This section describes the manifestations and treatment of the eating and smelling challenges faced by laryngectomees. These include swallowing problem, food reflux, esophageal strictures, and smelling difficulties.
Consuming food that stays longer in the stomach (e.g., proteins such as white cheese, meat, nuts) can reduce the number of daily meals, thus reducing the need to drink liquids.
Clearing the stuck food can be accomplished using these methods:
- Eating slowly and patiently
- Taking small bites of food and chewing very well before swallowing
- Swallowing a small amount of food at a time and always mixing it with liquid in the mouth before swallowing. Warm liquid makes it easier to swallow.
- Moisten dry/crumbly foods with sauces, gravies
- Flushing the food with more liquids as needed. (Warm liquids may work better for some individuals in flushing down the food)
- Sit upright while eating/drinking, and stay upright for at least 30-45 minutes after mealtime
- Avoiding food that is sticky or hard to chew.
- Some medications are available in several dosages which may be manufactured in smaller size pills or capsules. It is therefore possible to swallow the desired dose by taking several small pills or capsules.
- The size of pills of some generic medications may vary depending on their manufacturers. If this is the case it may be possible to find a smaller size pill produced by a different manufacturer.
- Some medications are also available as a suspension. It is best to check with one’s physician and pharmacy if a commercially available suspension is available, or can be prepared by one's pharmacy.
- Pills can be crushed and dissolved in room temperature liquids, or broken down to small pieces prior to ingestion. However, slow release medications may lose their time delay action when crushed. Ingestion of large gel capsules may not be possible.
- Capsules can be opened and their content swallowed. However, this exposes some medication to the stomach acidity that may inactivate and reduce their potency.
- Some crushed medications or capsule contents may be irritating to the mouth and/or esophagus and stomach.
- It is best to check with one’s physician and/or pharmacist if dissolving a pill or capsule’s contents is an option.
- When oral ingestion is not an option other routes of drug administration may be possible. These include intramuscular and intravenous injection, aerosols, and rectal or vaginal suppositories.
- When the size of a tablet or capsule is too large the physician may select a similar medication (from the same class or with similar effects) that is available in smaller size pill or capsule.
There are two muscular bands or sphincters in the esophagus that prevent reflux. One is located where the esophagus enters the stomach and the other is behind the larynx at the beginning of the esophagus in the neck. The lower esophageal sphincter often becomes compromised when there is a hiatal hernia which may occur in more than 3/4 of people over 70. During laryngectomy the sphincter in the upper esophageal sphincter ( the cricopharyngeus ) which normally prevents food from returning to the mouth is removed. This leaves the upper part of the esophagus flaccid and always open which may result in the reflux of stomach contents up into the throat and mouth. Therefore, regurgitation of stomach acid and food, especially in the first hour or so after eating, can occur when bending forward or lying down. This can also occur after forceful exhalation when those who use a TEP try to speak.
- Burning in the chest (heartburn)
- Burning or acid taste in the throat
- Stomach or chest pain
- Difficulty in swallowing
- A raspy voice or a sore throat
- Unexplained cough (not in laryngectomees, unless their voice prosthesis leaks)
- In laryngectomees: granulation tissue forms around the voice prosthesis, voice prosthesis device life is shortened, voice problems
- Losing weight (in those who are overweight)
- Reducing stress and practicing relaxation techniques
- Avoiding foods that worsen symptoms (e.g., coffee, chocolate, alcohol, peppermint, and fatty foods)
- Stopping smoking and passive exposure to smoke
- Eating small amounts of food several times a day rather than large meals
- Siting when eating and staying upright 30-60 minutes later
- Avoiding lying down for 2-3 hours after a meal
- Elevating the beds' head side by 6-8 inches (by putting blocks of wood under 2 legs of the bed or a wedge under the mattress) or by using pillows to elevate the upper portion of the body by at least about 45 degrees
- Taking a medication that reduces the production of stomach acids, as prescribed by one's physician
- When bending down, bending the knees rather than bending the upper body
Most laryngectomees experience problems with swallowing (dysphagia) immediately after their surgery. Because swallowing involves the coordination between more than 20 muscles and several nerves, damage to any part of the system by surgery or radiation can produce swallowing difficulties. The majority of laryngectomees relearn how to swallow with minimal problems. Some may only need to make minor adjustments in eating such as taking smaller bites, chewing more thoroughly, and drinking more liquids while eating. Some experience significant swallowing difficulties and may require assistance in learning how to improve their ability to swallow by working with an SLP who specializes in swallowing disorders. Swallowing dysfunction, due to fibrosis often requires a change in diet, pharyngeal strengthening, or swallow retraining especially in those who have had surgery and/or chemotherapy. Swallowing exercises are increasingly used as a preventing measure.
