Midterm Flashcards
- What are some important points to discuss in preoperative and postoperative laryngtectomy counseling?
Medical concerns
-Tell me what you know about the surgery
-Fear of death (laryngeal cancer has a high cure rate(ballpark average of all stages 75-80%). But don’t know if will live or die. Can take awhile to get good staging on cancer.
Describe surgery—use simple terms and diagrams. 2 tubes, with surgery lose valve that directs things to the right tube, that is why the airway is now connected to the neck.
Communication
• No post op voice (not even a whisper). Only aided communication in the beginning.
• Provide info on different forms of alaryngeal speech
• How long does Rx take? Esophageal: usually about 24 visits. Tracheoesophageal and artificial larynx: about 12 visits
• How much does it cost? Depends on insurance
• Hearing evaluation usually advised. Can’t hear voice in initial low intensity if issue, or spouse can’t hear voice.
• Should you practice artificial before surgery—Dr. W thinks there is enough going on already
General Orientation
-Return to employment: 80%ish return, others may retire. May have to take a lot of time off work
-Activies involving water: Not good idea. Nothing to stop water from going in to lungs. Have some devices for snorkeling, etc. but still sketchy
-taste and smell: sense of taste can be effected by lack of sense of smell (not breathing air in through nose)
-Eating/swallowing: tend to have more difficulty. May need to take longer to eat with smaller bites.
General care
A. Cleaning stoma sube
B. Cleaning stoma
C. Stoma covers
D. Humidity
E. Shaving
F. Sleeping
A. Cleaning stoma tube
A. Stoma tubes can look different. Usually wear stoma tubes after surgery for 2-3 weeks. 12-24 days. Stoma tube goes into stoma and into trachea. Help to collect mucous and gunk that is a consequence of surgery, respiratory system suddenly losing the upper filtering features. Stoma tubes worn right after surgery usually have 2 parts—inner canula and outer canula. Laryngectomy wears inside of the stoma. Does kind of scrape, can irritate the tissue of the trachea. May want to use introducer to put stoma tube in. Gives it more of a blunt tip, keeps the edges from scraping the tissue. Can’t breath while introducer is in, need to hold breath for a second or 2. Has little lock on it typically so when bend over it doesn’t fall out. Periodically during the day will remove the inner canula to clean it. Pull out in restroom, wash off any gunk that is accumulated iln it. Don’t remove outer canula when just briefly cleaning. A couple times a day will remove outer canula, clean them really well. Can boil them, use hydrogen peroxide. Need cleaned at leastonce or twice a day, wear for 2 to 3 weeks. Often may not know they are supposed to clean them, how to clean them. Often he will ask them if they are cleaning them and they are often like I don’t know. Can usually tell because starts to smell. He has them remove it, shows them how to clean it. Can use bottle brush for stoma tubes basically to help as well. Stoma tube helps to hold stoma open so it doesn’t stenose. Airway often reacts by narrowing, body tries to heal itself, close up stoma. Some tend to stenose on some note for the rest of their life. Few will have to wear something in their stoma forever. One thing Dr. Watterson will watch for, if he sees stoma is starting to get more closed he sends to ENT. Is possible to do a stoma revision. Those who need long term tubes don’t use the same ones as post off. A more long term tube is usually a stoma button instead. Major suppliers sell stoma buttons of different kinds. Can get hard acrylic, different types. Want it to be tight enough in stoma that holds itself in. A lot of patients like softer ones better, curl up and then stick in stoma. Has little cuff that helps retain it so won’t fall out when bend over. Might wear stoma button forever, maybe for a certain amount of mohts, ex: 3, 6. If laryngectomee 5 weeks out from surgery, may say I measured his stoma each time, decreased in diameter by 4 milimeters. Usually ENT will say “let’s put in stoma button”. He will order stoma button. Has ruler for stomas, will usually move it along until finds one that fits like stoma. Stomas are sized like shoes. Ex : “size 14”. Doesn’t really mean anything, can’t just measure. Use either until stenosing stops or ENT does procedure to reenlarge the stoma.
B. Showers
stoma guard. Can order from various websites. Has hole in bottom for breathing. Covers stoma and breathe from hole in bottom, water just runs off. Most prefer this kind, there are other kinds.
C. Stoma covers
laryngectomees should wear to cover them almost all the time. There are directions for knitting ones in one of the books. Can get different ones to match with different outfits. Can wear this for covid. Takes awhile to remember when sneeze, comes out of stoma. Never want to sit directly across from laryngectomee in case this happens and they forever. More off to the side.
D. HME
heat moisture exchanger. Put over stoma, helps to medicate the airway. HME and stoma covers help to filter the air breathed through trachea (functions of upper airway). Peel off backing plate, put on around the stoma. Cost about a dollar a day to wear. Showering is good in terms of humidity.
