Head and Neck Cancer Flashcards
Risk factors/cause
Tobacco smoking (important factor: frequency and length of consumption)
Alcohol consumption
Combination of tobacco and alcohol use significantly increases risk
Use of smokeless tobacco
GERD
Human Papillomavirus (HPV) (cancers normally seen in oropharyngeal region)
Symptoms
Laryngeal Cancer
Persistent hoarseness
Odynophagia
Dysphagia
Dyspnea
General Symptoms
Unexplained weight loss
Ear pain
Enlarged lymph nodes/lumps in the neck which continue to grow
Difficulty breathing
Fatigue
Hemoptysis
Cancer Type
- Squamous cell carcinomas (SCC): Almost 90% of all
HNC are SCC. Squamous cells that line the moist
surfaces inside the head and neck regions - Adenocarcinomas
- Sarcomas
- Melanomas
- Lymphomas
- Thyroid cancer types: Papillary (most common),
medullary cancer (hereditary), anaplastic
Symptoms
- Persistent hoarseness: Glottic tumors
- Dysphagia
- Odynophagia
- Dyspnea
General Symptoms
- Unexplained weight loss
- Ear pain
- Enlarged lymphnodes/ lumps in the neck which
continue to grow - Difficulty breathing
- Fatigue
- Hemoptysis
Diagnosis
- Head and neck examination:
Visually examing all of the structure of oral cavity, pharynx, and larynx
(endoscopy; stroboscopy) - Lymph node palpation: performed by ENT or head and neck surgeon
- Imaging (CT/MRI/PET) CT: DEPTH
- Direct laryngoscopy: examination under anesthesia
- Fine needle aspiration cytology (FNAC)
- Biopsy: tissue is taken directly from the tumor& FNAC & BIOPSY are only tests that can CONFIRM the presence or absence AND the type of cancer
Staging (TMN Classification)
T = primary tumor size and extent
N = absence or presence and extent of regional lymph node metastasis
M = absence or presence of distant metastasis
Lymph node distribution:
* I = submental/submandibular nodes
* II = upper jugulodigastric group
* III = draining the nasopharynx and oropharynx, oral cavity, hypopharynx, larynx
* IV = inferior jugular nodes draining the hypopharynx, subglottic larynx, thyroid, esophagus
* V = posterior triangle group
Staging
chemo/radiation
Stage 1 = T1/N0/M0
Stage 2 = T2/N0/M0
Stage 3 = T3/N0/M0, T3/N1/M0
Stage 4 = any T4/N0/M0/, any T2/N2/M0, any T/N3/M0, any T/any N/M1
Automatically considered Stage 4 cancer if T4, T2/N2, N3, or M1
Organ Preservation
- Combination of primary chemotherapy and radiation therapy
- Aims to preserve the larynx and avoid a permanent stoma
- Pros: Preserves the larynx, avoids creating a stoma
- Cons: Severe swallowing and voice issues after high does of chemoradiation
Radiation Therapy
- Pros: Preserves the larynx, avoids creating a stoma
- Cons: Damages healthy tissue and organs in area, acute/delayed toxicity, xerostomia, mucositis dental caries, dysphonia, dysphagia, hypothyroidism, lymphedema
Conservation Surgeries
- Hemilaryngectomy: vertical removal of laryngeal structures (may involve complete removal of on VF and partial removal of structures on contralateral side)
- Transoral robotic surgery: includes tongue base, tonsil, and supraglottic masses
-Pros: minimally invasive procedure, eliminates need for post op tracheostomy, better swallowing, breathing, and voice outcomes
Subsites
- above glottis- supraglottis= false vf, epiglottis
- VF= Glottis
- blelow glottis= Subglottis= cricoid, trachea
Hypopharynx
- not apart of the pharynx
- Piriform sinuses, post cricoid
region, posterior pharyngeal wall
Radiation Therapy
Radiation therapy damages healthy tissue and
organs in the area surrounding the target
* Acute and delayed toxicity
* Vulnerable areas: Oral cavity, skin, thyroid
Xerostomia, mucositis, dental caries
Dysphonia/Dysphagia
* Hypothyroidism
Lymphedema
- Lymphedema development
is the result of injury or
scarring to the lymph
vessels or removal of the
lymph nodes - Lymphedema results in an
accumulation of lymphatic
fluid in the interstitial
tissue. - Can cause severe swelling
of the face and neck region
resulting in discomfort, and
at times respiratory
compromise - Physical therapy or Lymphede specialized SLP services
LARYNGEAL “CONSERVATION” SURGERY
- Laser excision: Type I to V; depending upon the
amount of vocal fold resected. Type V cordectomy
involves a complete removal of the vocal fold. - Partial Laryngectomy
- Supraglottic laryngectomy:
Involves removal of structures
above the glottis including the
epiglottis.
