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)  

Recreational Cannabis consumption can accelerates the growth of HPV positive head and neck squamous cell carcinoma

The ingredient that causes people on cannabis to feel the euphoria or “high” is associated with accelerating cancer growth in patients with human papilloma virus (HPV)-positive head and neck squamous cell carcinoma.  

Researchers at the University of California San Diego School Of Medicine demonstrated in animals and human cell line, showed how the presence of tetrahydrocannabinol (THC) in the bloodstream enhances the growth of HPV positive squamous cell cancer cells.  When activated, p38 MAPK pathway prevents cell death (apoptosis), thus allowing HPV positive squamous cell cancer cells to grow uncontrollably.

The team also analyzed blood samples from patients with HPV-related throat cancer and similar to the cell lines, the blood samples showed p38 MAPK activation and loss of cancer cell death in tumors from patients with THC in their blood.

The researchers stated that there is now scientific evidence that daily marijuana use can drive tumor growth in HPV-related head and neck cancer.

The study was published in Clinical Cancer Research in January 2020. 

Paroxismal hypertensive episodes caused by direct massage of the carotid artery by a Doppler ultrasound of the neck in a laryngectomee.

Paroxysmal hypertension can occur after radiation to the head and neck. Patients exhibit sudden elevation of blood pressure (> 200/110 mm Hg) associated with an abrupt onset of headache, chest pain, dizziness, nausea, palpitations, flushing, and sweating.

A recent case report in Journal of Medical Ultrasound describes a laryngectomee who experienced repeated paroxysmal hypertensive episodes following direct massage of the carotid artery during Doppler ultrasound of the neck. This test is often performed to detect carotid artery stenosis in head and neck cancer patients who received radiation of the neck. 

The radiation damage to the carotid artery baroreceptors might have increased their hypersensitivity to the mechanical and ultrasonic stimulation during the diagnostic test, leading to the hypertensive episodes. It is recommended that patients who had received radiation therapy for head and neck cancer and require Doppler ultrasound of the carotid artery should be monitored for paroxysmal hypertension by recording their blood pressure prior and after the test.

The emerging role of aspirin and metformin in the management of head and neck cancer patients.

Aspirin was found to be associated with risk reduction of secondary primary cancer for patients with head and neck squamous cell cancer (HNSCC).  A population-based analysis of 18,243 patients by Dr Yu-Shan Lin and colleagues from Taipei Medical University Hospital, Taipei, Taiwan; found that aspirin use was associated with 25% reduction in secondary primary cancer incidence of squamous cell carcinoma in head and neck cancer patients. This was attributed mainly to reduced risk of esophageal and stomach cancer.

The function of cyclooxygenase-2 (COX-2) inhibition has been recognized as major mechanism of chemoprevention for aspirin. Many growth factors and inflammatory cytokine known to promote cancer progression were produced, packaged and secreted by thrombocytes, such as platelet derived growth factor, vascular endothelial growth factor and transforming growth factor-β . The inhibition of COX-2 enzymes in thrombocytes results in blockade of synthesis of prostaglandins  from arachidonic acid.The downstream actions of PGE related with GF and cytokines plays essential roles in angiogenesis, cell proliferation and invasion. A platelet count of more than 400,000/μL was associated with higher mortality for patient with HNSCC and the poor prognosis could be overcome by antiplatelet medications.

Metformin (a sugar lowering agent) is a widely used for the treatment of type 2 diabetes mellitus. Metformin use in diabetic patients has been associated with decreased cancer incidence and mortality. This effect seems to result from a reduction in circulating insulin levels, but there are also data indicating direct anti-tumor effects of metformin. 

Several studies demonstrated that metformin is important in the inhibition of cell proliferation, G0/G1 cell cycle arrest, apoptosis and regulation of various proteins involved in cancer pathways, thus corroborating its potential in vitro and in vivo anti-tumor effects.

Three studies demonstrated that diabetics taking metformin had decreased rates of local and regional recurrence and metastasis and improved overall survival and disease-free survival rates. Individuals taking metformin had a lower incidence of HNSCC than those not taking metformin.  

Future studies are warranted to explore the use of aspirin and metformin in in the management of HNSCC patients.

