CHAPTER 1: Diagnosis and treatment of laryngeal cancer
Laryngeal and hypopharyngeal cancer may spread by direct extension to adjacent structures, by metastasis to regional cervical lymph nodes, or more distantly, through the blood stream to other locations in the body. Distant metastases to the lungs and liver are most common. Squamous cell carcinomas account for 90 to 95 percent of laryngeal and hypopharyngeal cancer.
Smoking, and heavy alcohol consumption are the main risk factors for laryngeal cancer. Exposure to human papilloma virus (HPV) has been mainly associated with oropharyngeal cancer and to a lesser degree with laryngeal and hypopharyngeal ones.
There are about 50,000 to 60,000 laryngectomees in the USA. According to the Surveillance Epidemiology and End Results (SEER) Cancer Statistics Review of the National Cancer Institute, an estimated 12,250 men and women are diagnosed with cancer of the larynx each year. The number of new laryngectomees has been declining mainly because fewer people are smoking and newer therapeutic approaches can spare the larynx.
Effective diagnostic testing is used to confirm or eliminate the presence of cancer, monitor its progress, and plan for and evaluate the effectiveness of treatment. In some instances, it is necessary to perform repeat testing if a person’s condition has changed, a sample collected was not of good quality, or an abnormal test result needs to be confirmed. Diagnostic procedures for cancer may include imaging, laboratory tests, tumor biopsy, endoscopic examination, surgery, or genetic testing.
The following tests and procedures may be used to help diagnose and stage laryngeal cancer which influences the choice of treatment:
Physical examination of the throat and neck: This enables the doctor to feel for swollen lymph nodes in the neck and to view the throat by using a small, long-handled mirror to check for abnormalities.
Endoscopy: A procedure in which an endoscope (a flexible lighted tube) is inserted through the nose or mouth into the upper airway to the larynx, enabling the examiner to directly view these structures.
Laryngoscopy: A procedure to examine the larynx with a mirror or a laryngoscope (a rigid lighted tube).
CT scan (computed tomography): A procedure that generates a series of detailed radiographs of body sites, taken from different directions. A contrast material such as an injected or swollen dye enables better visualization of the organs or tissues.
MRI (magnetic resonance imaging): A procedure that uses a magnet and radio waves to generate a series of detailed pictures of areas inside the body.
Barium swallow: A procedure to examine the esophagus and stomach in which the patient drinks a barium solution that coats the esophagus and stomach, and x-rays are obtained.
Biopsy: A procedure in which tissues are obtained so that they can be viewed under a microscope to check for cancer.
- The extent the cancer has spread (the “stage”)
- The appearance of the cancer cells (the “grade”)
- The location(s) and size of the tumor
- The patient's age, gender, and general health
- Ear, nose, and throat doctors (otolaryngologists)
- General head and neck surgeons
- Medical oncologists
- Radiation oncologists
- The extent to which the cancer has spread (the “stage”)
- The location and size of the tumor
- Maintaining the patient's ability to talk, eat, and breathe as normally as possible
- Whether the cancer has returned
- What is the size, location, spread, and stage of the tumor?
- What are the treatment options? Would they include surgery, radiation therapy, chemotherapy or a combination of these?
- What are the expected side effects, risks and benefits of each kind of treatment?
- How can side effects be managed?
- What are the chances of saving the voice with each of the above treatments?
- How to prepare for treatment?
- Will the treatment require hospitalization and if so for how long?
- What is the estimated cost of the treatment and will insurance cover it?
- How will the treatment affect one’s life, work and normal activities?
- Is a research study (clinical trial) a good option?
- Can the physician recommend an expert for a second opinion regarding the treatment options?
- How often and for how long will there be a need for follow-ups?
chapter 2. Having surgery: types of laryngectomy, outcome, pain management and seeking a second opinion.
Types of laryngectomy
- Internist and/or family physician
- Any specialist one sees for a specific medical problem (i.e. cardiologist, pulmonologist, etc.)
- Radiation oncologist
- Medical oncologist
- Speech and language pathologist (SLP)
- Social worker or mental health counselor
When facing a new medical diagnosis that requires making a choice between several therapeutic options, including surgery, it is important to get a second opinion. There may be different medical and surgical approaches and a second (or even third) opinion may be invaluable. Getting such an opinion from physicians experienced in the issues at hand is judicious. There are many situations when treatment cannot be reversed. This is why choosing the course of therapy after consulting with at least one more specialist is very important.
The second doctor may agree with the first doctor’s diagnosis and treatment plan. Conversely, the other physician may suggest a different approach. Either way, the patient ends up with more valuable information and also with a greater sense of control. Eventually one may feel more confident about the decisions he/she makes, knowing that all options have been considered.
Gathering one’s medical records and seeing another physician may take some time and effort. Generally, the delay in initiating treatment will not make the eventual treatment less effective. However, one should discuss any possible delay with the physician.
There are numerous ways to find an expert for a second opinion. One can request a referral to another specialist from the primary doctor, a local or state medical society, a nearby hospital, or a medical school.
The degree of pain experienced after laryngecomy (or any other head and neck surgery) is very subjective, but, as a general rule, the more extensive the surgery, the more likely the patient will experience pain. Certain types of reconstructive procedures, where tissue is transferred (a flap) from the chest muscles, forearm, thigh, jejunum, or a stomach pull up are more likely to be associated with increased or prolonged pain.
Those who have a radical neck dissection as part of the surgery may experience additional pain. At present, most patients undergo a "modified radical neck dissection" when the spinal accessory nerve is not removed. If the spinal accessory nerve is cut or removed during surgery, the patient is more likely to have shoulder discomfort, stiffness, and long term loss of range of motion. Some of the attendant discomfort of this procedure can be prevented by exercise and physical therapy.
For individuals who experience chronic pain as a result of laryngectomy or any other head and neck surgery, evaluation by a pain management specialist is usually very helpful. (See Pain management in Chapter 12)
chapter 3. Side effects of radiation treatment for head and neck cancer
Nausea and vomiting
- Eating small, frequent meals throughout the day instead of three large meals. Nausea is often worse if the stomach is empty.
- Eating slowly, chewing the food completely, and staying relaxed.
- Eating cold or room temperature foods. The smell of hot or warm foods may induce nausea.
- Avoiding difficult to digest foods, such as spicy foods or foods high in fat or accompanied by rich sauces.
- Resting after eating. When lying down, the head should be elevated about 12 inches.
- Drinking beverages and other fluids between meals instead of drinking beverages with meals.
- Drinking 6- 8 ounce glasses of fluid per day to prevent dehydration. Cold beverages, ice cubes, popsicles, or gelatin are adequate.
- Eating more food at a time of the day when one is less nauseous.
- Informing one’s health care provider before each treatment session when one develops persistent nausea.
- Treating persistent vomiting immediately, as this can cause dehydration.
- Administering anti-nausea medication by a health care provider.
- Small amount of urine
- Dark urine
- Rapid heart rate
- Flushed, dry skin
- Coated tongue
- Irritability and confusion
Repair of nonrestorable and diseased teeth prior to RT may reduce the risk of this complication. Mild osteoradionecrosis can be conservatively treated with debridement, antibiotics, and occasionally ultrasound. When necrosis is extensive, radical resection, followed by microvascular reconstruction, is often used.
