Coughing and phlegm by Glenn E. Peters, M.D
Coughing and phlegm are what I would like to address next.
Are you taking steps to make sure that the air that you inhale is properly humidified?
Is your stoma bare or covered?
The excessive phlegm production is a natural response by your lungs whenthey are exposed to dry, unfiltered air. Its their way of protectingthemselves.
Another thing you can do is to take advantage of the humidity that is leaving your body every time you exhale. Wear something around your lower neck like a woven stoma bib or a loose fitting kerchief; these things will trap some of your body's own expired moisture. Also, keeping your lower respiratory tract properly humidified will lessen your risks for viral infections (colds) and pneumonias.
What Makes Speech? by Glenn E. Peters, M.D.
My subject today concerns the differences in sound produced by different users of the TEP. You have probably noticed in the Support Group meeting that some folks sound great and others seem to struggle.
So why is that?
Let’s start this discussion with the real way that a larynx helps "talk". To put in the simplest terms, all a larynx does is to make the air coming out of our lungs vibrate. That’s it—just vibrate. Speech does not come from the larynx, a vibrating air column does. What we know as speech occurs when this vibrating air column is made into words by our throats, mouths, tongues, lips, teeth, and so on. A case in point is your Servox, which provides vibration only.
Now that we have this background information, let’s get on to our question. Remember that a TEP replaces the larynx by supplying another source of vibrating air. This time what vibrates is the lining of your throat in the lower part of your neck just above your stoma. The differences in speech quality largely center around the differences in this part of the throat and upper esophagus. These differences include the following:
As you can see, there is a long list of factors that play a role in the development of speech with a TEP. The bottom line is that each patient should be evaluated on an individual basis for this device. While the TEP is probably the state of the art at this present time it might not be best for every patient. To find out more, ask your doctor.
Introduction: Dr. William Carroll
Many readers will not know me so I will take a moment to introduce myself. I joined the Otolaryngology faculty at UAB in June 1996 and am an associate of Dr. Glenn Peters. I received my Otolaryngology training at the University of Michigan and practiced there for 4 ½ years. I then spent a couple of years in private practice only to realize that I was not able to do much of the work which I really enjoy - taking care of patients with cancer in the Head and Neck region. This prompted a return to a "teaching" hospital and I feel very fortunate to be affiliated with UAB. My wife and I are not total newcomers to Alabama. We met during college days at Auburn and our extended families live in the Southeast.
I recently saw a patient who reminded me of a common problem for those with a tracheostomy or tracheotomy. When required to breathe through a stoma, several of the functions of the upper airway are bypassed. Obviously, this results in loss of voice, loss of the ability to filter inspired air, and an altered sense of smell and taste. Another very important function of the nose and mouth is to humidify inspired air. The lungs and trachea are accustomed to air that is 100% humidified. When the air is drier, the normal secretions thicken and become hard to clear, there is more chance of developing infection (pneumonia) and bleeding and crusting may appear. Early on, after undergoing a laryngectomy or tracheotomy, the dryness that occurs in the airway is quite a problem. This is the reason for wearing the moist air collars during the hospital stay. Fortunately, for most patients, this problem quickly becomes less of an issue. The humid climate of the southeast is a benefit and many patients can cope with the dryness simply by covering the stoma with a bib or scarf. In the winter, however, the humidity indoors with the heat on can easily be as low as 30%. The tissues that are designed to deal with 100% humidity are then exposed to 30% humidity. The problems listed above may begin to appear.
If you are having none of these difficulties, don’t worry; keep caring for your stoma as you have been. If you are experiencing crusting, streaky bleeding, difficulty clearing secretions or are having difficulty clearing a chest cold, try adding more moisture. Make sure you are drinking a lot of water and juices. Try moistening the bib that you wear over the stoma. Take a couple of steamy showers a day. Use a cool mist humidifier in your bedroom (clean frequently so that mold doesn’t grow). If you’re doing these things and still have problems, call us. We’d like to check things over.
Hey Doc, by Glenn E. Peters, M.D
Why is it necessary for me to see you so often? Didn't you tell me you "got it all"?
First of all, I don't think that the term, "get it all", applies in the surgical treatment, or any other form of treatment for that matter, when you are talking about cancer. Cancer is a diverse population of cells some of which are programmed to spread throughout the body. This can occur when a tumor is just barely or not even clinically detectable or when the tumor is massive. It just depends on the genetic make up of any given tumor. By the way, Not all tumors necessarily have these groups of cells. Therefore, even though a cancer can be completely removed from the head and neck area, that does not mean that it may not have the capability to show up somewhere else in the future. To screen for this, we get yearly chest X-Rays, blood work when indicated, and check for things like persistent bone or skeletal pain.
Next, we know that whenever someone develops a cancer in the head and neck there is between a 10 to 20 percent chance that they will get another cancer in the region. This also includes the esophagus and the lung. We screen for these tumors by frequent physical examinations in the clinic. The head and neck is a wonderful area to work in for both the physician and the patient in that 80 percent of the area can be examined directly in the clinic without having to rely on expensive X-Rays, CTscans, MRIs , and the like. Also, the general rule is that if your tumor is going to recur or a new one develop, 80 to 90 percent of these will do so within the first two years. That is why we see you more often during that time.
So, besides being a pleasure to see you and keep up with your goings-on, we are really trying our best to catch a problem in its very earliest stages; that is, when we have the absolute best chance to take care of it.
Glenn E. Peters, M.D.
Doc, we are getting a lot of requests for help with swallowing and dry mouth. How long will this last and what can we do to get through it?
O.K. It looks like you want some help getting through radiation therapy. In previous issues, you have touched on some of the most basic things-diet modification, Ensure and similar products, BLADES as we call the blender, fresh fruit and the like. You are on the right track.
Just like surgery, radiation causes a wound that requires adequate nutrition to heal properly; and remember that even though radiation does not kill cancer by heating the cells, the side effects of the therapy are identical to a burn. Burns are some of the most physiologically demanding wounds and can effect metabolism in the most profound ways. And since these wounds are actually bigger and cover more surface area than a surgical incision, their nutritional and metabolic demands can be profound indeed.
First of all, I hope that those of you who are in this situation and are smokers got the message that the reason you are in this predicament is very likely due to your tobacco consumption. Therefore, for once and for all, use the problems that you are having with radiation to QUIT SMOKING. Use the analogy of burning leaves in the fall. Remember that wonderful smell as the smoke billowed off of that pile of burning leaves? Then remember what happened when the wind shifted and the smoke got in your eyes? IT BURNED, didn't it!! And exactly what is a cigarette but a concentrated bunch of burning leaves, right? Folks, we're not talking rocket science here.
Next, let's talk about all that thick, ropy mucous that is building up in your mouth and your throat. In our practice at UAB we are big believers in the powers of CLUB SODA. During our training as interns and residents we used sodium bicarbonate to clean out endotracheal tubes for patients in our intensive care units. That stuff was great at cutting the thick, tenacious mucous that would build up in the tubes.
Club soda, or carbonated water, has the same properties. When used as a mouth wash and a gargle it does a great job in cutting through the goo. You can also use it as a beverage for meal times as it seems to have superior wetting properties when compared to water alone. Buy the small 12 ounce bottles and keep them chilled. It won't work if it looses it's fizz. Try it, you'll like it (hopefully).
Lastly, let's talk some serious nutritional delivery for a moment. Let's face it, radiation is no walk in the roses, although in the RIGHT setting it can do just as good as surgery for treating cancer in the head and neck. All of the acute or short term side effects of radiation add up to make eating and drinking less than a pleasurable experience.
