Oropharyngeal Health After Cancer: What Every Laryngectomy Should Know

1. Oropharyngeal Health After Cancer: What Every Laryngectomy Should Know Katrina M. Jensen, M.A., CCC-SLP Director, Medical Speech Pathology Privia Medical Group of North Texas Texas Health Care, PLLC Otolaryngology & Facial Plastic Surgery Associates

2. Disclosures I am employed by Texas Health Care, PLLC as the Director of Medical Speech Pathology. I am a collaborative investigator with MD Anderson through the Cancer Prevention & Research Institute of Texas for which I receive a grant stipend. I serve as a clinical consultant for Medtronic, GI divisionfor which I receive compensation.

3. Xerostomia:It’s More Than Just Dry Mouth • Salivary flow/production may be adequate for deglutition • Submandibular gland is frequently impacted by radiation treatment

4. Concerns Beyond Oral Comfort: • Dental/Gingival Health • Dysguesia • Mucosal Integrity • Aerodigestive Chemistry

5. Dental/Gingival Health • Enzymatic function of saliva on “biofilm” • Protects enamel from plaque; diminished tartar • Dry gums=capillary death; gum retraction • Increased sensitivity • Increased caries, risk of tooth death • Increased risk for mandibular infection

6. Dysguesia • “Taste Buds” • Nerve receptors on tongue surface • Need moisture to stimulate • Prolonged dryness linked to nerve damage • Burning tongue • Altered perception • Disabled receptors

7. Mucosal Integrity • Delicate surface tissue • Thin cellular surface layer • Saliva acts as surfactant/ “protector” • Responsible for oropharyngeal proprioception • Prone to infectious process without adequate surfactant

8. Aerodigestive Chemistry • Saliva is nature’s lubricant • The original “probiotic” • Enzymatic breakdown of biofilm • Bicarbonate effect • Increased potential for acid reflux damage • Less saliva translates to less bacteria • yeast proliferation

9. Optimizing Oral Health • Focus has been on oral comfort • Need to marry comfort with chemistry • Optimize natural saliva production • Adequate hydration • Gum • Xyletol candy/lozenges

10. Optimizing Oral Health • Dental Hygeine • Bicarbonate rinse • May be used as often as desired • Helpful to use prior to meals to improve taste • Keffir cultures • Yogurt • Avoid capsules

11. Optimizing Oral Health: Overnight • Humidification • Needs to be at bedside table • Xylomelt • Bicarbonate rinse at bedside • Water at bedside

12. Optimizing Pharyngeal Health • Yeast and Acid are two biggest culprits • Pharyngeal irritation/damage • Can extend throughout esophagus • TEP implications • Alkaline Water • Dental Hygeine • Active Yogurt cultures • Minimize yeast products

13. THC Research Data • 1 year study (2nd year ongoing) • 202 H&N patients (53 TL) (101 control) • Oral Health Protocol • Twice daily brushing • 3x/day bicarbonate rinse • Alkaline water • Nightly humidification • Yeast Elimination • 2 daily yogurt products

14. THC Research Data • 101 H&N patients: 26 TL • 74 reported excellent compliance (20TL) • 6-7 days/week followed protocol • 7 reported moderate compliance (1TL) • Missing 1-2 elements 6-7 days/week • Excellent compliance 3-5 days/week 20 patients with poor compliance (5TL)

15. THC Research Data • 81 patients with excellent or moderate compliance were compaired to controls: • Oral comfort (Likert scale) • Dental Caries • Dysguesia • Thrush infections • Device lifetime(21 TL)

16. THC Research Data • Oral Comfort (1-5; 1=extreme discomfort/pain; 5=no issue) • Baseline mean 2.7 • Program compliance mean 3.5 • Dental Caries • Control: 322 • Program Compliance: 108 • Dysguesia (1-5; 1=no taste; 5=normal) • Baseline Mean: 3.7 • Program Compliance: 4.4 • Thrush Infections • Control: 237 • Program Compliance: 41 • Device Lifetime (21TL) • Control: 114 days • Program Compliance: 186 days

17. Translation: Optimized oropharyngeal health can serve to improve quality of life, may assist in preventing illness and reduce cost associated with care.