Fibrosis in the head and neck can become even more extensive in those who have surgery or further radiation. Post radiation fibrosis can also involve the skin and subcutanous tissues, causing discomfort and lymphedema.
Treatment includes removal of the blockage (endarterectomy), placing a stent ( a small device placed inside the artery to widens it ) or a prosthetic carotid bypass grafting.
More information about complications of RT can be found at the National Cancer Institute Web site at:
chapter 4. Side effects of chemotherapy for head and neck cancer
Chemotherapy can, however, cause several temporary side effects. Although these may be worse with combined radiation therapy, they generally disappear gradually after the treatment has ended.
The more common side effects are nausea, vomiting, diarrhea, sores (mucositis) in the mouth (resulting in problems with swallowing and sensitivity in the mouth and throat), increased susceptibility to infection, anemia, hair loss, general fatigue, numbness in the hands and feet, hearing loss, kidney damage, bleeding problems, malaise, and balance problem. An oncologist and other medical specialist watch for and treat these side effects.
chapter 5. Lymphedema, neck swelling and numbness after radiation and surgery
Radiation creates scarring which interferes with the function of the lymphatics. The cervical lymph nodes are generally removed when the cancer is excised. When the surgeons remove these glands, they also take away the drainage system for the lymphatics and cut some of the sensory nerves. Unfortunately, most of the severed lymphatics and nerves are permanently cut. Consequently it takes longer to drain the area, resulting in swelling. Like flooding after a heavy rain when the drainage system is broken, the surgery creates a backup of lymphatic fluid that cannot drain adequately, as well as numbness of the areas supplied by the severed nerves (usually in the neck, chin, and behind the ears). As a result, some of the lymphatic fluid cannot re-enter the systemic circulation and accumulates in the tissues.
- Difficulty in breathing
- Impairment in vision
- Motor limitations (reduced neck motion, jaw tightness or trismus and chest tightness)
- Sensory limitations
- Speech, voice and swallowing problems (inability to use an electrolarynx, difficulty in articulation, drooling, and loss of food from mouth)
- Emotional issues (depression, frustration and embarrassment)
- Manual lymph drainage (face and neck, deep lymphatics, trunk, intra oral)
- Compressive bandages and garments
- Remedial exercises
- Skin care
- Elastic therapeutic tape (Kinesiotape)
- Oncology rehabilitation
- Diuretics, surgical removal (debulking), liposuction, compression pumps, and elevation of the head alone are ineffective treatments.
A head and neck lymphedema therapist can select non-elastic bandages or compression garments that are worn at home. These place gentle pressure on the affected areas to help move the lymph fluid and prevent it from refilling and swelling. Application of bandages should be done as directed by a specialist. There are several options, depending on the location of the lymphedema to improve comfort and avoid complications from pressure on the neck.
There are physical therapy experts in most communities who specialize in reducing swelling and edema. Consult one's surgeon to find out if physical therapy is a good therapeutic option for lymphedema.
Skin numbness after surgery
chapter 6. Methods of speaking after laryngectomy
Individuals normally speak by exhaling air from their lungs to vibrate their vocal cords. These vibration sounds are modified in the mouth by the tongue, lips, and teeth to generate the sounds that create speech. Although the vocal cords that are the source of the vibrating sounds are removed in laryngectomy, other forms of speech can be created by using a new pathway for air and a different airway part to vibrate. Another method is to generate vibration by an artificial source placed on the outside of the throat or mouth and then using the mouth parts to form speech.
The method(s) used to speak again depend on the type of surgery. Some people may be limited to a single method, while others may have several choices.
Each method has unique characteristics, advantages and disadvantages. The goal of attaining a new way to speak is to meet the communication needs of each laryngectomee.
Speech and language pathologists (SLPs) can assist and guide laryngectomees in the proper use of the methods and/or devices they use to obtain the most understandable speech. Speech improves considerably between six months and one year after . Active voice rehabilitation is associated with attaining better functional speech.
Of the three major types of speech following laryngectomy, esophageal speech usually takes the longest to learn. However, it has several advantages, not the least of which includes the freedom from dependency on devices and instrumentation.
The voice prosthesis is inserted into the puncture (called tracheoesophageal puncture or TEP) created by the surgeon in the back of the neck stoma. The hole is made at the back of the trachea (the windpipe) and goes into the esophagus (food tube). The hole between the trachea and esophagus can be done at the same time as the laryngectomy surgery (a primary puncture), or after healing from the surgery has occurred (a secondary puncture). A small tube, called a voice prosthesis, is inserted in this hole and prevents the puncture from closing. It has a one-way valve at the end on the esophagus side which allows air to go into the esophagus but prevents swallowed liquids from coming through the prosthesis and reaching the trachea and lungs.
Speaking is possible by diverting the exhaled air through the prosthesis into the esophagus by temporarily occluding the stoma. This can be done by sealing it with a finger or by pressing on a special Heat and Moisture Exchanger (HME) filter that is worn over the stoma. (See HME advantages in chapter 9) An HME partially restores the lost nasal functions. Some people use a “hands free” HME (automatic speaking valve) that is activated by speaking (See Using hands free HME in chapter 9).
After occlusion of the stoma exhaled lung air moves through the prosthesis into the esophagus causing the walls and top of the esophagus to vibrate. These vibrations are used by the mouth (tongue, lips, teeth, etc.) to create the sounds of speech.
There are two different basic types of voice prosthesis: the patient-changed type, designed to be changed by the laryngectomee or by another person, and the indwelling type, designed to be changed by a medical professional (an otolaryngologist or SLP).
The HME or hands free valve can be attached in front of the tracheostomy stoma in different ways: by means of an adhesive housing (or base plate) that is taped or glued to the skin in front of the stoma, or by means of a laryngectomy tube or stoma button that is placed inside the stoma.
Patients who used TEP had the best results in speech intelligibility six months and one year after .
It makes a buzzing vibration that reaches the throat and mouth of the user. The person then modifies the sound using his/her mouth to generate the speech sounds.
There are two main methods to deliver the vibration sounds created by an artificial larynx into the throat and mouth (intra orally). One is directly into the mouth by a straw-like tube and the other through the skin of the neck or face. In the last method, the electrolarynx (EL) is held against the face or neck.
ELs are often used by laryngectomees shortly after their laryngectomy while they are still hospitalized. Because of the neck swelling and post surgical stitches the intra oral route of delivery of vibration is preferred at that time. Many laryngectomees can learn other methods of speaking later. However, they can still use an EL as a back-up in case they encounter problems with their other speaking methods.
A pneumatic artificial larynx is also available to generate speech. This method uses lung air to vibrate a reed or rubber material that produces a sound. The device’s cup is placed over the stoma and its tube is inserted into the mouth. The sound generated is injected into the mouth through the tube.
Those who are unable to use any of the above methods can use computer generated speech using either a standard laptop computer or a single purpose speech aid. The user types what he/she wants to say onto a keyboard, and the computer speaks out loud what has been typed. Some cell phones can operate in the same manner.