Swallowing function change after a laryngectomy and can be further complicated by radiation and chemotherapy. The incidence of swallowing difficulty and food obstruction can be as high as 50% of patients and, if not addressed, can lead to malnutrition. Most difficulties with swallowing are noticed after discharge from the hospital. They can occur when attempting to eat too fast and not chewing well. They can also happen after trauma to the upper esophagus by ingesting a sharp piece of food or drinking very hot liquid. These can cause swelling which may last a day or two. (I describe my experiences with eating in my book a in Chapter 20 entitled Eating.)
- Abnormal function of the pharyngeal muscles (dysmotility)
- Cricopharyngeal dysfunction of the the cricoid cartilage and the pharynx
- Reduced strength of the movements of the base of the tongue
- Development of a fold of mucous membrane or scar tissue at the tongue base called "pseudoepiglottis". Food can collect between the pseudoepiglottis and the tongue base
- Difficulty with tongue movements, chewing, and food propulsion in the pharynx because of removal of the hyoid bone and other structural changes
- A stricture within the pharynx or esophagus may decrease food passage leading to its collection
- Development of a pouch (diverticulum) in the pharyngoesophageal wall that can collect fluid and food resulting in the complaint of food "sticking" in the upper esophagus
Chewing the food well and mixing it with liquid in the mouth prior to swallowing is helpful, as is swallowing only small amounts of food each time and waiting for it to go down. Drinking liquids between solid foods is helpful in flushing down the food. Eating takes longer; one must learn to be patient and take all the time needed to finish the meal.
In most cases, dilation is successful, and patients can stabilize in as soon as six weeks but up to eight months. A small number of patients, however, continue to have severe dysphagia; that's when pharyngeal reconstruction is needed. This can be accomplished by obtaining a flap of non-radiated tissue (i.e., forearm) to create a wider throat.
- Barium swallow radiography
- Videofluoroscopy (motion X-ray study)
- Upper endoscopic evaluation of swallowing
- Fiberoptic nasopharyngeal laryngoscopy
- Esophageal manometry (measures esophagus muscle contractions)
The specific test is chosen according to the clinical condition.
Strictures after laryngectomy can be due be related to the effects of radiation as well as the tightness of the surgical closure and can also gradually as scarring develops. Interventions that can help the patient include:
- Dietary or postural changes
- Myotomy (cutting the muscle)
- Dilatation (see below)
- Placement of self-expanding plastic stents (see below)
Dilatation of the neopharynx and esophagus
Wire Guided Balloons used for esophageal dilatation
An injection through an esophago-gastro-duodeno-scope can be performed whenever a percutaneous injection is not feasible. This method is used in patients with severe post-radiation fibrosis, disruption of the cervical anatomy, and anxiety or inability to withstand a percutaneous injection. This method allows direct visualization and greater precision. The injection into the PES segment is often done by a gastroenterologist and is followed by gentle expansion by balloon massage to facilitate uniform distribution of the Botox®.
The “polite yawn technique” can also help laryngectomees regain their capacity to smell. This method is known as the “polite yawn technique” because the movements involved are similar to those used when one attempts to yawn with a closed mouth. Swift, downward movement of the lower jaw and tongue, while keeping the lips closed, will create a subtle vacuum, drawing air into the nasal passages and enabling the detection of any scent through the new airflow. With practice, it is possible to achieve the same vacuum using more subtle (but effective) tongue movements.
- Squeezing the nostrils with the fingers
- Placing a cotton ball in each nostril
- Wearing a surgical mask over the nose with or without a fitted piece of plastic
Basic skills for laryngectomees by Elizabeth Finchem
There was a time, not so long ago, when the International Association of Laryngectomees Annual Meeting program included ‘speech improvement’ breakout sessions that provided tiered training for designated groups (beginner, intermediate, or advanced speakers) to improve their skills for whichever method they chose to communicate with year after year. Some folks referred to these sessions as “Jim’s Dog and Pony Show” since Jim Shanks, PhD, SLP, taught all of them at one point or another. Along the way the demonstrations included how learning to smell, taste and blow related to speech techniques we could use to improve the intelligibility of our speech after laryngectomy. I also learned the finer points of fluent esophageal speech while attending these demonstrations that amounted to very practical hands on labs for learning and teaching. I hope sharing some of these tried and true techniques will be helpful for your rehabilitation, and for those who are learning how to work with laryngectomees.
You may wonder how you can possibly sniff up your nose or blow your nose again? Try it. Take those first few steps. Lips together and drop you lower jaw to draw air in with a sniff action, or reverse it by bringing your lower jaw back up as you use your tongue to thrust the air upward through the nose to blow one side at a time.