- Acid Reflux
- Being on Oxygen
- CPR and Anesthesia concerns
- Dry Mouth - Xerostomia
- Dental Issues
- Nebulizer Usage
- Neck and Shoulder Dysfunction
- Pain Management
- Peg Tube
- Recurrent Disease
- Second Primaries
- Stroke and Vascular Problems Related to Head Neck Radiation
Introduction to Swallowing Difficulties
Next to voicing, swallowing is probably the function most affected by laryngectomy surgery. While many patients have worked through them and are swallowing "normally" within a short period of time, most all Laryngectomees will have to deal with some type of swallowing challenge at one time or another. In this section, we provide information on what type of challenges you may encounter and why, as well as helpful information from around the web and from our own family of "larys" who have "been there; done that!"
EATING AFTER STOMACH PULL-UP
After having a stomach pull-up, I was having difficulty eating because my stomach would only hold 4 oz. at a time, then I would have to wait an hour. This meant to gain or maintain weight, I had to eat or drink almost every hour and would eat one hour, drink the next. I was told that gravity would cause the stomach to drop down a bit and expand and now, 5 weeks after surgery, I can finally consume over twice as much and not feel as full. This also allows me to drink something with my meals, which I couldn't before. (Roger Scharmen)
practical tips for swallowing problems
ALOE VERA FOR SWALLOWING
Buy some drinkable aloe vera and sip an ounce twice daily. I had problems with swallowing but they have improved a lot since I started the aloe vera routine. I am using the Lily of the Desert brand but I am sure that others would work as well. (Sydney Gartenberg)
TROUBLE SWALLOWING PILLS or FOOD?
1. I have a hint for people who cannot swallow large pills, such as calcium or multi vitamins. I was working hard at crushing them, even with a mortar and pestle. This took hard work to pulverize them until I had a brainstorm, and took out my mini food processor and VOILA, in no time flat I was ready to mix in applesauce. In 15 minutes I can do enough for a week. I put my daily dose into saved sealable small prescription containers. I do one day at a time, so I don't miscalculate the accurate daily dosage. This job is now easy and effortless. Carole Rabin
2. Capsules can be opened and poured into a hollow in a spoonful of apple sauce or pudding.
3. My capsules for Prilosec (or the capsule generic) are full of little granules. I use a teaspoon, snip part of the way through the middle of the capsule with sharp pointed scissors, then break it open and let the granules fall into the teaspoon. I usually use the teaspoon to pour the granules on the back of my tongue and take a swallow or two of water...and they are gone. Pat Sanders
4. This is just a helpful hint if you get a pill stuck. We found that Yogurt (plain or without chunky fruit) will help dislodge the pill. Hope this will help someone! Kimberly Iagmin
5. The adage is a spoonful of sugar makes the medicine go down? Well for me, HONEY helps slide the med pills downnnnnn...
and liquid vitamins are available from catalogs...
Jim Maloney, Marshalls Creek, Pennsylvania
6. When I got something stuck, I called my doctor's office. His physician's assistant suggested mashing a banana and drinking water. Well, I asked her to stay on the phone when I tried it. It works better than anything else I've ever tried. Using the mashed banana works better than applesauce because of it's texture. It slides down and then drinking the water helps push down the stuck food. Apparently, this is used for people that have diseases that effect a persons swallowing.
Rita in NJ
7. Every now and then the members talk about swallowing pills. I spray my mouth area with Biotene mouth spray just before taking my pills. It seems to lubricate my mouth and throat for them to slide right down.
TIPS FOR EASIER SWALLOWING
1. For mild swallowing problems: Since you most likely do not have as much saliva as you did, try sipping a little water after chewing your food. Then chew enough to mix the water and food before swallowing. You might have to do this several times to get a thin consistency to swallow.
Zilpha Basone, SLP
2. If you like wine, try adding a jigger of wine to an 8 oz glass of water to have with your dinner. Tasty!
Zilpha Basone, SLP
GET A FOOD "CHOPPER" TO HELP WITH SWALLOWING
There's a handy food processor for folks who have swallowing problems. It's made by Toastmaster and is called a "Chopster". It usually costs about $10.00 (yep, 10 bucks). Keep a eye out for it in stores like Target or K-Mart. It does a good job of fine chopping about 1/2 cup of food like cooked meat, raw vegetables, nuts, or chili. Add some liquid like gravy or sauce before chopping to help ease the swallowing of the chopped food.
(Clayton R Schwalen)
EATING AND FOOD IDEAS
This section has dietary hints, recipes, hints for those who eat slowly, and more comments from members on ways they deal with their eating problems.
EXPLANATION OF DILATION PROCEDURE
A plain explanation with graphics
Another optional treatment is VitalStim Therapy.
VitalStim Therapy ® is a safe and effective treatment for patients suffering with difficulty swallowing or dysphagia. It was developed in the USA in response to the 15 million populations living with dysphagia . FDA (Federal Drug Association) has approved this therapy in December 2001.