Diaphragmatic breathing (also called abdominal breathing) is the act of breathing slowly and deeply into one's lungs by using the diaphragm muscle rather than by using one's rib cage muscles. When breathing using the diaphragm, the abdomen, rather than the chest is expands. This method of breathing allows for greater utilization of the lung capacity to obtain oxygen and dispose of bicarbonate gasses. Neck breathers are often shallow breathers who use a relatively smaller portion of their lung capacity. Becoming accustomed to inhaling by using the diaphragm can increase one’s stamina and also improve esophageal and trachoesophageal speech.
CHAPTER 7. Mucus and respiratory care
Coughing up mucus through the stoma is the only means by which laryngectomees can keep their trachea and lungs clear of dust, dirt, organisms, and other contaminants that get into the airway. Whenever an urge to cough or sneeze emerges laryngectomee must quickly remove their stoma cover or Heat and Moisture Exchanger (HME) filter and use a tissue or handkerchief to cover their stoma to catch the mucus.
The best mucus consistency is clear, or almost clear, and watery. Such consistency is, however, not easy to maintain because of changes in the environment and weather. Steps can be routinely taken to maintain a healthy mucus production as shown below.
Prior to becoming a laryngectomee, an individual’s inhaled air is warmed to body temperature, humidified and cleansed of organisms and dust particles by the upper part of the respiratory system. Since these functions do not occur following laryngectomy, it is important to restore the lost functions previously provided by the upper part of the respiratory system.
Following laryngectomy the inhaled air does not get humidified by passing through the nose and mouth; accordingly, tracheal dryness, irritation and overproduction of mucus develop. Fortunately, the trachea becomes more tolerant to dry air over time. However, when the humidity level is too low the trachea can dry out, crack, and produce some bleeding. If the bleeding is significant or does not respond to increase in humidity, a physician should be consulted. And if the amount or color of the mucus is concerning, one should contact a physician.
Restoring the humidification of the inhaled air reduces the overproduction of mucus to an adequate level. This will decrease the chances for coughing unexpectedly and plugging the HME. Increasing the home humidity to 40-50% relative humidity (not higher) can help in decreasing mucus production and keeping the stoma and trachea from drying out, cracking and bleeding. In addition to being painful, these cracks can also become pathways for infections.
- Coughing out or suctioning the mucus using a suction machine to clean the airway
- Avoiding exposure to cold, dry or dusty air
- Avoiding dust, irritants and allergens
- When exposed to cold air, consider covering the stoma with a jacket (by zipping it all the way) or a loose scarf and breathing into the space between the jacket and the body to warm the inhaled air.
- Preventing water from getting into the stoma when showering (see below)
Following a laryngectomy which involves lymph neck dissection most individuals develop areas of numbness in their neck, chin and behind the ears. Consequently, they cannot sense cold air and can develop frostbite at these sites. It is therefore important to cover these areas with a scarf or warm garment.
A suction machine is often ordered for a laryngectomee prior to leaving the hospital for use at home. It can be used to suction out mucus when one is unable to cough it out and/or to remove a mucus plug. A mucus plug can develop when the mucus become thick and sticky, creating a plug that blocks part or, infrequently, even the whole airway.
The plug can cause a sudden and unexplained shortness of breath. A suction machine can be used in these circumstances to remove the plug. It should therefore be readily available to treat such an emergency. Mucus plugs may also be removed by using a saline “bullet” (0.9% sterile salt water in a plastic tube) or by squirting saline solution into the stoma. The saline can loosen the plug that can be cough out. This condition may become a medical emergency and, if the plug is not successfully removed after several attempts, dialing 911 may be life saving.
Blood in the mucus can originate from several sources. The most common is from a scratch just inside the stoma. The scratch can be caused by trauma while cleaning the stoma. The blood generally appears bright red. Another common cause of coughing blood in a laryngectomee is irritation of the trachea because of dryness which is common during the winter. It is advisable to maintain a home environment with adequate humidity levels (about 40-50%) to help minimize drying the trachea. Squirting sterile saline into the stoma can also help (See above in the Mucus production section).
Bloody sputum can also be a symptom of pneumonia, tuberculosis, lung cancer, or other lung problem.
Persistent coughing of blood should be evaluated by medical professionals. This may be urgent if it is associated with difficulties in breathing and/or pain.
Because laryngectomees and other neck breathers no longer breathe through their nose, their secretions are not being dried by moving air. Consequently, the secretions drip out of the nose whenever large quantities of them are produced. This is especially common when one is exposed to cold and humid air or irritating smells. Avoiding these conditions can prevent a runny nose.
After a laryngectomy the inhaled air bypasses the upper part of the respiratory system and enters the trachea and lungs directly through the stoma. Laryngectomees therefore lose the part of the respiratory system that used to filter, warm and humidify the air they breathe.
The change in the way breathing is done also affects the efforts needed to breathe and potential lung functions. This requires adjustment and retraining. Breathing is actually easier for laryngectomees because there is less air flow resistance when the air bypasses the nose and mouth. Because it is easier to get air into the lungs, laryngectomees no longer need to inflate and deflate their lungs as completely as they did before. It is therefore not unusual for laryngectomees to develop reduced lung capacity and breathing capabilities.
There are several measures available to laryngectomees that can preserve and increase their lung capacity:
- The use of an HME filter can create resistance to air exchange. This forces the individual to fully inflate their lungs to get the needed amount of oxygen.
- Regular exercise under medical supervision and guidance. This can get the lungs to fully inflate and improve individuals’ heart and breathing rates.
- Using diaphragmatic breathing. This method of breathing allows for greater utilization of the lung capacity. (See Diaphragmatic breathing and speech in chapter 6)
CHAPTER 8. Stoma care
It is very important to cover the stoma at all times in order to keep out dirt, dust, smoke, micro-organisms, etc., from getting into the trachea and lungs.
There are various kinds of stoma covers. The most effective ones are called Heat and Moisture Exchanger (HME) filters because they create a tight seal around the stoma. In addition to filtering dirt, HMEs preserve some of the moisture and heat inside the respiratory tract and prevent the person from losing them. The HME filters therefore assist in restoring the temperature, moisture and cleanliness of the inhaled air to the condition before the laryngectomy.
The stoma often shrinks during the first weeks or months after it is created. To prevent it from closing completely, a tracheostomy or laryngectomy tube is initially left in the stoma 24 hours a day. Over time this duration is gradually reduced. It is often left overnight until there is no more shrinking.
Stoma care when using a base plate or adhesive housing: The skin around the stoma can become irritated because of repeated gluing and removal of the housing. The materials used to remove the old housing and prepare for the new one can irritate the skin. Removal of the old housing can also irritate the skin especially when it is glued.
An adhesive removal wipe containing liquid (e.g. Remove TM, Smith & Nephew, Inc. Largo Fl 33773) can assist in removing the base plate or housing. It is placed at the edge of the housing and helps the housing detach from the skin when it is lifted off. Wiping the area with Remove TM cleans the site from remnants of the seal used to glue the housing. It is important to wipe off the leftover Remove TM with an alcohol wipe so that it will not irritate the skin. When a new housing is used wiping off the Remove TM prevents it from interfering with placing glue again.