Actually, food becomes more like medicine than anything else. But remember, nutrition is the key to not only to a speedy recovery, but it also plays a large role in your ability to ultimately kick your cancer because you are keeping your immune system intact and healthy as well.
The bottom line is this: if things get too bad and your weight starts to fall off rapidly, then you really might want to consider some sort of feeding tube to help you through the short term. At UAB we rely almost exclusively on the PEG or Percutaneous Endoscopic Gastrostomy to help our patients. In fact, we often put this in before radiation even begins, just so we know that we can keep a patient's nutrition up from the get go. We think that it really makes a difference. So if you really are getting in trouble, get a tube.
You should expect the recovery from radiation to take anywhere from 3 to 12 months, depending on where exactly you received your radiation. Folks who had their mouthes radiated will take longer than those who received it only to their larynges. Hang in there. We know it's is tough and we are pulling for you.
Glenn E. Peters M.D.
"Please tell me how long it takes to stop coughing up blood from my lungs and stoma? I am so tired of this; I just need to know........."
Let's talk about your ‘air conditioning’ system. Before your laryngectomy you were breathing through your mouth and more importantly through your nose. Your inspired air was being filtered and humidified by your upper respiratory tract. Inspired air was taken from the relative humidity of your ambient air and moisturized up to 100% by the time it reached the gas exchange units in your lungs, called alveoli. At the same time, particulate matter was removed by the mucous blanket which coats the lining of the nose and throat.
After your laryngectomy, you were left without this normal filtration/humidifying system. Your lungs responded in a very normal and protective manner by producing an increased amount of mucous to filter and humidify the air that was coming in. Bloody sputum can result when you cough excessively to clear this increased amount of mucous. You also may be more susceptible to bronchitis ( an infection and inflammation of the lining tissues of the tracheo-bronchial tree) because you are breathing unfiltered, dehumidified air.
So, what to do?
1. Make sure you have had a recent chest X-Ray to rule out any significant lung pathology.
2. Make sure that your sputum is not discolored (in addition to bloody). Discolored is green or yellow. This may indicate an infection like bronchitis or pneumonia which may require antibiotics.
3. Do everything possible to increase the amount of moisture in the air you inhale. Some tricks include wearing a stoma bib, but you can also wear a scarf or a turtle neck shirt or sweater. This allows you to conserve the moisture that is LEAVING your lungs in the area around your stoma. Another thing you can do is to irrigate your stoma with CLEAN tap water or saline. Two to three cc's four times a day should help. Other tricks include wearing a soft stoma vent (see your M.D. for the proper size). A small plastic spray bottle filled with tap water can be used to create a mist to dampen your stoma bib. It becomes a portable humidifier---- MOISTURE IS THE KEY. MUCOUS RULES!
4. Lastly, be patient. Your lungs are going through some major changes. Ultimately, they will adapt to the new you. Things generally improve within 3 to 4 months after surgery.
As always, if problems persist, please see your M.D.
Glenn E. Peters M.D.
Question: In our meetings, there has been some discussion about why we can't bend over after eating and drinking because liquids and even some foods will run back up the esophagus. Please explain what has been done that creates this problem and if we need to adapt ourselves because it will always be that way?
Let’s talk about this reflux thing for a minute. Under normal circumstances, there are two muscular bands or sphincters in the esophagus which prevent reflux. One is located where the esophagus joins the stomach and the other is located behind the larynx at the beginning of the esophagus in the neck. The lower esophageal sphincter (LES) often becomes compromised when there is a hiatal hernia, a condition resulting from a weakness in the diaphragm which allows the stomach to slip up from the abdomen into the lower chest cavity. When this happens you get what is known as gastroesophageal reflux- the condition we all hear so much about in the media these days. The other sphincter, the cricopharyngeus or the upper esophageal sphincter (UES) prevents things from coming up the esophagus into the throat and mouth. This muscular ring takes its origin from the lower part of the larynx, a part called the cricoid cartilage. But guess what—you ain’t got one no more since your cricoid was taken out when your larynx was removed.
This leaves the upper part of your esophagus sort of flaccid and always open and this could result in the reflux of stomach contents up into your throat and mouth. About 80% of the general adult population has a hiatal hernia. So if you have a hiatal hernia and, in addition, have had a laryngectomy then you get a double whammy.
So what’s a guy/girl to do? Gastroesophageal reflux is usually managed with medicine to stop the stomach from making acid, along with dietary and lifestyle modifications. Severe cases may require surgery to keep the stomach from slipping up into the chest. Taking care of reflux from the UES is more problematic, however. Simply knowing that this is a problem and its cause are probably the most important things. Avoid bending over when you have a full stomach after meals. You may also might try reducing the size of each individual meal and eat four or five times a day instead of the usual three.
Glenn E. Peters M.D.
Let's Talk Thyroid by Dr. Glenn E. Peters
In doing a laryngectomy we usually try to save both lobes (sides) of the gland. We will remove some of the gland, half of the gland, or even all of the gland depending on the extent of the tumor in the larynx or the trachea. Your doctor could tell you for sure how much of the thyroid was removed.
What can happen, though, is your gland might not be working like it should, particularly if you had radiation therapy to your lower neck. This can result in a decrease in the level of thyroid hormone released by the gland. Symptoms can include a decrease in your energy level, weight gain, and changes in your hair and skin texture. Thyroid hormone levels are easily checked with a simple blood test and deficiencies can be corrected with a once a day pill.
Glenn E. Peters M.D.
"Can radiation cause dizzy or fainting spells (vasovagal syncope)?"
Let’s start by reviewing some anatomy. Then, I will address the problem some patients have when they turn their heads and get a little dizzy and light headed. On either side of your neck is the carotid arteries which are the main suppliers of blood to the head and more specifically, the brain. This artery comes into the neck from the chest as a single large artery, the common carotid artery, then splits in the upper neck to become the external carotid artery supplying blood to the face and head outside of the skull and the internal carotid artery supplying blood to the brain. Where this artery splits is called the carotid bulb and you can usually feel it as a pulsating mass in the upper neck. The carotid artery and especially the carotid bulb are enervated by some specialized nerve fibers that are sensitive to the chemical content of the blood and also to the pressure of the blood inside of them.
Now, lets say you have had surgery on the neck or radiation to neck. Remember that either of these can cause some degree of scarring around this blood vessel resulting in some degree of "squeeze" on them. The nerves, that I mentioned above, read this as an increase in the pressure INSIDE of them and set in motion automatic measures to lower the blood pressure. These include a lowering of the heart rate and a dilatation of the blood vessels in the rest of the body. The net result of all of this is a relative lowering of the blood pressure to the brain and the sense of dizziness and being light headed. This whole thing can be made even worse if you have some degree of athersclerosis (cholesterol plaque)or if you are taking medicines for high blood pressure. Dehydration also may be a contributing factor.
If you have this problem, unfortunately there is not much that can be done to eliminate it. The most important thing is to simply be aware that the problem exists and not change positions rapidly, i.e. lying to sitting or sitting to standing. Take your time when you get up and don’t immediately start walking. You might want to make sure you are well hydrated and that your blood pressure is under good control and your anti-hypertensive medicine is right for you. If the problem is severe enough that you almost black out or if it occurs very frequently, please check with your doctor and make sure that you are not having transient ischemic attacks (mini strokes) or something wrong with the heart itself causing it to be an inefficient pump.
Glenn E. Peters M.D.
Why does my nose run all the time after my laryngectomy?
