DOC I HAVE LARYNGEAL CANCER

Cancer of the larynx are not that common in a family practice however there are fairly many cases in the ENT Department.

The only patient I saw in my clinic was a elderly man with loss of voice at the age of 55. He was referred to the ENT department after medication did not improve his voice. There a biopsy of the swelling in the larynx  show evidence of early cancer. He was treated by surgical removal of the swelling followed by radiotherapy. Happily he was well after the treatment except for still some hoarseness of the voice but there was no recurrence of the cancer.

The cases in the ENT department were different. Most have extensive surgery with tracheostomy. There has to be proper care of the tracheostomy. In most cases the tracheostomy can be closed after reconstructive surgery and speech therapy.

Laryngeal cancer occurs when the cells lining the larynx(the vocal box) become abnormal and proliferates giving rise to cancer cells.

It affects more men than women.

Various causes may be involved:
1.Genes. -males over the age of 55 years are at four times higher
risk than females.

2.Smoking. People who smokes have a higher risk than non smokers

3.Drinking alcohol can increase the risk of laryngeal cancer.

4.Occupation. There is evidence that workers exposed to sulfuric acid and asbestos have a higher risk of developing laryngeal cancer.

The following are symptoms of  Laryngeal cancer:
1.Hoarseness or other changes in the voice

2.A painless lump in the neck-usually a lymph node
infiltrated by cancer cells

3.Cough that does not go away

4.Persistent sore throat or a feeling that there is something
stuck in the throat

5.Difficulty in breathing or speaking

6.Ear pain

7.Weight loss

Diagnosis of Laryngeal Cancer is by:
Examination of the throat, vocal cords and neck for abnormal lumps

An endoscope is inserted into the throat to look at the vocal cords and their movement.

The ENT specialist may extract issue (biopsy) which can be sent for testing, to confirm if there is a cancerous growth.

If a tumor is found, magnetic resonance imaging (MRI) can be
used to assess its size.

Treatment depends on the diagnosis of the laryngeal cancer and its spread outside of the vocal box.
Usually most laryngeal cancer are slow spreading.

A.Radiotherapy.
This is the most common treatment for small cancer of the larynx. This involves the use of radiation to attack cancer cells, stopping them from growing or multiplying.

B.Chemotherapy.
This involves the use of anti-cancer medication to treat
the cancer.

For both methods, the patient may experience side-effects such as tiredness and nausea.

Radiotherapy are often used together with chemotherapy.

C.Surgery
Surgery is used only when the cancer can not be treated by
radiotherapy or chemotherapy because the removal of the vocal
cords or the entire larynx can cause the loss of voice.
The lymph node in the neck may also be removed at the same time.

If surgery is done , usually a tracheostomy or hole in the
windpipe is done to allow air to enter or escape from the tubes in the lungs.

Some patient may also require a feeding tube after surgery because swallowing of food is affected by the surgery.
Most people will learn to swallow again so the feeding tube is
temporary.

Early treatment is recommended as it increases the patient’s chances of survival.
Delayed action could result in the cancer spreading to other parts of the body, making it more difficult to treat.

Living with a Tracheostomy.
The tracheostomy in the windpipe is necessary for air to enter and leave the lungs.
However the tracheostomy must be kept clean at all time and free of infection. Suction of mucus stuck in the windpipe may be necessary.
It is also dangerous for water to enter the windpipe and the lungs through the tracheostomy opening.
The tracheostomy opening should always be protected with a a
plastic stoma shield or scarf to prevent dust, water or smoke to
enter the windpipe.

After the surgery there may be loss of voice.

A speech therapist is usually needed to teach the patient to learn to speak again.
He can teach the patient to use the oesophagus to force air
through the throat to produce new gutterial sounds.

In the meantime, communication can be done with writing pads or computer.
New electronic and mechanical devices can also produce new
sounds

No one can be fully protected from laryngeal cancer.
However, you can modify your lifestyle practices to reduce your
chances of contracting laryngeal cancer.

