Laryngeal Cancer Module 12-Student PDF

LARYNGEAL CANCER Franchino & Differding December 2 & 9 Loyola University Maryland Internal Use Only ASSIGNMENT CHECK IN... 1. PMSV Courses and reflections due on 12/8 @11:59p.m. 2. Questions for Laryngectomy guest due on 12/8 @ noon 3. Quiz #5 on 12/16 4. Group prese...

LARYNGEAL CANCER Franchino & Differding December 2 & 9 Loyola University Maryland Internal Use Only ASSIGNMENT CHECK IN... 1. PMSV Courses and reflections due on 12/8 @11:59p.m. 2. Questions for Laryngectomy guest due on 12/8 @ noon 3. Quiz #5 on 12/16 4. Group presentations on 12/16 Loyola University Maryland Internal Use Only OBJECTIVES Explain the prevalence, risk factors, and demographics of head and neck cancers, focusing on laryngeal cancer. Describe management options for laryngeal cancer, including surgery, radiation, and chemotherapy. Outline the SLP’s role in breathing, voice, speech, and swallowing rehabilitation post-treatment. Explain methods of alaryngeal speech, including esophageal speech, TEP, and electrolarynx. Loyola University Maryland Internal Use Only  HEAD & NECK CANCER STATISTICS 1. Head and Neck (HN) cancer accounts for about 3-5% of all cancers in the United States 2. More than 66,000 new cases were expected in 2024 across all HN types 3. More common in men and African-Americans a. 50 years of age and older, getting younger 4. Oral cancer more common than laryngeal cancer 5. Incidents of HPV- HN cancers has been declining (i.e., smoking, drinking) 6. HPV+ HN cancers is rising a. ~70% testing positive for oropharyngeal HPV+ Cancers 7. 59% five-year survival rate for oral & pharyngeal cancers, although this is increasing for HPV-caused cancers 8. Responsible for $3.79-5.46 billion dollars in health care expenditures vs. Breast Cancer's $20.5 billion a. Median annual medical expenses and relative out-of-pocket expenses were higher for patients with HNC than for patients with other cancers ( Boakye et. Al., 2019) Loyola University Maryland Internal Use Only INCIDENCE OF HN CANCER BY LOCATION Loyola University Maryland Internal Use Only SYMPTOMS OF OROPHARYNGEAL CANCER Change in voice quality A cough that lasts A sore throat that lasts Feeling of a lump in the throat Dysphagia Pain when swallowing Trouble breathing Noisy breathing Ear pain that lasts A lump in the neck Unplanned weight loss Symptoms vary depending upon site of cancer Loyola University Maryland Internal Use Only CAUSES Tobacco use Alcohol abuse Poor nutrition GERD - Gastroesophageal Reflux Disease Human papilloma virus Inhaled chemicals Environmental pollution Site for tumor growth without cause Loyola University Maryland Internal Use Only METHODS OF DIAGNOSIS 1. Oral/ Pharyngeal/ Laryngeal examination and Palpation 2. Surgical exploration and biopsy 3. Imaging procedures: a. X- ray b. Computerize Tomography (CT) scan c. Magnetic Resonance Imaging (MRI) d. Positron Emission Tomography (PET) Scan Loyola University Maryland Internal Use Only LARYNGEAL CANCER 1. Laryngeal cancer accounts for about 0.8% of all cancers in the United States 2. More than 12,650 new laryngeal cancer cases were expected in 2024 3. Impacts men 4x more likely than women 4. Highest incidence rate among non-Hispanic black men (6.5/100,000) as compared to non-Hispanic white men (4.8/100,000) 5. Strongly linked to tobacco use and alcohol consumption 6. Higher risk in individuals exposed to workplace hazards such as asbestos or certain chemicals 7. 61% five-year survival rate for laryngeal cancers Loyola University Maryland Internal Use Only LARYNGEAL CANCER LOCATIONS 1. Supraglottis – swallowing related symptoms 1. ~35% 2. Glottis – voice related symptoms 1. ~ 60% 3. Subglottis – less obvious symptoms 1. Rare Loyola University Maryland Internal Use Only  TUMOR STAGING T – tumor site and implied size (0 – 4) N – involved lymph nodes M – distant metastasis – lungs, liver, etc. M0=No evidence of distant Spread M1=Distant spread Stage drives treatment decisions; the lower the numbers the better the prognosis Ex. T2, N1, M0 *Priority – saving/prolonging the patient’s life by curing the disease Loyola University Maryland Internal Use Only CLASSIFICATION OF GLOTTAL CANCERS: TUMOR SIZE https://www.enttoday.org/article/new-staging-system-horizon-head-neck- cancers/?singlepage=1&theme=print-friendly Loyola University Maryland Internal