Is it a cold or a sinus infection?
Answer: Your nose runs after a laryngectomy because you no longer breathe through your nose but through your stoma. Because there is no longer any air flowing through your nose the tissues lining the nasal cavities become engorged with blood and do what they are supposed to do--make mucous. This is a self-limited process and requires several weeks for the body to get adjusted before the condition improves. You should avoid taking any anti-histamine medications, particularly if you have had radiation, as this can make the dryness from the radiation even worse.
Glenn E. Peters, M.D.
Hey Doc, ever since my laryngectomy I seem to have trouble with constipation every once in a while and I really haven’t changed my diet. Why is that?
Answer: In order to have a natural bowel movement you need to strain a little. Normally straining is done by closing the vocal cords and increasing the pressure in your chest by exhaling against the closed vocal cords. The same thing happens when you strain to lift a heavy object. Without a larynx you can’t strain normally because your stoma will not allow you to restrict the outflow of air from your lungs. The solution then is to eat a diet which will provide a large amount of bulk to your stool as in a diet high in fiber …your basic old healthy fruits and vegetable diet along with grain products that don’t have all the "good" refined out of them. You also want to stay very well hydrated with plenty of water, juices and liquids.
Dr. Glenn E. Peters
Ever since my laryngectomy food just doesn’t taste the same. You didn’t operate on my tongue (Did you?) so why is it that I don’t taste as well as I did before surgery?
Taste is a complex special sense. What we know as "taste", particularly the more delicate tastes, is really smell. The subtle tastes of eggs, certain cheeses, fruits, wines and the like depend on an intact sense of smell for their discrimination. Smell relies on our ability to move air containing certain molecules into the highest recesses of our noses. When we eat, the air with the odor bearing molecules goes behind the palate up into the nose. Following your laryngectomy, you no longer breathe through your nose but through your stoma. This results in less air reaching the smell part of your nose. The bottom line to all of this is that with a decreased sense of smell, it naturally follows that your sense of taste will be less as well.
Some patients learn how to "sniff" a little air up into the nose to enhance their sense of smell. Another tip is to add a little extra spice or cook with pungent herbs to help the job that your tongue is doing for you. This may make your food a little more enjoyable. Bon Apetit.
Glenn E. Peters, M.D.
By far and away, the question that I am most frequently asked is "Doc, did you get it all?" I thought I might just explain this concept and let everyone know that the "get it all" really doesn’t apply to cancer , i.e. malignancies. Let’s start by reviewing just what a cancer is in the first place. A cancer is a lesion that has the capacity to act in a lethal fashion and ultimately result in the death of the patient. Cancers come about when a group of cells, for whatever reason, looses their normal control mechanisms and begin to grow out of control. As a result of this growth and loss of regulation some groups of these cells take on new genetic characteristics and become further programmed to carry out certain specialized functions. One of the most important new functions is the ability to invade the surrounding lymphatics and blood vessels and ultimately spread to other parts of the body. Therefore, cancers are programmed to spread.
The ability of a cancer to metastasize or spread to other organs can occur at any time during a lesion’s development and growth. We usually see this happen with larger tumors, but even the smallest and earliest cancers possess this genetically programmed ability to metastasize.
Surgery and radiation therapy are designed to take care of the tumor that exists locally in the head and neck area. Unfortunately, at this time, there does not exist any form of therapy that can address cells that might get out and set up shop at other sites. The best we can hope for is early detection of any new sites of possible spread. That is why a program of close and careful follow up and surveillance is so important.
So, in summary, we hope to eradicate tumors in the head and neck area with surgery and radiation. Most times we can get everything, that we can see and feel, out.- But does that mean that we "got it all"? Most times it does indeed mean just that—but remember that we are dealing with a disease that by its very nature is designed to spread. So adopt a healthy life style and keep those follow up appointments.
Glenn E. Peters, MD
Doc, a lady laryngectomee wrote in to our Internet group and asked what harm there was in having several glasses of wine every evening. How about it? Can we continue to have a cocktail?
It is well established throughout the literature written about head and neck cancer that tobacco and alcohol are both the most common risk factors associated with the development of the disease. Usually, we see both factors acting together to cause the problem; however, tobacco alone or alcohol alone have been clearly identified as independent risk factors, each capable of causing cancer.
Now here is where the water gets a little muddy. New research has been looking at the role of certain chemical compounds called anti-oxidants particularly in their roles of not only preventing the development of cancer but also slowing down the development of atherosclerosis. One of the sources of these anti-oxidants is RED WINE. Distilled spirits, beer, and white wine do not contain the anti-oxidant compounds. Several studies have actually shown some health benefits from one or two glasses of red wine several times a week. By the way, broccoli and cauliflower also contain even higher levels.
So what’s a girl to do? Generally, folks who get into trouble (ie cancer) from alcohol and tobacco are not just users but ABUSERS of the stuff. Around the time patients are treated for their cancers they usually quit smoking and drinking, using this time in their lives as the best possible excuse to quit. A lot of these patients have self-control problems and cannot do anything in moderation. That’s why we as clinicians discourage even modest use of alcohol because we worry that it will only lead the patients back to their old ways.
So the answer to this question lies within each of us as individuals. Can we each be careful and responsible enough to limit intake while still taking advantage of the possible health benefits an occasional glass of red wine has to offer? If the answer is "no" then don’t start even with a sip because it will only lead to trouble again.
Glenn E. Peters M.D.
The Doc on E-mail!!! (Excerpts from a message to New Zealand)
First of all, from the symptoms you describe it sounds as though you have had a neck dissection of some sort to remove the lymph nodes from the right side of your neck. In doing this operation it is necessary to indeed cut the nerves responsible for feeling in that side of your neck. The area of numbness likely extends from your ear down onto your neck then onto the upper chest and the top of your shoulder. Unfortunately, the numbness is permanent to a large degree. The actual area involved may over time decrease in size as sensory nerves grow into the numb area from surrounding normally sensate areas.
The weakness that you have noticed in your right shoulder is also from sacrificing another nerve in the neck, the spinal accessory nerve, which supplies the trapezius muscle on your back. The trapezius muscle helps you to raise your shoulder when you raise your arm. You have probably noticed that you have difficulty working above your head with your right arm. This is because you have difficulty raising your shoulder. The pain in your right shoulder is from stiffening in the capsule of your shoulder joint and also from some slight downward displacement of the shoulder from loss of the trapezius. The only real remedy for this is a vigorous program of exercise that is designed to strengthen the other muscles that help the trapezius to raise the shoulder.
The tightness and stiffness in your neck is indeed scarring in the soft
tissues. Several factors have contributed to the development of this
problem:
1. Radiation therapy causes fibrosis in the tissues under the skin, the amount
of which can vary from patient to patient.
2. Surgery also can cause scarring.
3. A fistula and its repair can be a contributing factor. Each of these things
can lead to the problem, but when they occur together, the problem is made
much worse.
Use stretching exercises and massage to loosen the scarred tissue.
This is going to be a slow process, like 6 months to a year, but it should
loosen up some if you work on it.
Glenn E. Peters, MD
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Everybody tells me to cover my stoma. Why do I need to do that?
So you want to know about why it is necessary to keep your stoma covered, do you? Well we will give it a try. Stoma covers come in all sizes, shapes, colors. Some folks even use articles of clothing to cover their stomas. These include ascots, scarves, dickeys, turtle neck sweaters or shirts, cowl neck tops for women, etc. They all serve the same basic function and that is to keep the "bad" out and the "good" in.