Stoma care when using tracheostomy tube: The buildup of mucus and the rubbing of the tracheostomy tube can irritate the skin around the stoma. The skin around the stoma should be cleaned at least twice a day to prevent odor, irritation and infection. If the area appears red, tender or smells bad, stoma cleaning should be performed more frequently. Contacting one’s physician is advisable if a rash, unusual odor, and/or yellowish-green drainage appear around the stoma.
Protecting the stoma from water when showering
It is important to prevent water from entering the stoma when taking a shower. A small amount of water in the trachea generally does not cause any harm and can be rapidly coughed out. However, inhalation of a large amount of water can be dangerous.
Methods to prevent water from entering the stoma are:
- Covering the stoma with the palm and not inhaling air when water is directed at the vicinity of the stoma.
- Wearing a bib with the plastic side out.
Laryngectomees are at risk of inhaling (aspirating) water that may not be free of bacteria. Tap water contains bacteria; the number of bacteria varies depending on the cleaning efficacy of the water treatment facilities and their source (e.g., well, lake river etc.). Pool water contains chloride that reduces, but never sterilizes the water. Sea water contains numerous bacteria; their nature and concentrations varies.
When unclean water gets into the lungs it can sometimes cause pneumonia. Developing aspiration pneumonia depends on how much water is inhaled and how much is coughed out, as well as on the individuals' immune system.
Preventing aspiration into the stoma
One of the major causes of respiratory emergency in a neck breather is the aspiration of thin paper tissue or paper towels into the trachea. This can be very dangerous and can cause asphyxiation. It usually happens after covering the stoma with a paper towel when coughing out sputum. Following the cough there is a very deep inspiration of air that can suck the paper back into the trachea. The way to prevent this is to use a cloth towel or a strong paper towel that does not break easily, even when moist. Thin tissues should be avoided.
Another way to prevent aspiration of paper tissues is to hold one's breath until one has completely finished wiping off the sputum and removed the paper tissue or paper towel from the stoma area.
Aspiration of other foreign material should also be prevented by covering the stoma at all times by an HME, foam cover, or stoma cover.
Aspiration of water into the stoma while taking a shower can be prevented by wearing a device that covers the stoma (see above). One can keep the HME on while showering and/or avoid breathing in when water is directed at the stoma’s site.
Taking a bath in a tub can be done safely as long as the water level does not reach the stoma. The areas above the stoma should be washed with a soapy washcloth. It is important to prevent soapy water from entering the stoma.
chapter 9. Heat moisture exchanger (HME) filter care
It is very important that laryngectoees wear an HME. In the United States, the filters are available through Atos Medical and InHealth Technologies. The HME filter can be attached by using an intraluminal device inserted into the trachea or stoma, that includes laryngectomy or tracheostomy tubes, Barton Mayo ButtonTM and/or Lary Button TM . The filter can also be inserted into a housing or a base plate attached to the skin around the stoma.
The filter captures the warm, moistened, and humidified air upon exhalation. It is coated with chlorhexidine (anti-bacterial agent), sodium chloride (NaCl), calcium chloride salts (traps moisture), activated charcoal (absorbs volatile fumes), and is disposable after 24 hours of use.
The filter’s advantages also include: increasing the moisture within the lungs (subsequently leading to less mucus production), decreasing the viscosity of the airway secretions, decreasing risk of mucus plugs, and re-instating the normal airway resistance to the inhaled air.
In addition, the HME filters reduce the inhalation of bacteria, viruses, dust and pollen. Inhaling less pollen can reduce the airway irritation during high allergens season. Wearing a HME may reduce the risk of getting viral and bacterial infection, especially in crowded or closed places. A new HME filter designed to filter potential respiratory pathogens is available (Provox Micron TM, Atos Medical).
It is important to realize that simple stoma covers, such as a laryngofoamTM filter, ascot, bandana, etc., do not provide the same benefits to a laryngectomee as an HME filter.
The effect of an HME on breathing as a laryngectomee
Laryngectomy compromises the respiratory system by allowing the inhaled air to bypass the nose and upper airways which normally provide humidification, filtration and warmth. It also reduces the resistance and the effort needed for inhalation by removing air resistance and shortening the distance the air travels to the lung. This means that laryngectomees do not have to work as hard to get air past the upper part of the system (nose, nasal passages, and throat), and their lungs do not have to inflate as much as they did before unless the person works to retain their capacity through exercise and other methods. An HME increases the resistance to inhaled air and therefore increases inhalation efforts, thus preserving previous lung capacity.
In some individuals the shape of the neck around the stoma makes it difficult to fit a housing or a base plate. There are several types of housing; a speech and language pathologist (SLP) can assist in selecting the best one. Finding the best HME housing may take trial and error. Over time, as the post surgical swelling subsides and the area around the stoma reshapes itself, the type and size of the housing may change.
Below are the suggested instructions on how to place the housing for the HME. Throughout the process it is important to wait patiently and allow the liquid film-forming skin protecting dressing (i.e., Skin PrepTM Smith & Nephew, Inc. Largo, Fl 33773) and silicone skin adhesive to dry before applying the next item or placing the housing. This takes time, but it is important to follow these instructions.
Remove TM will interfere with the new adhesive).
Using hands free HME
The hands free HME allows speaking without the need to manually press on the HME to close it off, thus blocking exhalation through the stoma and directing air to the voice prosthesis. This device frees one’s hand and eases vocational and recreational possibilities. Note that when using a hands free HME more pressure is generated when air is exhaled thus potentially leading to a break in the HME housing’s seal. Reducing the exhalation pressure when speaking, speaking slower and softly (almost whispering), and taking a breath after 5-7 words can prevent a break in the seal.
The key to speaking with a hands free HME is to learn how to speak without breaking the seal. Using diaphragmatic breathing allows for more air to be exhaled, thus reducing speaking efforts and increasing the number of words that can be articulated with each breath. This method prevents buildup of air pressure in the trachea which can break the housing’s seal. It may take time and patience to learn how to speak in such a way, and guidance by a skilled SLP can be helpful.
It is very important to place the HME housing according to the steps outlined in the section on HME care (See Placing an HME Housing above) including cleaning the area around the stoma with RemoveTM, alcohol, water and soap, placing Skin PrepTM and finally glue (Skin TagTM). Following these instructions can prolong the life of the housing and reduce the likelihood of an air leak through the seal.
Air inhalation is slightly more difficult when using a free hands HME as compared to a regular HME. It is possible to allow for greater amounts of air intake by rotating the valve counter-clockwise in both Atos FreeHandTM and InHealth HandsFreeTM devices.
Despite the challenge of keeping the seal, many laryngectomees value the ability to speak in a more natural way and the freedom of using both hands. Some learn that it is possible to keep the seal much longer when they use a voice amplifier thus requiring less effort and generating less air pressure. (See Increasing the voice using a voice amplifier in Chapter 6)
Wearing the HME overnight
Some HMEs are approved for wear 24/7 ( i.e. Atos Medical). If the seal lasts, one can keep it overnight. If it does not last, it is possible to use an improvised base plate for the night period. An Atos Xtra BasePlateTM can be trimmed down by removing the outer soft part and leaving the inner rigid part. The plate is “sticky” and thus can cover the stoma without glue, even enabling one to speak.
