Clinical Practice Guidelines for diagnosis, treatment and follow-up. Guidelines by the European Head & Neck Society, European Society for Medical Oncology, and the European Society for Radiology and Oncology.

This EHNS-ESMO-ESTRO Clinical Practice Guideline provides key recommendations for managing Squamous cell carcinoma of the oral cavity, larynx, oropharynx and hypopharynx (SCCHN).

 

• It covers clinical and pathological diagnosis, staging and risk assessment, treatment and follow-up.
• Opportunities for personalized medicine in SCCHN are also discussed.
• All recommendations were compiled by a multidisciplinary group of experts from different institutions and countries.
• Recommendations are based on available clinical evidence and the collective expert opinion of the authors.

Click to read the original recommendations.

Increased risk of serious illnesses including advanced stage cancer due to COVID -19 pandemic

 

The prolonged COVID-19 world wide pandemic led to an increase in medical problems due to other etiologies. Medical providers are facing growing number of patients with previously undiagnosed late stage cancers, and recurrence of a previously diagnosed malignancies.  This led to an increase in the number of radical surgeries including laryngectomies and increase in the death rate among patients with many types of cancer.    

This is likely due to several factors that include the reluctance of individuals to seek medical care because of fear of contracting COVID-19 at medical facilities; the closure or reduction of clinical services, the suspension of cancer screening, the deferral of routine diagnostic work, the requirement to obtain COVID-19 testing prior to some medical procedures, and the utilization of telemedine without physical examination instead of an actual office visit.

It is therefore important that individuals do not defer their medical, dental, and mental care during the COVID-19 pandemic. It is especially important that those who were previously diagnosed with an ailment including cancer continue their treatment and follow up. Those who experience new or unusual signs and symptoms that may indicate an aggravation of their condition or a new ailment should seek medical care without delay. Postponing care or ignoring symptoms may lead to complications and deterioration making future care more difficult and may lead to increase morbity and mortality.

Oral Intubation Attempts in Patients with a Laryngectomy: A Significant Safety Threat.

Brenner and colleagues presented national data from the American Academy of Otolaryngology–Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom’s National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. The data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.

Click to read the study. 

COVID 19 infection in laryngectomees reported in Italy and Scotland

 

Three studies from Italy and Scotland reported seven laryngectomees who  developed COVID -19 infection. Two acquired the infection while in the hospital after undergoing laryngectomy. The infection was serious in three of them and they required intubation and intensive care admission. All the patients survived.

The authors concluded that individuals who have undergone laryngectomy for head and neck squamous cell carcinoma are high risk for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and may be at risk for worse outcomes of COVID-19 due to anatomical changes in their airways.

What are marijuana's effects on lung health?

The American Lung Association is concerned about the health impacts of marijuana use, especially on lung health, and caution the public against smoking marijuana because of the risks it poses to the lungs. Like tobacco smoke, marijuana smoke is an irritant to the throat and lungs and can cause a heavy cough during use. It also contains levels of volatile chemicals and tar that are similar to tobacco smoke, raising concerns about risk for cancer and lung disease. 

Marijuana smoking is associated with large airway inflammation, increased airway resistance, and lung hyperinflation, and those who smoke marijuana regularly report more symptoms of chronic bronchitis than those who do not smoke. Smoking marijuana may also reduce the respiratory system’s immune response, increasing the likelihood of the person acquiring respiratory infections, including pneumonia.

Whether smoking marijuana causes lung cancer, as cigarette smoking does, remains an open question. Marijuana smoke contains carcinogenic combustion products, including about 50% more benzoprene and 75% more benzanthracene (and more phenols, vinyl chlorides, nitrosamines, reactive oxygen species) than cigarette smoke. Because of how it is typically smoked (deeper inhale, held for longer), marijuana smoking leads to four times the deposition of tar compared to cigarette smoking.  However, well-designed population studies have failed to find an increased risk of lung cancer associated with marijuana use.

 

Smoking marijuana 

Impact of active smoking on outcomes in HPV+ oropharyngeal cancer

Researchers from Harvard Medical School, and Cleveland Clinic studied the impact of active smoking on survival in human papillomavirus - positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) patients from 2001 to 2015.