Don’t smoke. Smoking increases the risk of laryngeal cancer by two to four times. Those who smoke, can still lower their risk by cutting down on the number of cigarettes smoked a day. Better still, quit smoking.

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A front page of The Family Doctor from 1889 (Photo credit: Wikipedia)

THE FAMILY DOCTOR

“I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous.”
The Hippocratic Oath


When I first started as a family doctor in 1974, the medical doctor was regarded like a fatherly figure to most patients. He was kind, compassionate and caring for his patients and a friend to their family.
It was something I aspire to become.

Not every general practitioner can be a family doctor.
The family doctor knows the family of his patients like the back of his hands.

For example I see the father for his monthly review of  high blood pressure( A Simple Guide to Hypertension), his wife for osteoporosis( A Simple Guide to Osteoporosis), the younger son for weekly injections of vitamin when he was suffering from leukemia( A Simple Guide to Blood Cancer) and undergoing chemotherapy, the oldest son who is married and now worried about finances ( I promised that I will help him out if he does not abort the child) because his wife is confirmed as pregnant. The oldest son now has 2 children of school going age. The younger son whom the father was worried may be infertile as a result of his chemotherapy is now a proud father of a baby boy. The father himself had hoarseness of the voice which after not improving for 2 weeks was sent for biopsy of his vocal cord and found to have cancer of the larynx( A Simple Guide to Laryngeal Cancer). He was treated for this and has been free of cancer for 10 years.

Somehow the family of the patient becomes intertwined with your life and you find yourself asking the patient about his wife, sons and their children each time you meet .That is only one family.

Another patient whose wife was diagnosed with cancer of the breast ( A Simple Guide to Breast Cancer) after routine mammogram found several lumps in her breast (one of which turned up to cancerous on biopsy) consulted me regarding the removal of the breast which her surgeon wanted to do. It was a small lump which showed early cancer. My advice was remove the lump and then do radiation therapy. However her surgeon thought otherwise and opted to remove the breast. The removed breast was found to be free of cancer. Apparently the cancerous cells had been removed during the earlier biopsy. So an unnecessary major operation

was done . The wife asked me not to tell her teenage daughter about the removal of the breast and up to today her daughter who now has a five year daughter still does not know about her mother’s breast removal.
Her husband who had been smoking cigarettes in the toilet for many years subsequently had a bypass operation for his coronary artery blockage( A Simple Guide to Ischemic Heart Disease) . After the operation he asked for me to come to his house to remove all the stitches instead of going to the hospital.
His brother subsequently had cancer of the prostate ( A Simple Guide to Prostate Cancer)and had a catheter inserted into his bladder in order for him to pass urine into a bag. One morning I was called to attend to him because the catheter had slipped out and he was unable to pass urine.
I had to go to the nearest pharmacy to get a similar catheter which can be inserted into his bladder and can be retained inside the bladder. The extent that the family doctor goes out his way to make sure his patient is well showed his commitment to the family and their trust in him.

These are just another example of the trust between the family doctor and the patients. There are many many other families whose trust in their family doctor make us go all out to help and treat them like part of a family.
The family doctor not only diagnose the pregnancy for a newly married couple. He also see pregnant woman for antenatal monthly reviews up to the 5th month of her pregnancy before sending to a obstetrician in a private or public hospital for her further checkup and delivery.

He sees the baby as early as 5 days after their birth for treatment of the baby’s jaundice or infection of the navel.

He teaches the mother breastfeeding methods through pregnancy and baby guides published by milk companies and advises on how to feed the child  and burping of the child.
He also follows up with the necessary childhood vaccinations and medical checkups.

As the child grows older, treatment of infectious diseases like influenza, common cold, measles , rubella and mumps follows.

Once in a while you will have a child with high fever having fits coming to the clinic. These are attended to immediately because of the danger of damage to the brain.

Parents of the children will come to see you occasionally for cold, cough and diarrhea and sometimes conjunctivitis.

Grandparents will see you for old age illness like rheumatism pains, diarrhea or incontinence.