Covering (hiding) the HME
Following laryngectomy individuals breathe through a tracheostomy site that opens through a stoma on their neck. Most place an HME or a foam filter over the stoma to filter the inhaled air and maintain warmth and humidity in the upper airway. The covered stoma site is prominent and laryngectomees face a choice whether to cover the HME or filter with a garment, an ascot, or jewelry or to leave it uncovered.
The pros and cones of each choice:
Breathing may be easier without an additional cover which can interfere with air flow. Leaving the area exposed allows for easier access to the stoma for purpose of cleaning and maintenance and enables a rapid removal of the HME in case one needs to cough or sneeze. The urge to cough or sneeze is often very sudden and if the HME is not taken out quickly it can become clogged with mucus.
Exposing the site provides an unspoken explanation for the weak and rusty voice of many laryngectomees and encourages others to listen to them more attentively. It also makes it easier for health care providers to recognize the laryngectomees’ unique anatomy in case emergency respiratory ventilation is needed. If this condition is not rapidly recognized ventilation may be administered through the mouth or nose rather than through the stoma. (See Ensuring adequate urgent care of neck breathers including laryngectomees in Chapter 17)
Openly displaying the covered stoma site also reveals the person’s medical history and the fact that he/she are cancer survivors who go on with their lives despite their handicap, cancer being the leading indication for a laryngectomy. Although there are many cancer survivors in the community, their identity is hidden from outward appearances.
Those who cover their stoma site with a stoma cover or cloth often do it because they do not want others to be distracted or offended by the site. They also do not want to expose anything that is disfiguring and want to be inconspicuous and appear as normal as possible. Covering the site is often more common among females who may be more concerned with their physical appearance. Some individuals feel that being a laryngectomee is only a small part of who they are as a person; they do not want to “advertise” it.
There are advantages and repercussions to each approach and the final selection is up to the individual.
There are two types of voice prosthesis: an indwelling one that is installed and changed by a speech and language pathologist (SLP) or otolaryngologist and a patient-changed one.
The indwelling prosthesis generally lasts a longer time than the patient managed device. An indwelling prosthesis can function well for weeks to months. However, some SLPs believe that it should be changed even when it does not leak after six months because, if left for a longer time, it can lead to dilatation of the fistula.
The patient managed voice prosthesis allows a greater degree of independence. It can be changed by the laryngectomee on a regular basis, (every one to two weeks). Some individuals change the prosthesis only after it starts leaking. The old prosthesis can be cleaned and reused several times.
- The location of the puncture should be easily accessible; the site of the puncture may, however, migrate over time, making it less accessible.
- The laryngectomee should have adequate eyesight and good dexterity, enabling him/her to perform the procedure, and capable of following all the steps involved.
Two videos made by Steve Staton explain how to change a patient-changed prosthesis:
Leakage through the voice prosthesis is predominantly due to situations in which the valve can no longer close tightly. This may be due the following: colonization of the valve by fungus; the flap valve may get stuck in the open position; a piece of food, mucus or hair (in those with a fee flap) stuck on the valve; or the device coming in contact with the posterior esophageal wall. Inevitably, all prostheses will fail by leaking through, whether from Candida colonization or simple mechanical failure.
If there is continuing leakage through the prosthesis from the time it is inserted, the problem is generally due to the fact that the flap valve remains open because of negative pressure generated by swallowing. This can be corrected by using a prosthesis that has a greater resistance. The trade-off is that having such a TEP may require more effort when speaking. It is, nevertheless, important to prevent chronic leakage into the lungs.
Leakage around the prosthesis can also occur if the prosthesis is too long for the user’s tract. Whenever this occurs, the TEP moves back and forth in the tract (pistoning), thereby dilating the tract. The tract should be measured and prosthesis of more appropriate length should be inserted. In this circumstance, leakage should resolve within 48 hours. If the tissue around the prosthesis does not heal around the shaft within this time period, comprehensive medical evaluation is warranted to determine the cause of the problem.
Another cause of leakage around the prosthesis is the presence of narrowing (stricture) of the esophagus. The narrowing of the esophagus forces the laryngectomee to swallow harder using greater force, so that the food/liquid goes through the stricture. The excess swallowing pressure pushes the food/liquid around the prosthesis.
Increasing the diameter of the prosthesis is generally not recommended. Generally a larger diameter TEP is heavier than a smaller one, and the weakened tissue is often not able to support a bigger device, making the problem even worse. The use of prosthesis with a larger esophageal and/or tracheal flange may be helpful, as the flange acts as a washer to seal the prosthesis against the walls of the esophagus and/or trachea, thus preventing leakage.
Warm water works better than room temperature water in cleansing the prosthesis probably because it dissolves the dry secretions and mucus and perhaps even flushes away (or even kills) some of the yeast colonies that had formed on the prosthesis.
- Reduce the consumption of sugars in food and drinks. If you consume them, brush your teeth well after consuming sugary foods and/or drinks.
- Brush your teeth well after every meal and especially before going to sleep.
- Diabetics should maintain adequate blood sugar levels.
- Take antibiotics only if they are needed.
- After using an oral suspension of an antifungal agent, wait for 30 minutes to let it work and then brush your teeth. This is because some of these suspensions contain sugar.
- Dip the TEP brush in a small amount of mycostatin suspension and brush the inner voice prosthesis before going to sleep. (A homemade suspension can be made by dissolving a quarter of a mycostatin tablet in 3-5 cc water). This would leave some of the suspension inside the TEP. The unused suspension should be discarded. Do not to place too much mycostatin in the prosthesis to prevent dripping into the trachea. Speaking a few words after placing the suspension will push it towards the inner part of the TEP.
- Consume probiotics by eating active-culture yogurt and/or a probiotic preparation
- Gently brush the tongue if it is coated with yeast (white plaques)
- Replace the toothbrush after overcoming a yeast problem to prevent re colonizing with yeasts
chapter 11. Eating, swallowing, and smelling
- Ingesting adequate, but not too much liquid
- Drinking less liquid in the evening
- Consuming “healthy” food
- Consuming a low carbohydrate and high protein diet (high sugar enhances yeast colonization)
- Requesting dietitian assistance
- 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
- Sitting upright when eating and staying upright thirty to sixty minutes later
- Avoiding lying down for three hours after a meal
- Elevating the head of the bed by 6-8 inches (by putting blocks of wood under two 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, bend the knees rather than bend the upper body
Swallowing functions 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 fifty percent 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 personal experiences with eating in my book “My Voice” 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
- Eating slowly and patiently
- Taking small bites of food and chewing very well
- 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.
- Flushing the food with more liquids as needed. (Warm liquids may work better for some individuals in flushing down the food.)