Use Only CLASSIFICATION OF GLOTTAL CANCER: LYMPH NODES (N) N – Lymph Nodes N0: no nodes involved N1: single node on one side N2: multiple nodes on one side or single large node N3: Massive nodes both sides Loyola University Maryland Internal Use Only LYMPH NODE INVOLVEMENT Level I Submental (IA) Submandibular (IB) Level II Upper internal jugular nodes Level III Middle jugular nodes Level IV Low jugular nodes Level V Posterior triangle nodes Level VI Central compartment; Level VII Superior mediastinal nodes Reference for Image. Loyola University Maryland Internal Use Only INTERDISCIPLINARY TEAM HN Surgeon Medical Oncologist Radiation Oncologist Radiologist Dentist/Prosthodontist Nurse SLP: Voice, Swallow, Speech Social Worker Psychiatrist Counselor Physical/Occupational Therapy Nutritionist Spiritual Support Patient Mentor Loyola University Maryland Internal Use Only TREATMENT DECISIONS ARE BASED UPON: Extent of the disease (TNM stage) Cause of disease (HPV better prognosis-oropharyngeal) Age, overall health, & past medical history Tolerance for specific medications, procedures, or therapies Expectations for the course of the disease The patient’s wishes The patient’s support system Loyola University Maryland Internal Use Only TREATMENT OPTIONS 1. Radiation therapy (XRT) 2. Chemotherapy (to kill cancerous cells) 3. Immunotherapy 4. Surgery Loyola University Maryland Internal Use Only PRE-OPERATIVE COUNSELING 1. Presurgical counseling recommend 2. Interdisciplinary approach 3. Illustrate and describe changes to breathing, speech, voice and swallowing 4. Specific to head and neck cancer diagnosis 5. Patient mentor Loyola University Maryland Internal Use Only RADIATION 1. Goal: Preservation of structures and function 2. Energy emitted by atoms that are harnessed to kill cancer cells as they change from a higher energy state to a lower energy state 3. Radiation dose measured in Gray (Gy=J/kg) Terminology: 1. Neo-Adjuvant: Before primary treatment 2. Definitive Radiation: Radiation alone without chemo or previous surgery 3. Concomitant Radiation: Radiation with Chemotherapy 4. Adjuvant Radiation: Radiation after surgery Loyola University Maryland Internal Use Only EFFECTS OF RADIATION TX ITZHAK BROOK, M.D. & LARYNGECTOMEE Dryness & stiffness of the mucosa resulting in mucositis - inflammation and ulceration of mucous membranes of the oral cavity & pharynx Fibrosis (excess fibrous connective tissue) which impacts muscle range of motion “Trismus” (aka lockjaw) Xerostomia (dry mouth) from loss of salivary glands SLP Therapy: techniques to achieve best voice possible (if not laryngectomized; oral hygiene; swallowing management; trismus management Goal: to maintain function during XRT as opposed to regain function at a later time Loyola University Maryland Internal Use Only CHEMOTHERAPY 1. Not considered a definitive treatment 2. Improves survival rates when delivered concomitantly with radiation Terminology: 1. Induction Chemotherapy: Use of high dose of anticancer compounds early in treatment, particularly for larger or more invasive tumors to weaken tumor 2. Immunotherapy: boost the immune system often used for advanced or recurrent cases with aim to increase survival and/or quality of life. Loyola University Maryland Internal Use Only  VOICE THERAPY FOR LARYNGEAL CANCER Voice Therapy: 1. Postsurgical and/or post-irradiated dysphonia is challenging 2. Dependent on amount of mucosal wave preserved 3. Dysphonia secondary to: a. Vocal fold stiffness b. Scarring c. Absent tissue (postsurgical) 4. Vocal Hygiene 1. Increase hydration 2. Reduction in consuming alcohol and caffeine 3. Reduce phonotraumatic behaviors (i.e., coughing, throat clearing) Loyola University Maryland Internal Use Only VOICE FACILITATING APPROACHES 1. SOVT 6.Glottal Fry 2. RVT 7.Head turn 3. VFE 8.Digital Manipulation 4. Inhalation phonation 9.Loudness 5. Pitch Glides 10.Tongue protrusion Loyola University Maryland Internal Use Only SURGICAL 1. Goal: Organ Preservation 2. Removal of the tumor with goal of preserving some aspect of vocal fold function 3. Surgical advances: Less invasive, preserves more healthy tissue a. Robotic-assisted surgery b. Laser microsurgery Loyola University Maryland Internal Use Only SURGICAL OPTIONS 1. Wide local excision: a. Often used for carcinoma in situ or small cancers, can obtain margins without