Slides Flashcards
What are some important points to discuss in preoperative and postoperative laryngtectomy counseling?
a. Preoperative and Postoperative Orientation
i. Medical concerns
ii. Tell me what you know about surgery (surgeon/nurse/friend)
iii. Fear of death
iv. High cure rate
v. Describe surgery.
vi. Pre-op visit by laryngectomee?
b. Communication
i. No post op voice
ii. Provide info on different forms of Alaryngeal speech
iii. How does Rx take?
iv. How much does it cost?
v. Hearing evaluation
vi. Should you practice pre-surgically?
c. General orientation
i. Return to employment.
ii. Activities: swimming, fishing
iii. Taste and smell
iv. Eating/swallowing
d. General care
i. Cleaning stoma tube
ii. Cleaning stoma
iii. Stoma covers
iv. Humidity
v. Shaving
vi. Sleeping
Describe the five stages associated with grief/loss relative to laryngectomy.
a. Denial
i. When the patient doesn’t accept a diagnosis
ii. Going center to center to get retested.
b. Anger
i. Initially they make appear angry at you.
c. Bargaining
i. With a deity or themselves
d. Depression
i. Early psychotherapy is usually not a good option because of the inability to talk after surgery.
e. Acceptance
i. They have accepted their diagnosis
Generally discuss the early history of laryngectomy.
1829: Albers removed a larynx from a dog.
1866: Patrick Watson removed a larynx from a human.
1873: Billroth removed human larynx to treat cancer.
By 1887, 103 laryngectomys had been performed: 39% died from the immediate effects of the operation, 20% died of recurrence.
1892: George Crile performed the first laryngectomy in the US.
1925: laryngectomy becomes accepted procedure.
List three ways of increasing the humidity of air inhaled for laryngectomees.
a. HME
b. Sleeping with a humidifier
c. Living in a more humid place
d. Taking a shower
Why does hearing loss affect the communication ability of both laryngectomees and their spouses?
All Alaryngeal speech is at a low level so it is hard for them to hear themselves speak as well as other people have difficulty hearing them
How is eating/swallowing effected by laryngectomy?
- Many patients complain of loss and smell
* Sometimes it comes back and sometimes it does not - Radiation may impact swallowing
- Decrease taste
- Decrease overall enjoyment of eating
- Increase in the length of time required to eat meals
What causes cancer?
a. Cancer occurs when
i. There is damage to a cell’s suicide program
ii. Cells do not receive or recognize suicide signals
iii. There are defective genes for identifying DNA defects
iv. Defective genes override suicide
b. Inheritance
c. Virus
d. Chemicals
e. Radiation
List the risk factors for laryngeal cancer.
a. Tobacco
b. Alcohol
c. Poor Nutrition
d. GERD/LPR
e. Papilloma virus
f. Weakened Immune System
TAPGPW
List the general symptoms of laryngeal cancer.
a. Persistent cough
b. Persistent hoarseness
c. Prolonged sore throat/ear pain
d. Dysphagia
e. Dyspnea/stridor
f. Unexplained weight loss
g. Lump in throat/neck
PPPDDUL
What is surgically removed in a typical total laryngectomy? CATTHINE
a. Cricoid and @ two tracheal rings (Where the larynx is attached to the trachea)
b. Arytenoids
c. Thyroid
d. True and false vocal cords
e. Hyoid
f. Intrinsic muscles of the larynx except cricopharyngeus
i. Cricopharyngeus
1. Surgeons usually try to save some of that muscles because that is where the prothesis will vibrate.
g. Neck dissection (maybe)
1. If there is evidence that the cancer has left the larynx and entered the lymph system. Leaves that side of the next really leather like and tough
h. Epiglottis
In general, how is laryngeal cancer treated?
a. Radiation Therapy
b. Surgery
c. Chemotherapy
Describe the anatomy of the esophagus.
a. Posterior to trachea
b. Extends from C5-6 to T11
c. @ ½ inch diameter at pharynx
d. @ 1 inch diameter at stomach
e. Made up of two type of fibers
* Outer longitudinal fibers
* Inner circular fibers
How is the PE segment innervated in normals? In laryngectomees?
a. The area of the PE segment is innervated by one branch of the Superial Laryngaeal Nerve but most of it is innervated by the Recurrent Laryngeal Nerve
b. During a laryngectomee a portion of the superior laryngeal nerve is cut
c. The RLN does not get cut
d. Innervation to the PE segment is retained
* If it wasn’t the UES and LES would be hypertonic (floppy)
How would a Stage 1 laryngeal cancer usually be treated?
- Radiation Therapy
- Cordectomy
- Subtotal/Total laryngectomy
What is a supraglottal laryngectomy? hemilaryngectomy?
a. Supraglottic laryngectomy
* Thyroid cartilage above ventricle
* Epiglottis
* Aryepiglottic fold
* Usually the hyoid bone
b. the surgeon removes part of the thyroid cartilage, including the underlying vocal cord or cords. This type is not done very often anymore as radiation is usually the first step of treatment for tumors on the vocal folds.
Generally, what activities are precluded by laryngectomy and why?
- Water activites
- Because the stoma is a straight shot to the lungs
Discuss some important points with regard to management of a tracheostomy tube.
- Cleaning stoma tube
- Cleaning stoma
- Stoma covers
- Sometimes the stoma will continuously try to heal so a stoma button is installed
- Humidity
- The air doesn’t get filter through a stoma so particles will just flow through
- HME will filter and moisten the air.
What advice would you give a laryngectomee about wearing a stoma cover/HME?
- Sometimes the stoma will continuously try to heal so a stoma button is installed
Humidity
* The air doesn’t get filter through a stoma so particles will just flow through
* HME will filter and moisten the air.
Describe the functions of the esophageal and cardiac sphincters.
d. Continuous with Pharynx at the Pharyngoesophageal (PE) segment
i. The junction of the pharynx and the esophagus is continuous
e. Upper Esophageal Sphincter (UES): Upper one inch of the esophagus
i. to prevent air from entering into the esophagus during breathing
ii. to prevent reflux of esophageal contents into the pharynx to guard airway aspiration
f. Thoracic Segment: Middle eight inches
g. Lower Esophageal Sphincter (LES) aka Cardiac Sphincter: Lower one inch
i. prevents the reflux of gastric contents back into the esophagus
Is quality of life is better for patients treated with chemo-radiation versus surgery.
No, QOL is similiar
Does the type of alaryngeal communication effect QOL?
Not according to most of the articles we discussed
What is a Pearson “near-total” laryngectomy?
- Tried to save one piece of the arytenoid so that it would move during phonation
- Sometimes it worked and sometimes it did
- Revisions were common because of no vibration
- Still have a stoma
What are the major advantages/disadvantages of conservation surgery?
Advantages
* Retain natural airway
* Because the larynx is essentially still there.
* May have a better voice than alaryngeal speaker
* Not necessarily
* Reduced impact on QOL
Disadvantages
* Lower cure rate, especially when lymph nodes are involved
* Because the surgeon is removing tissue based on what they can see – cancer cells cannot be seen so some cells may be left behind.
* Sampling of tissue on the margin of the tissue removed is done to check for cancerous cells and to see if more tissue needs to be removed
* Surgery for cancer has to remove all cancer cells to be successful.
* Dysphagia
* Lose protection mechanism for the airway.
How is speech intelligibility related to quality of life after surgery for head/neck cancer?
Lower sentence intelligibility and word intelligibility scores were associated with diminished self-perceived QOL
