Palliative Care AAO-HNS Crse

Palliative Care in
Otolaryngology
Kenneth M. Grundfast, MD, FACS
Wednesday September 3, 2008
Palliative Care in Otolaryngology 1

Questions:
1. What is palliative care?
2. What is palliative care in
otolaryngology?
3. Why should we discuss
palliative care?

Palliative
Adjective
Moderating pain or sorrow by making it easier to
bear.
Noun
Remedy that alleviates pain without curing.
Source: WordNet 1.7.1 Copyright © 2001 by
Princeton University. All rights reserved.
Date "palliative" was first used in popular

English literature: sometime before 1657
Palliative Care
 Relieving symptoms without attempting to
cure the disease; often refers to treatment
of terminal disease
 Often linked with hospice care; American
Academy of Hospice and Palliative
Medicine (AAHPM)
 Can have an expanded scope – all care
that is not directed toward complete cure

Palliative Medicine
• A new ABMS medical specialty
• Many specialists were hospitalists,
oncologists, some intensivists,
pulmonologists, psychiatrists, a pediatric
otolaryngologist
• Hospitals are developing palliative care
teams
• Can request a consult from a palliative
care team
When to request a palliative
medicine consult.
 Current therapeutic regimen no longer
effective
 Cannot control disease
 Cannot alleviate symptoms
 Patient’s suffering cannot be alleviated
 Patient, family, physician having difficulty
coping
 Need advice, expertise in dealing with
issues of death and dying
Palliative Care for Surgeons
 American College of Surgeons has developed principles of palliative
care
 Principles Guiding Care at End of Life
 Statement of Principles of Palliative Care was endorsed when it
was recognized that palliative care is equally appropriate to

patients earlier in the course of illness, including those receiving
life-prolonging treatments.
 American College of Surgeons: Principles Guiding Care at End
of Life. Bulletin of the American College of Surgeons

1998;83:46.
 ACS Statement of Principles of Palliative Care. Bulletin of the
American College of Surgeons: 2005;90(8):34-35.

ACS Principles of Palliative
Care
 Respect the dignity and autonomy of patients, patients'
surrogates, and caregivers.
 Honor the right of the competent patient or surrogate to
choose among treatments, including those that may or
may not prolong life.
 Communicate effectively and empathically with patients,
their families, and caregivers.
 Identify the primary goals of care from the patient's
perspective, and address how the surgeon's care can
achieve the patient's objectives.
 Strive to alleviate pain and other burdensome physical
and nonphysical symptoms

Care
 Recognize, assess, discuss, and offer access to services
for psychological, social, and spiritual issues.
 Provide access to therapeutic support, encompassing
the spectrum from life-prolonging treatments through
hospice care, when they can realistically be expected to
improve the quality of life as perceived by the patient.
 Recognize the physician's responsibility to discourage
treatments that are unlikely to achieve the patient's
goals, and encourage patients and families to consider
hospice care when the prognosis for survival is likely to
be less than a half-year.

Care
 Arrange for continuity of care by the
patient's primary and/or specialist
physician, alleviating the sense of
abandonment patients may feel when
"curative" therapies are no longer useful.
 Maintain a collegial and supportive attitude
toward others entrusted with care of the
patient.
Core Competencies for Surgical
Palliative Care = Patient Care
 Possess the capacity to guide the transition from curative and
palliative goals of treatment to palliative goals alone based on patient
information and preferences, scientific and outcomes evidence, and
sound clinical judgment
 Perform an assessment and gather essential clinical information
about symptoms, pain, and suffering
 Perform palliative procedures competently and with sound judgment
to meet patient goals of care at the end of life
 Provide management of pain and other symptoms to alleviate
suffering.
 Communicate effectively and compassionately bad news and poor
prognoses
 Conduct a patient and family meeting regarding advance directives
and end-of-life decisions
 Exercise sound clinical judgment and skill in the withdrawal and
withholding of life support Care in Otolaryngology
Palliative 11
Palliative Care = Medical Knowledge
 Acute and chronic pain management
 Non-pain symptom management
 Ethical and legal basis for advance directives,
informed consent, withdrawal and withholding of
life support, and futility
 Grief and bereavement in surgical illness
 Quality of life outcomes and prognostication
 Role of spirituality at the end of life

