Laryngeal Cancer Darrick StiffGraduate Student ClinicianPacific University

What is Laryngeal Cancer? www.cancer.gov

•Laryngeal cancer is the growth of malignant cells that are found in the tissues of the larynx.

Risk factors Carncer Research UK: http://www.cancerresearchuk.org/home/

•Alcohol•Tobacco•Diet•Medical conditions and infections•Previous cancer•Family history •Occupation and indoor air pollution

Signs and Symptoms of Laryngeal Cancer

www.cancer.net

•Hoarseness or changes in vocal quality•Airway obstruction/difficulty breathing•Noisy breathing•Odynophagia (painful swallow)•Fatigue•Unexplained weight loss•Choking (penetration or aspiration of

bolus)•Chronic bad breath

Team members Winship Cancer Institute: https://winshipcancer.emory.edu/Default.aspx

•Patient and their family•Speech Pathologist •Dietician•Respiratory Therapist•Physician•Oncologist-Cancer Specialist•Otolaryngologist – Head and Neck surgeon•Nurse(s)•Certified Nursing Assistants (CNA)•Psychiatrist

Methods of Initial Diagnosis of Laryngeal CancerWinship Cancer Institute: https://winshipcancer.emory.edu/Default.aspx

• Physical examination externally for tactile evidence abnormal growth in the larynx.

• Endoscopy for visible evidence of abnormal growth in the larynx.

• Laryngoscopy is a low tech option using a light and mirror to look down into the larynx for visual confirmation of abnormal growth.

• CT, MRI and Barium Swallow allow a multi-dimensional view of any abnormal growth of tissues in relation to typical anatomical structures.

Methods of diagnosisMD Anderson Cancer Center: http://www.mdanderson.org/

•Blood tests- some tumors release substances called tumor markers that can indicate if the tumor is malignant. These tests are often inconclusive and further testing should be done to confirm.

•Biopsies can be taken from the tumor to give confirmation that growth is malignant by a pathologist.

Surgical Treatment Options National Cancer Institute: http://www.cancer.gov/

• Cordectomy- removal of the vocal folds• Supraglottic laryngectomy- removal of the area

above the larynx ONLY.• Hemilaryngectomy- removal of half the larynx,

preserving the Pt. voice.• Partial larygectomy- partial removal of the larynx in

effort to save Pt. voice. • Laser surgery- often a CO2 laser used to make

bloodless cuts to remove tissue and surface lesions.• Total laryngectomy- complete removal of the larynx

Review of anatomy

Communication options for total laryngectomy.•Writing •Alternative and Augmentative

Communication (AAC)•Mouthing words•Gesturing•American Sign Language (ASL)•Electro larynx (EL)•Tracheoesophageal puncture (TEP) or

surgical voice restoration (SVR) (Evans, Carding & Drinnan, 2009).

Why TEP? (Hinni & Crujido 2013)

•Total laryngectomy is often much easier to perform than more technical procedures like hemilaryngectomy in the United States.

•Total and near-total laryngectomy are still viable life saving options in spite of advances in both laryngeal surgery and chemoradiation.

•Partial laryngectomy are used more for Pt. in areas where healthcare is not as readily available, and costs less to maintain long term when compared to TEP.

Role of the SLP(Hinni & Crujido, 2013)

• Preoperative- Meeting with Pt. to answer questions, explaining differences in anatomical structure using diagrams and models, explaining the importance of having a functional communication system postoperatively and potential communication systems.

• Postoperative- Valve/heat moisture exchange (HME) insertion, replacement, establishment of a functional communication system, Modified barium swallow (MBS), valve adjustment to maintain function and reduce leakage into the trachea.

• Video

Tracheo-Esophageal Puncture

http://www3.imperial.ac.uk/cpd/courses/ subject/medical/svr

Types of TE valves (Balm, van den Brekel, Tan, Hilgers, 2011)

• TE Valves are classified by who is inserting the valves (Balm, van den Brekel, Tan, Hilgers 2011).