Now let's talk about the bad first. Obviously, the stoma can present an exciting target for all manner of vermin such as gnats, flies, wasps, bees, hummingbirds, and possibly even a misdirected bat! If your stoma is large enough your children or your grandchildren at play may even pose a risk from any of a variety of projectiles. Most importantly, though, the air you breathe is dirty. Dust, dirt and pollen offer the biggest challenges. This is especially true for those who work or play in dusty, dirty environments. So much for the "bad" we want to keep out!
Now you might just wonder what "good" the stoma cover keeps in. The answer is "moisture". This is, moisture that is generated by your lungs and is lost with every breath unless something is done to retain it. And why is moisture so important? The most important reason is that the gas exchange in your lungs is most efficient when the humidity is high. A high moisture content also assists with the natural cleaning mechanisms in the lungs and helps cut down on what we all know as CRUSTS. Folks that keep their stomas covered have much less problems with crust formation; they cough less, have less mucous production, need to irrigate less, have fewer bouts of bronchitis, and on and on.
So, don't think of your stoma as your new nose. It doesn't work the same way. Keep it covered and you'll find you have much less difficulty with it.
Glenn E. Peters M.D. Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, Alabama, USA
Swallowing Difficulty (following laryngectomy) by William Carroll, M.D.
Some degree of difficulty swallowing (dysphagia) is common after most types of laryngectomy, whether total or partial. In most cases, the swallowing problems are not severe and tend to improve over time. The causes of swallowing difficulty differ depending on whether the laryngectomy has been partial (hemi-laryngectomy, or supraglottic laryngectomy) or total.
Let’s discuss the partial laryngectomy situation first. As you know, the production of sound or voice is not the most basic function of the larynx. The most basic function is to separate the food and the air which are both taken in through the mouth. The larynx acts as a gate or door. It closes by reflex action when a swallow occurs. It opens when air is inhaled, closes when food or liquid is swallowed. It keeps air moving toward the lungs and food moving toward the esophagus. Part of the larynx is removed during surgery and part of the normal nerve supply is interrupted. The reflexes that direct the larynx to open and close are often disrupted. The main problem that develops is aspiration, or food going into the breathing passage (trachea) instead of the swallowing passage (esophagus). Aspiration may be minor and cause nothing more than a little cough with swallowing or may be severe and cause pneumonia. Early after surgery, almost every patient has some degree of aspiration. Typically this situation improves with swallowing therapy and oral intake can be resumed. Unfortunately, there are occasions when the protective reflexes can never be fully regained and oral intake remains unsafe due to the risk of aspiration. This is rare but can require long-term feeding tube dependence.
In contrast, aspiration almost never occurs after a total laryngectomy because the breathing and swallowing passages are surgically separated. To understand the swallowing changes that occur after total laryngectomy, a little anatomy review would be helpful. The back wall of the larynx actually makes up the front wall of the pharynx or upper esophagus. When the larynx is removed, part of the front wall of the pharynx / esophagus is removed also. When the remaining portion of the pharynx is closed with sutures, the circular opening becomes smaller. Imagine a string tied in a circle. Cut out a piece of the string and toss it out. Now tie the remaining two ends back together. The new circle will always be smaller than the original circle. Just how much smaller depends on how much string was removed. Those patients who start with tumors confined to the inside of the larynx usually have plenty of pharynx left to make a very adequate swallowing passage. Some, however, not only have their larynx removed, but also have part of their esophagus or pharynx removed as well. For these patients, the new "circle of string" can be quite tight. The extreme situation occurs when not only the larynx but also the entire pharynx or upper esophagus has to be removed. This is called a laryngo-pharngectomy. In these cases, the swallowing passage has to be completely reconstructed using small intestine, stomach or a ‘tubed’ skin flap.
Total laryngectomy also disrupts the nerve and muscle fibers that normally contract to help food move down the esophagus. Occasionally patients will have spasm of the remaining muscle, which makes the opening into the esophagus very tight. Plenty of tissue is present to allow easy swallowing, but the muscles are in spasm (hyper-contracted) and won’t allow food to pass. This situation can necessitate a surgical procedure called a myotomy (myo = muscle, tome = to cut) which divides the spastic muscle.
The other factors that can lead to difficult swallowing are radiation before or after surgery, or a wound infection or fistula occurring after surgery. Both make the tissues of the pharynx and esophagus more stiff and less stretchy when food is trying to pass. Both processes can actually narrow the caliber of the opening into the esophagus as well.
Many of the same factors that effect swallowing so dramatically after laryngectomy can also effect the ability to use a voice prosthesis (Blom-Singer valve) or esophageal speech. We’ll save that topic for next time...
William Carroll M.D., Otolaryngology, Kirklin Clinic, Birmingham, AL
Why did my friend have his TEP done at the same time as his surgery? I had my puncture done months later.
Let's discuss the timing of TracheoEsophageal Punctures. There are two opinions as to the proper time to do the procedure. There are surgeons who think that the TEP should be done as part of the laryngectomy (a primary TEP) and then there are those, myself included, who think it is best done as a separate procedure (a secondary TEP). Each camp has a long list of reasons why their approach is better and I will review those with you now.
The main advantage of the primary TEP is obvious: patients will be using their prostheses sooner during their convalescence. This saves a second operation and a second anesthetic. It also has the advantage that the feeding tube can be put into the esophagus through the puncture instead of through the nose, making the patient more comfortable. The main disadvantage has to do with wound healing and maturation of the stoma. The site of the puncture might shift relative to its position in the stoma, making placement of the prosthesis difficult.
Now, for the secondary TEP: I prefer to allow about eight weeks to pass between the time of the laryngectomy and the TEP. The main reason is I want to see how the wounds heal and, particularly, how well the stoma matures. It helps me to see if the stoma is going to shrink in size, called stenosis, and whether a stoma vent will be necessary. The patient needs to be swallowing well, especially foods like meat, as this indicates that the throat is the proper size. In addition, this allows some time for the initial pain and swelling from the laryngectomy to subside. I feel that I can do a better job and have more control of the positioning of the puncture inside the stoma after the stoma has fully healed. The down side, of course, is the need to have a second operation and the need to use a Servox for several weeks or months longer after the laryngectomy.
The bottom line is there are no differences in the speech results in comparing the large series of patients who had either the primary or the secondary TEP.
Glenn E. Peters M.D.
The Shrinking Stoma by Glenn E. Peters, M.D.
When your laryngectomy was done, part of the reconstruction was to create your stoma. This was done by suturing the cut end of your trachea to the skin of your lower neck. Under ideal circumstances we want the stoma to be at least as big as the diameter of your trachea, but actually hope that it might be slightly bigger.
So why do they get smaller with time? Several factors are at work. Any time we create a surgical wound, and the stoma is certainly a surgical wound, the body responds by laying down scar tissue as a natural part of the healing process. Scar tissue is very dense and tough, much more so than surrounding normal tissue. Scar tissue has one tendency that will ultimately affect the final result and that is CONTRACTURE. That's right, by their very nature, all scars get SMALLER. Usually that's not a problem for linear scars on the skin but when the contracting scar involves a round opening, then the possibilities become quite obvious. The opening will get smaller.
There are several things that contribute to a small stoma. These include not removing enough skin from the lower neck during the surgery, compromising the blood supply to the cut end of the trachea, putting in too many sutures, too much tension on the trachea-skin suture line, poor nutrition, prior irradiation to the neck, and infection. Also, some folks just simply have a small trachea from the start so their stomas naturally will be smaller.