I remember frequent cases where I will have to catherize the patient in order to relieve them of their urine blockage and bloated bladders. Then there are the chronic cases of diabetes, hypertension and strokes.I was often called for house calls sometimes in the middle of the night to attend to febrile fits in children, asthma, strokes, heart attacks and severe infections which prevent them from coming to the clinic.

In the past the family doctor was like a friend to the family. He treats the baby, the older children, the pregnant mothers, working fathers and their grandparents. Even now there are families who still bring their grandchildren to consult me.
Most of  the family know how to contact me during an emergency.

I know their names and the children’s names and also their family situation.

In many cases the patients who are poor are charged a token amount otherwise they will not see you due to their pride.
They however do not have to pay their medical fees or medicines.

During our recent relocation of our clinic while going through the medical record cards in order to discard those patients who have not seen me for at least 10 years. I found that there were patients still owing money since 1974 when I first started the clinic. I do not believe in chasing patients for their money.

There was this Indian foreman who was in charge of our estate rubbish removal. He was poor but he brought his family to see me asking the money to be owed. For 10 years he brought his family for treatment . Knowing that he was poor I did not expect any payment for all these treatments. Yet at the age of 55 years ( the retirement age at that time) he was able to withdraw funds from the government Central Provident Fund( A compulsory saving scheme meant for retirement). To my surprise he asked my nurses to calculate all the medical bills over the years to added up so that he can pay the whole sum. It was a pleasant surprise for me.

At that time a family doctor was really a family doctor looking after babies, children, pregnant mothers, working fathers and grandparents.

Times have changed since the 1990s. Pregnant women goes to their obstetrician.

Babies and children are treated by their pediatricians.

Working parents are treated by their company doctors.

Grandparents may be treated by geriatricians.

In spite of all these changes there are still many families who still remember their family doctors and come back to us when the other doctor’s medicines do not work.
They know that they can depend on us and can come to us for advice.
That is the essence of a family doctor whose duty is to guide, treat and educate a full generation of patients.

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A TALE OF 2 CANCERS
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NASOPHAYNGEAL CANCER (A Simple Guide to Nasophayngeal Cancer)


The Ear Nose and Throat Department treats all cancers of the ear nose and throat.
Some of the throat and mouth cancers are treated together with the Dental Surgery Department.
In the 1970s one of the most common and deadly cancer was the Nasopharyngeal Cancer which  now is known to be linked with Epstein-Barr virus.
Treatment was difficult because of the closeness of the nose cancer to the brain and the frequently late diagnosis.
Surgical treatment is usually not considered unless it was at an early stage.
The treatment of choice was deep X-ray radiation to the affected area followed by chemotherapy in all cases spread of the cancer to other organs.
The mortality rate was high compared to the present modern treatment today of gamma knife treatment.
At the time of my assignment, there was a woman patient in the ward who was in the advanced stage of nasopharyngeal cancer and undergoing chemotherapy.
She was a teacher of 32 years of age who was mostly sick during the time there.
She was emaciated with vomiting during her chemotherapy and loss of appetite.
She was always in pain because the cancer has spread to the brain.
We had to give painkillers and anti-vomiting injections every now and then in order to relieve her symptoms.
Because of the injections, she was also in a sleepy state most of the time.
She has quite a few visitors including her family and her students, most of whom were dejected at the state of her condition.
I tried talking to her on several occasions but she was most too tired to answer except in short sentences.
One morning her bed was cleared and we know that she has succumbed to her illness in the night.


It was sad but quite a lot of nasopharyngeal cancer patients had succumbed in this way including my father-in-law during my medical student days.