G. Cleaning area around stoma
G. Cleaning area around stoma necessary. Can use washcloth, can use oil if get chafing. Get any dried mucous. Tweezers are handy to get dried mucous away from stoma. Sometimes may need to reach into stoma to get dried mucous. He recommends tying fishing line to tweezers to if drop it can pull the tweezers back out. As SLP can remove if in way, it will eventually come out (assuming they know how to clean). Need to keep clean lifelong. Generally will see the surgeon maybe a couple times after surgery, then tell them they don’t need to come back unless there is a problem. Oncologist typically continues to monitor for cancer.
- Describe the five stages associated with grief/loss relative to laryngectomy.
Denial—may not believe diagnosis and need for surgery, make seek second opinions, doctor shop for someone who will tell them something different
Anger—often angry at themselves, especially if they are a smoker. May be angry at others who smoked around them. Often misdirected toward others.
Bargaining—with deity, superficial being, promising to be better.
Depression—pretty common. Impact on speaking can make therapy difficult initially.
Acceptance
- Generally discuss the early history of laryngectomy.
Was first conducted on a dog in 1829. Did not survive very long. The first time with a human was in 1866. Initially had not very great odds (39% death rate). Became accepted procedure in 1925.
- List three ways of increasing the humidity of air inhaled for laryngectomees.
• HME, stoma cover, humidifier
- Why does hearing loss affect the communication ability of both laryngectomees and their spouses?
• When initial doing rehab and learning a new form of speech, the initial results may be low in intensity. If they can’t hear the progress they’re making, that can be discouraging. Also, if their significant other, who is the person they are closest to, can not hear their speech, they will have little incentive for therapy and the communication will be broken down anyway
- How is eating/swallowing effected by laryngectomy?
• Initially voice is totally gone, have to learn new form of speech. Swallowing can potentially be impacted, could result in dysphagia. Commonly need to eat smaller bites and usually takes longer to eat.
- What causes cancer?
Inheritance (laryngeal cancer no strong link), viruses (ex: HPV16), chemicals, radiation
- List the risk factors for laryngeal cancer.
Tobacco, alcohol and nutrition (these 3 are “nested factors”:people who smoke also tend to drink, have poorer nutrition). GERD/LPR, papilloma virus, weakened immune system
- List the general symptoms of laryngeal cancer.
Persistent cough, persistent hoarseness, prolonged sore throat/ear pain, dysphagia, dyspnea/stridor, unexplained weight loss, lump in throat/neck
- What is surgically removed in a typical total laryngectomy?
All of the larynx above the 3rd Tracheal ring. Arytenoids, thyroid, cricoid and two tracheal rings, true and false VF, epiglottis, hyoid, all intrinsic muscles of larynx except cricopharyngeus. May have neck dissection. Most of thyroid gland left if possible, just remove the middle.
- In general, how is laryngeal cancer treated?
Mostly through radiation therapy, surgery, or chemotherapy.
Radiation therapy—usually lasts 5-8 weeks, receiving 50-80 Gy total. Limit is usually 80Gy.
Stage 0/Stage 1: 1. Radiation therapy preferred first. 2. Cordecomy (don’t see often, usually radiation enough) 3. Subtotal laryngectomy Stage 2: 1. Radiation therapy 2. Subtotal or total laryngectomy 3. Chemotherapy to prevent metastasis (not used often) Stage 3 or 4: 1. Total laryngectomy then radiation 2. Radiation therapy with surgery salvage 3. Chemotherapy combined with radiation 4. Chemotherapy to prevent metastasis
- How would a Stage 1 laryngeal cancer usually be treated?
Stage 0/Stage 1:
- Radiation therapy preferred first.
- Cordecomy (don’t see often, usually radiation enough)
- Subtotal laryngectomy
- What is a hemilaryngectomy? supraglottal laryngectomy?
hemilaryngectomy–Remove ½ of thyroid lamina, sometimes part of cricoid. True and false VF. Vocal process of arytenoid or entire arytenoid. Epiglottis remains.
supraglottal–Portions of the larynx above the glottis are removed
- What advice would you give a laryngectomee about wearing a stoma cover/HME?
• It should be done—when we breathe in the typical way, we actually have a prebuilt filter in our system. We have mucous and little hairs and boogers that all trap things and prevent them from going into our lungs. With your stoma, you no longer have that filter built into your body. So, it is important to wear these items to replace that job and filter the air for you.
- What is a “near-total” laryngectomy?
A form of laryngectomee where a vocal fold is left behind, and a makeshift ____ is fashioned for this vocal fold to theoretically vibrate against.