Palliative Care = Practice Based Learning
 Recognize quality of life and quality of death and
dying outcomes as important components of the
morbidity and mortality review process
 Understand their measurement and integration
into peer review process and quality
improvement of practice
 Be skilled in the use of introspection and self
monitoring for practice improvement

Palliative Care = Professionalism
 Surgeons must maintain professional
commitment to ethical and empathic care, which
is patient focused, with equal attention to relief of
suffering along with curative therapy.
 Respect and compassion for cultural diversity,
gender, and disability is particularly important
around rituals and bereavement at the end of life.
 Maintenance of ethical standards in the
withholding and withdrawal of life support is
essential.
Karnofsky Performance Scale

Palliative Performance Scale
% Ambulation Activity and Self-Care Intake Conscious
Evidence of Level
Disease
100 Full Normal Activity Full Normal Full
No Evidence of
Disease
Some Evidence of
Disease
with Effort or
Some Evidence of Reduc
Disease ed
70 Reduced Unable Normal Job Full Normal Full
/ Work or
Some Evidence of Reduc
Disease ed
60 Reduced Unable Hobby / Occasional Normal Full or
House Work Assistance or Confusion
Significant Disease Necessary Reduc
ed
50 Mainly Unable to Do Any Considerable Normal Full or
Sit/Lie Work Assistance or Confusion
ExtensivePalliative
Disease Care in Otolaryngology
Necessary Reduc 16
ed
Palliative Performance Scale
40 Mainly As Above Mainly Norm Full or

in Bed Assistance a Drowsy
or or
Reduc Confusio
30 Totally As Above Total Care Reduc
ed Full
n or
Bed ed Drowsy
Bound or
20 As As Above Total Care Minim Confusio
Full or
Above al n
Drowsy
Sips or
10 As As Above Total Care Mouth Confusio
Drowsy
Above Care n
or
Only Coma
0 Death - - - -

Why discuss palliative care in
otolaryngology ?

otolaryngology ?
 Approximately 75% of patients seen in an
otolaryngology practice need no surgery;
usually, 4 office patients seen for every one that
needs a surgical procedure done
 Some conditions within the scope of an
otolaryngology practice have no known cure or
usual treatment is a mode of management
known to be only partially effective
 Cancer and benign tumors cannot always be
totally excised; surgery can cause dysfunction
otolaryngology ?
Advancements Advancements
in Otolaryngology in Palliative Care
What we need to
learn and know

Palliative Care in
Otolaryngology
 Otology-neurotology
 Hearing loss, tinnitus
 Head and neck oncology
 Cancer
 Laryngology
 Voice, swallowing
 Rhinology and allergy
 Intractable chronic rhinosinusitis

Concepts of cure
 Total cure
 Eradicate the condition / assure that the condition
does not recur = back to normal
 Partial cure
 Improve the condition / get better but not back to
normal
 Unattainable cure
 Medical and/or surgical management will not alter the
course of the condition or disease

Patient Expectations
 Alleviate symptoms
 Preserve function
 Preserve life
 Cope with the condition
and the situation

Surgeon’s Options
 Observe, explain, reassure, but
not actively intervene =
observation, watchful waiting
 Intervene with medical
management
 Intervene with surgical
management

What can an otolaryngologist
do for the patient if unable to
cure the condition that the
patient has?

57 year old
Vietnamese
man admitted to
Boston Medical
Center
September 8,
2007

Past history and exam
 PMH: Was seen initially in our clinic in May 2007
with two week history of lower right neck mass
that was non-tender, associated with change in
voice, seven pound weight loss in previous
month
 Smoked ½ pack cigarettes per day x 40 years + 2
beers per day
 Exam:
 Right supraclavicular 4.5x4.5 cm. Level 4 fixed mass
 Flexible laryngoscopy – normal cords, cord motion

Studies done in 2007
 CT thorax: “extensive bulky conglomerate
lymphadenopathy throughout the mediastinum
and right hilum and a parenchymal or
peribronchovascular mass in the medial aspect
of the right upper lobe.”
 CT of the neck with contrast: “Right
supraclavicular and anterior mediastinal nodal
conglomerates intimately associated with the
right brachiocephalic and proximal common
carotid arteries.”

