Integrating Palliative and Curative Care Strategies in the Practice of Otolaryngology

Key Points

The goal of palliative care is to provide relief of suffering regardless of life expectancy or treatment status.
Palliative care requires a multidisciplinary approach to address the physical, emotional, and spiritual distress that a patient may be experiencing.
Palliative care is now a medical specialty in its own right with services at most hospitals.
Palliative care modalities include surgery, chemotherapy, radiation therapy, assorted pharmacologic interventions, and mind-body therapies to relieve discomfort.
Palliative chemotherapy protocols are evolving with the newer immune checkpoint inhibitors that are being actively studied in clinical trials.
Integrative or complementary medicine overlaps palliative care and has arisen because many patients seek out relief when none is forthcoming in the conventional setting.
Medical marijuana is now legal in many countries around the world and in 33 states and the District of Columbia in the United States. It may be smoked in the plant form or used in synthetic preparations for the relief of nausea and vomiting during chemotherapy treatment, for the treatment of anorexia and weight loss in patients with AIDS, and to relieve spasticity in patients with MS.
Acupuncture is a traditional Chinese medicine technique that has been shown to have efficacy in dysphagia, pain, xerostomia, lymphedema, and psychologic distress.
Pain affects most head and neck patients at some point, and adequate pain relief is considered a fundamental human right. Pain should be treated in a stepwise fashion based on the patient's subjective reporting of intensity.
Oral mucositis is a common, painful, and usually self-limited side effect of radiation therapy that can contribute to dysphagia and malnutrition during treatment.
Cachexia is a condition of severe weight loss, muscle wasting, and loss of fat that is not reversed by increasing caloric intake. It appears to be mediated by inflammatory cytokines and can be an independent risk factor for death.
Dysphagia is common in head and neck cancer patients and puts the patient at risk for malnutrition and aspiration. It should be assessed during the diagnostic workup to implement nutritional support and swallowing therapy early.

Palliative care is the provision of care that provides relief of suffering and the maintenance of quality of life for patients with advanced illness regardless of life expectancy. Hospice care is a form of palliative care that is offered at the end of life with the goal of relieving discomfort, maintaining dignity, and facilitating the transition for the patient and family. Palliative care is relevant to any stage of serious illness and may be provided at the same time as curative therapies. Palliative care can relieve the symptoms of the disease process itself or it can relieve side effects from the therapies that typically include surgery, radiation, and chemotherapy, sometimes given in combination. The relief of suffering requires empathy on the part of the clinician to anticipate the myriad stresses and needs of the patient undergoing cancer care, as well as an integrated multidisciplinary approach. Palliative care practitioners can help patients and their families better understand their illness and express what is most important to them, particularly as illness or treatment side effects progress. Palliative care is now a medical specialty, and palliative care services are available in approximately 75% of hospitals with more than 50 patient beds.

This chapter discusses the treatment modalities that can be considered palliative. For the head and neck cancer patient, these include, but are not limited to, surgery, radiation therapy, chemotherapy, pain management, nutritional support, swallowing and speech therapy, psychologic support, and miscellaneous pharmacologic interventions and alternative therapies to alleviate radiation-induced mucositis, xerostomia, and dysphagia.

Palliative Surgery

Palliative surgical procedures in head and neck cancer patients often comprise measures that not only provide relief but also extend life despite the persistence of disease. Examples include debulking of a tumor that causes compressive symptoms, tracheostomy for airway obstruction by a tumor, and vascular stenting or embolization in the event of bleeding from tumor erosion of larger vessels, including carotid artery. In some instances, reconstructive procedures may be indicated to close a persistent radiation-related fistula or cover an exposed carotid artery. In these situations, the least invasive procedure should be chosen to accomplish the respective goals of restoring swallow function, covering an open wound, or preventing a carotid artery blowout. Dysphagia is common in head and neck cancer patients, and esophageal dilation or percutaneous gastrostomy (PEG) tube placement are common procedures to restore nutrition, during and sometimes after treatment. Surgery for voice restoration when there is true vocal cord paralysis secondary to recurrent laryngeal nerve invasion by tumor or iatrogenic damage from surgery in the neck or skull base can have a profound impact on quality of life by restoring a patient's ability to communicate with family and prevent or treat aspiration. Injection laryngoplasty is a simple and quick intervention for voice restoration that can now be done in the office on an awake patient with relatively low risk and morbidity. The use of hydroxyapatite can give relief for approximately 1 year, and hyaluronic acid injection can provide relief for a shorter period. Medialization thyroplasty with silastic or Gore-Tex implant can provide more permanent vocal restoration. In deciding on an intervention, it is helpful to consider the anticipated course of disease and likely survival time. In my practice, I have performed a series of palliative total laryngectomies for nonfunctional larynges after successful but highly morbid laryngeal sparing concurrent chemotherapy with radiation. After treatment, these patients had persistent severe dysphagia and/or aspiration despite interventions to relieve esophageal obstruction. Typically, they also had strained voicing and airway insufficiency requiring tracheostomy. In these patients, total laryngectomy with placement of tracheoesophageal prosthesis restored swallow ability with reasonable voicing using esophageal speech and provided a safer airway. Sometimes the distinction between palliation and therapy is blurred, and sometimes palliative surgery can prolong life or even be curative.

Consider the case of a 90-year-old man with a T3N0M0 glottic carcinoma who initially refused definitive therapy. He was treated with palliative radiation therapy delivered in low doses to manage airway symptoms. This resulted in a poorly functioning larynx with a strained and barely audible voice, respiratory insufficiency that interfered with his favorite activity, dancing, and poor swallowing function making him dependent on a PEG tube for adequate nutrition. He continued to refuse a total laryngectomy as a potentially curative measure until it was explained to him that this, in combination with a tracheoesophageal puncture and prosthesis, would also palliate his major complaints related to voicing, breathing, and eating. Following total laryngectomy, the patient was disease free, symptom free, and back on the dance floor.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here