Possible Problems

 

 

Smelling

 

Smelling and Blowing Your Nose

 

As a laryngectomy we have no airflow thought our nose to smelling and blowing your nose can be a challenge. There is a technique that can be learned to help with that capability called a Polite Yawn Technique. I involves using your mouth cavity to capture air and force it out you nose by closing our jaw with your mouth closed. The air has to go somewhere so it goes out the nose. The reverse action can be done to draw air into the nose to enable some smell.

This technique is explained at the following link from the Dutch Cancer Society:

http://www.hoofdhalskanker.info/wpavl/wp-content/uploads/Olfaction-regained_VO.pdf

There is also a video on YouTube that show the effectiveness of the technique as indicated by the use of a manometer (not necessary to learn the technique).

https://www.youtube.com/watch?v=2ZwdksPy4Z0

Another YouTube video shows how the technique looks when being done:

https://www.youtube.com/watch?v=z29Pw_ATWZc

 For those that can not perform the Polite Yawn technique here is another method that uses a baby nipple and tubing to create a device to help:

https://www.youtube.com/watch?v=9AY1pYGW3W0

 


 

There are a lot of ways to learn how to sniff and smell again. All of them
are related to being able to suck in liquid through a straw. If you can do
that, try blowing bubbles with the straw. Doing these means you can use
your mouth as a bellows - to pull in air or push out air. When you use a
straw, you also have your soft palate closed. That's the connection between
your nasal passages and your mouth. It can take some practice to learn to
open and close it on purpose, but it can start with a clicking, snorting
sound coming from the top back of your mouth. When you do the straw action
with your lips closed, air has to go through that opening in your soft
palate - which means air flow in and out through your nose.

In my experience larys tend to lock down our soft palates. (I don't know
why.) Once you can open it up food will taste better, you can blow your
nose, and taking a sniff of the air is easy.

Be well,

Julain

 


 

I am a biologist and taught biology using th human organism for almost all of my examples. I reasoned that if those tissues with the sensory cells were intact, there was NO reason that the sense of smell or taste should be inhibited directly BY THE ACTION OF THE SURGERY. The drinking straw thing--that's is a problem for certain people that have a certain level of radical surgery and a particular form of reconstruction that prevents specific muscular actions from taking place. I was/am not one of those few, so I use a straw quite frequently. In fact, drinking with a straw is easier, if not "cleaner" for me than more normal tipping of the glass, because of how the muscles below my tongue and along the underside of my jaw & thorax now work (I sometimes dribble).

I was able to move air through my nose by the second day after surgery while still in the hospital. I was not able to experiment with taste and flavors for a while because I was not allowed to swallow (at all) for a little over 2 weeks. In the hospital, I quickly noticed the alcohol swabs used on me, the disinfectant in the hand-cleaner my nurses and visitors used on their way in & out of the room, the scent one of my nurses wore and I noticed when I was awakened one of those annoying frequent times in the night.

When I realized I must be doing something to get the air to pass by the sensory area of my nose, I was delighted! I did not have t work at it much, but was pretty quickly able to push and pull air through my head with what I later learned had the name of "polite yawning." When you see a frog do it, it's called 'buccal respiration' ('buccal" meaning 'cheeks'). Frogs pull in air to their cheeks.move it around just a tad, then pump it back out. They are blessed with the ability to diffuse oxygen directly through their skin, including the lining of their mouth, so they can sit quietly and breather with no body/lung effort whatsoever. I mimicked a frog in those early days of experimentation, but now can move mouth air up into the back of the throat and into my nasal area without much (if any) thought and almost no externally observable effort.

