HEADLINES
Head & Neck Cancer Support Group
Kirklin Clinic – Birmingham, AL
distributed by American Cancer Society, edited by Pat Sanders
March 2001

Ask the Doctor – Neck Dissection

What is a neck dissection?  My wife had a laryngectomy but I don’t know whether she had the “dissection” - - or why/why not.

Thanks, Florence and Matt Bressler, Jupiter, FL     brezz132@cs.com

That’s a big topic so I’ll hit the highlights.

Simply put, a neck dissection is an operation that is done to remove the lymph nodes in the neck.  There a two fundamental types of neck dissections: one that is done when we know there is cancer present in the lymph nodes (“therapeutic” neck dissection) or one that is done when there is a high likelihood that microscopic disease may be present in the nodes, even though we can’t feel them or they don’t show up on scans (“elective” neck dissection).

Now, let’s take this a little further.  Therapeutic neck dissections vary depending on the amount of cancer that may be present in the nodes.  Large, bulky nodes may require a “radical” neck dissection for complete removal.  The radical neck dissection was first used in the first decade of the 20th century and has changed little since it was originally described.  The radical neck dissection is the most comprehensive operation that can be done for cancer in the cervical nodes.  It is a complete clean out of all node bearing groups and also involves the removal of the internal jugular vein, the sternocleidomastoid muscle, and the spinal accessory nerve that goes to the trapezius muscle.  Obviously, this can result in a cosmetic deformity in the neck and more importantly weakness in raising the shoulder and arm from sacrifice of the spinal accessory nerve.

Smaller nodes and elective neck dissections can be handled with a “functional or modified” neck dissection.  This is a more targeted operation wherein the nodes that are either involved and/or at highest risk for involvement are removed.  In doing the modified operation you usually leave the jugular vein, the stercleidomastoid muscle, and the spinal accessory nerve.  This results in less cosmetic deformity and less problems with your shoulder.

Neck dissections can be done either when the larynx is removed or later if nodal metastases appear.  More and more, we are doing elective operations at the same time we operate on the larynx. We have found that this gives us important information about the status of the nodes (whether there is microscopic disease) and also whether we need to use radiation after surgery.

So that's neck dissections in a nutshell.

Glenn E. Peters, M.D. , F.A.C.S. 
Director, Division of Otolaryngology - Head and Neck Surgery                    
University of Alabama at Birmingham,  Birmingham, Alabama, USA

Look Before You Leap

On Sunday past, my wife and I drove to our daughter's to sit for three days with child, house, and horse.  Since our daughter is our only child and she is the mother of our only two grandchildren, we have given serious consideration to moving to that area, a town of about 35,000, which is some 130 miles away from where we now live. 

On Tuesday morning, my prosthesis for the TEP quit working, zap, no sound, no nothing.  Of course, I had carried my Servox with me.  I attempted to change out the prosthesis with NO luck and in the process used all of the capsules which I had with me. Having no  capsules, I got the phone book and looked for Hospitals or ENT clinics and finally found one with a Speech Pathologist; however, when I mentioned what I needed, she went blank.  She had no idea where I might find a gel cap, didn't know how to change out a  prosthesis, in fact had never  seen one. I told her that should we moved to that area, I would have a lot of educating to do.  She agreed. 

We continued with our original plans, met with a Real Estate Agent, and did some preliminary house hunting but did not find what we were really looking for. Our daughter returned from her trip, we visited for a while, then, decided to make trip back to our house.  We arrived around 10:00 PM, too tired to attempt to replace the prosthesis but did so this morning and am back talking as before. 

Moral of this story: investigate the area you might move to, to determine if there is help  in that area or people who know how to assist a laryngectomee in the event of an emergency.  Should we decide to move, I will visit, prior to the move, the office of each and every ENT, to make sure that they are aware of me and what I am and what assistance I may need in the future.         Charles Lamar <neckbreather@prodigy.net>

Ed. Note:

One place to go for empty capsules is a pharmacy.  Some people even buy theirs from their druggist.  Having the insertion tool, the pharmacist could tell in a hurry what size would fit in the groove.

 

WHAT YOUR PROSTHESIS TELLS YOU       by  Pat W Sanders

If you wear the kind of prosthesis that you change yourself, you might be missing an opportunity to learn something by examining the one you are removing.  After you take it out, do you toss it, drop it in some peroxide or other cleaning solution to re-use later, or do you take a good look at it in strong light?  It can tell you a couple of things, especially if you leave your prosthesis inserted for long periods.

Some of us are told by our SLPs or doctors to change the prosthesis often, and right after the TEP surgery, it is wise to do so.  If you have your puncture surgery while there is still swelling from the laryngectomy, it is even more wise to have frequent checkups. As the swelling goes down, the puncture often becomes shorter requiring a change in prosthesis length. Many of us go through reductions in size from something like 3.0 to 2.6 to 2.2 to 2.0 over a period of time.  You might need the 3.0 for only 2 weeks, whereas, the change from 2.2 to 2.0 might take a year. The longer prosthesis will piston (move back and forth) in the shorter puncture causing leaks around the prosthesis and perhaps enlarging the diameter of the puncture, creating another problem. At first, a close watch is kept on the size and type (another subject altogether), to see if you need a change.   Leaks and speech problems are indications that a change in length may be needed.

