Dysautonomia in oral and head and neck cancer patients

Dysautonomia is an umbrella term referring to a group of several medical conditions that cause a malfunction of the Autonomic Nervous System (ANS). This is the part of the nervous system that controls automatic processes or the things that one’s body does without having to think about them, such as heart rate, blood pressure, digestion, dilation, and constriction of the pupils of the eye, kidney function, and temperature control. Dysautonomia can be acute and reversible or non-reversable, chronic and progressive.

Dysautonomias in adults often are associated with, and may be secondary to, another disease process or a drug.  Common secondary causes include medications, chemotherapy, radiation treatments, spinal cord or head injury, or diabetes . 

Oral, head and neck cancer patients that receive radiation as part of their treatments, can have varying degrees of scatter radiation to these structures, and years after treatment develop some of the manifestations of dysautonomia. When the ANS doesn’t work as it should, it can cause heart and blood pressure problems, trouble breathing, and loss of bladder control among other symptoms.

People living with various forms of dysautonomia have trouble regulating some of the ANS systems, which can result in lightheadedness, fainting, unstable blood pressure, abnormal heart rates, and malnutrition.

● Balance Problems

● Fatigue

● Nausea, Vomiting, GI Trouble

● Irregular Heart Rate and Blood Pressure

● Fainting/ Loss of Consciousness

● Lightheadedness, Dizziness, Vertigo

● Brain Fog/ Forgetfulness

● Exercise intolerance

Patients with autonomic disorders usually require a multi-disciplinary team, as autonomic disorders can impact almost every organ and system of the body. While each specialist will have his or her own areas of expertise, it is still important for each member of the patient’s team to be familiar with the most up-to-date information on the patient’s autonomic disorder.

There is no cure for dysautonomia. Secondary forms of dysautonomia may improve with treatment of the underlying disease. The best that can be done is to deal with the various manifestations of it and their individual symptoms. Treating symptomology is not the same as treating the disease and is a coping mechanism not a cure. Lifestyle changes will be necessary for many of the symptoms to be reduced or mitigated.

Read more about dysautonomia at https://thedysautonomiaproject.org/dysautonomia/

Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

 

Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that Head Neck require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown.

 Cortina et al from the Massachusetts Eye and Ear, Boston, studied the risk factors to requiring dilations after TL/TLP.  49 patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022 were evauated.  Thirty-five (71%) patients underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group.

The authors concluded that shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

Endoscopic dilation balloon

Quality of Life, Dysphagia, Voice Problems, Depression, and Anxiety after Laryngectomy

 

Wulff and colleagues from Zealand University Hospital, Køge, Denmark.; determine health-related quality of life (HRQoL), including voice problems, dysphagia, depression, and anxiety after total laryngectomy, and investigate the associations between HRQoL and the late effects.

The 172 participants scored worse than normative reference populations on all scales/itemss, except one, and almost half of the scales/items showed a clinically relevant difference. Moderate/severe dysphagia was present in 46%, moderate/severe voice problems in 57%, depression in 16%, and anxiety in 20%. Younger age, increasing numbers of comorbidities, increasing voice problems, increasing dysphagia, and increasing depression symptoms, were associated with a lowered EORTC QLQ-C30 summary score.

The study illustrated that a substantial proportion of participants experienced clinically significant late effects and increasing levels of these were associated with a lowered HRQoL.

Loneliness and quality of life in head and neck cancer patients

 

Patients with head and neck cancer (HNC) are at risk of loneliness because of the effects of the disease and its treatment on important social interactive functions such as appearance, speech, facial expression, and eating. Dahill and colleagues from Aintree University Hospital, Liverpool, UK, evaluated the association between loneliness and the quality of life, mental illness, physical health, and premature mortality.

The investigators survived 140 patients treated for primary squamous cell HNC between 2015 and 2016. Tumor sites were oropharyngeal (42%), oral (35%), laryngeal (14%), and elsewhere (9%).

In response to the question "How often do you feel lonely?" three-quarters said "hardly ever" and only 6% "often". Similar responses were obtained for the other three indicator questions. It is encouraging that a relatively small proportion had serious issues with loneliness. Similarly, one-quarter had feelings of loneliness and a minority had serious problems. Patients who were younger, who lived in more deprived circumstances, who had advanced disease and had been treated with chemotherapy or radiotherapy reported greater levels of loneliness.