So how do we (as surgeons) manage the stoma and try to reduce the risk of shrinkage or stenosis. Well, the first thing we try to do is to avoid or correct those things that I mentioned above. The second thing we try to do is control the scarring and shrinking process that we all know will occur as you heal. This includes vigorous stomal hygiene to cut down on crust formation and infection. Humidification is important as well. We will also place a small soft stoma vent that can be worn after surgery which will hopefully cause the shrinking scar to mature in an open position. This vent can be removed for cleaning and inspection of the stoma.
So what is the ideal size for a stoma? The answer varies for each patient. The opening should be large enough for adequate airflow so you don't experience any shortness of breath at rest or with exercise. It should be large enough to allow you to remove crusts and secretions with ease. The kicker comes in with the insertion of the speech prosthesis. Since the prosthesis itself takes up some room it will reduce the cross-sectional area of the stoma. Therefore, we generally like to see a stoma at least 1.5 to 2 cm in diameter before entertaining doing the TEP.
So what do we do for a small stoma? There are several schools of thought here. There are a number of surgical procedures, which have been developed for the correction of stomal stenosis. The problem with more surgery is what? That's right. More contracting scar tissue! Therefore, I have started dilating or stretching small stomas with progressively larger stoma vents. This takes longer to achieve your desired goal, but avoids the vicious cycle of surgery, scar, and more contracture.
What do you see in a pathology report that makes you send a larynx cancer patient for radiation?
When we do surgery for cancer of the larynx or any other head and neck site we look to the pathology report for some very important information. The report contains information about the primary tumor and the lymph nodes if they were removed. Let's talk about the primary site. First of all we look at the status of the margins of normal tissue which surrounds the malignancy. This is the "get it all" that everyone wants to know about. In surgery we use our senses of sight and feel to determine how much extra tissue we need to take to see if our initial margins are clear. However, there are times when cancer CELLS extend well beyond what we can see and feel at the operation. We will often do FROZEN SECTIONS at the time of surgery to check the margins and take more tissue if needed. The problem is that frozen sections are not a 100% guarantee of clear final margins, so the PERMANENT SECTIONS may come back positive several days later. In this setting we recommend radiation. Secondly, if the tumor is invading deeply into cartilage or bone then we would recommend radiation. Lastly, if there is evidence of the tumor extending into the neighboring blood vessels, lymphatics, or nerves, then we would recommend radiation.
Now, let's talk about the lymph nodes. The decision to remove the lymph nodes is based on whether there is a high likelihood that they contain metastatic cancer. Obviously, if there is an enlarged node at the outset then the decision to remove then is clear. If there are no nodes present, either on physical examination or on CT scan, then the decision to take them out depends on the size and the site of the primary tumor. Having said all of that, what we look for in the path report is the number of involved nodes (greater than one) and whether the cancer has extended outside the capsule of the node. If either of these exist then we would add post operative radiation therapy.
So why do we add radiation? Radiation is given to control microscopic disease that may remain after surgery. It is designed to cut down on the chance of cancer recurrence in the HEAD AND NECK. It has NO effect on cutting down on the chances of cancer showing up somewhere else such as the lungs, liver or the bones. Most patients that die of head and neck cancer do so from a recurrence in the head and neck and not from distant disease, so the utility of radiation therapy becomes obvious.
Glenn E. Peters M.D.
IRRIGATION AND HUMIDIFICATION
Let's talk about your ‘air conditioning’ system. Before your laryngectomy you were breathing through your mouth and more importantly through your nose. Your inspired air was being filtered and humidified by your upper respiratory tract. Inspired air was taken from the relative humidity of your ambient air and moisturized up to 100% by the time it reached the gas exchange units in your lungs, called alveoli. At the same time, particulate matter was removed by the mucous blanket, which coats the lining of the nose and throat.
After your laryngectomy, you are left without this normal filtration/humidifying system. Your lungs respond in a very normal and protective manner by producing an increased amount of mucous to filter and humidify the air that is coming in. Bloody sputum can result when you cough excessively to clear this increased amount of mucous. You also may be more susceptible to bronchitis (an infection and inflammation of the lining tissues of the tracheo-bronchial tree) because you are breathing unfiltered, dehumidified air.
So, what to do? Everything possible to increase the amount of moisture in the air you inhale. Irrigate your stoma with clean tap water or saline solution four times a day and it will help your breathing. You will be taught how to do this in the hospital, but it is very simple. Fill a syringe with two to three cc's of water, take a deep breath and squirt some of the water into your stoma. You will cough and you are supposed to. If you cough before you get much water into the stoma, repeat immediately. You are softening any bits of hardened mucous or blood and coughing it out. This is extremely important.
A cool mist humidifier in your bedroom will help you to breathe moist air while sleeping. Put fresh water in daily, and every week or two, to prevent bacteria, clean and soak the tank with a solution of one teaspoon of bleach in one gallon of water. Rinse thoroughly before refilling.
Some tricks for retaining warmth and humidity in your trachea and lungs include wearing a stoma bib, but you can also wear a scarf, a turtle neck shirt or sweater. Foam stoma protectors are also available. Covering your stoma allows you to conserve the moisture that is trying to leave your lungs as you exhale. You might also wear a soft stoma vent (see your MD for the proper size). A small plastic spray bottle filled with clean tap water can be used to create a mist to dampen your stoma bib. It becomes a portable humidifier. Lastly, be patient. Your lungs are going through some major changes. Ultimately, they will adapt to the new you. Things generally improve within 3 to 4 months after surgery.
MOISTURE IS THE KEY!!
Bo-Tox and the Laryngectomy Patient by William Carroll, MD
Bo-Tox has been in the news a lot recently. Bo-Tox is short for Botulinum Toxin, which is the bacterial by-product responsible for the dreaded disease botulism. The substance blocks the activity of skeletal muscle and in large doses causes complete paralysis. Bo-Tox has been used medically in small and well-regulated doses to treat spasms of facial, neck and laryngeal muscles. Cosmetic surgeons have begun using Bo-Tox to get rid of frown lines just above the nose and the "crow’s feet" or squint lines that appear at the outer corners of our eyes with aging.
There may be a new application for Bo-Tox for the laryngectomy patient. As you know, tracheo-esophageal puncture (TEP) with insertion of a speech prosthesis has become a mainstay for voice rehabilitation after laryngectomy. Occasionally patients are unable to produce sound when the TEP is placed. One of the causes of lack of phonation in this situation is spasm of the pharyngeal muscles (cricopharyngeus spasm). The traditional method of dealing with this problem has been a surgical procedure called myotomy. Physicians are beginning to try Bo-Tox injections into the muscle to block the spasm and hopefully avoid surgery. Our colleagues at the University of Iowa have seen encouraging early results with this treatment for a small group of patients. At UAB, we are beginning to use this technique as well. No one knows yet if Bo-Tox for cricopharyngeus spasm will become routine. There will very likely continue to be those patients who require surgical myotomy. We’ll keep you posted as we learn more about the applications of Bo-Tox for laryngectomy patients.
Stomach Pull-ups by Doctor Peters
Dr. Peters, I hear people talking about a 'flap'. Are there different kinds of flaps? What is a stomach pull-up or a jejunum? Is it possible to have a TEP after these surgeries?
Let’s discuss flaps, stomachs, jejunums, and other ***chitlins. We need to begin this with a brief review of the laryngectomy. Remember that the larynx sits in the throat or pharynx and when it is removed we have to close the pharynx so you can swallow again. The most common way to reconstruct this area is to simply close it with several layers of sutures, thereby creating a tube through which saliva, solids and liquids can pass. Dr. Carroll has discussed this in one of his earlier pieces. (Swallowing Difficulty, HeadLines, Dec 1998) This is called "primary closure".
