Kirklin Clinic Head & Neck Cancer Group, Birmingham, AL
distributed by American Cancer Society
Pat Sanders, Editor
Esophageal Dilation in Head & Neck Cancer Patients to Include Laryngectomy
Patients with head and neck cancers treated with radiation, chemotherapy, or surgery. i.e., laryngectomy with or without jejunal interposition, radial free arm flap, and tracheo-esophageal voice prosthesis (TEP), develop dysphagia from oropharyngeal dysfunction, and pharyno-esophageal strictures. Traditionally, strictures in these patients have been dilated using rigid endoscopy conducted under general anesthesia, which necessitates rapid luminal expansion during dilation because general anesthesia cannot be frequently used, and these strictures sometimes rapidly recur.
My presentation will address a new dilation technique involving EGD scopes, the Savary-Gilliard dilation technique conducted over a vascular guide wire placed at endoscopy in the stomach or duodenum. If the stricture prevented passage of the 5 mm scope, the vascular guide wire was placed under direct vision through the stricture, and then checked by fluoroscopy to be positioned below the diaphragm, and in the stomach. This per oral endoscopic procedure is performed in our GI out patient endoscopy unit, using topical anesthesia, and minimal conscious sedation with Demerol and Versed. Patient comfort and acceptance of the procedure is aided by radiation and/or the prior surgery having diminished oropharyngeal sensation, our use of small endoscopes, a thin flexible guide wire, and rapid dilation technique. This procedure can even be performed in patients whose stricture had been judged radiographically to be 1 mm or less in size, which sometimes necessitates using a biliary dilator (3 mm) because the smallest Savary-Gilliard dilator would not pass (5 mm).
Since many of these patients have chronic fibrotic strictures that do not allow rapid increases in luminal diameter, these patients tolerate being dilated in progressive small increments (1 mm), over weekly intervals eventually achieving a lumen size of 14-16 mm, which will allow swallowing of most consistencies, if thoroughly masticated, and the patient has a safe functional swallow. Since some of these strictures will rapidly recur, the patient will then undergo repeat dilations again to 14-16 mm, and during the process the patients are taught self-dilation using Maloney dilators, which can sustain their lumen size in the above range when done daily.
As many of these patients have oropharyngeal dysphagia from radiation and surgical defects, once a lumen size of 5-10 mm is achieved, swallowing therapy is immediately reinstituted, if not previously done. Prior to dilating a tight stricture, intensive swallow rehabilitation is compromised because of a “bounce back phenomenon”, caused by the stricture, resulting in barium, fluid, and food seeking the area of least resistance, i.e., the airway. Sometimes with airway penetration, it is difficult to determine poor pharyngeal contraction, impaired laryngeal protection, which results in little barium entering the post cricoid region (i.e., no pump pressure) versus a post cricoid stricture and the “bounce back phenomenon”. A per oral dilation eliminates the latter possibility. Alternatively, dilation of a stricture at the pharyngo-esophageal junction alone does not achieve a functional safe swallow with deficient oropharyngeal swallowing mechanisms. Thus, this interplay between oropharyngeal dysfunction versus a physical obstruction unites speech language pathologists, radiologists, otolaryngologists and gastroenterologists into a common goal of restoring swallowing function in the patient with head and neck cancer.
Content for my presentation will come from cases discussed at out UAB Polydisciplinary Swallowing and Esophageal Conference that I direct. Following my presentation, the attendees should have knowledge of the use of outpatient per oral endoscopic dilation in the treatment of head and neck cancer patients.
Lawrence F. Johnson, M.D.
Professor of Medicine
University of Alabama at Birmingham
Traveling Thoughts from…….. Jim Lauder
Normally when I travel about the country, whether by plane, train or automobile, I sleep. As soon as I hit the seat, I am sawing logs. I am sitting on the 9:15 AM train to Ronkonkoma heading home after a whirlwind trip to New York City to speak to Laryngectomee groups. I don’t dare sleep this time because the last time I slept on this train, I awoke to find my camera missing from around my neck. I am writing this to prevent myself from falling asleep, as well as reflect on my trip.
Any who have heard me speak in front of groups know that I like to “wing it”. I do not have notes or a prepared speech. I try to find out what the audience wants by asking the group to tell me what is on their minds and I will tailor my talk to address their interests. These talks can generally last for hours but, on many occasions, time is the limiting factor.
This weekend, I was speaking along with my friend Richard Crum of InHealth fame, who was to talk about the TEP and InHealth products and services. I was to talk about the artificial larynx in general and what is new in the field. Until recently, the latter was an extremely short subject. This time, I had something really cool to talk about in the “new” category.
Our audience consisted mainly of Speech Pathologists and Laryngectomees from the NYC and Northern Jersey area. Included in this group were Jay Lemaster and Tom Beneventine, two Laryngectomees that care about and have been helping Laryngectomees for many, many, years. I always like it when Jay and Tom are in the audience because if the crowd is slow in asking questions, Jay and Tom take up the slack and ask leading questions that help the group to move along with asking their own questions.
This meeting started off, like so many of them, with a Speech Pathologist asking “What is the best artificial larynx?” I get this question a lot and my answer is always “Whatever works best for him or her.” I have heard excellent voices with the old AT&T (Western Electric) as well as with the Servox, TruTone, NuVois, Cooper-Rand, and others.