When I am at the stove, this act of moving air to smell is more or less automatic--I rarely "think" about doing it anymore and only concentrate on doing it when I am seriously evaluating something I am cooking, altering spicing, or experimenting with. I sometimes stop and consciously make the effort to pay attention when I have a particularly fine cup of coffee from some new coffee I have recently roasted. In this way I am able to better pick up the delicate florals that might be otherwise missed by simply swilling the cup down. (grin)

Regarding taste; I have found that while certain flavors absolutely require the "air connection" that involves the sensory area of the nose, there are far more flavors of which I find myself much more sensitive BECAUSE I am essentially relying only on the tongue to "taste" the flavor.

I can now better pick out specific chemicals from certain items because the nose is not dominating the sensory reactions. Mints, for instance are easier to tell apart one from another. The methyl salicylate that provides the primary taste we associate with wintergreen, as another example, stands out like a loud bullhorn against the background "noise" of the flavors in a candy, beverage, or desert drink. I can much better pick out the
sensation(s) of umami and know better how much I need to moderate that flavor aspect one way or the other. (This, in fact, was a pleasant surprise with respect to my cooking and I have added a number of umami additives to my cooking shelf!)

Many sweet treats, especially hard candies and baked good with fillings or that are covered in reduced sweet sauces, have become too sweet--and often too "chemically" tasting--for me these days, especially when the various sugars are combined with aromatic oils. Orange oil, as an example, is SO intense since the laryngetomy!

The Bottom line for me is that while my sense of taste & smell have been altered to one degree or another and has, indeed, required some adjustments, it has been in no way a loss in my life.

Be encouraged! You will adapt and perhaps discover new abilities that cause your cooking to evolve and improve!

We are all puling for you!
Kirk


 



 

Following the recent discussion on the sense of smell after laryngectomy, and the possibilities for its rehabilitation, I would like to once more draw attention to the website of the Netherlands Cancer Institute, where you can find very useful information and teaching material both for patients and SLPs about the nasal airflow inducing maneuver/polite yawning method, also mentioned by some of you. This is a well-researched and documented rehabilitation method, which enables the majority of laryngectomy patients to remain able to smell: if your sense of smell was normal before the laryngectomy, you still should be able to smell after the surgery. The instruction material contains many videos that make the recovery easier to understand and accomplish. With the help of your SLP this will be even easier. Also the American Cancer Society mentions this rehabilitation method on their website since earlier this year. https://www.cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer/after-treatment/follow-up.html

All this Netherlands Cancer Institute copyrighted documentation is freely available for teaching purposes and for sharing with your health care provider(s) and your fellow patients.

With kind regards, Frans Hilgers.

 

Prof. Frans JM Hilgers, MD PhD, Head and Neck Surgeon Chairman-emeritus Department of Head and Neck Oncology and Surgery The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital Professor-emeritus Institute of Phonetic Sciences (ACLC), University of Amsterdam Plesmanlaan 121, 1066CX Amsterdam, The Netherlands.
www.hoofdhalskanker.info; www.gpracademy.com; www.franshilgers.nl

Links:
- Olfaction regained patient manual: https://www.avl.nl/flipbooks/Polite-yawning_manual%20for%20patients.app/Polite-yawning_manual%20for%20patients.app/Contents/Resources/index.html#p=1
- Olfaction regained SLP manual: https://www.avl.nl/flipbooks/Polite-yawning_manual%20for%20SLPs.app/Polite-yawning_manual%20for%20SLPs.app/Contents/Resources/index.html
- Olfaction regained refrence textbook (for those who want to go into more detail concerning the scientific backgrounds): https://www.avl.nl/flipbooks/Olfaction%20regained_FB-ST/index.html
Access to these and other documentations can also be achieved through the HN department website: https://www.hoofdhalskanker.info/olfaction-rehabilitation-after-total-laryngectomy/

*Text at the ACS website:
Restoring your sense of smell : If you have lost your sense of smell, or are smelling odors that aren't really there, olfactory rehabilitation might be another part of your recovery. Problems with smell (called olfactory disorders) can affect your appetite, sense of taste, food enjoyment, and how much you eat. Nearly all people who have had a laryngectomy will find they cannot smell things the way they did before. This is because air no longer travels through your nose. With olfactory rehabilitation, you can be taught techniques that cause nasal airflow and may help you recover your sense of smell. Examples are the nasal airflow-inducing maneuver (NAIM) and polite yawning. Olfactory rehabilitation (rehab) is available at some large medical centers. Talk to your health care team to learn more.