The study showed that loneliness was associated with a worse overall quality of life, and worse physical and social-emotional function. Dahill and colleagues recommended that lonely patients need to be identified as early as possible so that support and interventions can be implemented and outcomes improved. 

Information about support and interventions to help individuals with HNC click this link. 

Tobacco Cessation Following Laryngeal Cancer Diagnosis Predicts Response to Treatment and Laryngectomy-Free Survival

Krutz and colleagues from the University of Oklahoma Health Sciences Center studied the effect of tobacco cessation following laryngealcancer diagnosis on response to first-line therapy, laryngectomy-free survival, and overall survival in patients who were current smokers at the time of diagnosis.

The authors evaluated 140 patients diagnosed with laryngeal squamous cell carcinoma, who were smokers at the time of diagnosis, and were treated with first-line definitive radiation or chemo/radiation with the intent to cure.

Of the 140 current smokers, 61 patients (45%) quit smoking prior to treatment initiation. Smoking, quitters had 3.7 times higher odds of achieving a complete response to first-line therapy than active smokers (odds ratio: 3.694 [1.575-8.661]; P = .003).  Quitters were 54% less likely to require salvage laryngectomy within 7 years of diagnosis than active smokers (hazard ratio: 0.456 [0.246-0.848]; P = .013). Quitters had a statistically significant increase in 7-year overall survival compared to active smokers (P = .02).

This is the first study to show that in newly diagnosed laryngeal cancer patients who are current smokers at the time of diagnosis, tobacco cessation significantly increases therapy response, laryngectomy-free survival, and overall survival. These data stress the importance of systematically incorporating tobacco cessation programs into laryngeal cancer treatment plans.

Who is the best surgeon and what is the best place to have laryngectomy?

 

Saraswathula from Johns Hopkins University in Baltimore, and colleagues evaluated therelationship between surgeon volume and operative morbidity and mortality for laryngectomy.

The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. 

The authors found that higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity.

The authors concluded that there is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care.

Fatal Tracheoesophageal Puncture Leakage Associated With Lenvatinib.

Fatal tracheoesophageal puncture leakage associated with Lenvatinib treatment was reported by Salvatori S. and Tanvetyanon  T.  from Moffitt Cancer Center and Research Institute, Tampa, FL. The report was published in Cureus [15(8): e43490]. 

Tracheoesophageal puncture (TEP) is a voice restorative is often used in laryngectomees. Though generally safe, TEP may develop leakage. Lenvatinib is a tyrosine kinase inhibitor (TKI) with anti-tumoral activity against head and neck malignancies. TKIs, including lenvatinib, have been associated with organ perforation or fistula formation. The authors described a patient with adenoid cystic carcinoma of the larynx who had a TEP for several years. After approximately two weeks of treatment with lenvatinib, the patient developed a leakage of TEP. Despite several interventions, the patient died three months afterward due to a retropharyngeal abscess secondary to Fusobacterium nucleatum infection.

To the authors’ knowledge, this is the first report of fatal lenvatinib-associated TEP leakage. They urge clinicians to be cognizant of the potentially rapid development of this complication when prescribing TKI for patients with TEP.

 

Leakage through voice prosthesis barrel (central leakage):

Quality of sexual life after total laryngectomy for cancer.

 Babin and colleagues from the Department of Otolaryngology of the University of Caen France, reviewed 24 studies that evaluated sexual life after total laryngectomy (TL) for cancer. The main endpoint was the impact of impairment of quality of sexual life after TL. The secondary endpoints were the type of sexual impairment, associated variables and their treatment.

 The study population consisted of 1511 TL patients aged 21 to 90 years, with a male/female sex ratio of 7.5/1. Impaired quality of sexual life was reported by 47% of patients on average. Erectile and ejaculatory function and ejaculatory behavior of male patients decreased after TL. Other impairments comprised decreases in libido, frequency of sexual intercourse and satisfaction. Tracheostomy, advanced disease stage, young age and associated depression were factors for impairment. In all, 23% of patients reported lack of postoperative support in this area.

The authors concluded that laryngectomy impacted both patients and partners, negative effects being reported in more than 30% of cases. The physical transformation has aesthetic and emotional impact, inhibiting sexuality. the quality of sexual life is severely impacted by TL for cancer. There is patient demand for improved management of sexuality.