• Indwelling valves are removed and inserted by a licensed SLP (Balm, van den Brekel, Tan, Hilgers, 2011).

• Non-indwelling valves are maintained by the individual using the valve (if possible) (Balm, van den Brekel, Tan, Hilgers, 2011).

• These valves are made by many of the companies who make tracheostomy tubes and speaking valves.

Let’s Give it a Try!

I brought some inspiration for your respiration!

Let’s try some alaryngeal speech.

Swallowing Complications (Hinni &

Crujido 2013)

•IT DEPENDS…•Build up of fungus around the the valve in

the esophagus.•Enlargement of the puncture site.•Leakage into the trachea increasing the

risk of aspiration pneumonia due to improperly fit valve.

Leakage Leakage of the valve can indicate:• The end of life of the valve • Insufficient valve seal (Balm, van den Brekel, Tan,

Hilgers, 2011). • Atrophy of the tracheoesophageal wall• Enlargement of the puncture site (Hinni & Crujido,

2013) risks of this are increased with:- advance nodal disease-post-operative stricture (narrowing of the

esophageal passage).-locoregional recurrence or metastatic disease-Gastroesophageal Reflux Disease(GERD) (Balm,

van den Brekel, Tan, Hilgers, 2011).

Treatment of enlarged fistula(Hinni & Crujido, 2013)

•Purse string suture •Silicone washer (non surgical)•Shrinking•Augmentation of the party wall•Closure of the fistula and secondary

fistula created.•Medications to treat GERD

Speech complications with TE valve(Hinni & Crujido 2013)

•“Pistoning” of the the valve • Enlargement of the puncture site.•Increased resistance of the valve

*Electro larynx instructions should be given to Pt. with total and non-total laryngectomy in case of valve failure.*

Compensatory Strategies

•Dependent on the type of surgery they may include:

•Supraglottic swallow•Dry swallows•Super-supraglottic swallow•Pharyngeal Expectoration (hock it up)•Check Vocal quality after the swallow•Diet and texture modifications

Potential Future Speech treatment (Kubert et. Al 2009)

•Hands free Electro-Larynx (EL) uses electromyography of the recurrent laryngeal nerve (RLN) to change pitch forEL users.

Device to increase patient participation

•The larkelis a way thatIndividuals with laryngectomy and tracheostomy can stillparticipate in water activities

Patient Patience• Individuals dealing with cancer can be overwhelmed

with the large of amounts of information, grief, pain, and many other changes that have occurred which have been placed on them very quickly.

• They often need time to deal with these major changes.

• Speech-Language Pathologists are called to provide all communication options, their pros and cons of each method.

• Information should also be given to express the importance of having a reliable and functional communication system

ReferencesBalm, A. J., van den Brekel, M., Tan, I., & Hilgers, F. (2011). The

indwelling voice prosthesis for speech rehabilitation after total laryngectomy: A safe approach. Otolaryngologia Polska, 65(6), 402-409.

Evans, E., Carding, P., & Drinnan, M. (2009). The voice handicap index with post-laryngectomy male voices. International Journal of Language & Communication Disorders, 44(5), 575-586.

Hinni, M., & Crujido, L. (2013). Laryngectomy rehabilitation: A perspecitve from the united states of america. Current Opinion in Otolaryngology & Head and Neck Surgery, 21(3).

Kubert, H., Stepp, C., Zeitels, S., Gooey, J., Walsh, M., Prakash, S., . . . Heaton, J. (2009). Electromyographic control of a hands-free elextrolarynx using neck strap muscles. Journal of Communication Disorders, 42, 211-225.

Logeman, J. (1998). Swallowing disorders after treatment for laryngeal cancer. Evaluation and treatment of swallowing disorders: (2nd ed., pp. 281-301). Austin, TX: Pro Ed.