Social isolation and loneliness in laryngectomees

 

Laryngectomees, face many psychological, social and personal challenges . Laryngectomees also experience social isolation and loneliness (SIL) because of their difficulties in communication and their post-surgical deformities.  A study by Itzhak Brook MD from Georgetown University, published in European Annals of Otorhinolaryngology, Head and Neck diseases; shed light on this issue by evaluating the frequency of SIL in laryngectomees.

Members of Facebook laryngectomee support groups were asked if they experience social SIL. Statistical analysis used: 'N-1' Chi squared test.  A total of 379 individuals responded (208 males, 171 females). A total of 237 (62.6%) reported SIL (117 males, 120 females). SIL was present in 117 males ( 56.2% of males)  and 120 of females ( 70.2 % of  females). Ninety four individuals ( 61 males and 33 females) reported their method of speaking. SIL was reported in voice prosthesis users in 17 (47%) males, and 12 (66%) females). It was reported in electrolaryx users in 6 (24%) males, and 7 (43%) females. The difference between males and females was not significant in either group. However, the presence of SIL was significantly higher in all voice prosthesis users compared to all electrolarynx users.) The higher frequency of SIL in females compared to males may be due to their awareness of their anatomical changes following laryngectomy.

SIL is common in cancer survivors, contributing to poor outcomes and is associated with increased risk of cardiovascular disease, hypertension, stress, decreased quality of life, poor physical and mental health, and higher mortality. Loneliness was present in a quarter of HNC patients.(5)  Patients who were younger, lived in deprived circumstances, had advanced disease and had been treated with chemotherapy or radiotherapy reported greater levels of loneliness. Loneliness was associated with a worse overall quality of life, and worse physical and social-emotional function. 

Despite the limitations of our analysis, due to the use of a Facebook group that included various groups of laryngectomees, and the lack of a validated standard test to analyze loneliness, our data highlight the high frequency of SIL in laryngectomees. It is hopeful that these findings would inspire further research and encourage clinicians to recognize and treat SIL in laryngectomees. Early recognition and interventions to relieve SIL are urgently needed.

link to the manuscript https://drive.google.com/file/d/1Vqqy1BBMYQa35a_J5bD7IT4Sx3r5JZ06/view?usp=sharing

Instructions for inpatient care of laryngectomees.

 It is advisable that laryngectomees provide the Instructions below to the medical staff who cares for them:

INSTRUCTIONS:  INPATIENT CARE OF LARYNGECTOMEE

 

GENERAL

• 100% neck breather. Breathe through neck stoma.
• Air, oxygen, suction and respiration resuscitation is through my stoma.
• Keep my trachea moist by inserting saline bullets every 3-4 hours.
• I do not have radial artery pulse on my left/right arm (in case you had a free flap)

.

RESPIRATORY SUPPORT:

• To deliver respiratory support, or if I am unconscious, remove HME (heat moisture exchanger filter) if you wear one).
• Oxygen given to me should be humidified.
• Oxygen mask should be “child-mask” size over stoma.
• If I am not able to cough, I need to be frequently suctioned through the stoma. 

COMMUNICATION:

• I am unable to speak without HME (if you wear one  over my stoma.
• Without HME, I can communicate via lip reading or writing on a board or paper.
• I have a round 10 mm plastic voice prosthesis inside my trachea, visible through the stoma.
• Don’t remove, even if I need to be intubated. 

NEED ASSISTANCE?

Contact a speech pathologist for supplies & help.

Click to get the link to obtain the Instructions 

The sixth edition of the Expanded Laryngectomee Guide is available

 

I am happy to announce the publication of the 6 th edition of the Expanded Laryngectomee Guide, now spanning 379 pages. This updated and revised edition offers valuable information to assist laryngectomees and their caregivers with a wide range of concerns, including medical, dental, and psychological issues.

The guide includes comprehensive details on head and neck cancer and its surgical treatments, side effects of radiation and chemotherapy, various speaking methods, and care for the airway, stoma, and voice prosthesis. It also addresses eating and swallowing challenges, and provides guidance on respiration, preventive medicine, urgent care, anesthesia, and traveling. Additionally, the guide offers helpful resources specifically for laryngectomees and head and neck cancer patients.

The E Book is free for download  https://bit.ly/3xvA49f   

Paperback and Kindle are available at https://www.amazon.com/dp/B0D7SHQN48  

Oral HPV infection before and after treatment for HPV16-positive and negative head and neck squamous cell carcinoma

 Oral HPV infection can persist in the oro-pharynx after treatment for head and neck squamous cell carcinoma (HNSCC), with different patterns observed for HPV16-positive and HPV-negative tumors:

For HPV16-positive HNSCC:

• Most patients have detectable oral HPV16  prior to treatment.
• After treatment with radiation or chemoradiation, many patients clear the oral HPV16 
• However, a significant proportion (around 25%) continue to have detectable oral HPV16 infection after treatment completion.