 


 

Runny Nose

 

Even though you are not breathing through your nose directly (and some of Larys don't even possess easy indirect nasal contact) the body's cholinergic and histaminic responses still work just fine.

Contact with various particles, allergens, microorganisms, viruses, and so on, will send the nasal passages and upper brachial passages into their regular responses of making more mucus to "flush out" particles you have breathed in or in response to attack by adenoviruses, rhinoviruses, or even influenza viruses.

It does not require that these particles or viruses touch the nasal passages directly to get the response mechanism in the nasal passages going. The trigger can be quite remote from the nasal area and still cause/produce a runny nose and/or excess brachial mucus.

In fact, playing around inside your stoma and messing with your TEP (brushing, swabbing, or turning the TEP on its axis in the puncture site) can trigger a cholinergic/histaminic response in your nasal passages. This physical mechanism is known as a vagally-mediated reflex. You mechanically disturb (touch) a location and the body responds chemically and physically by dumping histamine, which further makes cells dump more fluids, increasing thin mucus secretions. It is a cascade effect and can last minutes to hours depending upon the individual and the location & level of disturbance.

I typically experience this a few times a week when I have to get a little more aggressive at cleaning out my TEP with my little brush or spend just a little too long trying to get mucus removed from the tracheal side of the TEP and the visible part of my upper trachea. I know it as soon as it happens (actually, it takes about 30 sec. to a minute for the full effect to
manifest):

- I push too much on the TEP for a little too long and I get a "funny"
feeling in the area above my neopharynx (this is above and behind my
trachea.
- Then my nose begins to run just a little, and before long, I have a
full-on runny nose that typically lasts for 15-30 minutes. Some days I may have a runny nose from this that lasts over an hour.

When I am going out for an appointment or out for the evening, I am careful to be very gentle in cleaning my TEP, so I do not have to deal with a runny nose while I am away from home or out with other people.

My ENT/Surgeon acknowledged that this is a well-known effect with many Larys and gave me a prescription for a nasal spray, Ipratropium bromide (0.03%), to prevent or alleviate the effect. The problem with this route is that you need to pre-treat 15-minutes to an hour before stimulation (cleaning the TEP or swabbing the tracheal area) to prevent the effect. It takes 15 minutes or more for the stuff to work after the effect starts and since (in my case) the effects only last 15-30 minutes, it is a waste of time (and expensive medicine) to apply the spray after the runny nose begins. I do not know if it is going to happen until it happens, so I do not like to pre-treat. Nasal steroids, like Flonase and the like, can also largely prevent the histaminic effects (they work differently than Ipratropium), but you have to use them for several days in a row before they can be effective against the histaminic responses.

If you have seasonal allergies or allergies to household dust and such (which I do), regular application of mild nasal steroids like Flonase/fluticasone during your worst seasons can really help reduce the runny noses. Now that Flonase/fluticasone is an Over-The-Counter product, you do not need a prescription to give it a try. A full month's supply is about $15 where I live (I have seen it as low as $10 and as high as $21 in local pharmacies and Big-Box stores, here in Central Indiana). I use it for about a month when the trees produce gobs of pollen in the spring and again for about a month in late summer when the ragweed pollen around here is so thick you can see it in the air (you know it's bad when it leaves a yellow coating on my car's windshield). The rest of the year, I just try to take it easy on how rough I am in cleaning out my TEP and have only occasional bouts of runny nose.

Best to you as you chase down that running nose!
Kirk Janowiak

Posted 2/2019

 


 

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