- Avoiding food that is sticky or hard to chew. One needs to find out for him/her self what food is easier to ingest. Some foods are easy to swallow (e.g. toasted or dry bread, yogurt, and bananas) and others tend to be sticky (i.e. unpeeled apples, lettuce and other leafy vegetables, and steak).
- Dietary or postural changes
- Myotomy (cutting the muscle)
- Dilatation (see below)
An injection through an esophago-gastro-duodenoscope 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®.
Smelling after laryngectomy
chapter 12: Medical issues after radiation and surgery: pain management, cancer spread, hypothyroidism, and prevention of Medical errors
Most individuals with head and neck cancer receive medical and surgical treatment that removes and eradicates the cancer. However, there is always the possibility that the cancer may recur; vigilance is needed to detect recurrence or possibly new primary tumors. It is therefore very important to be aware of the signs of laryngeal and other types of head and neck cancer so that they can be detected at an early stage.
Signs and symptoms of head and neck cancer include:
- Bloody sputum
- Bleeding from the nose, throat, mouth
- Lumps on or outside the neck
- Lumps or white, red or dark patches inside the mouth
- Abnormal-sounding or difficult breathing
- Chronic cough
- Changes in voice (including hoarseness)
- Neck pain or swelling
- Difficulty in chewing, swallowing or moving the tongue
- Thickening of the cheek(s)
- Pain around the teeth, or loosening of the teeth
- A sore in the mouth that doesn't heal or increases in size
- Numbness of the tongue or elsewhere in the mouth
- Persistent mouth, throat or ear pain
- Bad breath
- Weight loss
Individuals with these symptoms should be examined by their otolaryngologists as soon as possible.
Head and neck cancer spread
Laryngeal cancer like other head and neck cancers, can spread to the lungs and the liver. The risk of spread is higher in cases larger tumors and in tumors that had been recognized late. The greater risk of spread is in the first five years and especially in the first two years after the cancer appears. If the local lymph glands do not reveal cancer the risk is lower.
Individuals who had cancer at one time may be more likely to develop another type of malignancy not related to their head and neck cancer. As people age, they often develop other medical problems that require care, for example, hypertension and diabetes. It is therefore imperative to receive adequate nutrition, take care of one’s dental (See Dental issues in Chapter 14), physical and mental health, be under good medical care and be examined on a regular basis (See Follow-up by family physician, internist and medical specialists
in Chapter 13). Of course, head and neck cancer survivors, like everyone else, need to watch for all types of cancers. These are relatively easy to diagnose by regular examination and include breast, cervix, prostate, colon, and skin cancer.
Most laryngectomees develop low levels of the thyroid hormone (hypothyroidism). This is due to the effects of radiation and the removal of part or all of the thyroid gland during laryngectomy surgery.
Thyroid deficiency can be corrected by taking synthetic thyroid hormone (Thyroxine). This medicine should be taken on an empty stomach with a full glass of water thirty minutes before eating, preferably before breakfast or at a similar time of day. This is because food containing high fat (e.g., eggs, bacon, toast, hash brown potatoes, and milk) can decrease thyroxine absorption by fourty percent.
Several formulations of synthetic thyroxine are available, but there has been considerable controversy if they are similar in efficacy. In 2004 the FDA approved a generic substitute for branded levothyroxine products. The American Thyroid Association, Endocrine Society, and the American Association of Clinical Endocrinologists objected to this decision, recommending that patients remain on the same brand. If patients must switch brands or use a generic substitute, serum thyroid stimulating hormone (TSH) should be checked six weeks later.
Because there may be subtle differences between synthetic thyroxine formulations, it is better to stay with one formulation when possible. If the preparation must be changed, follow-up monitoring of TSA serum levels should be done to determine if dose adjustments are necessary.
After starting therapy, the patient should be reevaluated and serum TSH should be measured in three to six weeks, and the dose adjusted if needed. Symptoms of hypothyroidism generally begin to resolve after two to three weeks of replacement therapy and may take at least six weeks to dissipate.
A thyroxine dose can be increased in three weeks in those who continue to have symptoms and who have a high serum TSH concentration. It takes about six weeks before a steady hormone state is achieved after therapy is initiated or the dose is changed.
This process of increasing the dose of hormone every three to six weeks is continued, based upon periodic measurements of TSH until it returns to normal (from 0.5 to 5.0 mU/L). Once this is achieved, periodic monitoring is needed.
After identification of the proper maintenance dose, the patient should be examined and serum TSH measured once a year (or more often if there is an abnormal result or a change in the patient's condition). Dose adjustment may be needed as patients age or have a weight change.
Medical errors can be reduced by:
- Being informed and not hesitating to challenge and ask for explanations
- Becoming an “expert” in one’s medical issues
- Having a family or friends remain in the hospital
- Getting a second opinion
- Educating medical providers about one’s condition and needs (prior to and after surgery)
The occurrence of errors weakens patients trust in their health care providers. Admission and acceptance of responsibility by medical providers can bridge the gap between them and the patient and can reestablish lost confidence. When such a dialogue is established, more details about the circumstances leading to the mistake can be learned thus helping to prevent similar errors. Open discussion can assure patients that their providers are taking the mater seriously and that steps will be taken to make their hospital stays safer.
- Implement better and uniform medical training
- Adhere to well established standards of care
- Perform regular records review to detect and correct medical errors
- Employ only well educated and trained medical staff
- Counsel, reprimand, and educate staff members who make errors and dismiss those who continue to err
- Develop and meticulously follow algorithms (specific sets of instructions for procedures), establish protocols and bedside checklists for all interventions
- Increase supervision and communication among health care providers
- Investigate all errors and take action to prevent them
- Educate and inform the patient and his/her caregivers about the patient’s condition and treatment plans
- Have a family member and or friend serve as a patient advocate to ensure the appropriateness of the management
- Respond to patients’ and family complaints, admit responsibility when appropriate, discuss these with the family and staff and take action to prevent the error(s)
chapter 13: preventive care: follow-up, avoiding smoking, and vaccination
- Proper dental care
- Routine examinations by family physician
- Routine follow-up by an otolaryngologist
- Appropriate vaccinations
- Stop smoking
- Using proper techniques (e.g. using sterile water for stoma irrigation)
- Maintaining adequate nutrition
Continual medical follow-up by specialists, including the otolaryngologist, radiation oncologist (for those who got radiation treatment), and oncologist (those who received chemotherapy), is crucial. As time passes from the initial diagnosis, treatment and surgery, follow-up occurs with less frequency. Most otolaryngologists recommend monthly follow-up examination in the first year after diagnosis and or surgery and less often afterwards, depending on the patient’s condition. Patients should be encouraged to contact their physician whenever new symptoms arise.
It is important for laryngectomees to be vaccinated for influenza regardless of age. Influenza can be more difficult to manage and vaccination is an important preventive tool.
Available vaccines include:
2. The nasal-spray flu vaccine - a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine" or FluMist®). LAIV (FluMist®) is approved for use in healthy individuals ages 2-49 years (with the exception of pregnant women).
A new vaccine for influenza is prepared for every new season. While the exact strains that cause influenza are unpredictable, it is likely that strains that caused the illness at other parts of the world will also cause illness in the U.S. It is best to consult one’s physician prior to vaccination to ensure that there is no reason why one should not be vaccinated (such as egg allergy).
