Laryngeal Cancer Therapy and Management
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| Head and Neck Cancers | head and neck cancers include cancers in the lips, mouth, nose, salivary glands, pharynx, and larynx
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| Epidemiology of HNC | 5th most common cancer in the world (4% of all cancers)
HPV positive HNCs are more amenable to treatment than HPV negative HNC
Alcohol and tobacco increases risk of HNC
Over 90% of HNCs fall under squamous cell carcinoma
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| Signs and Symptoms of Laryngeal Cancer | Hoarseness/change in voice that persists over 2wks
Enlarged lymph nodes/lump in neck
Airway obstruction/diff. breathing/noisy breathing
Persistent sore throat or globus sensation
Diff. swallow
Ear pain, esp. from throat to ear
Bad breath
Choking
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| Squamous Cell Carcinoma (SCCA) | Squamous cells are thin/flat cells on surface of skin in linings of various organs
SCCA is most common cancer of upper aerodigestive tract
SCCA spreads in predictable ways depending on site of origin
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| TNM Classification | Tumor staging - most important prognostic indicator
T: Tumor location, size, extent
N: involvement of regional lymph nodes
M: metastasis (has it spread)
Numbers combined to stage cancer, higher numbers + increased severity
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| T: Tumor Location | T1: small tumor very localized
T4: very large highly invasive tumor
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| N: Involvement of regional lymph nodes | N0: no spread to neck lymph nodes
N3: spread to one or more lymph nodes measuring more than 6cm
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| M: Metastasis | M0: No evidence of distant spread
M1: distant spread
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| Cancer Staging | Radiographic studies (CT, MRI, PET), operative, and pathologic findings are included in tumor classification and staging
Presenting stage is the most important prognostic indicator
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| Stage I | Small tumor (T1), no spread to lymph nodes (N0) and no distant metastasis (M0)
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| Stage II | A tumor with spread to nearby areas (T2), but has not spread to lymph nodes (N0) or to distant parts of the body (M0)
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| Stage III | Any larger tumor (T3), no spread to lymph nodes (N0) or metastasis (M0)
Or a smaller tumor (T1, T2), that has spread to regional lymph nodes (N1) but has no sign of distant spread (M0)
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| Stave IVA | Any invasive tumor (T4a) with wither no lymph node involvement (N0) or spread to only a single lymph node (N1), but no metastasis (M0).
Also used for any tumor with spread to the lymph nodes (N2) but no metastasis (M0)
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| Stage IVB | any cancer (any T) with extensive spread to lymph nodes (N3), but no metastasis (M0)
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| Stage IVC | Indicates there is evidence of distant spread (any T, any N, M1)
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| Team Management of Laryngeal Cancer | H&N Surgeon
Medical Oncologist
Radiation Oncologist
Anesthesiologist
Nurse
Dentist
Dietician
SLP
AUD
OT
PT
Respiratory Therapist
Social Worker
Psychologist/Psychiatrist
Laryngectomee
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| Medical Workup Includes | Physical Exam
Laryngoscopy
Biopsy
Imaging studies (x-ray, CT, MRI, bone scans, PET)
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| Medical Approaches to Management | Radiation therapy
Chemotherapy
Clinical Trials
Surgery
Combination of above approaches
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| Surgical Options | Total Laryngectomy
Partial Laryngectomy (cordectomy, vertical hemilaryngectomy, supraglottic laryngectomy, subtotal laryngectomy)
Composite resection
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| Cordectomy | Surgical procedure where part or all of the VFs are removed. Most often, this is performed when a pt has a small tumor on the glottis or VFs
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| Hemilaryngectomy | An operation to remove part of the larynx, but it is going to include modifiers of which specific parts were removed. Think of drawing a vertical line down the larynx.
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| Supraglottic Laryngectomy | Process to remove the supraglottis (everything above the VFs), sometimes referred to as a horizontal laryngectomy
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| Subtotal Laryngectomy | May meet requirements of adequate tumor resection in those that undergo total laryngectomy. Uninvolved column of innervated larynx thats sacrificed in total laryngectomy can be preserved in a subtotal laryngectomy. Removing everything above cricoid cart.
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| Composite resecton | Removal of part of the lining of the mouth and lower jaw
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| Potential Post-Treatment Complications | Trauma
Loss of upper body strength
Limited mobility: neck/shoulders
Tracheostomy
Aspiration pneumonia
Radiation induced neoplasms of neck
Stoma stenosis
Pain
Breathing diff.
Osteoradionecrosis
Infections
Fistula
Necrosis
Coughing
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| Medical follow-up | Regular follow-up medical and dental examinations to check for signs of recurring cancer, second primary cancer, and to manage any side effects from treatment
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| Medical Outcomes | 1. Survival rate
2. Pts. functional abilities which are greatly impacted by the amount of tumor resected
3. Pts. perception of their QoL
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| Psychosocial consideration | Acceptability
Quality of relationships
Financial stress
Fatigue
Emotional stress
Altered body image
Depression
Job loss
Anxiety
Decreased self-esteem
Substance abuse
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| Alaryngeal speech modes | Artificial larynx: provides vibration when places on pts neck or in the mouth
Esophageal speech: uses the esophagus as a sound source
Tracheoesophageal speech: directs air from trachea to esophagus so that sound is produced
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| Pneumatic Devices | Piece fits over stoma, small unit inside for sound, and tubing that carries sound to mouth. Sound is shaped by articulators
Adv: non-electric sounding, easy to learn, intelligible, inexpensive
Dis: bulky, requiere access to stoma, seal hard to main.
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| Electrolarynx | Uses electric power to drive a vibrator that provides a sound source
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| Electrolarynx (oral type) | Adv: easy to use, small, have loudness and pitch controls, less noisy than neck types, provides adequate loudness for noisy places, can be used right after surgery, good intell.
Dis: electronic sounding, expensive, ongoing cost for batteries, practice
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| Electrolarynx (neck type) | Adv: easy to use for some, small, loud/pitch controls, can provide adequate loud for noisy places, good intell. can be fitted to use intraorally
Dis: electronic sounding, hard for scarring/fibrosis, moderate cost, batteries
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| Esophageal Speech | Sound source in patient's esophagus
UES intact and allows air to be trapped within PE segment
Adv: non-electric sound, no external device
Dis: hard to learn, not loud, gas trapping need good artic skill
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| Techniques for Obtaining Esophageal Air Supply | Injection method
- glottal press
- glossopharyngeal press
inhalation method
Swallowing method
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| Tracheoesophageal Speech (TES) | Made possible by surgical fistula &prosthesis
Pt occludes stoma after inhaling, then exhales, PE vibrates
Ad: non-electric sound, no external device, short learn period, flex. loudness/pitch
Dis: TEP needs to be primary procedure, maintenance of valve
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| Tracheostomy Valves | Used in conjunction with TE voice prosthesis
Valve is at level of stoma
Can be inside the stoma or around it
A: hands-free, air humidifier
D: needs good seal, physical restrictions, remove for coughing, costly humid. replaced daily
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| TES | Best outcomes for fundamental frequency, max phonation, and intensity
Perceptually, TES was reported to be the most pleasant and comprehensible to listeners
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