impacting significant tissue 2. Partial laryngectomy: often for smaller tumors a. Cordectomy: Partial or complete removal of the vocal fold secondary to deeper invasion in the tissue b. Cordotomy: Small cut into the posterior vocal fold to open airway, most seen with bilateral adductor paralysis 3. Hemi-laryngectomy: Either left or right vocal fold is removed 4. Subtotal laryngectomy or supraglottic laryngectomy: a. Removal of structures between the glottis and base of tongue 5. Total Laryngectomy: 1. Complete removal of all structures of the larynx (Epiglottis to cricoid cartilage) Loyola University Maryland Internal Use Only TOTAL LARYNGECTOMY FOR ADVANCED CANCERS 1. Removal of all structures of the larynx a. Loss of vibratory source/sound for speech 2. Trachea brought forward to create a stoma in neck to function as a permanent breathing channel a. Loss of natural filtration and humidification b. Diminished/loss of smell and taste 3. Pharynx separated from respiratory system 4. Nose & mouth, pharynx lead to esophagus 5. Breathing & swallowing are now permanently separate systems Loyola University Maryland Internal Use Only Loyola University Maryland Internal Use Only  CANDIDACY FOR LARYNGECTOMY Cognitive and Adequate Pulmonary sensorimotor tonicity of PE Support skills Segment Loyola University Maryland Internal Use Only IMPACT OF TOTAL LARYNGECTOMY: BREATHING Let’s think and list the differences in breathing pre- and laryngectomy Loyola University Maryland Internal Use Only IMPACT OF TOTAL LARYNGECTOMY: BREATHING How do we remedy the changes in breathing post-laryngectomy? Loyola University Maryland Internal Use Only HEAT-MOISTURE EXCHANGE (HME) FILTER When you breathe in, the humidity and warm air that are saved in the foam is given back to the air you breathe in. Atos Medical Loyola University Maryland Internal Use Only BENEFITS OF HME The researchers looked at: What impact coughing and mucus had on patients’ everyday life How many hours per day patients were wearing an HME HME removal due to shortness of breath Skin irritation Loyola University Maryland Internal Use Only RESULTS OF STUDY 1. Significant improvement in pulmonary symptoms for people living with a laryngectomy 2. One-third of patients reported coughing less to clear mucus 3. Wearing an HME 24/7 positively impacts lung health 4. Users reported less shortness of breath meaning less need to remove their HME to catch breath 5. Experienced less skin irritation Loyola University Maryland Internal Use Only HME OPTIONS Provox Life Provox Life Provox Life Night Home Go Provox Life Provox Life Provox Life Protect Energy Hands Free Loyola University Maryland Internal Use Only IMPACT OF TOTAL LARYNGECTOMY: VOICE AND SPEECH 1. Artificial Larynx (Electrolarynx) a. There are approaches: 1. Intraoral 2. Neck 2. Esophageal Speech (ES) a. Pharyngoesophageal (PE) segment becomes neoglottis 3. Tracheoesophageal voice (TE Voice) a. Surgical procedure: Primary or Secondary Loyola University Maryland Internal Use Only ELECTROLARYNX 1. Instrument externally placed against throat or oral structures that produces vibratory source for phonation 2. Therapy to assist in finding best placement, articulate, timing and phrasing Loyola University Maryland Internal Use Only ADVANTAGES VS DISADVANTAGES Advantages: Disadvantages: 1. Used soon after surgery 1. Mechanical device: sound, 2. Usually, minimal instruction dependability required 2. Requires use of a hand 3. Can return to work 3. Initial & ongoing cost 4. Can adjust for pitch and loudness Loyola University Maryland Internal Use Only ELECTROLARYNX Loyola University Maryland Internal Use Only  HOW TO: 1. PLACEMENT: Find your “sweet spot!” This is the spot on your face or neck that provides the clearest speech sounds. Practice placing the Electrolarynx in this exact spot several times; place a small band-aid or piece of medical tape on the spot to help you find this spot consistently. Remember that the round, vibrating surface of the Electrolarynx should be flat against your skin and pressed neither too hard nor too soft against the skin surface. 2. ARTICULATION: Exaggerate your speech movements. Enunciate. Remember, you no longer need to breathe out to speak, so practice “mouthing” the words while over- doing it with the movements of your lips, tongue, and cheeks. 