The best way to diagnose Influenza is a rapid test of nasal secretions by one of the diagnostic kits. Because laryngectomees have no connection between the nose and the lungs, it is advisable to test nasal secretions in addition to tracheal sputum (using a kit that was approved for sputum testing).
One "advantage" of being a laryngecomee is that one generally gets fewer infections caused by respiratory tract viruses. This is because “cold” viruses generally first infect the nose and throat; from there they travel to the rest of the body, including the lungs. Because laryngectomees do not breathe through their noses, cold viruses are less likely to infect them.
It is still important for laryngectomees to receive yearly immunization for influenza viruses, to wear a Heat and Moisture Exchanger (HME) device to filter the air that gets into the lungs, and to wash their hands well before touching the stoma or the HME or before eating. The Atos (Provox) Micron HME with electrostatic filter is designed to filtrate potential pathogens and to reduce susceptibility to respiratory infections.
The influenza virus is capable of spreading by touching objects. Laryngectomees who use a voice prosthesis and need to press their HME to speak may be at increased risk of introducing the virus directly to their lungs. Washing hands or using a skin cleanser can prevent the spread of the virus.
Vaccination against the pneumococcal bacteria
It is advisable that laryngectomees and other neck breathers get vaccinated against the pneumococcus bacterium which is one of the major causes of pneumonia. Pneumococcal polysaccharaide vaccine - A 23-valent pneumococcal polysaccharide vaccine (PPV23) (Pneumovax, Merck) is mainly used in older adults and persons with underlying medical conditions. PPV23 is recommended for all adults older than 65 years and for persons 2–64 years with underlying medical conditions.
Individuals with head and neck cancer should receive counseling about the importance of smoking cessation. In addition to smoking being a major risk factor for head and neck cancer, the risk of cancer is further enhanced by alcohol consumption. Smoking can also influence cancer prognosis. Patients with laryngeal cancer who continue to smoke and drink are less likely to be cured and are more likely to develop a second tumor. When smoking is continued both during and after radiation therapy, it can increase the severity and duration of mucosal reactions, worsen the dry mouth (xerostomia), and compromise the patient outcome.
chapter 14: Dental Issues and hyperbaric oxygen therapy
Dental problems are common after exposure of the head and neck to radiation therapy.
- Reduced blood supply to the maxillary and mandibular bones
- Reduced production and changes in the chemical composition of saliva
- Changes in the bacteria that colonize the mouth
Because of these changes dental caries, soreness, and gingival and periodontal inflammation can be particularly problematic. These can be lessened by good mouth and teeth care, i.e., by cleaning, flushing, and using fluorinated toothpaste after each meal when possible. Using a special fluorinated preparation with which to gargle or apply on the gum helps in preventing dental carries. Keeping well hydrated and using saliva substitute when needed are also important.
It is advisable that patients receiving radiation therapy to the head and neck visit their dentist for a thorough oral examination several weeks prior to initiation of the treatment and be examined on a regular annual or semiannual basis throughout life. Getting regular dental cleaning is also important.
Because radiation treatment alters the blood supply to the maxillary and mandibular bones patients may be at risk of developing bone necrosis (osteoradionecrosis) at those sites. Tooth extraction and dental disease in irradiated areas can lead to the development of osteoradionecrosis. Patients should inform their dentist about their radiation treatment prior to these procedures. Osteoradionecrosis may be prevented by administration of a series of hyperbaric oxygen therapy (see below) before and after extraction or dental surgery. This is recommended if the involved tooth is in an area that had been exposed to a high dose of radiation. Consulting the radiation oncologist who delivered the radiation treatment can be helpful in determining if this is necessary.
- Flossing each tooth and brushing with toothpaste after each meal
- Brushing the tongue with a tongue brush or a soft bristled toothbrush once a day
- Rinsing with a baking soda rinse daily. Baking soda helps neutralize the mouth. The rinse is made of one teaspoon of baking soda added to 12 oz. of water. The baking soda rinse can be used throughout the day.
- Using fluoride in fluoride carriers once a day. These are commercially available and are also custom made by dentists. They are applied over the teeth for ten minutes. One should not rinse, drink, or eat for thirty minutes after fluoride application.
Stomach acid reflux is also very common after head and neck surgery, especially in individuals who have had partial or complete laryngectomy (see chapter 11). This can also cause dental erosion (especially of the lower jaw) and, ultimately teeth loss.
- Taking acid reducing medication
- Eating small amounts of food and liquid each time
- Not lying down right after eating
- When lying down, elevate the upper part of body with a pillow
to 45 degrees
HBO therapy can be performed as an outpatient procedure and does not require hospitalization. Hospitalized patients may need to be transported to and from the HBO therapy site if it is an outside facility.
- A unit designed for one person in an individual (monoplace) unit, while the patient lies down on a padded table that slides into a clear plastic tube.
- A chamber designed to accommodate several people in a multiperson HBO room where the patient may sit or lie down. A hood or mask delivers the oxygen.
Chapter 15: Psychological issues:
depression, suicide, uncertainty, sharing the diagnosis, the care giver, and
source of support
- Anxiety and fear of recurrence
- Social isolation
- Substance abuse
- Body image
- Return to work
- Interaction with spouse, family, friends, co-workers
- Economic impact
- A feeling of helplessness and hopelessness, or that life has no meaning
- No interest in being with family or friends
- No interest in hobbies and activities one used to enjoy
- A loss of appetite, or no interest in food
- Crying for long periods of time, or many times each day
- Sleep problems, either sleeping too much or too little
- Changes in energy level
- Thoughts of suicide,
including making plans or taking action to kill oneself, as well as
frequently thinking about death and dying
Coping with and overcoming depression are very important, not only for the well -being of the patient, but also may facilitate recovery, increase one’s chance for longer survival and ultimate cure. There is growing scientific evidence of a connection between mind and body. Although many of these connections are not yet understood, it is well recognized that individuals who are motivated to get better and exhibit a positive attitude recover faster from serious illnesses, live longer, and sometimes survive immense odds. Indeed, it has been shown that this effect may be mediated by alterations in the cellular immune responses and a decrease in natural killer cell activity.
There are, of course, many reasons to feel depressed after learning one’s cancer diagnosis and living with it. It is a devastating illness for patients and their families, even more so because medicine has not yet found a cure for most types of cancer. By the time the disease has been discovered, it is too late for prevention and, if the cancer has been discovered at an advanced stage, the risk of dissemination is high and the chance of ultimate cure significantly decreased.
Many emotions run through the patient’s mind after learning the bad news. “Why me?” and “Can it be true?” Depression is part of the normal mechanism of coping with adversity. Most people go through several stages in coping with a difficult new situation such as becoming a laryngectomee. At first one undergoes denial and isolation, than anger, followed by depression, and finally, there is acceptance.
Some people get “stuck” at a certain stage such as depression or anger. It is important to move on and get to the final stage of acceptance and hope. This is why professional help as well a understanding and assistance by family and friends are very important.
