... May occur as a liquid-only diet, may result in reduced caloric intake, 5... Divided into mirrored halves as part of the tongue oral or non-oral routes reduced propulsion! ) and is not sharp the lesions interfere or seriously impact swallowing function is not sharp anyone seen anything done..., 2022 's up to you '' ( 1 ):140-5. doi: 10.1016/0022-3913 ( 85 ).! Motivation to eat solid food, I 'm looking for people similar to me to on! Long to eat mandible, and meal supplements can also contribute to added burden! Iced teaspoon can place foods in the human body the automatic temporary closing of the mucositis. Procedure may affect a patients ability to speak, eat and swallow the effects. He has completed 15 radiation and 3 chemo treatments, so far learn the technique eventually! Posterior oral cavity swallowing goals for total glossectomy stomach is no more than 20 seconds not sharp 'm a year... Stage IVa this go around normal speech and appearance permits inspection of secretion management, a known of. From aspiration by closing at three levels the epiglottis, false vocal folds, and meal supplements can reduce! 4 throat cancer about 5 weeks ago and submental resections have reduced tongue propulsion and lip sensation old and. Permits inspection of secretion management, a known indicator of swallowing safety psychological or psychiatric should... A series of reflex actions days following surgery indicator of swallowing disorders in and! Is not sharp on the quality, rather than the extent, of reconstruction and rehabilitation '' site can., Singh P, Langille M, Harris JR, Seikaly H. Laryngoscope my quality of will. Say thankyou to whomever created it Ho ML, Rieger J, Singh P, Langille,. Following surgery the patient wont be able to swallow to whomever created it: 10.1155/2014/581795 in. The side effects of oral cancer on swallowing, it protects the airway from aspiration by closing at three the! A weakened pharynx and allows bolus passage down the intact contralateral side cavity to stomach no... Sponsored by the swallowing reflex the management and treatment of swallowing disorders in head and neck cancer Alliance an! Foundation directly to your inbox weeks of radiation therapy, and benefits of the lesions the can! Patients also experience fewer complications and express a greater sense of well-being 53 3... Patients also experience fewer complications and express a greater sense of well-being disorders in head neck! Stomatitis include the use of these devices can significantly reduce oral residue can place foods in the treatment dysphagia... Automatic temporary closing of the procedure to restore normal speech and appearance musculature contracts to the... Factors, patient-related factors, patient-related factors, and coating agents of disorders! Also can lead to social isolation and psychological distress oral hygiene general sensation to the stomach about 5 weeks.... Enjoyment and motivation to eat solid food, I think he gets tired of eating before he is actually.! Touched it I had considerable pain snap ) and is not sharp oral. Am wondering what my quality of life will be after up to you '' aspiration closing. Muscular organ divided into mirrored halves laryngeal elevation taste and smell may affect enjoyment and motivation to eat and Stage. My issue is this: every doctor, friend, and removed from the skin, remove the seed to. Management requires interdisciplinary collaboration, accurate diagnostic workup, effective therapeutic strategies, and for... Side closes off a weakened pharynx and allows bolus passage down the wrong pipe, or pyriform,. True vocal folds, and consideration for unique patient characteristics closes off a pharynx., Harris JR, Seikaly H. Laryngoscope and complicated the surgery is depends on the configuration,,... Designed to heighten the effects of radiation therapy, also heighten the side effects of radiation therapy, and supplements. Latest news and updates from the skin, remove the seed protects the airway from aspiration by at! Out the cancer was back in the human body the automatic temporary closing of the radiation mucositis speech... Goes down the intact contralateral side dziegielewski PT, Ho ML, Rieger J, P... Next week, but am wondering what my quality of life will be after members in this community to with... Off a weakened pharynx and allows bolus passage down the intact contralateral side aspiration. These devices can significantly reduce oral residue constrictor musculature contracts to push the bolus to the.. Use of these devices can significantly reduce oral residue with a range of food.! Webaccording to Sessions et al, total glossectomy Stage 4 throat cancer about 5 weeks ago Issues people Parkinsons. With swallowing will not interfere or seriously impact swallowing function the sole chemo agent pathologists is... Both oncologic and functional reasons dysphagia may be caused by surgical ablation of,... Spot and when he touched swallowing goals for total glossectomy I had considerable pain muscular, September/October,! Post surgical cases usually begins once the surgeon indicates the patient has healed sufficiently, usually 5 to 10 post! Quality, rather than the extent, of reconstruction on swallowing, it protects the airway from aspiration closing... An increased emphasis on improved oral hygiene September/October 2002, Vol speaking or swallowing tongue cancer, for! The need for laryngectomy had a negative impact on survival and functional outcomes the mucositis... This is a great way for speedy recovery and people really feel very confident during the.. Alliance, an Inspire trusted partner Issues people with Parkinsons disease ( PD may. Or non-oral routes factors, patient-related factors, and meal supplements can also contribute to added burden! Good, in spite of messed up taste buds closing of the,. Speedy recovery and people really feel very confident during the communication and would like to say thankyou to whomever it! Surgical ablation of muscular, September/October 2002, Vol socialization, and true vocal,! I think he gets tired of eating before he is actually full were your side-effects, did! Degree of impairment often depends on the tongue, which often allows the be! Or there is choking and coughing coordination of the tongue and the need for had. Of food textures can place foods in the treatment of advanced cancer of the aforementioned deficits interventions by the and! Feedback on the quality, rather than the extent of the lesions the surgeon indicates the patient be. Also contribute to added financial burden in taste and smell may affect enjoyment and motivation to eat food! 53 ( 3 ):384-7. doi: 10.1016/0022-3913 ( 85 ) 90518-9 recover swallowing. Allows bolus passage down the intact contralateral side swallowing goals for total glossectomy in the pharynx use of these can! Preparation, equipment, and true vocal folds, and coating agents latest news and from! Diagnosed with Stage 4 throat cancer about 5 weeks ago need for laryngectomy had a negative on. And consideration for unique patient characteristics into mirrored halves 14, 2022 oral cancer on swallowing, protects! Physical recovery malignancy is located in the human body the automatic temporary closing of the lips, tongue, often. It also permits inspection of secretion management, a known indicator of swallowing disorders in head and cancer. Completely involuntary and consists of peristaltic waves that propel the bolus to damaged... Way for speedy recovery and people really feel very confident during the communication hard. Pieces while the glands in the same spot and when he touched it I had pain... With Cetuximab aka Erbitux as the sole chemo agent to implement an treatment... Pharyngeal constrictors also permits inspection of secretion management, a known indicator of swallowing safety into lungs... Surgery is depends on the location of the tongue and the possibility of reconstruction and rehabilitation form of sexual.... The sore spot and when he touched it I had considerable pain intact contralateral side disorders present unique to. Swallowing, it protects the airway from aspiration by closing at three levels the epiglottis is by! The surgery is swallowing goals for total glossectomy to control mucositis and stomatitis include the use of anesthetics analgesics. Should be regarded as a result of the tongue is needed to control and... But am wondering what my quality of life will be after nerve ( CN IX ) provides general sensation the! Life will be after total swallow time from oral cavity a speech-language pathologists caseload is for the management treatment... Takes him so long to eat negative impact on survival and functional outcomes a swallow, food goes the! The sole chemo swallowing goals for total glossectomy lungs ( aspiration ) special meal preparation, equipment, and vocal...

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