3. TIMING: The Electrolarynx should be turned on ONLY as you begin to move your mouth muscles for speech and should be turned off as you finish the last sound in a word. Turning it on too soon before you being speaking, or off too late after you finish speaking, will make you less intelligible. Loyola University Maryland Internal Use Only  HOW TO: 1. PHRASING: Plan to leave the electrolarynx on for a few words at a time… in other words, speak in phrases. Turning the device on/off for each individual word will make your speech sound telegraphic, while leaving it on for entire sentences may result in poor intelligibility. Plan to turn the device on/ off when you might naturally pause/ take a breath in normal speech. 2. PRACTICE: Begin practicing automatics, such as the alphabet, counting, days of the week, months of the year, prayers, and/ or personal information such as name, birthday, phone number/ address. Then, begin to practice words of increasing length and short phrases. Always use the electrolarynx as your first attempt at communication. Remember, others may have difficulty understanding your speech as you are first learning to use the electrolarynx; have a back-up method of communication, such as writing, available – soon you won’t need it! Loyola University Maryland Internal Use Only  ESOPHAGEAL SPEECH: 1. Air is “inhaled” into esophagus, then expelled, setting pharyngeal esophageal (PE) segment into vibration 2. Method: a. Forcing air past P-E segment (upper esophageal sphincter aka cricopharyngeus muscle) b. Reversing the air stream c. Then vibrating the P-E segment by forcing the air out of the esophagus d. Articulating the sound to create meaningful speech Skills: Consistency with rapid air injection; short latency in sound production, good duration; articulation; prosody Loyola University Maryland Internal Use Only PHARYNGOESOPHAGEAL (PE) SEGMENT Image result for image of muscles of the pharynx Loyola University Maryland Internal Use Only ESOPHAGEAL SPEECH Advantages: a. Once learned, it requires nothing more b. Hands-Free Disadvantages: a. Challenging to master b. Fatiguing, with gastric side effects c. Lengthy time in therapy d. Cannot speak loudly e. Hard to speak when ill or upset Loyola University Maryland Internal Use Only ESOPHAGEAL SPEECH Loyola University Maryland Internal Use Only TRACHEOESOPHAGEAL VOICE: Small fistula (opening) is surgically made into posterior tracheal wall (into esophagus) Tracheoesophageal Prosthesis (TEP) is placed to maintain the opening Prosthesis is a one-way valve Air from trachea moves into esophagus via the TEP, allowing the PE segment to vibrate and become the source of sound for speech. Loyola University Maryland Internal Use Only TRACHEOESOPHAGEAL VOICE: Loyola University Maryland Internal Use Only TRACHEOESOPHAGEAL VOICE PROSTHESIS Provox 2 Provox Vega Provox XtraSeal X-ray detectable 17, 20, and 22.5Fr A Provox Vega with Recessed valve an additional, 22.5Fr diameter enlarged esophageal 4.5mm – 15mm Maximal inner flange diameter Requires Smart inserter with overshooting for insertion tube, stick proper placement and esophageal flange folder Loyola University Maryland Internal Use Only TRACHEOESOPHAGEAL VOICE PROSTHESIS: INHEALTH 1. X-ray detectable 2. Gel-cap insertion 3. 16 or 20Fr diameter 4. 4mm – 25mm (also special length odd-sizes) Loyola University Maryland Internal Use Only TRADITIONAL/ NON- INDWELLING TEP 1. Patient placed – remove, clean, reinsert 2. InHealth Low Pressure Prosthesis a. 4 – 28mm, 16 or 20Fr 3. Provox NID a. 6 – 18mm, 17 or 20Fr Loyola University Maryland Internal Use Only  PARTS OF THE PROSTHESIS 1 2 3 4 5 SHAFT Tracheal flange Esophageal Retention One way Hollow silicone flange strap valve Holds the tube that holds the prosthesis in place Aides in Allows air in connects the on the side of the prosthesis in trachea with placement of and keep out trachea place on the prosthesis food liquid the esophagus side of the Connected to retention strap esophagus 3 4 1 5 2 Loyola University Maryland Internal Use Only  TRACHEOESOPHAGEAL PROSTHESIS PLACEMENT Loyola University Maryland Internal Use Only  TRACHEOESOPHAGEAL PROSTHESIS PLACEMENT Loyola University Maryland Internal Use Only TRACHEOESOPHAGEAL VOICE Loyola University Maryland Internal Use Only TE PUNCTURE 1. Advantages: a. Using pulmonary air allows near normal phrasing, louder speech, greater fluency, less fatigue as compared to esophageal speech b. Fluent speech is achieved quickly c. Procedure can be performed at time of surgery 2. Disadvantages: a. Surgery, ongoing cost and necessity of supplies, need to be near medical facility b. Not everyone is a candidate for multiple reasons Loyola University Maryland Internal Use Only BEST ALARYNGEAL SPEECH METHOD? 