You may, after following whatever weekly or monthly change schedule that your therapist recommends, be able to wear your prosthesis for longer periods of time.  However, if you have a yeast problem, you will have to change it more frequently as well as treat for the yeast.  Leaks through the prosthesis are sometimes an indication that it is time to change. However, many people get nervous about a leak and will change it rather than take the time to clean it in place and be sure it is positioned correctly. We have discussed many times using the small intradental brush to clean the inside of the prosthesis and then flushing with one of several different tools.  For those who can easily reach the prosthesis, you might use your finger or a long swab to be sure the prosthesis isn't tipped because of accidentally tugging on the strap, or perhaps putting a stoma vent in and moving the prosthesis to a different angle, again, accidentally.  Sometimes, after doing all you can, just sleeping on it will tend to correct a leak overnight and you can postpone changing to another prosthesis for a while longer.

When it is time to put in a new one, remove the one you are using, lay it aside and proceed with your regular routine of inserting another prosthesis.  Then, rinse the old one under the tap and look carefully at it, preferably in the sunlight.  If you see little areas that look like yellow powder that has hardened, that is yeast. Check around the edges of the flange that holds the prosthesis in the esophagus and see if they are smooth.  Sometimes the edge will feel rough and if you scrape away the roughness, the edge is no longer perfectly round. This is part of what yeast does. If you find any of this, wash the prosthesis with soap and water, drop it in a plastic bag, and take it with you the next time you see your SLP.  If your appointment is a long time off, call to ask if you need medication for the yeast.

If you have a hardened scale around the outside of the shaft, you have probably left it in too long and need to change more frequently.  If you have worn it a long time, there will likely be some stains at the esophageal end, but stains are not what you are looking for. The yeast and scale are the problems.  So, next time you change it,  take a good look and see what your prosthesis tells you.

Saying Goodbye to my Old Voice                          by David Blevins

I have two answering machines.  Both still have my “old” voice on them.  After mentioning that fact, a laryngectomee friend thought that I should erase them both.  The thought was that my failure to do so meant I was failing to let go of a piece of the past... the sound of my old voice.  I don’t think so.  It is just that I see no particular reason to change those messages.  There is probably more of the old country expression, “If it ain’t broke, don’t fix it.”, in my thinking than any attempt to hold on to something which is gone.

Actually, one of the machines has a regular message and also a second vacation one which I switch to when out of town.  The regular message was in my pre-cancerous voice, while the vacation one was obviously done when the cancer had established itself in a vocal cord.  To me, the second one is the very sound of cancer. 

I do find it a little more difficult to listen to the second one than the first.  It sounds strained and even painful.  But since I rarely have reason to call my own phone numbers, I almost never hear them anyway and I see no particular reason to change them.  And besides, I never really sounded like either of those voices anyway...at least to me.

Do you remember the first time you heard a recording of yourself?  I certainly was shocked.  “I don’t really sound like that, do I?”, I asked.  Despite being told that I did, it was hard to believe.  Of course the answer to that little mystery is that no one hears the voice you heard yourself making.  The reason is that your ear is closer to the source of the sound, but also because you heard subtle vocal resonance from the sinus cavities and other structures of your head which made the short journey to your own ear but never got transmitted to other listeners.

If you have heard a recording of yourself now, you are also likely to have been a little shocked.  In addition to a continuing difference between what you hear versus what others hear, there is that even greater gap between what you remember your voice sounding like and this new one.  Perhaps you have also been surprised when someone said they could still hear “you” in the new voice, whether it is your voice with an artificial larynx or TEP (TracheoEsophageal Puncture).  But even though you may not hear the “old you” in that voice, it makes sense that it would be there since most of what makes your speech uniquely yours is still intact.

Speech is just one of those many things we do not think about much until something goes wrong with it.  But it turns out that only one part of the speech making apparatus is lost when the larynx is removed.  What remains is your tongue, teeth, oral cavity, and even your sinuses, which all go to help produce the voice that is distinctly yours. Therefore, it should not come as a surprise that others can recognize the old us in our voice even when we might have a hard time recognizing our own recorded voice.

But if it is too painful for you to hear your old voice on an answering machine or in another recording, just put that sample of your old voice away and don't destroy it.  It may be important later to have that as a remembrance for some other family member, or perhaps as a sample which might be used to fine tune some future artificial larynx which could come closer to duplicating your old voice.

But in the meantime, I say “goodbye, old voice”.  The voice I heard in my ear only sounded that way to me anyway.  As to those recorded voices . . . what others heard... I say good riddance.  I must admit that I do miss my old singing voice (whether anyone else does or not!)  But I shall continue to make the most of the one octave I have.  Besides, I think singing doesn’t really come from the larynx anyway, but from the heart.