RESOURCES FOR LARYNGECTOMEES By Itzhak Brook MD , M Sc,

 

•       The Laryngectomee Guide. Paperback and Kindle at http://goo.gl/z8RxEt   Free download at https://www.entnet.org/laryngectomee-guide/  (helpful for new patients)

The Laryngectomee Guide is available (Free eBooks) in 24 languages. https://dribrook.blogspot.com/2018/08/the-laryngectomee-guide-is-available-in.html

 

•       The Laryngectomee Guide Expanded Edition, 5TH  edition., Paperback and Kindle at https://www.amazon.com/dp/B0BBJPY5P2  Free download at https://bit.ly/3QGTqNa

(Recommended for seasoned patients)

 

•      The “Laryngectomee Guide for COVID-19 Pandemic” provides information for laryngectomee and neck breathers how to cope with the pandemic. The E books are free. Available at https://amzn.to/3i5XncR   as paperback, and at  https://bit.ly/3hZHynb   as eBook (free).

 

•       “My Voice: A Physician’s Personal Experience with Throat Cancer.” Paperback and Kindle at http://goo.gl/j3r51V   Free download at https://dribrook.blogspot.com/p/my-voice-physicians-personal-experience.html  

 

•        Rescue breathing of neck breathers including laryngectomees

Video:  https://www.youtube.com/watch?v=YE-n8cgl77Q  

Manual: https://bit.ly/3k1iRO5   

 

Pravastatin antifibrotic efficacy in reversing radiation-induced fibrosis after radiation therapy for head and neck cancer

 

A prospective study done by Celine Bourgier and colleagues from Université de Montpellier, France; .showed that pravastatin (a statin) is an efficient antifibrotic agent in patients with established cutaneous and subcutaneous radiation-induced fibrosis (RIF) after radiation therapy for head and neck cancer. 

The primary endpoint was reduction of RIF thickness by more than 30% at 12 months, as measured by cutaneous high-frequency ultrasonography. Secondary endpoints included RIF severity reduction, pravastatin tolerance, and quality of life. 

Sixty patients were enrolled from February 2011 to April 2016. The mean interval between RIF diagnosis and pravastatin initiation was 17.1 months. Pravastatin was stopped before 11 months of treatment in 18 patients (because of grade ≥2 adverse events related to pravastatin in 8 patients [13%]). In the 40 patients in whom pravastatin efficacy was assessed by high-frequency ultrasonography at baseline and at 12 months of treatment, a reduction of RIF thickness ≥30% was observed in 15 of 42 patients (35.7%). At the 12-month clinical evaluation, RIF severity was decreased in 50% of patients (n = 21), and the patients' self-perception, mood state, and social functioning were significantly improved. Pravastatin was well tolerated.

 The authors concluded that this phase 2 prospective study supports the notion of radioinduced fibrosis reversibility. It showed that pravastatin (40 mg/d for 12 months) is an efficient antifibrotic agent in patients with grade ≥2 cutaneous and subcutaneous fibrosis after head and neck cancer radiation therapy.

Hyperventilation in neck breathers including laryngectomees.

 Hyperventilation can occur in neck breathers including laryngectomees. Hyperventilation reduces the level of carbon dioxide in the blood. It can upset the acid-base balance in the blood making it more alkaline. The syndrome is characterized by repeated episodes of excessive ventilation in response to fear, anxiety or panic. It can also occur during an orgasm or intense sexual activity, as well as heavy physical activity.

Neck breathers are more prone to this condition because rapid breathing ventilate the lungs quicker than in non-neck breathers as the inhaled air enter the trachea through the stoma, bypassing the upper airways.

The existence of hyperventilation in laryngectomees was evaluated by Brook by sending a questioner to 256 laryngectomees. Fifty-four of the 72 individuals who return the questioner experienced one or more episodes of hyperventilation. It was associated with heavy physical activity in 28 (51%) individuals, sexual activity in 15 (38%), anxiety in 8 (15%), and intense coughing in 7 (13%). The symptoms experienced were: fast or deep breathing in all cases, shortness of breath (50 or 96%); anxiety, fear, panic, or strong feeling of dread or doom (38 or 70%); dizziness (27 or 50%); generalized weakness (16 or 30%); sweating (13 or 34%); fainting (4 or 7%); and chest pain (4 or 7%).