Methods of speaking after laryngectomy

Allegra and colleagues from the  University of Catania, Catania, Italy compared the acoustic quality of the rehabilitated voice achieved with esophageal speech (ES) and tracheoesophageal speech (TES), and acoustic quality impacts on 67 laryngectomees.  The authors found a significantly better  functional voice performance in TES patients compared to ES.  However, there was no significant differences between the two groups in physical, emotional, and socioeconomic performance.

The authors concluded that the rehabilitation of laryngectomized patients must be addressed by a multidisciplinary team that considers the personalities, personal needs, and relational conditions of individual patients in order to determine and apply the phonatory rehabilitation method most suitable for achieving a better quality of life.

Comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer.

Patel et al. from  Boston University School of Medicine, analyzed the National Cancer Data Base  between 2003 and 2011 (published in Cancer,June 2019) comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer.

They identified 8703 patients with stage III/IV (excluding T1 tumors) laryngeal squamous cell carcinoma treated with chemoradiation (CRT) or partial laryngectomy (PL) and total laryngectomy(TL)  with or without adjuvant therapy.

The authors found that:

• Among patients with non-T4, low nodal burden (T2N1 or T3N0-N1) disease, no survival differences were observed between CRT, PL, and TL.
• Patients who had non-T4, high nodal burden (T2-T3N2-N3) disease who underwent TL with or without adjuvant treatment had a higher risk of death compared with those who received CRT.
• No statistically significant difference in outcome was noted between CRT and PL for all stage groups.   

The authors concluded that patients with non-T4, high nodal burden disease may benefit from definitive CRT. Total laryngectomy remains advantageous in patients with T4 disease.

Head and Neck Squamous Cell Carcinona ( HNSCC) is more common and advanced in those living with Human Immunodeficiency Virus (HIV)

Several studies showed that patients living with HIV have a 3 fold higher risk of developing all types of HNSCC including those associated with HPV despite anti-retroviral therapy. This may be because HIV+ patients have a higher rate of alcohol rate and tobacco rate, increased incidence of oral HPV infection and immune suppression ( low CD4 count).

Findings of several studies illustrated that :

• HPV infection is may be more prevalent in HIV+ patients.
• The  HIV  virus may have a direct oncogenic role in HHNSCC.
• HIV+ patients may present with HNSCC at a younger age and a higher stage.
• Lower CD4 count may predispose patients to HPV related HNCSCC.
• HIV + HNSCC+  have a poorer survival rates than HIV- HPV + .
• HNSCC patients who are HPV+ tend to have a more favorable outcomes regardless of HIV status.

As the number of aging HIV+ patients increases learning more the pathophysiology of HNSCC in these patients, outcomes, and ultimately tailored treatment to these unique patient population will become more important.

Use of nonsteroidal anti-inflammatory drugs improved patient survival for PIK3CA-altered head and neck cancer (HNC).

A new study by UC San Francisco and University of Pittsburgh has found that regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, significantly improves survival for a third or more patients with HNC. 

NSAIDs improved the overall 5-year survival rate from 25% to 78% for patients whose cancer contained a specific altered gene, known as PIK3CA. The survival for patients whose gene was not altered was unaffected by NSAID use.

PIK3CA is the most commonly altered oncogene in head and neck squamous carcinoma, and is found in a third of all tumors. In HNC associated with the human papillomavirus (HPV), PIK3CA is mutated in more than half of tumors.

The retrospective study included 266 patients. Most patients (67%) received post-surgery chemotherapy and/or radiotherapy. PIK3CA gene activating alteration was found in 28% in the patients. Among the patients who regularly used NSAIDs, 93% used aspirin (81mg/day) as a component of the NSAID regiment, and 73% took aspirin exclusively.

The investigators learned that regular use of NSAIDs for at least 6 months provided markedly prolonged improved survival compared to non-use for patients whose PIK3CAgene was mutated or amplified. In these patients, NSAIDs raised overall five-year survival from 25% to 78%. However, patients without alterations in their PIK3CA gene were no better off by taking NSAIDs.

This is the first study to show a strong clinical advantage of regular NSAID use for HNC patients with mutations in the PIK3CA gene and may indicate a clear, biological reason to implement NSAID therapy in certain cases of HNC patients

Through analysis of both cell line and mouse studies, the researchers speculated that NSAIDs likely blocked tumor growth by reducing the production of an inflammatory molecule called prostaglandin E2.

The researchers have designed a prospective, randomized clinical trial to address the study’s limitations (small numbers and retrospective nature of the study) to assess the clinical significance of this therapeutic use.