Ms. Clarke provides an excellent overview of the rehabilitation process for the head and neck cancer patient. She highlights pretreatment and posttreatment rehabilitation issues and details the nature of each multidisciplinary intervention. I concur with the rehabilitation process that she describes and second the importance of multidisciplinary interventions beginning prior to treatment.
Patients with head and neck cancer face a range of problems with speech, swallowing, respiration, and cosmesis, as well as the psychosocial implications of those problems. Whether the treatment protocol includes surgery or radiotherapy plus or minus chemotherapy, treatment can result in significant changes in the patients functional abilities. As Weiss has stated in an editorial in OtolaryngologyHead and Neck Surgery:
I know that the larynx preservation protocol is extremely hard on the patient, may not culminate in larynx preservation after all the effort, and indeed may not be equally efficacious with respect to survival when compared with standard treatment for tongue and hypopharynx primaries. I also know that many laryngectomees are rehabilitated well and cope beautifully. I share this knowledge with the patient, but it rarely deters him or her from choosing the larynx preservation option. The patients perception of the quality of life governs the entire decision....
We all heartily endorse the goal of preserving the patients life, and when the choice is a stark onebetween aggressive therapy on the one hand and certain death on the otherthen the choice is clear for the physician. But the choice is rarely so stark. Quality of life counts for a great deal in the patients minds. It should matter just as much to us.
That eloquent discussion indicates that the patients functional status must be considered when planning and executing treatment for head and neck cancer. The Clarke manuscript underscores this critical issue. Clarke describes the need for active, multidisciplinary rehabilitation planning and integration of services prior to, during, and after treatment.
Although many of us have advocated this type of intervention for the past 15 to 20 years, the development of managed care has interfered dramatically with the multidisciplinary team process, as described by Clarke. Managed care has made it difficult to accomplish pretreatment teaching and even a great deal of the posttreatment rehabilitation, especially by the team of professionals required by the head and neck cancer patient. The amount of time needed for rehabilitation for the head and neck cancer patient is often lengthy, and managed care often does not approve of such prolonged rehabilitation.
Unfortunately, those of us involved in rehabilitation of head and neck cancer patients over the past 15 to 20 years have not collected enough data supporting the need for the interdisciplinary approach. A number of studies on individual interventions have been completed, but few investigations have examined the team approach described by Clarke. It is critical that we perform such studies to ensure that the head and neck cancer patients rehabilitation needs are not forgotten or excluded from third-party coverage.
I would like to highlight some of the key issues raised by Clarke and to identify several controversial points in the manuscript.
Role of Tumor Board in Planning Treatment and Rehabilitation
The role of the tumor board is increasingly important as a setting in which all professionals can meet to develop the treatment plan in light of the patients psychosocial and functional needs, as well as to plan the rehabilitation schedule. The tumor board meeting alerts all team members to the patients needs so that they can attempt to complete their interventions prior to the onset of treatment. All of the rehabilitation professionals should participate in that tumor board, including the speech-language pathologist, social worker, and dentist/maxillofacial prosthodontist.
Clarke discusses the pretreatment assessment by the dentist for extractions, but an additional comment is needed regarding pretreatment planning for any possible prosthetic intervention posttreatment. Many patients have dental extractions pretreatment without consideration of the need to save selected teeth in order to have successful posttreatment intraoral prosthetic intervention. Whenever possible, the pretreatment counseling of a total laryngectomy candidate should include the speech-language pathologist so as to ensure that the patient is aware of the various communication options, as described by Clarke.
With managed care, most patients enter the hospital on the day of their initial treatment (whether surgery or radiation), and there is little time for even a day of pretreatment teaching. However, that teaching is critical so that the patient can more successfully adapt to the changes wrought by the treatment. The tumor board meeting can be used to schedule prehospitalization times for the patient to receive some preoperative teaching.
Management of the Tracheostomy and Tracheostomy Cuff
Two controversial areas involve management of the tracheostomy and the tracheostomy cuff in relation to swallowing rehabilitation. Clarke indicates that after surgery, a cuffed tracheostomy is used initially with an inflated cuff to prevent aspiration. Typically, we prefer to have the cuff deflated as much as possible so as not to irritate the tracheal walls and to allow better laryngeal movement during swallowing attempts. If the tracheostomy cuff is fully inflated to completely eliminate any aspiration of saliva, it will be overinflated and in complete contact with the tracheal wall, definitely restricting laryngeal motion during swallowing.
Decannulation of the temporary tracheostomy in the head and neck cancer patient is another controversial point. In the rehabilitation of swallowing disorders, if a patient is chronically aspirating his or her own secretions or the food used in swallow therapy, the tracheostomy is left in place to ensure better pulmonary toilet. Once the patient has reestablished functional swallowing with no aspiration, the tracheostomy is eliminated. Thus, in our center, tracheostomy removal or decannulation depends on a return to normal swallowing. We have not seen any patient whose swallowing rehabilitation was compromised by the tracheostomy.
Rehabilitation Needs of Nonsurgical Patients
Most of Clarkes discussion focuses on surgical patients. Recently, organ-preservation protocols utilizing high-dose radiotherapy and chemotherapy have produced severe swallowing abnormalities. Often, the patient is unable to move any food through the mouth or pharynx and requires aggressive rehabilitation. Generally, the rehabilitation pattern of choice in the irradiated patient consists of pretreatment counseling, initiation of exercises to preserve range of motion in the pharynx, and posttreatment reassessment and continued therapy.
Postoperative learning of self-care is critical to the head and neck patients feelings of self-esteem and independence. Unfortunately, here again, managed care has interrupted that self-teaching process, often causing the patient to leave the hospital 4 to 5 days after surgery and allowing minimal time for teaching of self-care. Good communication between the acute-care nursing staff and the home-care nursing staff is critical to ensure that the self-care regimen is reinforced and continued when the patient is at home.
In discussing the supraglottic laryngectomy, Clarke describes the supraglottic swallow as involving bearing down to close the vocal folds. In fact, the supraglottic swallow involves a gentle breath-hold to close the vocal folds, whereas the super supraglottic swallow involves bearing down while holding the breath to close the airway entrance.[5-7] This is a critical difference for the supraglottic laryngectomee, who needs therapy directed at closing the space between the remaining tongue base and arytenoid cartilage, which, together, form their reconstructed airway entrance.
In summary, the Clarke article presents an excellent overview of the optimal rehabilitation process for the head and neck cancer patient, whether treated by surgical procedures or radiotherapy. Although there are some areas of controversy and additional details could have been included, the article provides community physicians, who may see a smaller number of head and neck cancer patients, with an excellent road map for establishing optimal rehabilitation for their patients and for obtaining the necessary referrals to other professionals to offer the multidisciplinary rehabilitation approach.