Now, the problem comes when we have to deal with larger tumors or tumors that arise on the side or the back of the larynx. This creates a situation where we do not have enough tissue to close the pharynx primarily. In this case we borrow tissue from elsewhere in or on the body to supply this extra tissue needed for closure. This tissue, transferred from another site, is generically called a "FLAP". So what about these flaps? Historically speaking, we started with skin flaps from the neck and upper chest. We then moved on to flaps from the upper chest, which included a portion of the large muscle on the chest called the pectoralis major. From there we went to using the entire stomach which was turned into a tube and used to recreate not only the throat but also the entire esophagus as well (the gastric "pull-up"). Then we finally got into what are called "free flaps". These are pieces of tissue which are completely detached from the body -- the "free" part -- and transferred to the neck where they are hooked back up using an operating microscope. The jejunum (a segment of small intestine ) and the radial forearm flap are the most commonly used in this category.
Lastly, the question has arisen as to whether or not a TEP can be used in patients that have had flap reconstruction following their laryngectomies. My answer has always been that this needs to be individualized on a case by case basis. I have put TEPS in just about all of the flaps that I have mentioned above. This includes the gastric pull-up and the jejunum. We are just a little more careful in evaluating patients for this device after the flaps, but it can be done with good results.
***chitlings - (pronounced chit-lins) Southern talk for chitterlings (entrails). From the time of settling of the South, nothing could be wasted and the entrails of the pig were cleaned and used as food prepared in various ways, such as sausage casings, but they were often fried and considered a delicacy.
Doctor Peters, we know a PEG tube is often used for a throat cancerpatient during healing or while having difficulty swallowing. We would like some insight into three problems.
1. If, over a period of a couple of years, a patient has repeated dilations, manages soft food occasionally, but is on mostly a liquid diet, what are the choices to be able to eat again?
2. When leakage occurs, is there a good way to stop it or a product to put on the skin to avoid excess irritation?
3. When you are eating easily and it is time to remove the PEG tube, are there complications involved in the healing after removal of long time PEGs? If it doesn't close up properly, where do you go from there?
Answer:
Okay gang let's talk PEG tubes. You have been gracious enough to send me some questions so I will do my best to answer them.
1. The first question concerns a chronic problem with difficulty swallowing despite repeated dilations. Let me give you my opinion about dilation. Basically, I don't think it works. Let's look at the problem. You have a round organ such as the esophagus. Around this circular organ you have scar tissue. The most basic thing that scar tissue does is to CONTRACT. When you have contracture around a circular organ you get narrowing or stricture. Now let's look at what happens when you dilate something. What you do is forcibly break up the scar causing a new wound. This results in quess what? That's right, more scar tissue. And what is scar going to do? CONTRACT!!! Therefore, you have set up a vicious cycle of scar, contracture, more scar and more contracture. Hence, no improvement. It is my feeling that to truly improve the situation, you have to bring in new tissue that is not affected by this cycle.
2. When leakage occurs around a PEG tube it is always best to make sure that the tube is tight against the body wall. Make sure the bumper or balloon inside the stomach is working properly and the outer flange can be snugged up to the skin. Not too tight, but just right. A single layer of gauze is usually enough to catch any drainage.
3. Generally PEG tubes can be removed in the office and the wound will close on its own in 2 to 3 days. It is very rare for the fistula (ya'll remember what a fistula is from our last encounter) not to close, but if it doesn't, it is a matter of a limited out-patient surgery to rectify the situation.
Doctor Peters, we know a PEG tube is often used for a throat cancerpatient during healing or while having difficulty swallowing. We would like some insight into three problems.
1. If, over a period of a couple of years, a patient has repeated dilations, manages soft food occasionally, but is on mostly a liquid diet, what are the choices to be able to eat again?
2. When leakage occurs, is there a good way to stop it or a product to put on the skin to avoid excess irritation?
3. When you are eating easily and it is time to remove the PEG tube, are there complications involved in the healing after removal of long time PEGs? If it doesn't close up properly, where do you go from there?
Answer:
Okay gang let's talk PEG tubes. You have been gracious enough to send me some questions so I will do my best to answer them.
1. The first question concerns a chronic problem with difficulty swallowing despite repeated dilations. Let me give you my opinion about dilation. Basically, I don't think it works. Let's look at the problem. You have a round organ such as the esophagus. Around this circular organ you have scar tissue. The most basic thing that scar tissue does is to CONTRACT. When you have contracture around a circular organ you get narrowing or stricture. Now let's look at what happens when you dilate something. What you do is forcibly break up the scar causing a new wound. This results in quess what? That's right, more scar tissue. And what is scar going to do? CONTRACT!!! Therefore, you have set up a vicious cycle of scar, contracture, more scar and more contracture. Hence, no improvement. It is my feeling that to truly improve the situation, you have to bring in new tissue that is not affected by this cycle.
2. When leakage occurs around a PEG tube it is always best to make sure that the tube is tight against the body wall. Make sure the bumper or balloon inside the stomach is working properly and the outer flange can be snugged up to the skin. Not too tight, but just right. A single layer of gauze is usually enough to catch any drainage.
3. Generally PEG tubes can be removed in the office and the wound will close on its own in 2 to 3 days. It is very rare for the fistula (ya'll remember what a fistula is from our last encounter) not to close, but if it doesn't, it is a matter of a limited out-patient surgery to rectify the situation.
Doctor, I hear people talking about a fistula. Exactly what is a fistula, why do some people get one and what can be done to help it to heal?
All right, let's talk about fistulae. By the strictest definition, a "fistula" is a connection between two epithelial surfaces. Epithelium is the lining of an organ or the covering of a body part such as the skin. The organs of most concern in the head and neck are the mouth, the throat, and the esophagus. Therefore, a fistula in our area represents a connection between the mouth, throat, or esophagus and the skin of the neck.
What's the problem with a fistula? Well the most obvious problem is the leakage of saliva and anything else you swallow through the fistula onto the neck. The ramifications of this are obvious on social, convenience, and nutritional levels. Nobody wants to go around draining onto your neck all the time. Also, if the fistula is near your stoma some of this stuff can go down into the lungs and possibly lead to pneumonia or a lung abscess. All of this leads up to the fact that we try to do everything we can to avoid a fistula.
What are the main causes of a fistula? At the time of surgery we try our best to close the inside of the throat and esophagus to avoid a leak. We use antibiotics during and shortly after your surgery to cut down on the chance of infection. The main thing that leads to a fistula is poor wound healing. Things such as too much tension on the wound, a wound infection after surgery, poor nutrition, continued use of alcohol and tobacco, and prior radiation are the usual things that lead to problems with wound healing and the formation of a fistula.
So if a fistula develops, what can we do about it? The first thing we, as surgeons, do is to encourage it to drain into an area that will minimize the chances of infection in the rest of the neck and keep the drainage out of the stoma. Given enough time most fistulae will heal on their own without additional surgery. There is of course the hassle factor of dealing with external drainage and needing to use an alternative method of feeding such as a PEG during the healing phase. Surgical closure is reserved for those fistulae which do not close on their own and those that pose some danger particularly to the stoma and the lungs.
What are the long term side effects of a fistula? The most commonly encountered problem is a stricture or narrowing in the upper esophagus which may affect the ease of swallowing. Most patients that develop a fistula do not experience any long term problems.