Hemilaryngectomy:
* Involves vertical
removal of
laryngeal structures.
* May involve complete
removal of one vocal
fold and partial removal
of structures on the
contralateral side
TRANSORAL ROBOTIC SURGERY
- Minimally invasive procedure
- Tongue base, tonsil and
supraglottic masses. - Usually eliminates the need
for a post op tracheostomy - Better swallowing, breathing
and voice outcomes
TOTAL LARYNGECTOMY
- Removal of the entire larynx, including the
epiglottis, hyoid bone, larynx, and cricoid
cartilage - Neck dissection
- Thyroidectomy
- Reconstruction*
- Salvage laryngectomy: Total laryngectomy
performed following previous curative intent
radiation therapy with or without
chemotherapy
TOTAL LARYNGECTOMY: RECONSTRUCTION
- Pectoralis Major Flap
- Free Flap
- Radial forearm
- Jejunal
- Thigh flap
Extended procedures: Glossectomy, pharyngectomy,
esophagectomy
FUNCTIONAL IMPLICATIONS
- Loss of original
sound source - Permanently
altered airway:
mucous
management (nasal
and stoma),
breathing, snoring,
sneezing, blowing,
sipping, coughing - Disfigurement
- Altered olfactory
and taste sensation - Dysphagia and
digestive problems - Alterations in head,
neck and shoulder
function/ sensation - Alterations in
lymphatic
drainage pattern - Hypothyroidism
- Depression
PRE-OPERATIVE EXAMINATION
- Oral Mechanism Examination
- Articulation
- Brief Cognitive Assessment
- Current swallowing function
- Nutritional Status
- Hearing Acuity
- Literacy
- Visual Acuity
- Physical limitations and support system
PRE-OPERATIVE COUNSELING
- Introduce yourself
- What have you
heard? - How do you learn
best? - Anticipate potential barriers
to recovery, discharge, learning and the rehabilitative - Patients goals?
- Review basic information
- Cancer
- Removalof Larynx
- Stoma
- Appearance
- Estimated
POST-OPERATIVE GOALS
- Prepare the patient & family for discharge
- Suctioning
- Nutritional Support
- Nursing
- Effective Communication
- Stoma Care Supplies
- An emergency plan
- Education and emotional support
- Evaluation of Swallowing
- Preliminary communication training
- Discharge planning and physician orders
EDUCATION AND TRAINING
- Laryngectomy Kit
- Stomam care/pulmonary hygiene
- Showering
- Humidification
- Bowel issues
- Lifting
- Smell/taste
- Tube Feedings
- Laughing/ crying
- Snoring/ Coughing/
- Sneezing
- Blowing/ Sipping
- Oral Care
OUTPATIENT REHABILITATION
- Pulmonary rehabilitation
- Adequate nutritional intake
- Altered Olfaction and Taste sensation
- Neck and Shoulder Dysfunction
- Lymphedema management
- XRT care
- Emotional support
- Communication
FACTORS TO CONSIDER: STOMA CARE
- Adequate stoma size
- Skin care
- Appropriate protective coverings
- Stoma covers
- HME’s
- Mucous management
- Emergent medical care issues
HME: HEAT MOISTURE EXCHANGER
- Disconnect between upper and lower airways resulting
in the loss of humidification, cleaning and moisturizing
of inhaled air through the nose - HME: Provides humidification in patients with
tracheostomy: Not limited only to laryngectomy patients - HME sits over the stoma heating and moistening it in
the process. - Contains foam treated with calcium chloride. As the
person breathes out, the foam collects and saves
humidity and warm air - The goal is to approximate the temperatures and
relative humidity at the nasal level pre-surgery, to the
temperature levels at the trachea, post-surgery
VOICE REHABILITATION
- Artificial larynx
- Tracheoesophageal speech
- Esophageal speech
- Selection of most functional
communication method - Communication training
- Ongoing communication
maintenance and upkeep
ARTIFICIAL LARYNX TRAINING
Parameters of AL speech
* Handedness
* Placement
* On/off device activation
* Articulation strategies
* Distractors
* Pragmatics
* Device Maintenance*
Training hierarchy
* Sounds
* Words
* Phrases
* Sentences
* Conversational speech
* Prosodic features: pitch, emphasis, intensity
ARTIFICIAL LARYNX TRAINING
Advantages
* Generally easy to
learn.
* Equal in intelligibility
to esophageal speech
* More easily
discriminated in noise
than is esophageal
speech
* Can be easily adapted
and changed to an
intraoral device.