 

For HPV-negative HNSCC:

• Oral HPV  is less common prior to treatment compared to HPV16-positive cases.
• Oral HPV rates tend to remain low after treatment completion.

 

In summary, oral HPV16 infection is more likely to persist after treatment in patients with HPV16-positive HNSCC compared to those with HPV-negative tumors.

 This means that patients with this type of cancer are still carrying the HPV16 in their body and can potentially spread it to others. However, since this virus is very prevalent in individuals ( can be found in almost half of adults ) the significance of this information is unclear.

A systematic review and random effects meta-analysis of 60 studies reported increased cancers in the population with previous HPV-associated cancer when compared to controls. The clinical implications of persistent oral HPV infection after treatment are still being investigated, but it may increase the risk of recurrence or second primary tumors.

Navigating Uncertainty: Coping Strategies for Cancer Patients Facing an Uncertain Future

Cancer diagnosis brings with it a whirlwind of emotions, and perhaps one of the most daunting is uncertainty about the future. From treatment outcomes to long-term prognosis, cancer patients often grapple with a sense of unpredictability that can be overwhelming. In this article, we explore the challenges of uncertainty in cancer patients and offer strategies for coping and finding hope in the face of the unknown.

Uncertainty in cancer patients stems from various sources, including the unpredictable nature of the disease itself, the efficacy of treatments, and the impact on daily life. The fear of recurrence, side effects of treatment, financial concerns, and changes in relationships can all contribute to feelings of uncertainty. Moreover, the unpredictable trajectory of the disease can make planning for the future seem like an impossible task.

 

Coping Strategies include:

1. Open Communication: Honest and open communication with healthcare providers is crucial for addressing concerns and understanding treatment options. Patients should feel empowered to ask questions and seek clarification about their prognosis and the potential outcomes of treatment. 

2. Support Systems: Building a strong support network of family, friends, and fellow cancer survivors can provide emotional support and practical assistance during challenging times. Support groups offer a safe space for sharing experiences and coping strategies, reducing feelings of isolation and loneliness. 

3. Mindfulness and Acceptance: Practicing mindfulness techniques, such as meditation and deep breathing exercises, can help cancer patients cultivate acceptance of uncertainty and live in the present moment. Mindfulness encourages patients to acknowledge their emotions without judgment and find peace amidst the chaos. 

4. Education and Advocacy: Knowledge is empowering, and staying informed about one's diagnosis, treatment options, and potential side effects can help alleviate anxiety and uncertainty. Patients are encouraged to become advocates for their own health, actively participating in decision-making processes and seeking second opinions when necessary. 

5. Setting Realistic Expectations: While hope is essential for maintaining resilience, it's important for cancer patients to set realistic expectations and embrace uncertainty as part of the journey. Setting achievable goals and focusing on small victories can provide a sense of control and accomplishment. 

6. Seeking Professional Support: Professional counseling or therapy can offer additional support for cancer patients struggling with uncertainty and anxiety. Therapists trained in oncology can provide coping strategies, emotional support, and practical guidance for navigating the challenges of cancer survivorship.

 Despite the uncertainty that accompanies a cancer diagnosis, it's essential for patients to hold onto hope and find meaning in their journey. Each day brings opportunities for connection, growth, and resilience. By embracing uncertainty as a natural part of life and focusing on the present moment, cancer patients can cultivate a sense of peace and optimism in the face of an uncertain future. 

Uncertainty is an inevitable aspect of the cancer journey, but it doesn't have to overshadow hope and resilience. By implementing coping strategies, building strong support networks, and embracing mindfulness practices, cancer patients can navigate the uncertainties of the future with courage and grace. Remember, you are not alone in this journey, and there is always hope for a brighter tomorrow.

The power of a hug in caring for head and neck cancer patients

 

The power of a hug in caring for head and neck cancer patients can be immense. Cancer treatments, especially those targeting the head and neck area, can be physically and emotionally taxing. Patients often experience pain, discomfort, and emotional distress throughout their journey.

A hug can offer several benefits:

Emotional Support: Cancer treatment can evoke feelings of fear, anxiety, and depression. A hug provides emotional reassurance, comfort, and a sense of connection, reminding patients that they're not alone in their struggle.

Pain Relief: Hugs trigger the release of oxytocin, often referred to as the "love hormone" or "bonding hormone." Oxytocin has analgesic effects, reducing pain and promoting relaxation, which can be particularly helpful for patients dealing with physical discomfort.