Glenn E. Peters, M.D. , F.A.C.S.
A. Concerns and Considerations
As technology and our understanding of the mechanism of tracheoesophageal voice have advanced, a variety of prostheses have become available. Each device has distinct advantages and disadvantages, and there is no single prosthesis that meets the needs of allpatients. Furthermore, the specific requirements of an individual patient may change over time, and the prosthesis that is selected initially may not be appropriate for long-term use. The clinician, in consultation with the laryngectomee, must weigh several factors to determine which device will offer the optimum benefit for a specific individual.
The primary concerns in selecting the prosthesis type are to maintain the patency of the puncture tract and promote healthy tissue of the tracheoesophageal wall.
1. A 16 French duckbill style is often selected for the initial fitting of the voice prosthesis and when there is a concern for edema of the tracheoesophageal wall, as may occur during radiotherapy. The smaller diameter is preferable until the puncture site heals. The contour of the distal tip permits smooth insertion, and its slightly increased extension into the esophagus helps guard against underfitting and stenosis of the esophageal side of the puncture if edema occurs.
2. If the tissue of the tracheoesophageal wall has been heavily radiated or is weakened due to poorly controlled diabetes, nutritional imbalance, or other medical factors, a 16 French prosthesis made of soft silicone should be selected, because the larger, stiffer devices may cause irritation and/or dilation of the tract.
3. The thickness of the tracheoesophageal party wall may limit the choice of prosthetic devices, because some styles are not manufactured in extremely short or long lengths.
4. For patients with a narrowed esophagus, a duckbill style prosthesis may impinge on the posterior esophageal wall. This may prevent the prosthesis valve from opening, resulting in poor vocal quality, or alternately, it may cause the prosthesis to remain in the open position, resulting in leakage through the prosthesis.
5. When all requirements have been met to maintain the patency of the puncture tract and ensure the viability of the tracheoesophageal tissue, the clinician should consider the
aerodynamic characteristics that will promote a satisfactory vocal quality with a minimum of effort. The aerodynamic specifications of each device are available from the
manufacturer so that accurate comparisons can be made. Some general guidelines follow.
6. If there are any concerns regarding the patient’s ability to care for the device, an extended wear prosthesis should be selected. These prostheses are typically less likely to dislodge accidentally due to the design of the esophageal retention collar and they require infrequent changes by the speech-language pathologist or physician, reducing the patient’s responsibility for maintaining the device.
7. When there is limited availability of medical support services in the patient’s community, an extended wear device that can only be replaced by a physician or speech-language pathologist may represent a poor choice of prosthesis. Devices that are less commonly used, such as some of the imported prostheses, are contraindicated for patients who travel extensively and may require urgent support services while away from home.
8. The ease of insertion is maximal for the duckbill style prostheses, owing to the rounded distal tip. The trauma of insertion can be reduced for some of the hinged valve prostheses, which have a blunt tip, by use of a gelatin capsule system that encases the esophageal retention collar and contours the distal tip. The "retrograde insertion" required for some of the extended wear devices, by which the prosthesis is drawn through the oropharynx and into the puncture tract, can be uncomfortable for many patients, necessitating the use of topical anesthesia to reduce gagging. This placement technique is useful however, when there is a separation of the tracheoesophageal party wall and a concern that the prosthesis is not completely through the puncture tract when using the standard "front-loading" insertion technique.
9. In some circumstances, economic factors may influence the choice of prosthesis. In calculating the total cost, the clinician will need to consider the retail price of the prosthesis, as well as the typical longevity of each device.
Excerpted from:
Chapter 6, "Tracheoesophageal Speech" by Carla DeLassus Gress, ScD
In CLINICAL MANUAL FOR LARYNGECTOMY AND HEAD/NECK REHABILITATION
By Janina K. Casper, PhD and Raymond H. Colton, Ph.D.
Singular Publishing Group, Inc
San Diego, 1998
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Seeking a second opinion: "Before I make my decision.." Joanne F. Goldberg
In this explosive information age, it would be humanly impossible for any one person---physician or patient---to remain entirely abreast of every new development, and the question of when to seek a second opinion arises frequently.
What is the purpose of a second opinion? For some people, it is a perfectly justifiable effort to confirm a serious diagnosis. For others, it is an imperative to explore treatment options from the differing perspectives of different doctors. For still others, a second opinion is what it was never meant and ought never to be: shopping around for a "better diagnosis".
Some physicians who conduct clinical trials are able to offer newer---though not always better---treatments which cannot be made generally available to the public until those treatments have been studied and proven effective. In the event of a serious disease, it might be wise, through a second opinion, to explore such clinical trials and weigh them against existing treatments, as they may make up part of the range of treatment options from which you can choose.
One of the greatest obstacles in deciding to seek a second opinion is finding the right language to tell our physicians that, though we respect and trust their judgment, we would like to have the added consideration of others in the field, any of whom might have something to add to the understanding of our situation.
Consider the following approach to discussing a second opinion with your physician: "Before I make my decision, I would like to get a second opinion, in order to satisfy myself that I have examined every option available to me."
Using this approach, you first assert your intention to take responsibility for the choice of your treatment; your doctor should understand this and will appreciate that the final choice of treatment is your own. Second, you clearly state your desire to seek another opinion, leaving no question as to your purpose. And finally, you explain why you wish to pursue this path, without suggesting any lack offaith or comfort in your own doctor's abilities.
Interestingly, while most of us patients sweat it out, worried that we'll offend our doctors or wondering if they'll ever welcome us back after we get that second opinion, most doctors will respect our wishes without discussion or argument. The American College of Surgeons, for example, advises, "Consultation has always been a part of good medical practice, and a competent physician should not be insulted if you decide to get further advice."
In most cases---for example, 90% of those seen at one specialized second opinion clinic of a major cancer center---the second opinion will confirm what the patient has already been told. In some cases, a second opinion may uncover additional treatment options. In all cases, if you have any doubts or a nagging feeling that there may be something else for you to consider by way of your medical care, a second opinion will satisfy your curiosity, at least, and leave you with a wider range of options at very most. Always remember that the choice is yours.
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Is it harder to breathe after a laryngectomy?
David Blevins sent the following question for Dr. Peters:
After the laryngectomy, many larys seem to complain about a chronic shortness of breath, slower recovery from physical exertion, and even resistance to wearing anything over their stomas which feel like they are reducing air flow. Are these sensations accurate, and did something else change along with the humidification, filtration, and the air-warming functions of our nose, mouth, and throat? Is it now too "easy" for us to breathe...having lost the resistance to it provided by the upper part of our respiratory system.
Dr. Peters answer:
The real answer lies in what we have come to associate with adequate airflow and that is the SENSATION of air moving through our nose, mouth, and throat. Too many times I have seen patients immediately after their laryngectomies panicked and struggling to breathe. I watch them moving air and breathing well through their new stomas. It is only when I take their hand and put it in front of their stoma so they can feel the air flowing into and out of their lungs do they calm down. Therefore, I think it is the resetting of our normal sensory patterns that accounts for some of the problem. I also think that your ideas about resistance have some merit and should be considered. Happy New Year.
University of Alabama at Birmingham, Birmingham, Alabama, USA
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From just my observations and reading, it is amazing how often raising humidity turns out to solve so many of our mucous problems, helping to prevent crusting, plugs, and even mild bleeding.
But there is a disagreement among some professionals regarding tracheal irrigation. There are some laryngectomees who start out irrigating daily, keep doing so indefinitely, and do very well. Of course there is the question whether someone does well 'because' of doing some procedure, or 'despite' doing it. This is the problem with anecdotal or testimonial evidence, and why research is needed to answer these kinds of questions with more confidence.