This small survey illustrates that laryngectomees do experience hyperventilation syndrome.

Further studies are warranted to prospectively evaluate the incidence of hyperventilation in laryngectomees and other neck breathers. Such studies may highlight the need to address, prevent and treat this condition in laryngectomees.

First total laryngectomy by Theodor Billroth 150 years ago.

 

On December 31, 1873, in the Vienna surgery clinic, the German surgeon Theodor Billroth managed what no previous surgeon had been able to: complete ablation of the larynx in a human being, which quickly came to be known as “total laryngectomy”, without harmful immediate consequences. Billroth dared what none before had done. He had come to the conclusion that “the only way of saving life was to remove the entire larynx.”

This first total ablation of the larynx, preceded by a tracheotomy, was one of the great surprises of 19th century surgery.

This was possible because of the prior experimental study of laryngeal ablation performed in dogs by Vincent Czerny. The French physician Henri Chouppe enthused: “when experimental studies lead to practical results, one should hasten to do It”.

    Theodor Billroth operating 

Comparison of anxiety and depressive of head and neck cancer patients before and during the 2019 coronavirus pandemic.

 

Jiani Liu and colleagues from  Sun Yat-sen University, Zhuhai, China,  studied the effect of the COVID-19 pandemic on the anxiety and depressive symptoms of cancer patients before and during the 2019 coronavirus pandemic.

A total of 526 head and neck cancer patients were included in the final analysis; 27% of cases experienced anxiety and depression before the pandemic and 50 % during the COVID-19 pandemic. (P=0.018).

The present study demonstrates the significant impact of COVID-19 on the psychological states of cancer patients. This findings indicating the need for appropriate changes in treatment decisions, enhanced psychotherapy, and interventions to reduce the incidence of anxiety, depression, and even suicide during the pandemic.

"The 5th Edition of the Laryngectomee Guide Expanded Edition is available.

The 5th Edition of the Laryngectomee Guide Expanded Edition is available now. The 325 pages Expanded Guide is an updated and revised edition of the original Laryngectomee Guide. It is three time larger than the original Guide and also contains information how laryngectomees can protect themselves from COVID-19. It provides 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.

The E Book is free for download. 

The Guide is also available in Amazon   

Itzhak Brook MD

Atorvastatin is associated with reduced cisplatin-induced hearing loss in head and neck cancer petients

Cisplatin is widely used to treat cancers. It is the most ototoxic drug in clinical use, resulting in permanent hearing loss in approximately 50% of treated patients. There is a major need for therapies that prevent cisplatin-induced hearing loss. Studies in mice suggest that concurrent use of statins reduces cisplatin-induced hearing loss.

Fernandez and her colleagues (from the National Institute on Deafness and Other Communication Disorders, and Johns Hopkins University, Maryland ; University of Rochester Medical Center, New York; and Medical University of South Carolina, Charleston, South Carolina; USA) retrospectively examined hearing thresholds from 277 adults treated with cisplatin for head and neck cancer. The results were published in Clinical Trial Journal of Clinical  Investigation in 2021.

Pretreatment and posttreatment audiograms were collected within 90 days of initiation and completion of cisplatin therapy. The primary outcome measure was a change in hearing as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE).

Among patients on concurrent atorvastatin, 9.7% experienced a CTCAE grade 2 or higher cisplatin-induced hearing loss compared with 29.4% in nonstatin users (P < 0.0001).

 Analysis showed that atorvastatin use was significantly associated with reduced cisplatin-induced hearing loss (P ≤ 0.01). An adjusted odds ratio (OR) analysis indicated that an atorvastatin user is 53% less likely to acquire a cisplatin-induced hearing loss than a nonstatin user (OR = 0.47; 95% CI, 0.30-0.78). Three-year survival rates were not different between atorvastatin users and nonstatin users (P > 0.05).

The data indicate that atorvastatin use is associated with reduced incidence and severity of cisplatin-induced hearing loss in adults being treated for head and neck cancer. A prospective study is currently  conducted to evaluate the efficacy of statins in preventing hearing loss by cisplatin.

Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma:

 

Paroxysmal hypertension can be associated with failure of the carotid artery baroreceptors due to past exposure to radiation treatment. A case report describes a patient whose repeated paroxysmal hypertensive episodes were ameliorated following placement of a carotid artery stent for the treatment of carotid artery stenosis.

The patient that was diagnosed with hypopharyngeal squamous cell carcinoma in 2006, and received 70 Gy intensity-modulated radiotherapy in 2006 and underwent a total laryngectomy in 2008. He experienced paroxysmal hypertensive episodes since 2010 that exacerbated in frequency in 2019. Eighty percent left internal carotid artery stenosis was demonstrated by ultrasound and arteriography. Angioplasty and stenting of the left carotid artery was performed. A Doppler ultrasound study performed 5 months after the stent placement did not reveal any hemodynamic stenosis in the left carotid artery. The patient experienced postprandial hypotension and had experienced only three episodes of paroxysmal hypertension in the following 24 months. He was able to abort paroxysmal hypertensive episodes by eating warm food.

This is the first report of a patient whose paroxysmal hypertensive episodes that occurred following radiation of the neck subsided after placement of a stent in a stenotic carotid artery. The exact mechanism leading to this phenomena is unknown but may be due to several factors. The reversal of the carotid artery stent and improvement in blood flow to the carotid artery baroceptors may play a role in this phenomenon. Conclusion: The ability to ameliorate paroxysmal hypertensive episodes in a patient with carotid artery stenosis by stent placement may be a promising therapeutic intervention for paroxysmal hypertension.

                  Angiogram of the left carotid artery before stenting showing 80% stenosis

                                  Angiogram of the left carotid artery after stenting, no stenosis

Tracheitis in a laryngectomee due to Gram-negative bacteria

 

Laryngectomees run the risk of developing respiratory tract infections. A laryngectomee who developed trachitis is presented Brook to illustrate the risks and difficulties encountered in managing this infection in neck breather.

The patient presented with coughing of viscous green purulent sputum. He has been wearing a heat moisture exchanger filter (HME) spoke through a tracheo-esophageal voice prosthesis. The symptoms started 2 days after his voice prosthesis started to leak whenever he consumed liquids.

Sputum culture grew heavy growth of Klebseilla oxytoca, and Moraxella catararhalis, and medium growth of Stenothrophomonas (Xanthohmonas) maltophilia. The patient recovered after he was treated with oral levofloxacin  for 5 days. Humidification of the trachea and the airway was maintained by repeated insertions of 3-5 cc respiratory saline into the stoma at least once every two hours; and by breathing humidified air. The leaking voice prosthesis was replaced enabling the patient to consume adequate amount of fluids.

This is the first report of bacterial tracheitis due to multiple Gram-negative aerobic and facultative bacteria in a laryngectomee. The etiology of tracheitis in this patient is most likely due to aspiration of oral flora that contained these organisms through the leaking voice prosthesis (, or their acquisition through the stoma. A change in the consistency and color of the sputum was most likely due to the tracheal inflammation caused by these organisms. Obtaining a bacterial culture enabled their recovery and adequate elimination. 

Laryngectomees are at risk of aspirating liquids containing bacteria. When unclean liquids get into the lower respiratory tract, they can sometimes cause infection. Developing aspiration pneumonia depends on how much liquid is inhaled and how much is coughed out, as well as on the individuals' immune system.

This report highlights the importance of obtaining bacterial cultures and antimicrobial susceptibility that enabled eliminating the pathogens and restoring adequate mucus production. Treatment with a short course of antimicrobial as well as maintaining adequate hydration and respiratory tract humidification can restore the adequacy of the mucus.

Getting infected with both COVID-19 and influenza viruses

 

Co-infection of COVID-19 with other respiratory pathogens which may complicate the diagnosis, treatment, and prognosis of COVID-19 emerge new concern. Eleven prevalence studies with total of 3,070 patients with COVID-19, and 79 patients with concurrent COVID-19 and influenza were evaluated by Dadashi et al from Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran .The overlap of COVID-19 and influenza, as two epidemics at the same time can occur in the cold months of the year. The prevalence of influenza infection was 0.8% in patients with confirmed COVID-19. The frequency of influenza virus co-infection among patients with COVID-19 was 4.5% in Asia and 0.4% in the America. 