Studies done in 2007
 PET scan: “mutifocal increased FDG-uptake
corresponding to the bulky supraclavicular,
mediastinal and hilar nodes as well as the right
upper lobe mass noted on CT scan. Additional
foci of increased FDG-uptake were present in a
small prevascular node and within the left lung
hilum, possibly indicating contralateral node
spread.”
 MRI scan: confirmed the presence of metastatic
disease in the brain.

Diagnosis and management
in 2007
 Fine Needle Aspiration of the supraclavicular node was
positive for metastatic moderately differentiated
adrenocarcinoma. The cytological changes and
immunohistochemical profile were consistent with a
primary lung tumor.
 Patient was diagnosed with stage IV non-small cell lung
cancer involving the neck and brain. He was referred to
Radiation Oncology and Medical Oncology for treatment
and was told to follow up with Otolaryngology if and
when the need arose.
 Had XRT and chemotherapy

Patient returns in
September 2008
 Chief complaint: sore throat, dysphagia, increasing
hoarseness, progressively worsening difficulty breathing
 ROS: cough, wheezing
 Exam:
 Cachectic, multiple enlarged cervical nodes both
sides of the neck; nodular thyroid

 NPL: bilateral immobile vocal cords with 2-3 mm
glottic opening
 Now biopsies demonstrate that he has metastases to
brain, thyroid, and inguinal lymph nodes

Consult Palliative Care Team
 Assist delivering bad news
 Experience comprehending patient’s cultural
beliefs
 Experience with family meeting, interpreting
family dynamics; healthy care proxy
 Deciding on limits of care
 Proceed to tracheotomy
 Supportive care, pain management,
hospice
Palliative Care in Otolaryngology
Otolaryngology Clinics of North America
Grundfast Kenneth M, Dunn Geoffrey P
February 2009

Tracheotomy near the end of life
 Important interface between palliative care

team and otolaryngologists
 Decision making far more complex and
difficult than the surgical procedure
 Specific indications and risks to be
considered in the patient who is near
death

Tracheotomy in Palliative Care
T.Chan + A. Devaiah
 Tracheotomy facilitates assisted ventilation in
patients with progressive neuromuscular
disorder such as ALS
 Provides comfort and ability to speak when
patient has been intubated for a long time and
likely will need continued assisted ventilation
 Helps in management of chronic aspiration,
improves pulmonary toilet
 A difficult choice near the end of life

Why would the patient who is
near death need to have a
tracheotomy?

Why would the patient who is near
death need to have a tracheotomy?
NOT A GOOD IDEA MAYBE A GOOD IDEA
 No need to intervene  Avoid death from
when interventions are suffocation
being curtailed  Avoid larynx
 Risks inherent in complications if life is
anesthetizing and prolonged
operating on morbidly ill  Provide increased
patient comfort
 Taking away a natural  Allows patient to speak
way to die with family members and
 Potentially limits options loved ones before dying
for further care and  Facilitate care and
placement / disposition placement

Rehabilitation after Cranial Base
Surgery – S. Jalisi + J. Netterville
 Cranial nerve 1: Permanent anosmia, caution not
to use cooking gas at home; noxious gas
detectors at home
 Cranial nerve 2: If orbital exenteration, then
prosthesis, depend on vision other eye
 Cranial nerve 3: If ptosis, levator muscle
tightening, insert weights in eyelid
 Cranial nerve 4: Visual training, eye muscle surg.
 Cranial nerve 5: Oral training for mastication,
movement food bolus, swallowing
 Cranial nerve 6: Yse refractive prisms
 Cranial nerve 7: hypoglossal to facial
anastamosis; temporalis or masseter muscle
transposition; gracilis free tissue transplant
 Cranial nerve 8: BAHA, CROS hearing aid
 Cranial nerve 9: assist with swallowing;
pharyngeal flap for V-P incompetence
 Cranial nerve 10: Swallowing therapy,
cricopharyngeal myotomy, phonosurgery