LARYNGEAL CANCER (A Simple Guide to Laryngeal Cancer)


In contrast to the dangerous nasopharyngeal cancer (which was usually detected late), the Laryngeal Cancer is usually detected much earlier .
The symptom of hoarseness of voice was one of the easily symptom which prompts the patient to see a doctor.
Even then, some patient then to delay their checkup by a ENT surgeon preferring to see Chinese Sinsehs (Traditional Chinese healers) for treatment hoping to be cured of their condition.
We had a elderly female patient of 70 years who had an advanced stage of Laryngeal cancer which fortunately grow very much slower than the nasophayngeal cancer.
Although it had spread just outside of her larynx or vocal box, surgical removal of her cancer was successful.
A tracheostomy(hole in her windpipe) was done in order that she could breathe through the hole.
Her vocal box was completely removed and closed so her only way of breathing was through the hole.
By covering the hole partially ,she was able to utter some gutterial sounds which required a speech therapist to teach her to talk again.
Nowadays there are mechanical and electronic devices which can placed in the vocal box area to help the patient to talk
In the meantime she was recovering from her surgery in the ward.
Strict instructions was given to made sure the tracheostomy hole was not blocked and free of infection.
In the meantime I used to communicate with her through hand gestures and some written words.
She was cheerful in spite of her illness and I used to try to ‘talk’ to her with hand gestures and written words to keep her in good spirits.
Her relatives were also helpful and kind to her.
Once her condition was well enough to return home, she was discharged.


She even send me a thank you card for taking good care of her.
This was the one of the satisfying things about being a doctor.
It is always important to treat a patient well as another human being rather than a medical case.
When you treat a patient well and kindly , even other patients, nursing staff ,and hospital ‘amahs’(helpers or assistants) also know about it and treat you just as well.

In all, the ENT department was one of the satisfying department to work in and very essential to learn about managing a patient in the family practice.

Not many family doctors know how to remove a fish bone from the throat, a small marble from the nose of a child, remove wax from the ears, bleeding from the nose or treat peritonsillar abscess

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THE ENT DEPARTMENT


The Ear Nose Throat  (ENT) Department of

Image via Wikipedia

Singapore General Hospital is one of the smallest department with 4 consultant ENT Surgeons, 2 medical officers and 1 houseman.


It is however one of the most essential department of the hospital as 80% of cases are generally  the ear nose and throat conditions.


However 90% of the cases can be seen as outpatients or by experienced Accident and Emergency Doctors and General Practitioners.


Our job is to handle those ENT conditions which the Accident and Emergency Doctors could not handle.


Typical conditions are:


1.Foreign bodies in the ear and nose such as small marbles, small parts of toys, cotton buds in the nose of children, which can be removed with a nasal forceps or sucked out with suction tubes


2. Fish bones or chicken bones stuck  in the throat which can be removed by crocodile forceps.
If further down the throat an endoscope may be required to remove the bones sometimes under general anesthesia.


3.Severe infections of the ear with pussy discharge which require drainage of the pus.


4.Severe blockage of the ear by wax which my required syringing of the ear with warm water to remove the wax.


5.Peritonsillar  abscess or quinsy ( A Simple Guide to Tonsillitis)which is an abscess or bag of pus surrounding the tonsil causing blockage to food, swallowing and even breathing.
A cut just above the tonsil will usually drain the pus and relieve the blockage. However the patient will normally have to stay in hospital for one or two days to make sure the bleeding stop and he or she is able to swallow and breathe properly.
He or she is then scheduled for a future operation to remove his tonsils.


6.Bleeding from the nose(A Simple Guide to Epistaxis)  is an emergency which has to be attended quickly because of the danger of loss of blood.
Most mild bleeding of the nose comes from bursting of blood vessel of the septum and can be stopped easily by coagulating the blood vessel with silver nitrate or cautery (electrical burning) under local anesthesia.
In severe cases packing the nose with gauze packs anteriorly from the front or posteriorly from the back to plug the bleeding can be done with great discomfort to the patient.


7.Vertigo (A Simple Guide to Vertigo) or severe dizziness may be treated with an injection of stemetil with temporary relief. Recurrence especially in cases of Meniere’s Disease (A Simple Guide to Meniere’s Disease)  is quite common.


8.The cancer patients of the nose and throat are particular in danger of bleeding of the nose, breathing difficulty and spread of the cancer to the rest of the body. The most common cancer seen here is Nasopharyngeal Cancer (A Simple Guide to Nasopharygngal Cancer).
Other cancers are Cancer of the Larynx, Tongue, Salivary glands.
These will be talked about in the next blog.

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