18. References • Agrawal, N., & Goldenberg, D.Primary and salvage total laryngectomy. Otolaryngology Clinics of North America, 2008;41, 771-780. • Bajaj, Y., Shayah, A., Sethi, N., Harris, A. T., Bhatti, I., Awobem, A., Loke, D., & Woodhead, C. J. Clinical outcomes of total laryngectomy for laryngeal carcinoma. Kathmandu University Medical Journal, 2009; 7(3), 258-262. • Balfe, D. M., Koehler, R. E., Setzen, M., Weyman, P. J., Baron, R. L., & Ogura, J. H. Barium examination of the esophagus after total laryngectomy. Radiology, 1982;143, 501-508. • Belafsky P.C., PostmaG.N., Amin M.R.,Koufman J.A., Symptoms and findings of laryngopharyngeal reflux. Ear Nose Throat Journal, 2002;81(9 Suppl 2): 10-13. • Choi E.C., Hong WP, Kim CB, et al. Changes of esophageal motility after total laryngectomy. Otolaryngol Head Neck Surg.,2003;128:691-699. • Chu, E. A., & Kim, Y. J. Laryngeal cancer: Diagnosis and preoperative work-up. Otolaryngology Clinics of North America, 2008; 41,673-695. • Crary, M. A., & Glowasky, A. L. Using botulinum toxin A to improve speech and swallowing function following total laryngectomy. Archives of Otolaryngology-Head and Neck Surgery, 1996; 122, 760-763. • DennishG.W., Castell D.O. Inhibitory effect of smoking on the lower esophageal sphincter. New England Journal of Medicine,1971;284: 1136-1137. • Eerenstein, S. E., Grolman, W., and Schouwenburg, P. F. Microbial colonization of silicone voice prostheses used in laryngectomized patients Clin.Otolaryngol.Allied Sci., 1999; 24[5], 398-403. • Hoffman, H.T., Fisher H., Vandenmark D., Peterson KL, McCulloach T.M., Karnell L.H., and Funk G.F. Botulinum neurotoxin injection after total laryngectomy. Head and Neck 1997;19(2):92-7. • Jensen, K.M., Ducic, Y., Thompson, A.M., Garcia, F., Reflux surgery and it’s impact of voice restoration following total laryngectomy, Poster presentation American Sp Lang Hear Assoc, 2012 Ann Conv. • JobeB.A., Rosenthal E, WiesbergT.T., Cohen J.I., DomreisJ.S., DeveneyC.W., Sheppard B. Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech. Amer J of Surg2002;183:539-543. • KoufmanJA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice and swallowing disorders of the American academy of otolaryngology-head and neck surgery. Otolaryngol Head Neck Surg 2002; 127:32-34. • Lorenz KJ, Grieser L, Ehrhart T, Maier H. The management of periprosthetic leakage in the presence of supra-oesophageal reflux after prosthetic voice rehabilitation. Eur.Arch.Otorhinolaryngol., 268[5], 695-702. 2011. • Lorenz KJ, Grieser L, Ehrhart T, Maier H. Role of reflux in tracheoesophageal fistula problems after laryngectomy. Ann Otology, Rhinology & Laryngology 2010;119 (11):719-718 • Minjarez, RC; Jobe BA. Surgical therapy for gastroesophageal reflux. GI Motility online. Doi:10.1038/gimo56 (i2008-06-21). • Pattani KM, Morgan M, Nathan CO. Reflux as a cause of tracheoesophageal puncture failure. Laryngoscope 2009;119: 121-125. • Ramachandran, K., Arunachalam P.S., Hurren A., Marsh R.L., Samuel P.R. Botulinum toxin injection for failed tracheo-oesophageal voice in laryngectomees: the Sunderland experience. J Laryngol Otol., 2003;117(7):544-8. • SmitCF, Tan J, Lisbeth MH, et al. High incidence of gastropharyngeal and gastroesophageal reflux after total laryngectomy. Head Neck 1998;20:619-622. • Varghese B.T., Mathew, A. Sebastian S., Iype, E.M., Sebastian P., Rajan, B. Objective and perceptual analysis of outcome of voice rehabilitation after laryngectomy in an Indian tertiary referral cancer centre. Indian J Otolaryngol Head Neck Surgery, 2013; 65(Suppl 1):150-4. • Welch RW, Luckmann K, Ricks PM, Drake ST, Gates GA. Manometry of the upper esophageal sphincter and its alteration in laryngectomy. J Clin Invest 1979;63:1036-1041.

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