Among the 484 evaluated patients, 94 (20%) were active smokers, 226 (47%) were former smokers, and 164 (34%) never smoked. Among active smokers, 82 patients (87%) had a ≥10 packs/year and 69 (73%) had a ≥20 pack/year smoking history. Active smoking was a significant predictor of inferior survival and progression-free survival, and ≥20 pack/yeas predicted a decreased effect-size for inferior survival and progression-free survival.

The investigators concluded that active smoking at diagnosis is the most powerful predictor of survival and progression-free survival in patients with HPV(+) OPSC .

The study was published in Head Neck in February 2020.

The Effect of Laryngectomy on Couples' Sexual Functions in Men with Larynx Cancer

Dr Gür and colleagues from the Department of Otorhinolaryngology, Mersin University School of Medicine in Turkey investigated the effect of total or partial laryngectomies with or without adjuvant treatments on couples' sexual functions. 

The study included 39 male patients with laryngeal cancer and their female partners who were sexually active. Twenty-six patients underwent total laryngectomy, and 13 had partial laryngectomy.

The authors found that laryngectomies have negative impact on male erectile and ejaculatory functions, and also have negative effect on female partners' sexual functions. Presence of pre-operative erectile dysfunction and additional chemo-radiation therapy were the predictors to decrease in erectile and ejaculatory functions after surgery. The authors recommend that male patients and their female partners should be counselled about these issues before and after undergoing laryngeal surgery and adjuvant therapy. Those who experience sexual difficulties may be able to benefit from medical and psychological interventions.

Click to read about the impact of laryngectomee on sexuality and intimacy.

Recommendations for head and neck surgical oncology practice during the COVID-19 pandemic

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice.

An international consensus group published their recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic.

The COVID-19 pandemic created a significant  risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists.

A review summarizing some of the more readily available clinical protocols that can protect head and neck specialists caring for patients in an environment of a COVID-19 mediated COVID-19 pandemic was published by Kowalskiet al.   The authors recommend that for any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly It is recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. 

Dr. Brook's interview about becoming a laryngectomee, and coping with COVID-19

Dr. Itzhak Brook is a physician and laryngectomee.

In the interview made for the International Association of Laryngectomees 69th Annual Meeting - Voice Institute 60th meeting on June 13, 2020, he describes how he dealt with throat cancer, and became a laryngectomee. He also discusses how laryngectomees can protect themselves from COVID-19 virus and deal with the challenges of caring for their airways during this period.

Publication of the "Laryngectomee Guide for COVID-19 Pandemic" in English, Spanish, Portuguese, Italian, Romanian, Bosnian, Turkish, and Japanese.

The "Laryngectomee Guide for COVID-19 pandemic” is available in English, Spanish, Portuguese,  Italian, Romanian, Bosnian, Turkish, Malaysian, and Japanese.

The corona (COVID-19) pandemic presents many medical, social and psychological challenges for laryngectomees and their medical providers. The Laryngectomee Guide for COVID -19 provides information for laryngectomee and neck breathers how to cope with the COVID -19 pandemic. It contains information how to prevent the infection and deal with depression, social isolation, fibrosis, lymphedema, mucous problems, and voice prosthesis leak. It provides suggestions how to deal with esophageal dilation, hospitalization, and keep fit and eat well.

The Guide in English is available as eBook (free) at  https://bit.ly/3hZHynb , and paperback at: https://amzn.to/3i5XncR   through Amazon.com and https://bit.ly/3glrlJf through Lulu publishing. 

The Guide in Spanish is available as eBook (free) at https://bit.ly/3bFgPeb and paperback at https://bit.ly/32djqIW  

The Guide in Portuguese is available as eBook (free) at https://bit.ly/3eFcYPN and paperback at https://bit.ly/3pklpVJ  

The Guide is available from Associação Portuguesa de Terapeutas da Fala (APTF) (Portuguese Speech Therapists Association), SPORL- CCP, and Library of the Otorhinolaryngology Foundation.

The Guide in Italian is available as eBook (free) at https://bit.ly/2RfdrgE and paperback at 

 https://bit.ly/2DSWq92

The Guide in Romanian is available as eBook (free) at https://bit.ly/3nfGSgO and paperback at https://bit.ly/3a7kWAS   

The Guide in Bosnian is available as eBook (free) at https://bit.ly/2TzfKfG and paperback at https://bit.ly/3p2Mf4e  and  https://publish.sweek.com/books/244071/    

The Guide in Turkish is available as eBook (free) at https://bit.ly/2RHYIeg and paperback at 

 https://bit.ly/3cmgu0k

The Guide in Malaysian is included in The Laryngectomee Guide Malaysian Edition.  It is available as Paperback http://bit.ly/3n4fK3m  , eBook http://bit.ly/2X29Rcu 

The Guide in Japanese is available as eBook (free) https://bit.ly/3j94Don  , and paperback at: https://bit.ly/3jd85yf    

The eBook is also available from the Japanese Laryngectomee Association.