I cautioned the group to be aware that advertising and marketing of these devices by the manufacturers should be taken with a grain (if not a whole block) of salt. Anytime I see an ad proclaiming that the “so and so” instrument “sounds more like a natural voice” or “can be heard across a crowded room”, I cringe, because obviously these people do not have to use the instruments that they manufacture. They do have to market and sell these machines that they produce and painting a pretty picture is important to marketing the device, even if it is smoke that they are blowing.
I do caution the user of an AL to be aware of the servicing of that AL. An AL sounding good is a very important issue but it is not the only issue. The instrument should also be durable. What good is an instrument that sounds good but keeps breaking down and spends too much time in the shop instead of being used?
On the issue of service, be aware of the warranties of the various devices. Some have a 1 year warranty, many have a 2 year, while some have a 5 year warranty. Words like “limited warranty” and “comprehensive warranty” should raise warning flags. Comprehensive warranty is generally a good thing while a limited warranty may have exclusions in it that could negate the warranty and cost you money.
I had a new product to show the group on this trip. It is an “Emergency 9 volt adapter” for the Servox (Inton or Digital) artificial larynx. It is a very clever device that allows the Servox to utilize a 9 volt battery. It does add about 3 inches to the length of the Servox and adds little extra weight, if any. It is not meant to be a replacement for the standard rechargeable Servox battery, but it does allow the Servox to be used in the event of a power outage or other emergency situation where you cannot charge your regular batteries. It would have come in very handy during last year’s Florida Hurricane disasters. I have to give credit to Tom and Dorothy Lennox of Luminaud for manufacturing the device. Thanks Tom and Dorothy.
I then talked to the group about support groups and WebWhispers. I used the recent story of Sam Beights helping a neighbor in Oklahoma to use his artificial larynx which he had not been able to use in 2 years. Any who have not read about this should go to the March edition of Whispers on the Web http://webwhispers.org/news/mar2005.htm and read it in Murray’s Mumbles. It is a perfect example of how WW members will go the extra mile (in this case 115 miles) to help a fellow Laryngectomee in need. Without WebWhispers, this would not have been likely to happen. Thank you WW! You are what Laryngectomee “support” is all about.
I encourage all Laryngectomees, family members, Speech and other Professionals that are willing and able, to join a local or regional support group. You may not need the support, but you can certainly help with the supporting. Many “once active” clubs are languishing because of the lack of members. If you do not have a support group, maybe you can consider starting one in your area. There may very well be a “Sam Beights” in your area.
Well, my train is pulling into Ronkonkoma station and I still have my camera. Soon I will be on the plane sound asleep on my way back home to Texas.
For any groups (or future groups) that would care to have me address them, please let me know. I will do my best to accommodate your group when I am in your area.
Lauder Enterprises, Inc
P.S. I just passed through security at MacArthur Airport in Islip, Long Island, with a briefcase full of artificial larynges (with batteries installed in them). I passed through without any problems. I asked the TSA officer why the instruments did not alarm them. After all, there were numerous cylindrical objects with batteries in them. I thought for sure that I would be questioned about them. He told me that they are trained to recognize dangerous items and then promptly confiscated my TruTone adjusting screwdriver, which I had inadvertently put in my briefcase. He did swab the case to test for explosives and let me pass. No problem.
My advice to travelers who use an artificial larynx is: Bon Voyage!!! Have a nice trip.
Pets and Laryngectomees Communicate!
By Jane Varner
Did you know that dogs can learn up to 150 words? My dog, Razzie, is no rocket scientist and only seems to know about 60 or so, but among these are bacon, feed the dog, dinner, cat, Mommy, Daddy, dog food, she, stay, come, sit, and so forth. She also knows longer phrases like "you're just a baby" and "it will be OK."
I didn't know how she was going to react to me after my laryngectomy, especially because I was single and lived alone with her, although I did have a friend who could help. I had complications from prior radiation so could not talk at all for a while. Razzie was about 10 years old, a Sheltie (or baby Lassie). I need not have worried. She did better than I did.
After my surgery, I realized the most helpful thing I ever did for my dog when she was younger was to teach her a couple of hand signals for stay and come. Even old dogs can learn new tricks, so if you are facing surgery, please teach your dog to stay, especially with a hand signal. My stepfather has Alzheimer's and never taught his dog to stay, so the spunky Jack Russell Terrier (terror) ended up in the nearby Methodist Church service on Christmas Eve (Thank goodness the Methodists had a sense of humor). He's also stalked Baptists, but never got into their sanctuary. My dog is much better behaved because she is older. All she wants to do is pee in a neighbor's yard, when she gets out the front door, then, come back inside. Right now she's out in the back yard barking at a Doberman she can't see because of the wooden fence.
My dog could respond to me quite well without verbal commands, even at first. I couldn’t talk for three months, but I could make clicking noises to call her, and she would come right to my bed when I needed her. She's too fat to jump up on it because it's a tall bed, but since I could not talk, we both liked the comfort of petting.
A dog may get protective of you after a laryngectomy or notice other changes. Razzie follows me nearly everywhere and goes crazy over a UPS man coming to the door. Expect your pet to need to make some adjustments or become overly attached, even if you have a spouse or partner. Try to keep the pet's routine as normal as possible.
Pat Sanders, 205-980-8416; firstname.lastname@example.org