 Cranial nerve 11: Physical therapy
 Cranial nerve 12: Swallowing therapy
----------------------------------------------------
 Patients need to know prior to surgery the
functional impairments that are likely to occur
following surgery
 Total excision versus de-bulking of tumors
 All surgery today versus some surgery today

and more surgery later

When the tumor recurs after surgical
excision: S. Jalisi + A Elackattu
 Chemotherapy / radiation therapy
 De-bulking for symptom relief
 Management of fungating lesion, wound care ---
debridelment, dressings
 Microvascular free flap
 Mucositis – oral hygiene, oral care products
 Xerostomia - Vitamin C, saliva substitutes
 Cachexia – nutrition
 Hospice care, end of life orders
Refractory Chronic Rhinosinusitis
E. Mahoney + R. Metson
 Subset of patients with CRS continue to have
troublesome symptoms despite medical and
then surgical management
 “Sinusitis spectrum”: local disease and anatomic
factors versus systemic factors; the
“intermediates”
 Patients who fail initial medical/surgical therapy
need extensive medical assessment

Tips on Management of
Refractory Chronic Rhinosinusitis
 Neurology evaluation – rule out migraine, other
disorders
 Immuno-modulatory therapy – IVIG infusion
 Leukotriene inhibitors
 Aspirin de-sensitization
 Saline irrigations
 Longterm antibiotic therapy
 Topically administered antibiotic
 Antifungal therapy
 Discussions about changing expectations to
treatment
Recurrent Respiratory Papillomatosis
K. Johnson + Craig Derkay
 By definition, the disorder recurs
 Goal is airway and voice preservation
 Mainstay is repetitive surgical procedures
 Antiviral therapy
 Treat extra-esophageal reflux
 Immuno-therapy
 Birth canal, HPV vaccines
 Psychosocial considerations, family dynamics
Disorders of Swallowing
S. Langmore, G. Grillone, A. Elackattu, M. Walsh
 Surgical options – crico-myotomy,

tracheo-esophageal diversion, laryngeal
suspension, glottic closure
 Botox to control sialorrhea
 Change texture of feedings
 Enteral feeding
 Electrical stimulation, neural implant

 In consultation with the patient and caregivers,
determine what his/her priorities and wishes are
regarding prolonging life versus maximizing quality of
life. Is a feeding tube a viable option? Is aspiration-
preventing surgery an option? Is preventing aspiration a
high priority?
 Refer to a speech pathologist who specializes in
swallowing disorders for behavioral and dietary therapy.
Be sure that the speech pathologist understands the
patient's priorities in terms of quality of life, health, and
preventing aspiration.

 Continue to work with a speech pathologist as the
disease/condition worsens as long as the patient is
eating anything orally or has hopes of eating anything
orally. Rehabilitative techniques will evolve toward
compensatory techniques as the patient’s condition
worsens
 Feeding tubes and tracheostomy tubes are not always
maximally helpful for intractible dysphagia. They may
help or worsen the swallowing problem and may not
entirely avoid the risk of developing pneumonia. They
should be considered 'last resorts' not the first solutions.

Dysphonia and Dysarthria
S. Cohen, A. Elackattu, P. Noordzij,
M. Walsh, S. Langmore
 Voice, speech therapy
 Alaryngeal speech / TE speech
 Phonosurgery
 Presbyphonia:
 Voice therapy
 Bilateral medialization laryngoplasty

Tinnitus
A. Shulman + B.Goldstein
 “Tinnitology”, a new discipline
 Wide range in severity and ability to cope
 T T T= tinnitus targeted therapy = combination of
medication + instrumentation such as tinnitus masker
 MATP= medical audiologic tinnitus patient protocol;
Feldman masking curves
 Transcortical magnetic stimulation
 Surgery for otosclerosis
 Medication: Klonopin + / - Neurontin
 Alternative therapies: Ginko, acupuncture, etc
Anosmia
D. Lafreniere + N. Mann
 Occurs in the elderly, like presbycusis, can
be associated with Alzheimer’s Disease,
Parkinson’s Disease
 No specific treatment; zinc and alpha
lipoic acid have been tried
 Need to counsel patient – take steps to
avoid asphyxiation from carbon monoxide
or other noxious gases