Guide in English

Guide in Spanish

Guide in Portuguese 

Guide in Italian 

Guide in Turkish

 

Guide in Romanian 

Guide in Bosnian

Guide in Japanese

The Head and Neck Alliance offers links for Laryngectomee Guide and Laryngectomee Guide for COVID-19 pandemic.

Click this link to obtain The Laryngectomee Guide in 20 languages/dialects: English, French, Russian, Italian, Chinese (traditional and simplified), Korean, Indonesian,Turkish, Arabic, Bulgarian, Romanian, Portuguese, Persian (Farsi), Tagalog, Bosnian, and Spanish (Central American, Andine, Spain, and South American version) and Laryngectomee Guide for COVID-19 Pandemic.

All eBooks are Free.

Guidelines for head and neck care during COVID-19 pandemic

A special article just published by DrGivi and colleagues in JAMA Otolaryngology-Head & Neck Surgery, guidelines are presented for head and neck physical examination and surgical and non-surgical procedures during the coronavirus (COVID-19) pandemic.

Because head and neck examinations are considered high risk in patients with suspected or confirmed COVID-19, the authors developed recommendations for health care workers based on review of the literature and communication with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic.

The authors note that:

• Non urgent appointments should be postponed to limit infection of patients or health care workers. This may include postponing appointments for patients with benign disease and for those undergoing routine surveillance after treatment for head and neck cancer.
• Patients should be queried by telephone about new or concerning signs or symptoms that may indicate recurrence and/or pending issues, as well as symptoms suggestive of COVID-19.
• In-person clinic visits should be offered to those at risk for significant negative outcomes without evaluation.
• To maintain relationships with patients and support assessments that can be made without in-person examinations, the use of telephone, video, or telemedicine visits should be considered.
• In-person examinations should be limited to patients who need a thorough head and neck examination. Detailed guidelines are provided for physical examinations and associated procedures.

The authors are hopeful that following carefully planned routines and procedures, it will be possible to provide excellent care and help protect the safety and health of health providers and patients.

A model created by the National Cancer Institute predicts that tens of thousands of excess cancer deaths will occur over the next decade as a result of missed screening, delays in diagnosis, and reductions in oncology treatment caused by the COVID-19 pandemic. It is important that patients continue to be screened and treated.

To read the Guidelines click this link. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2764032

Endoscopic examination by an otolaryngologist

Mental health issues in head and neck cancer patients caused by the COVID – 19 pandemic

The current COVID-19 outbreak is spurring depression, fear, anxiety, and stress on a societal level. On an individual level, it may exacerbate anxiety and psychosis-like symptoms as well as lead to non-specific mental issues (e.g., mood problems, sleep issues, phobia-like behaviors, panic-like symptoms). Head and neck cancer patients (HNCP) (including laryngectomees) are more vulnerable to these psychological issues as well the viral infection. Laryngectomees may experience increased social isolation and loneliness.

Contributing to these are the difficulties in get medical and diagnostic care, prescription drugs, and medical supplies; and the economic situation.

HNCP with mental health issues such as OCD, PTSD, anxiety and depressive disorders, and paranoia may experience exacerbation of their symptoms.

HNCP can be proactive and alleviate some of their psychological vulnerability by:

• Reaching out and seeking support from mental health professionals (i.e., psychiatrists, psychologists, social workers)
• Getting medical and other supplies delivered to one’s residence  
• Engaging in healthy distractions such as reading, watching movies, taking walks, exercising, and learning a new skill
• Developing a routine
• Obtaining information from reliable sources
• Curbing media exposure to certain times in the day
• Being aware of what is anxiety and what is reality in one’s thoughts and conversations
• Following guidelines (i.e., using prescribed hand-washing methods, avoiding touching the face, avoiding hugging and shaking hands, staying at home and contacting one’s medical provider when experiencing medical problems)
• Connecting with family and friends through the internet, social media, video calls and phone

Following these guidelines can assist HNCP navigate through the corona virus pandemic.
To obtain more suggestions for laryngectomees how to cope with COVID-19 pandemic click the Laryngectomee Newsletter link.