There are others who cut back on irrigation to an as-needed basis, or stop doing it altogether as they (1) find other ways (such as good filtration) to keep things out of their lungs which might need to otherwise be coughed up and (2) keep up the humidity in their lungs through adding humidity and/or conserving it.
We can get lazy or careless regarding the first, and doing the second is not at all easy. It requires (depending on where you live, the season of the year, and your home design) adding humidity to the air generally, and further adding to that at the stoma level through the use of an HME or always dampened stoma cover. It is hard to get too much moisture into your lungs via water vapor.
One final thought: you would not have thought before your laryngectomy that squirting water into your lungs was a good thing to do. If you can keep the humidity up in them without doing so, it would logically seem preferable. Mother Nature's designs are usually pretty good.
David Blevins
David's points are actually quite valid. He emphasizes the role of humidification and actually reserves irrigation for more emergent situations. I think that as you get further out from your surgery that scenario actually becomes the reality of stoma care. WE tend to emphasize irrigation in the new laryngectomee because we feel that it probably represents the best way of dealing with stoma related emergencies, the most common of which are a mucous plug or a large crust. If we fail to stress the importance of irrigation while you are in the learning stages of your new life then you might neglect it as a useful tool when you really could benefit from it's application. Bottom line here is "wetter is better".
Dr. Glenn E. Peters
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WHAT ON EARTH HAPPENED TO MY THYROID GLAND?
First, the thyroid gland is shaped like a butterfly and lies in a position adjacent to the larynx and trachea. There are two lobes, one on each side of the larynx and trachea. These lateral lobes are connected by a narrow isthmus, which crosses the trachea just below the larynx.
In doing a laryngectomy, we try to save as much of the gland as possible. Usually, we can save both of the lateral lobes, which means you are left with essentially all of your thyroid tissue. However, sometimes it is necessary to resect half, or even all, of the thyroid in order to adequately remove the cancer. When we remove the larynx, we dissect the portion of the thyroid that we are going to save off of the larynx and trachea and leave it lying in the neck on either side of the esophagus. This means that your thyroid gland is actually in two halves, one on each side of the esophagus and slightly above your stoma.
The problem with thyroid function can come in several scenarios. The first one is obvious with the need to remove all of the thyroid tissue. You will be on thyroid replacement medication before you leave the hospital. (By the way, you will also be on calcium and vitamin D replacement before your discharge as well.) The other two scenarios are more subtle. The first involves leaving some thyroid tissue but compromising the blood supply in doing the laryngectomy. What happens is the thyroid slowly gives up the ship and dies.
The last and probably the most common thing to happen is radiation therapy. The radiation causes the small blood vessels in the gland to slowly stop up so you end up with a small scarred gland with poor blood supply and inadequate function.
Does everyone who has radiation to the neck need to be on thyroid replacement medicine? The answer is "no". If you are having the symptoms of becoming fatigued easily, low energy level, weight gain, etc., and if you have had radiation, then you should have your thyroid hormone levels checked with a simple blood test. Replacement medicine can then be given on the basis of those results.
Glenn E. Peters, M.D. , F.A.C.S.
Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, Alabama, USA
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Q. Dr. Peters, there was a big discussion recently in our WebWhispers online group about using ointments inside or around the stoma. What do you recommend in the use of antibiotic or antibacterial ointments?
A. That's a very interesting question. I think that if the stoma has "matured" or completely healed that nothing is needed. If a raw area develops from say using your speech prosthesis then a short course of an antibacterial is indicated until the area heals. I would not recommend a routine daily use of such products when nothing is wrong with the stoma.
I can think of three reasons that routine use should be discouraged. The first thing that comes to mind is that most antibiotic ointments have a petrolatum (i.e. petroleum) base. If a big "glop" of that stuff gets aspirated and finds its way into the lungs then a lung abscess could result. The second has to do with the fact that the main function of having petrolatum in a medicine is that it makes a seal on the surface. That is why we use it on a fresh wound, 'cause it seals the bad guys out. The other thing it does though is to seal moisture and any surface bacteria IN as well. This will create a situation that is chronically "wet" and actually damage normal skin. The last thing has to do with resistant bacteria. When bacteria are chronically exposed to an antibiotic they mutate in such a fashion that they become immune or resistant to that drug. That is why antibiotics should always be used sparingly and only when truly indicated. The classic example of this is the horrible practice of prescribing antibiotics to treat a cold which is generally caused by a virus.
So, when you have to use an antibacterial medication to treat an area of irritation around your stoma, use it sparingly and use a water soluble CREAM that won't risk damaging the lungs.
Glenn E. Peters, M.D. , F.A.C.S.
Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, Alabama, USA
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THE LASER (Light Amplification for the Stimulated Emission of Radiation)
Let's talk about the LASER. It is a device that focuses a very high intensity beam of energy on a very small spot. This results in tissue destruction or coagulation. Modern LASERs can be focused down to a spot size of less than 0.10 mm and hence are ideal instruments for precision cutting particularly when used in conjunction with an operating microscope. This makes them ideal for use in the larynx. The LASER most commonly used today in laryngeal surgery is the carbon dioxide LASER.
Applications for treating cancer of the larynx with the LASER are expanding. Initially, it was used for very small cancers which were confined to the mid-portion of the vocal cord. Surgeons in Europe, especially in Germany, and now in the United States, are using the LASER for larger lesions that involve more of the larynx. What we are trying to do is to remove the cancer endoscopically, that is through scopes placed in the mouth, and avoid an external incision. The beauty of the whole thing is that the uninvolved parts of the larynx can be preserved, with the patient retaining the ability to speak, swallow and breathe "normally". The patients for LASER surgery are highly selected and this technique cannot be used in every case of laryngeal cancer.
For example, the LASER cannot be used when the tumor involves the cartilaginous framework of the larynx or when it extends into adjacent areas of the throat. It is also very dependent on the skill and experience of the surgeon. However, in these groups of patients results are pretty encouraging. Another application of the LASER concerns its use in Photodynamic Therapy. In this setting a dye is injected into the patient that is preferentially picked by the tumor. The LASER is then used to "turn on" this chemical resulting in cell-killing in the tumor. Again, this application is being intensely investigated by a number of centers around the world.
LASERs are exciting tools whose real potential is still being realized. The goal is to adequately treat the cancer, but preserve as much normal function as possible. We will hear much about them in the coming years.
Glenn E. Peters, M.D. , F.A.C.S.
Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, Alabama, USA
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When do you know if radiation "worked"?
In general, XRT is like a sunburn: you don’t feel the effects until after you get home from the beach and you don’t get the full kill by radiation until a few weeks later. We frequently see "tumor" in radiated larynges a couple of weeks after radiation has ended. This is secretly discouraging to the doctor but a month later the tumor may be gone. For similar reasons, biopsies of tumor following radiation before 6 weeks has passed may reveal cancer cells but no one can predict if they are viable (able to grow and spread). Therefore, unless the tumor is LARGER, we avoid early biopsies.
Actually, we expect 95% of the patients that are destined to recur to do it within 2 years. The frequent exams may or may not help us detect that recurrence earlier while we can still affect the course of this disease.
Cancer anywhere in your body tries to rob you of your life and frequently robs you of your confidence. If you stop smoking and drinking, eat healthier and get some spiritual peace, you’ve done all you can do. Instead of worrying, try to enjoy life.
David Myssiorek, MD, Long Island Jewish Medical Center
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