Chronic Subjective Dizziness (CSD)
M. Ruckenstein + J.P. Staab
1. Persistence > 3 months of symptoms including
one or more of the following:
 Chronic lightheadedness
 Heavy-headedness
 Subjective imbalance frequently not apparent to others
 Feeling that “inside of the head” is spinning with
absence of perception of movement in the visual
surround
 Feeling that the floor is moving underneath
 Feeling of being detached from one’s environment
Chronic Subjective Dizziness (CSD)
M. Ruckenstein + J.P. Staab
1. Chronic hypersensitivity to one’s own
motion and/or to movement of objects in
the environment
2. Exacerbation of symptoms in settings
with complex visual fields such as
grocery stores or shopping malls or
when performing precision visual tasks
such as working at a computer
CSD Association with other disorders
 Anxiety
 Migraine
 Traumatic brain injury
Treatment of CSD
 Psycho-education
 Medications: SSRI’s
 Behavioral interventions
Tips on Management of CSD
 Educate to the patient about how malfunction
within the brain can cause symptoms
 Address any underlying anxiety disorder with
psychotherapy, medications including
antidepressants and anxietolytics, either alone or
in combination with each other
 Teach patient how to access information using
the internet. Vestibular Disorders Association
 Let the patient know that you and your team are
and will be easily accessible to provide support
Vestibular Rehabilitation
C.D. Hall + L. Clarke Cox
 Goal: reduce subjective symptoms, improve gaze and
postural stability particularly during head movements
 Mechanisms:
 Habituation – long lasting attenuation of a response to
a provocative stimulus
 Adaptation – remaining vestibular system adjusts
output according to demands placed on it
 Substitution – substitute alternative strategies for
missing vestibular function; visual clues instead of
vestibular input

Progressive hearing loss
A. Kozak + K. Grundfast
 Progressive hearing loss can be frightening
 Some medical treatments but none are reliably
effective; no diagnostic test for AIED, try steroids
= steroid responsiveness methotrexate
 BAHA, CROS hearing aid, assisted listening
devices, pocket talker, cochlear implant
 Career counseling, family counseling, assisting
with life changes
 Preserve hearing in the unaffected ear

Managing Intractable Head and Neck Pain
Abdel-Kader MehioM.D., Swapneel K. Shah,M.D.
DERMATOMES

Tips on Managing Head and Neck Pain
Abdel-Kader Mehio M.D., Swapneel K. Shah,M.D.
 Stepwise progression:
 Anti-inflammatory meds (steroids) > pulsed
radiofrequency> ablative procedures
 “Intravenous rescue” = lidocaine infusion,
magnesium infusion, metoclopramine infusion
 Regional blocks
 Physical therapy, acupuncture
 Refer to Pain Management Team

Keep this in mind:
Hippocrates said:
“A physician should aim to cure, heal
as often as possible, but comfort
always”

Conclusions
 Palliative Medicine is a newly approved
medical specialty
 Growing numbers of hospitals are now
developing palliative care teams
 Principles of palliative care are applicable
to the practice of otolaryngology
 Palliative care is not only for the dying
patient at the end of life

Palliative Care AAO-HNS Crse

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Palliative Care in

Palliative Care in Otolaryngology 1

Palliative Care in Otolaryngology 2

Date "palliative" was first used in popular

Palliative Care in Otolaryngology 4

 Statement of Principles of Palliative Care was endorsed when it

was recognized that palliative care is equally appropriate to

of Life. Bulletin of the American College of Surgeons

Palliative Care in Otolaryngology 7

Palliative Care in Otolaryngology 8

Palliative Care in Otolaryngology 9

Palliative Care in Otolaryngology 12

Palliative Care in Otolaryngology 13

Palliative Care in Otolaryngology 15

40 Mainly As Above Mainly Norm Full or

Palliative Care in Otolaryngology 17

Palliative Care in Otolaryngology 18

Palliative Care in Otolaryngology 20

Palliative Care in Otolaryngology 21

Palliative Care in Otolaryngology 22

 Cope with the condition

and the situation

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Palliative Care in Otolaryngology 27

Palliative Care in Otolaryngology 28

Palliative Care in Otolaryngology 29

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sides of the neck; nodular thyroid

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 Important interface between palliative care

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 All surgery today versus some surgery today

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 Surgical options – crico-myotomy,

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