Investigational Drugs and Biologics for Corona virus (COVID-19)

As of now, no drugs or biologics have been proven to be effective for the prevention or treatment of COVID-19. There are many investigational drugs and biologics under investigation for COVID-19. Hopefully some of them will be available for use in the near future. Some may be used in severe cases even before they are approved by the FDA.

Antiviral Agents:

• Remdesivir
• Lopinavir/ritonavir
• Rintatolimod
• Toll-like receptor 3 (TLR-3) agonist rintatolimod (Poly I:Poly C12U)
• Ampligen; AIM ImmunoTech)
• Azvudine (nucleoside reverse transcriptase inhibitor)
• Danoprevir (NS3/4A HCV protease inhibitor)
• Favipiravir (viral RNA polymerase inhibitor)

Immunomodulators and Other Investigational Therapies:

• Ifenprodil (NP-120; Algernon Pharmaceuticals) Brilacidin
• Remestemcel-L (Mesoblast Ltd) Eli Lilly and AbCellera are co-developing an antibody treatment .
• Anti-SARS-CoV-2 polyclonal hyperimmune globulin (TAK-888; Takeda) is being developed to treat COVID-19 in high-risk patients.
• Interleukin-6 inhibitors
• Anti-malaria drugs: Hydroxychloroquine and chloroquine

Vaccines

• INO-4800 (Inovio Pharmaceuticals):
• mRNA-1273 (Moderna Inc
• CureVac has an mRNA vaccine in development that is not yet ready for human testing.
• COVID-19 S-Trimer (GlaxoSmithKline and Clover Biopharmaceuticals)
• SARS-CoV-2 vaccine (Johnson & Johnson
• Sanofi is also collaborating with BARDA to develop a vaccine using their recombinant DNA platform.
• Several other vaccines are developed: by Novavax, Codagenix, Applied DNA Sciences and Takis Biotech, and  Altimmune, Inc.

To obtain more suggestions for laryngectomees how to cope with COVID-19 pandemic click the Laryngectomee Newsletter link.

 Corona virus (COVID-19)

Publication of the 4th edition of "The Laryngectomee Guide Expanded Edition”

The 4th edition of "The Laryngectomee Guide Expanded Edition” is available.

The 304 pages Expanded Guide is an updated and revised edition of the original Laryngectomee Guide. It contains twice more information on all topics, and also describes newer devices and products available for laryngectomees. The Guide provides practical information that can assist laryngectomees and their caregivers with medical, dental and psychological issues. It contains information about side effects of radiation and chemotherapy; methods of speaking; airway, stoma, and voice prosthesis care; eating and swallowing; medical, dental and psychological concerns; respiration; anesthesia; and travelling.

The Guide is available in paperback, and Kindle edition.
To download (free) the Guide click here.

Coronavirus outbreak and how laryngectomee and neck breathers can prevent getting the infection:

Watch the video "How laryngectomees can cope with the COVID-19 pandemic"

There has been a deadly outbreak of a novel strain of coronavirus in China causing severe respiratory illness and death. The virus has been spreading arround the world causing pandemic. The causative virus has been identified and its genome sequenced, which will allow confirmation of cases and development of a vaccine, though most likely not for about a year. As of today the CDC has recommended travelers avoid all nonessential travel to areas where the virus is prevalent. The virus is most likely spread by droplets. Those traveling to high risk areas should practice certain health precautions like avoiding contact with people with respiratory disease symptoms and careful hand-washing. Wearing a surgical mask is helpful, but it's more effective when worn by those with the disease. 

Human coronaviruses most commonly transmit from an infected person to others via: 

• The air by coughing and sneezing and rarely, fecal contamination
• Close personal contact, such as touching or shaking hands
• Touching an object or surface with the virus on it, then touching the mouth, nose, eyes or stoma (in neck breathers) before washing hands

   Coronaviruses are usually transmitted from animals, particularly bats, camels, and even snakes to humans. The first 4 cases were all workers in the Huanan Seafood Wholesale Market, which sells live poultry, aquatic animals, bats, and snakes to the public. Unfortunately, the virus has mutated to cause human to human transmission. 