This information highlights the importance of getting properly vaccinated for both COVID-19 and influenza and practicing safe prevention (wearing masks and maintaining distance) as advised by the local health authorities. Neck breathers including laryngectomee should practice extra vigilance to avoid respiratory infections.

Discordant in Detection of COVID-19 in the Nasopharynx Versus Trachea for Patients With Tracheostomies

Patients with tracheostomies have an anatomically altered connection between their upper and lower airways that could impact SARS-CoV-2 testing. Smith and colleagues from the University of Michigan retrospectively compared the detection of SARS-CoV-2 in hospitalized patients with COVID-19 and tracheostomies.

The authors employed SARS-CoV-2 RNA nucleic acid amplification test (NAAT) in 45 newly  tracheotomized patients in nasopharyngeal (NP) and tracheal (TR) samples taken within a 48-hour period.

Thirty-two (71.1%) of the 45 patients had entirely concordant results after tracheostomy. However, 13 (28.9%) patients had at least one set of discordant results, the majority of which were NP negative and TR positive.

The authors concluded that patients with tracheostomies may have a higher false-negative rate if only one site is assessed for SARS-CoV-2. They recommend analyzing samples from both the nasopharynx and trachea for these patients until more prospective data exist.

Quality of Life, Dysphagia, Voice Problems, Depression, and Anxiety After Total Laryngectomy

 Wulff and colleagues of the Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark,  determine the  health-related quality of life , including voice problems, dysphagia, depression, and anxiety after total laryngectomy, and investigate the associations between health-related quality of life  and the late effects. Included were 172 participants having undergone a laryngectomy 1.6 to 18.1 years ago for laryngeal/hypopharyngeal cancer.  

Participants scored worse than normative reference populations on all scales/items except one. Moderate/severe dysphagia was present in 46%, moderate/severe voice problems in 57%, depression in 16%, and anxiety in 20%. Decreasing age, increasing numbers of comorbidities, increasing voice problems, increasing dysphagia, and increasing depression symptoms, were associated with a lowered  summary score.

The authors concluded that a substantial proportion of participants experienced clinically significant late effects and increasing levels of these were associated with a lowered health-related quality of life.

Risk of aspiration when Provox Life FreeHands Flexivoice HME is not inserted correctly

 I would like to highlight a potentially serious problem that occurred to me when I used  the new Life HME filter. I placed it INCORRECTLY with the side with only 2 bars facing the stoma (see pictures) and it got separated and fell into the trachea after several minutes. Fortunately, I was able to cough it out.

Make sure that you attach the HME correctly with the side that has 3 bars (shaped like z) facing your stoma (see picture). If one has questions they  should contact their  SLP or Atos representative.

Filter side that should NOT face the stoma

Filter side that should 

face the stoma 

  

Correct way to insert HME to the FreeHands Flexivoice 

Hospitalization and mortality among 1216 people with total laryngectomy in the UK during the COVID-19 pandemic

 

People with total laryngectomy (PTL) have an altered anatomy for breathing and speaking. The presence of a neck stoma poses an additional virus entry point aside from the nose, mouth and conjunctiva. This could increase the susceptibility to COVID-19 for PTL.

Govender and colleagues from the University College Hospital in London performed a national audit to provide data on shielding, hospital admissions and mortality for patients with total laryngectomy in the UK over the pandemic. Data were obtained from 1216 PTL from 26 centers across the UK. A total of 24 (2% of total sample) tested positive for COVID-19. Eight of the 24 PTL that were hospitalized with COVID -19 died within 28 days. During the data collection time frame, 12% had a hospital admission (n = 151) with a median length of stay of 1 day (1–133 days). A total of 20 of these admissions (13%) had tested positive for COVID-19 with a median length of stay of 26 days. The overall mortality was 4% (41 patients), with eight deaths occurring within 28 days of testing positive for COVID-19.

Although the overall mortality in PTL over the first lockdown did not appear to be higher than the “best case” estimates from previous years one in three PTL who acquired COVID-19 and were admitted to hospital, died within 28 days of testing positive. 

Greater testing in the community is necessary to understand the prevalence of COVID-19 in PTL and if this group is indeed more susceptible. The potential for nasopharyngeal and tracheal aspirates to show differing results when testing for COVID-19 in neck-breathers requires further investigation.