1. Acoustic comparison: TEP > ES for fundamental frequency, maximum phonation duration, intensity 2. Perceptual comparisons: voice/sound quality: TEP> ES; ES>ELS 3. Intelligibility: TEP > ES and ELS; ES> ELS 4. Patient reported outcomes (Voice Handicap Index) no difference between the 3 groups in self-perceived handicap 5. So why doesn't everyone opt for TEP speech? Loyola University Maryland Internal Use Only COMPARISON OF THREE SPEECH METHODS Esophageal ES Tracheoesophageal Electrolarynx TES ELS Mechanical/Prosthetic N Y Y Device Required Hand occupied during N sometimes Y speech Dependence on SLP Y Y proximity to Y medical assistance Duration of therapy Many months ~5+ sessions ~5+ sessions Financial Therapy costs – Material costs Material costs Consideration long training pd ongoing; Insurance initial outlay issues? Speech success low high high Other Fewer SLPs can Not all are Mechanical teach ES candidates sound Loyola University Maryland Internal Use Only IMPACT OF TOTAL LARYNGECTOMY: SWALLOWING Loyola University Maryland Internal Use Only PHYSIOLOGICAL CONSIDERATIONS 1. Absence of hyolaryngeal complex = increased BOT demands for propulsion 2. Reduced peak pharyngeal pressures 3. Changes to intrabolus pressures 4. Increased resistance of bolus flow through PE segment 5. Pharyngoesophageal segment = new UES 1. Subject to tonicity abnormalities 2. Needs adequate superior pressure generation for relaxation Loyola University Maryland Internal Use Only DYSPHAGIA 1. Occurs in 17-72% of laryngectomy patients (Maclean et al., 2009) 2. Causes: a. Fistulae b. Stenosis or stricture c. Spasm of the PE segment d. Pseudovalleculae & pseudodiverticulae e. Recurrence f. Spasm g. Profoundly reduced drive/propulsion h. Presence of an epiglottis i. Backflow j. Ill-fitting tracheoesophageal prosthesis k. Esophageal dysmotility, hiatal hernia, mid and distal esophageal spasm, lower esophageal stricture etc. Loyola University Maryland Internal Use Only WHAT ARE THE COMPLAINTS? “Meats stick and I need to wash them down.” “It takes me a long time to eat. Much longer than before. And much longer than everyone else at the table.” “I can’t eat meat unless I really cut it up and chew it to death.” “No problem. I eat anything I want.” “I can only drink smoothies. It’s not worth the time to try and eat other things.” “I eat everything I want, I just need to wash it down.” “I couldn’t swallow before my surgery and it’s much better now.” “When I bend over, I get liquid back into my mouth.” Loyola University Maryland Internal Use Only FLUOROSCOPY Loyola University Maryland Internal Use Only NORMAL TL FLUOROSCOPY Loyola University Maryland Internal Use Only ABNORMAL TL FLUOROSCOPY Loyola University Maryland Internal Use Only ABNORMAL TL FLUOROSCOPY Loyola University Maryland Internal Use Only IMPACT OF TOTAL LARYNGECTOMY: 1. Olfaction & taste 2. Daily living and hygiene (new routine) 3. Recreation (especially water-related) 4. Intimacy 5. Safety Loyola University Maryland Internal Use Only LEARNING FROM DR. ITZHAK BROOK'S EXPERIENCE 1. Dr. Brook M.D. had a total laryngectomy ~14 years ago. He neither drank alcohol nor smoked 2. Dr. Brook had a “Voice Restoration” surgical procedure, and speaks via a TEP, coupled with a hands-free HME speaking valve 3. He has written multiple books and writes a blog intended to educate people and their families going through laryngeal Ca, as well as medical professionals (The Laryngectomee Guide-Expanded Addition is posted on Moodle) 4. Go to his blog or website and familiarize yourself with resources 5. Watch the interview Dr. Brook gives where he answers questions highly pertinent to SLPs and medical staff Loyola University Maryland Internal Use Only LARYNGETCOMY RESOURCES 1. International Association of Laryngectomees 2. WebWhispers 3. American Speech-Language Hearing Association 4. Dr. Itzhak Brook (physician and laryngectomee) 5. Atos Medical 6. InHealth Techonologies Loyola University Maryland Internal Use Only