- Avoid substance abuse
- Seek help
- Exclude medical causes (e.g., hypothyroidism)
- Determine to become proactive
- Minimize stress
- Set an example for others
- Return to previous activities
- Consider antidepressant medication
- Seek support from family, friends, professional, colleagues, fellow laryngectomees, and support groups
- Develop leisure activities
- Build personal relationships
- Keep physically fit and active
- Social reintegration with family and friends
- Find purposeful projects
Support by family members and friends is very important. The continuous involvement and contribution to others’ lives can be invigorating. One can draw strength from enjoying, interacting and impacting the lives of their children and grandchildren. Setting an example to one’s children and grandchildren not to give up in the face of adversity can be the driving force to be proactive and resist depression.
Getting involved in activities one liked before the surgery can provide a continuous purpose for life. Participating in the activities of a local laryngectomee club can be a new source of support, advice and friendship.
Seeking the help of a mental health professional such as a social worker, psychologist or psychiatrist can also be helpful. Having a caring and competent physician and a speech and language pathologist who can provide continuous follow-up is very important. Their involvement can help patients deal with emerging medical and speech problems and can contribute to their sense of well being.
Once one has been diagnosed with cancer and even after successful treatment, it is difficult and close to impossible to completely free oneself from the fear that it may return. Some people are better than others in living with this uncertainty; those who adjust well end up being happier and are more able to go on with their lives than those who do not.
What makes predicting the future difficult is that the scans used to detect cancer (positron emission tomography or PET, computed tomography or CT, and magnetic resonance imaging or MRI) generally only detect cancer that is larger than one inch; physicians may miss a small lesion located at a site that is difficult to visualize.
Patients have therefore to accept the reality that the cancer may return and that physical examination and vigilance are the best ways of monitoring their condition.
What often helps with coping with a new symptom (unless it is urgent) is to wait a few days before seeking medical assistance. In general the majority of new symptoms will go away within a short period. Over time, most people learn not to panic and to use past experience, common sense and their knowledge to rationalize and understand their symptoms.
Hopefully, over time, one gets better in coping with an uncertain future and learns to accept it and live with it, striking a balance between fear and acceptance.
- Separating oneself from the illness
- Focusing on interests other than cancer
- Developing a life style that avoids stress and promotes inner peace
- Continuing with regular medical check-ups
Caring for a loved one with cancer
There are also few "benefits" being a laryngectomee, including:
• No more snoring
Chapter 16: use of MRI, pet and ct scans in the diagnosis and follow up of cancer
MRI tests are painless. Some patients report feelings of mild to severe anxiety and/or restlessness during the test. A mild sedative can be given before the test to those who are claustrophobic or find it difficult to lie still for long periods of time. MRI machines produce loud banging, thumping, and humming sounds. Wearing earplugs can reduce the effect of noise.
PET and CT scans are often done in the same session and are performed by the same machine. While the PET scan demonstrates the biological function of the body, the CT scan provides information with respect to the location of any increased metabolic activity. By combining these two scanning technologies, a physician more accurately diagnose and identify existing cancer.
On occasion CT is not helpful, especially in those who had extensive dental work, including filings, crowns or implants, that can interfere with the interpretation of data. Not performing a CT spares the patient from receiving a substantial amount of radiation. Instead, an MRI of the area can be done.
Chapter 17: Urgent care, Cardiopulmonary
and care of Laryngectomees
- Determine the patient’s unresponsiveness
- Activate the emergency medical services
- Position the person by raising their shoulders
- Expose the neck and remove anything covering the stoma such as filter or cloth, that may prevent access to the airway
- Secure the airway in the stoma and remove anything blocking the airway such as the filter or HME
- Clear any mucus from the stoma
Neck breathers are at a high risk of receiving inadequate therapy when seeking urgent medical care because of shortness of breath.
Neck breathers can prevent a mishap by:
1. Wearing a bracelet that identifies them as neck breathers
3. Placing a sticker on the inside of their car windows identifying them as laryngectomees. The card contains information about caring for them in an emergency
4. Placing a note on their front door identifying them as neck breathers
5. Using an electrolarynx can be helpful and allow communication even in an emergency. Those who use a TEP for speech may not be able to speak because their HME may need to be removed.
It is up to laryngectomees to be vigilant and increase the awareness of the medical personnel and EMSs in their area. This can be an ongoing task, since knowledge by health providers may vary and change over time.
A video that explains the methods needed to administer urgent respiratory care to neck breathers can be viewed at: http://www.youtube.com/watch?v=YE-n8cgl77Q
Neck breathers can share this presentation with their emergency care givers (Closest ED and EMT).
Because laryngectomees cannot administer mouth to mouth breathing, the old CPR guidelines excluded them from providing the respiratory part of CPR. Since the new guidelines do not require mouth to mouth ventilation, laryngectomees can also deliver CPR. However, when possible the old CPR method using both airway ventilation and cardiac compressions should be utilized. This is because the “chest compressions only” method cannot sustain someone for a long period of time since there is no aeration of the lungs.
Laryngectomees who require CPR may also need respiratory ventilation. One of the common causes of breathing problems in laryngectomees is airway obstruction due to a mucus plug or foreign body. Removing these may be essential. Mouth to stoma resuscitation is important and is relatively easier to deliver than mouth to mouth breathing.
Laryngectomees who breathe through a Heat and Moisture Exchanger (HME) and perform CPR on a person in need of resuscitation may need to temporarily take their HME off. This allows laryngectomees to inhale more air when they deliver up to one hundred heart compressions per minute.
Chapter 18. Travelling as a laryngectomee
Taking a flight (especially a long one) on a commercial airline presents many challenges. Several factors can lead to deep vein thrombosis or DVT. These include dehydration (due to the low moisture in the cabin air at high altitude), lower oxygen pressure inside the plane, and the passenger’s immobility. These factors, when combined, can cause a blood clot in the legs that, when dislodged, can circulate through the blood stream and reach the lungs, where it can cause pulmonary embolism. This is a serious complication and a medical emergency.
These steps can be taken to prevent potential problems:
• Drinking at least eight ounces of water for every two hours on a plane, including ground time
• Avoiding alcohol and caffeine drinks as they are dehydrating
• Wearing loose-fitting clothes
• Avoiding crossing the legs while seating, as this can reduce blood flow in the legs
• Wearing compression socks
• If in a higher risk category, asking one’s doctor whether to take aspirin before flying to inhibit blood clotting
• Performing legs exercises and standing up or walking whenever possible during the flight
• Booking an exit row, bulkhead, or aisle seat that allows greater leg room
• Informing the flight attendants that one is a laryngectomee
• Placing medical supplies, including stoma care equipment and an electrolarynx (if used) in an accessible place in carry-on luggage (durable medical equipment and supplies are permitted to bring on board, as an extra carry-on bag)
• Communicating with flight attendants through writing if the noise during the flight make it difficult to speak
• Covering the stoma with a moist cloth to provide humidity
These measures make airline travel easier and safer for laryngectomees and other neck breathers.
• Paper tissues
• Tweezers, mirror, flash light (with extra batteries)
• Tweezers, mirror, flash light (with extra batteries)