Stress Reduction: Hugs can lower levels of stress hormones like cortisol, promoting a sense of calm and well-being. Managing stress is crucial for cancer patients as it can impact immune function and overall health.

Improved Mood: The physical touch of a hug stimulates the release of dopamine and serotonin, neurotransmitters associated with happiness and pleasure. This can uplift the mood of patients, offering a moment of joy amidst the challenges they face.

Enhanced Social Support: Cancer treatment often leads to social isolation as patients may feel alienated or misunderstood. A hug signifies empathy and solidarity, strengthening the patient's support network and fostering a sense of belonging.

Communication Without Words: Sometimes, words fail to convey the depth of care and compassion we feel for someone going through a difficult time. A hug serves as a powerful non-verbal expression of empathy, love, and support.

It's important to note that not everyone may feel comfortable with physical touch, so it's essential to respect individual preferences and boundaries. However, for those who are receptive, a simple hug can have profound effects on their well-being and healing journey.

I experienced the “power of a hug” as a patient with throat cancer. Read my article about this ib the Los Angeles Times https://www.latimes.com/health/la-he-my-turn-hugs-20110523-story.html    and my interview about it at https://www.youtube.com/watch?v=LG6AFlPQtM8

The Transformative Power of a Smile in Laryngectomees

After undergoing a laryngectomy, I received invaluable advice from a seasoned laryngectomee: before engaging in conversation, always start with a smile. He emphasized that this simple gesture has been instrumental in fostering a positive and approachable demeanor, particularly given the challenges of being understood with his altered voice. This was an invaluable advice that I learned to appreciate time and again.

The human smile is a universal language, transcending barriers of culture, language, and circumstance. Its power lies not only in its ability to convey happiness but also in its capacity to heal, comfort, and connect. For laryngectomees, individuals who have undergone surgery to remove their voice box due to cancer or other medical conditions, the simple act of smiling takes on profound significance, serving as a beacon of hope and resilience in the face of adversity. 

Laryngectomy is a life-altering procedure that not only robs individuals of their voice but also challenges their sense of identity and communication. The loss of speech can lead to feelings of isolation, frustration, and diminished self-esteem. However, amidst the silence, the smile emerges as a powerful tool for communication and emotional expression. 

A smile is more than just the movement of facial muscles; it is a reflection of the inner strength and resilience of the human spirit. For laryngectomees, whose voices may be silenced, the smile becomes their voice, speaking volumes without uttering a single word. It conveys warmth, kindness, and positivity, transcending the limitations imposed by their condition. 

Moreover, the act of smiling has been scientifically proven to have numerous physical and psychological benefits. When we smile, our brains release endorphins, neurotransmitters that promote feelings of happiness and reduce stress. This natural mood booster not only uplifts the spirits of laryngectomees but also enhances their overall well-being. 

Furthermore, a smile is contagious, capable of brightening the darkest of days and fostering connections with others. For laryngectomees navigating a world where communication may be challenging, a genuine smile can break down barriers, fostering empathy, understanding, and acceptance in their interactions with others. 

Beyond its individual impact, the smile of a laryngectomee serves as a beacon of hope for others facing similar challenges. It embodies resilience, courage, and optimism in the face of adversity, inspiring others to find strength in their own struggles. 

In addition to its emotional and social significance, the smile plays a practical role in the rehabilitation process for laryngectomees. Speech therapists often incorporate smile exercises into therapy sessions to help improve facial muscle control and articulation, facilitating the development of alternative methods of communication such as esophageal speech or the use of assistive devices. 

The power of a smile in the lives of laryngectomees cannot be overstated. Beyond its role as a symbol of joy and positivity, the smile serves as a lifeline, connecting individuals to their inner resilience and to the world around them. In a journey marked by challenges and obstacles, the simple act of smiling emerges as a beacon of hope, lighting the path towards healing, acceptance, and connection.

Anxiety, depression and quality of life following laryngectomy. A long-term prospective evaluation.

 

Mukoyama and colleagues from Nagoya University Graduate School of Medicine, Nagoya, Japan; assessed anxiety, depression and quality of life  in 150 patients with head and neck cancer undergoing laryngectomy.

The surgical procedures were total laryngectomy, pharyngo-laryngectomy and pharyngo-laryngo-oesophagectomy in 97 (65%), 41 (27%) and 12 (8%) patients, respectively. All quality of life items were significantly worse than those of the normal population at baseline and at 3 months after surgery. However, general health, vitality, mental health and bodily pain improved to normal levels within 1 year after surgery and were maintained for 5 years. In this study, 35% of patients were categorized as potential cases of depression, and 35% were potential cases of anxiety. During the follow-up period, the proportion of patients with anxiety gradually decreased after surgery.