Dr Brook interview “Physician’s personal challenges as a head and neck cancer patient and laryngectomee”. Brazilian Academy of speech and Voice. 2021

Dr Brook interview by Dr. Rui Imamura and Dr. Adriana Hachiya about “Physician’s personal challenges as a head and neck cancer patient and laryngectomee”. Brazilian Academy of speech and Voice. 2021 Voice Campaign.  San Paulo, Brazil. April 13, 2021. 

Issues discussed:

• Should doctors adopt a paternalistic stance, suggesting the best treatment for the patient or just expose the options and leave it to the patient to decide?
• Is it better that the physicians express a more optimistic or more pessimistic attitude regarding the prognosis?
• What advice would you give to a doctor who needs to give the news of advanced cancer to a patient?
• What were the main challenges you faced after laryngectomy?
• What touched you (in a good or a bad way) in these interactions between the doctors who treated you?

Link to the 14 minutes interview: https://youtu.be/ofaJ7XjhZ9k

Safety of celebrating the spring holidays with family and Friends for head and neck cancer patients.

 

The upcoming spring holidays (Easter, Passover and Ramadan) creates challenges for those who are looking forward to celebrating them in person with friends and family. The availability of vaccination against the virus made it easier to resume the tradition of in person celebration although the risk of acquiring the infection can be high in some situations.

Vigilance and mitigating the risk of acquiring COVID-19 infection are especially important for Individuals with cancer including of the head and neck, who are at greater risk of suffering from a serious and life threatening COVD -19 infection.

Celebrating the holidays in close settings can be risky because of the difficulty of maintain social distance, and adequate ventilation. Mask wearing is impractical while eating and drinking.

The Center of Disease Control’s Interim Public Health Recommendations for Fully Vaccinated provide useful guidelines that can help plan a safe Seder and avoid risky scenarios that would allow the COVID-19 virus to spread. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html

For the purposes of the CDC’s recommendations people are considered fully vaccinated for COVID-19 more than 2 weeks after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna), or  more than 2 weeks after they have received a single-dose vaccine (Johnson and Johnson/Janssen ).

Interpretation of the CDC recommendations to the spring holidays scenario for fully vaccinated people are:

•             It is permissible for fully vaccinated people to celebrate indoor with other fully vaccinated people or unvaccinated people from a single household who are at low risk for severe COVID-19 disease without wearing masks or physical distancing.

•             Wearing masks, practicing physical distancing, and adhering to other prevention measures is required when celebrating with unvaccinated people who are at increased risk for severe COVID-19 disease or who have an unvaccinated household member who is at increased risk for severe COVID-19 disease

•             Wearing masks, maintaining physical distance, and practicing other prevention measures are required when celebrating with unvaccinated people from multiple households

•             Avoiding medium - and large-sized Seder

•             Unvaccinated individuals from different households should refrain from celebrating in person.

Since the COVID-19  vaccine is not currently available to children, extra caution should be practiced when they are present. Outdoor gathering with masks or opening the windows to improve the ventilation, and distancing would be safest.

Although the available vaccines are helpful in curbing the spread of COVID-19 their efficacy against the variants of the virus in unknown. These variants seem to spread more easily and quickly than other variants, which may lead to more cases of COVID-19. It is there prudent to continue to maintain vigilance in the upcoming holiday.

Potential devastating impact of COVID-19 pandemic on the diagnosis and treatment of head and neck cancer

 

New data from the United Kingdom reveals potential devastating impact of COVID-19 pandemic on head and neck cancer patients. At the peak of the first lock down, there was a 59% drop in urgent referrals for people with a suspicion of head and neck cancer.

The devastating impact on projected five-year survival for people with head and neck cancer sees the pre-COVID projected 5 year survival of 47% will potentially drop to 43% of head and neck cancer patients.

This could lead to an additional 451 deaths in people with head and neck cancer in the United Kingdom.

The data from DATA-CAN (The Health Data Research Hub for Cancer) provided a valuable insight into the effects of the COVID-19 pandemic on all cancer patients and cancer services. The research found:

• A decline in urgent referrals for cancer (70% decrease) during the initial lock down
• A decline in chemotherapy attendances (40% decrease) during the initial lock down
• For certain cancers, these declines had only partially recovered.