Disadvantages
* Robotic quality
* Cost factor
* Requires use of one
hand for operational use
* Failure for mechanical breakdown
* Difficult to vary and
use the pitch
variation features
* Limited ability to
PHARYNGOESOPHAGEAL (PE) SEGMENT
- It is the sound generator for individuals using esophageal
speech or tracheoesophageal speech. The tonicity of the
PE segment greatly influences voice quality. - Diedrich (1968) used the term “pharyngesophageal” to
describe the anatomical region used for the generation of
post laryngectomy voice source. - The source of esophageal phonation is primarily derived
through response of the cricopharyngeus muscle. - The cricopharyngeus muscle is best described as a band
of muscle located in the transitional region between the
lower pharynx and the upper esophagus
ESOPHAGEAL SPEECH
Phonatory source or
sound generator is
the PE segment.
Esophageal speech is
based on the
technique in which
the patient transports
a small amount (±75
ml) of air into the
esophagus.
Two major methods of air intake:
Inhalation: Esophagus is in a state
of negative pressure and as air is
inhaled into the lungs, air also
enters the esophagus. Air pressure
in the lungs and esophagus become
equalized. Air can then be expelled
to produce vibration of the PE
segment.
Injection (glossopharyngeal press
and plosive injection) : Compressing
the intraoral air into the esophagus
with assistance from the tongue or
lips and sometimes the cheeks.
TRACHEOESOPHAGEAL SPEECH
What is a TE-Puncture?
* Fistula created between trachea and the esophagus
* A device/prosthesis made of medical grade silicone is
positioned within the “party wall”
* The prosthesis allows air to be shunted from the
lungs into the esophagus
* Vibration of the tissue in the lower pharynx serves as
the new sound source
TRACHEOESOPHAGEAL SPEECH 2
- Primary or secondary procedure for the purpose of
voice restoration. - Primary TEP: The TE fistula or puncture is created at
the time of the total laryngectomy (more common). - Secondary TEP: The TE fistula or puncture is created
months or at times years after the total laryngectomy. - Voice restoration is more successful after primary TEP*
- Creation of a tracheoesophageal (TE) fistula between
the trachea and the esophagus in the superior border of
the stoma.
CANDIDACY
- Generally Healthy
- Functional anatomy
Stoma
Neopharynx
Esophagus - Adequate pulmonary support
- Functional cognitive status, visual acuity and manual
dexterity - Social Support
- Reasonable expectations
TE SPEECH
Advantages
* Pulmonary air as the driving
force for the PE segment.
This allows the patient to
sustain phonation over a
longer period of time.
* Provides a more natural
speech-breathing action and
the acoustic, characteristics
of voice (intensity, frequency,
and rate) are closer to
approximate measures for
laryngeal speakers.
* TE speech is easy to acquire
and learn.
* Hands-free prosthesis
Disadvantages
* Daily maintenance of the prosthesis by the patient.
* Semi-permanent: Prosthesis needs to be changed regularlyUsually every 3 months.
* The recurrent leakage
of the prosthesis after a
period of time and
therefore required
replacement by the
clinician.
* if performed as a
secondary procedure,
requires additio
CONTRAINDICATIONS
- Inadequate pulmonary reserve: Hx of COPD,
emphysema, pulmonary fibrosis, interstitial
lung disease, - Inadequate depth and diameter of stoma to
accept prosthesis without airway compromise - Recurrent Disease
- Unresolved fistula
- “Bad” Tissues
- Reduced Income
- Poor or No Insurance
- Transportation Issues
PE SPASM: TREATMENT
- BOTOX: Relieves the cricopharyngeal spasm. May
or may not require multiple injections over time
(Senchuk, 2010) - Pharyngeal neurectomy- Performed to avoid
myotomy and consequent swallowing issues.
Efficacy with regards to spasm relief is variable
(Singer, et al.1986) - Cricopharyngeal myotomy- Associated with
formation of pharyngocutaneous fistula (at the
time of laryngectomy). However, successful in
restoring TE-speech if BOTOX fails (Hamaker,
2003) - Mechanical dilation: Relieves dysphagia, less
successful in restoring TE-speech (Chao et.al
TREATMENT: PE-SPASM
botox
BOTOX:
* Most extensively
researched, clinically
* Systematic review
(Senchuk, 2010):
Improved voice and
swallowing outcomes,
need for re-injection
was variable across
studies, dosage was
variable across studies,
EMG guided/non-EMG
guided,
videofluoroscopy
CONCLUSIONS
- Offer options not opinions
- Advocate for patients but more importantly teach
them to advocate for themselves - Encourage patients to take advantage of
community support - Encourage independence
- Develop/maintain a good working relationship
with physicians and other professionals - Support the patients right to choose