The authors concluded that anxiety, depression and quality of life in laryngectomized patients improved at one year after surgery and were maintained throughout the 5 years of the study..

Dr Itzhak Brook Keynote address. “ Back to Life” 2nd Annual Head and Neck Cancer Patient & Caregiver Symposium at Keck Medicine University of California. April 6, 2024.

 

Dr. Itzhak Brook Keynote address. “Back to Life”  after laryngectomy 2nd Annual Head and Neck Cancer Patient & Caregiver Symposium at Keck Medicine University of California. April 6, 2024

How wearing a hearing aid can improve speech

 

Hearing loss may make individuals perceive that their voice is weaker than it actually is. It may contribute to social isolation and make laryngectomees try to speak louder. In those who use tracheoesophageal speech and are trying to speak louder by generating greater expiratory effort a separation of the HME base plate from the skin can occur. This is especially true in those who use a hands free HME. Wearing a hearing aid enables a laryngectomee to hear their actual voice.

Decisional Conflict in Patients with Advanced Laryngeal Carcinoma

Heirman and colleagues from the Department of Head-and-Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, studied the decision conflict in patients with a locally advanced laryngeal carcinoma (T3 and T4). The decision is challenging due to the treatment choice between organ preservation and laryngectomy, both with different and high impact on function and quality of life (QoL). The complexity of these treatment decisions and their possible consequences might lead to decisional conflict (DC). This study aimed to explore the level of DC in locally advanced laryngeal carcinoma patients facing curative decision-making, and to identify possible associated factors.

Participants completed questionnaires on DC, level of shared decision-making (SDM), and a knowledge test directly after counseling and 6 months after treatment.

Directly after counseling by their medical providers, almost all participants (44/45; 98%) experienced clinically significant DC score (CSDC >25, scale 0-100). On average, patients scored 47% (SD 20%) correct on the knowledge test. Questions related to radiotherapy were answered best (SD 69%), whilst only 35% (SD 29%) of the questions related to laryngectomy were answered correctly. Patients' perceived level of SDM (scale 0-100) was 70, and for physicians this was 70 .

The authors concluded that most patients with advanced larynx cancer experience high levels of DC. Low knowledge levels regarding treatment aspects indicate a need for better patient counseling.

A poem by Anne Pitkin about life challenges of Laryngectomee published in JAMA in the Healing and Poetry Section January 23, 2024

 You can do everything you did before except swim.

If you swim, water will flood your lungs

    through the hole in your neck.

I can buzz Like a swarm of hornets.

I can see and I can hear.

I can walk into a store and buy groceries.

I can answer the phone. I can talk

in a voice not my own, not the instrument

by which I think out loud to learn what I am thinking,

the instrument by which you might have known me,

    by which I taught my classes, called the dog, loved—

the instrument I songed with, guffawed with

    so people could hear me coming,

the instrument with which I imitated Ethel Merman,

Florence Foster Jenkins, Martin’s parrot,

My seventh-grade teacher saying through her nose

    I am so tired of the asinine things you kids do…

I am an iceberg’s tip, my substance mute,

the moon without a shadow, a grove without wind or birds,

a street without nuance.

What used to be fluid lines of speech puddle unfinished,

the whispered aside, the quick wisecrack beyond me.

I used to love telling the story of the drunken Brits

awaiting the end of the world, counting down,

ten, nine, eight…all the way to 1—a pause

my best cockney,

Well, it ain’t the conflagration we’d been bankin’ on.

And it ain’t.

Someone online said, I’d rather die.

I did not. I am here. I am telling you this.

Anne Pitkin

Read the original publication in JAMA 

Artificial Intelligence helping laryngectomees to speak again

 The developments in artificial intelligence led to developments that can help laryngectomees use new ways by which they can speak again. Most of these methods are in the developmental stages. However, some, such as Google Duplex is available today.

Google Duplex is an artificial intelligence (AI) technology that mimics a human voice and makes phone calls on a person's behalf. It enables users to perform a variety of tasks -- including make reservations, schedule appointments and perform other functions -- without having to speak to someone.

Whispp’s language independent AI technology and calling app converts whispered speech and vocal cord impaired speech into a clear and natural voice of one’s choice, without any delay. By providing recordings, one’s Whispp voice can sound like the person’s own healthy voice.

Other methods of generating speech are under development. Tank and his colleagues from the University of Texas at Austin, have developed a non-invasive language decoder that can reconstruct speech from functional MRI data. This technology can one day help people who have lost their ability to speak called a semantic decoder. 

The Australian start-up Laronix is developing a bionic device that uses AI-based voice-cloning technology to restore the voices of laryngectomees.

 

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.