The researchers have now looked in detail at the impact on head and neck cancers and found that, at its worst, there was a drop of nearly 60% in urgent referrals for a suspicion of head and neck cancer during the first lockdown. This meant that 6 out 10 people who had symptoms potentially indicating head and neck cancer were not being referred to a specialist to investigate further.

Estimates suggest that this could have a devastating impact on five-year survival for people with head and neck cancer. Pre-COVID, around 47% of people with head and neck cancer would be projected to survive for five years or more. This figure could now drop to 43% which could potentially lead to an additional 451 deaths in people with head and neck cancer as a result of the pandemic.

Watch a video that presents the data and what can be done to mitigate the situation. 

Laryngectomees’ challenges coping with COVID – 19 Pandemic as vaccines are available.

Laryngectomees are more susceptible to some respiratory infections because the air they inhale is not filtered by passing through their nose. Consequently, they are at an increased risk of inhaling respiratory pathogens (viruses, bacteria, and fungi) directly into their lungs.

Laryngectomees are also at high risk for poor outcomes when contracting COVID-19 because of their propensity to suffer from collapse of the lower lobs of their lungs (atelectasis). This is due to loss of upper airway resistance and impaired mucociliary functions, and mucosal irritation from cold, or dry inspired air. Further comorbidities such as advanced age, chronic disease (pulmonary, peripheral vascular, cardiac, cerebrovascular), diabetes, and past smoking, increase this risk.

Therefore, laryngectomees have to be vigilant and protect themselves from becoming infected with COVID-19. This can be done by wearing eat and mosuture exchanger (HME) with greater filtering properties ( i.e., Provox Micron TM); using 2 surgical masks (preferably N95), one over the stoma and the other over the mouth and nose; staying at least 6 feet away from others; washing hands often with soap and water for at least 20 seconds; and not touching their stoma, HME, eyes, nose, and mouth with unwashed hands.

Laryngectomees can protect themselves by receiving vaccination against COVID-19. All COVID-19 vaccines currently available in the United States have been shown to be highly effective at preventing COVID-19. Based on clinical trials, experts believe that getting a COVID-19 vaccine may also help keep one from getting seriously ill even when one get infected with COVID-19. Becoming vaccinated may also protect people around the vaccinated person, particularly those at increased risk for severe illness from COVID-19. This also contributes to the curbing of the national and world pandemic.

Among the benefits of being vaccinated is the emotional relief of gaining protection from the virus, and the ability of feel safer in face to face social interactions and when seeking medical and dental care.

Clinical trials demonstrated that the known and potential benefits of these vaccine outweigh the their side effects, and the known and potential harms of becoming infected with COVID-19. The Center for Disease Control’s (CDC) has reported that severe allergic reactions to COVID-19 vaccines are very rare and happened at a rate of 11.1 cases per million vaccinations. 

Vaccination is not expected to relax the CDC recommendations for continued use of masks and social distancing. This is because vaccines are not 100% effective, their protective effect is not maximized for at least six weeks, and vaccines may keep a person from getting sick but not from transmitting the virus. Masks and HMEs reduce the spread of any mutated strain of the coronavirus, while vaccines may not be as effective in preventing the transmission of newer, more contagious strains.

It is advisable to contact one’s physicians for guidance about vaccination or if one gets ill with the Corona virus. There are currently treatments available that can be administered early in the course of the infection to mitigate the illness and prevent complications. It would be prudent to following the guidance and instruction issued by the CDC and the local government health authorities.

Cancer Care During the COVID 19 Pandemic

 

Dr Brook's Letter to the Editor  published  in the New York Times has an important message to all cancer survivors:

The prolonged COVID -19 pandemic has led to an increase in the number of patients who present with late-stage, previously undiagnosed cancers, and recurrence of a previously diagnosed malignancy.

This is probably due to the reluctance of people to seek medical care because of fear of contracting COVID -19 at medical facilities; the closing or reduction in clinical services; the requirement to obtain COVID -19 testing before some medical procedures; and the use of telemedicine without physical examination instead of an actual office visit.

It is important that people not defer their medical care during the pandemic. It is especially important that those who previously received a cancer diagnosis continue their treatment and follow-up. Those who experience new or unusual signs and symptoms that may indicate 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 leading to increased morbidity and mortality.

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.