Symptoms can range from those of a mild cold to severe respiratory distress and death. The first signs and symptoms are a fever, cough, and initially mild respiratory distress that often worsens due to development of pulmonary edema ("water on the lungs"). All deaths to date have been in Wuhan City. The incubation latent periods are not certain. 

The virus is likely to spread throughout the world because of international travel and precautions may be needed to implemented everywhere. Head and neck cancer may be more vulnerable to respiratory infections and should exercise caution to prevent getting infected.

As the epidemic of corona virus is spreading throughout the world it is important for laryngectomees to protect themselves. Most laryngectomees experience less “colds” than non laryngectmees. This is believed to be because respiratory viruses generally first infect the nose and move to other body sites (including the lungs). Because laryngectomees do not inhale through their noses this mode of getting infected does not exist.

However, respiratory viruses can also access the body through the mouth, and conjunctiva. In laryngectomees the virus can access the lungs directly through the stoma. Although the exact mode of infection transmission of Corona virus is yet unknown, it is prudent to assume that it would behave in a similar fashion. 

It is not yet known if laryngectomees are more susceptible to COVID -19. It is therefore prudent to be extra careful. There are several risk factors that places laryngectomees in increased risk to get infected.

Once laryngectomees get infected they may be more likely to develop a serious pneumonia because their airway are compromised.  Many have chronically dry  and irritated trachea and bronchi, and they often have reduced lung capacity and lower lobes athelectasis.

This is why it is wise that laryngectomees are careful and follow the Health Departments direction.

laryngectomees and neck breathers can protect themselves by:

• Wearing HME 24/7 especially when being around other people. HME with greater filtering ability would work better in reducing the risk of inhaling the virus ( i.e., Provox Micron TM, Atos Medical's XtraMoist). Provox Micron, has an electrostatic filter and 99.9% filtration rate and it’s cover prevents direct finger contact of the stoma. Wearing it protects other individuals from becoming  infected when the laryngectomee is infected.  A Provox HME Cassette Adaptor enables the use of a Provox HME Cassette to any tracheostomy tube with a 15 mm ISO connector. Those with tracheostomy can protect themselves by using ProTrach XtraCare HME.
• Wearing hands free tracheostoma valve because it does not require touching when speaking)
• Those who use a regular HME should wash their hands before touching their HME.
• Wearing a face mask ( preferable N95 respirator) over the stoma. A facemask with four strings can be modified to fit over the stoma. One of the strings can be extended with extra string; and the lower pair of strings can be tied behind the back. (see pictures)
• Wearing face mask or respirator over the nose and mouth, and protective glasses. (see picture below) This can prevent the virus from entering the body through these sites or spread to other people when infected. Men should shave their facial hair prior to wearing facemask or respirator. 
• Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available.
• Avoid touching your stoma, eyes, nose, and mouth with unwashed hands.
• Avoid close contact with people who are sick.
• Staying at least 6 feet from other who don't live with you.
• Clean and disinfect frequently touched objects and surfaces.

To prevent the spread to others stay home when you are sick, and cover your cough or sneeze with a tissue, then throw the tissue in the trash. 

If worn properly, a face mask can help block large-particle droplets, splashes, sprays or splatter that may contain germs (viruses and bacteria). Face masks may also help reduce exposure of the wearer’s respiratory secretions to others.

While a face mask may be effective in blocking splashes and large-particle droplets, it does not filter or block very small particles in the air that may be transmitted by coughs, and sneezes. Face masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the skin over the stoma.

Some face masks (i.e., N95) offer greater filtering abilities of germs and small dust particles. However, neck breathers and people with chronic respiratory, cardiac, or other medical conditions that make breathing difficult should check with their healthcare provider before using a N95 face mask because it can make it more difficult for the wearer to breathe.

It is prudent that laryngectomees follow the government and local health authorities’ instructions and avoid exposure to the virus by strictly isolating themselves.

To obtain more suggestions for laryngectomees how to cope with COVID-19 pandemic click the Laryngectomee Newsletter link.

Technique to place a facemask over the stoma in a laryngectomee

Wearing a facemask over the nose and mouth and protective glasses

Message from the Japanese Head and Neck Support Society. (in Japanese and English)

Message from the Singapore Cancer Society

Message from Nu Voice ( University of Southern California)  Los Angeles.

Click for further reading about protection of laryngectomees (International Achieves of Otorhinolaryngology)