VitalStim therapy is a specialized form of neuromuscular electrical stimulation (NMES) designed to treat swallowing disorders through muscle re-education. VitalStim therapy is administered by a small, carefully calibrated current delivered to the motor nerves of the patient's throat through specially designed electrodes causing the muscles responsible for swallowing to contract. At the same time, a dysphagia specialist guides the patient through active swallowing therapy to re-educate normal swallow function.
Most treatment sessions are within 60 minutes in duration. VitalStim therapy has helped thousands of patients with dysphagia, including patients resigned to live on feeding tubes. Therapy sessions are repeated between three and five times a week until swallowing patterns have been restored to a nearly normal level. Sufferers frequently see dramatic improvements in 6 to 20 daily sessions, sometimes in as little as 3 days.
The following discription is from the VitalStim site that is also listed below:
ESOPHAGEAL DILATION FOR SWALLOWING PROBLEMS
Dilation of the esophagus is usually a surgical procedure done in the hospital under anesthesia but is occasionally done in a Dr.'s office with or w/o anesthesia depending upon the Dr., the patient, and the problem. Once the esophagus is dilated to a width that both the Dr. and the patient are satisfied with--not an easy procedure-- then the width can be maintained at home by self-dilation. Those of us that do self dilation at home are really doing maintenance. The reason for the frequency is to maintain the esophagus at the same width the Dr. achieved in the Hospital. Otherwise whatever is causing the stricture--in my case--scar tissue-- will close the esophagus to at least the point that it was before the Dr. did the dilation.
For years I had a Dr. who would do the procedure in his office w/o anesthesia. That worked for quite a while if followed by self-dilation, but finally failed due to greater and more intense growth of scar tissue. He then found another Dr. for me who could do the job using different dilators, this following a visit I made to the Swallowing Clinic in Tampa where they were very helpful. I have been extremely fortunate for these Drs., who are responsible for the comfort I enjoy today, are few and far between, and tremendous and incalculable damage can be done by an unskilled practitioner.
All of us are different, and the reasons for the dilations are as various as the treatments offered. So, too, are the successes, be they temporary or permanent.
When I started getting dilated by the doctor at his office, it was done at least once a month and he suggested that I do self dilation. He ordered the dilators and I proceeded to do it at home. I even did it when camping.
I have always had a strong will to live and put up with self dilating if it would help my swallowing. I could only get up to a 36 Fr dilator in. But the doctor said my esophagus had been about the diameter of a ball point pen refill. 36 Fr is about the diameter of one of my fingers.
Prior to and during my dilating, I just had a tracheostomy. I got a fistula that wouldn't close and had to have my esophagus removed, stomach pulled up, and I got the laryngectomy "as a bonus", all of which ended the need to dilate.
Ok--the right way to do this. I did it first thing in the morning, before I had anything to eat or drink. I didn't use any of those deadening things. I hated the taste or feel of them. I just wet the dilator under the faucet, stuck it to the back of my throat, and started to guide it down, sometimes pulling it out and just starting over. Keep in mind, while this thing is down your esophagus, you can't swallow your saliva, so keep tissues handy or a washcloth for your "drooling". Once you get it down past the level of the constriction in your esophagus, try to leave it there for 10-15 minutes. After timing this, as best you can, then simply pull it out, clean yourself up (from the drooling), and get on with your day. You're supposed to try swallowing during the dilation, but I just couldn't do that. The saliva comes out your nose or heads that way.
I still get out into society, am very active in my retirement years. The dilating never interfered with any of my activities, including work. When done by the doctor, my throat was more sore than when I did it myself. I am happy I don't have to do it anymore.
I have a diverticulum or pouch in the wall of my esophagus as a result of surgery and reconstruction. A number of us larys have this pouch and it catches and hold food. I have this problem. Those of us that do, have a tendency to produce old food from two or three meals ago from our throat when we lean over and may have an esophageal diverticulum. Now, how do we deal with this pouch?
First, surgical correction is an option but generally not recommended. The benefits do not outweigh the risks. It is something that can be lived with. Opening up the throat and trying to rebuild the esophagus can lead to numerous follow on problems including fistulas, greater strictures and more inflexible scar tissue. It could also end your ability to speak using a TEP.
Second, how do we adjust to having a pouch? We eat soft or very well chewed foods taken in small bites washed down with water. I have oatmeal every morning and love it. After cooking the oatmeal and adding fruit to it, I add milk and stir the whole thing up to a nice consistency. Many of us use food processors on our food to make it easier to get down.
Third, is there a way to clear the pouch of resident foods? I wear a lary tube held in place by a tube holder which is a strap around the neck held in place with velcro. In the lary tube I wear an HME filter. I wear this arrangement 24/7. Every evening, after brushing my teeth, I take some water into my mouth and let it reach as far back and down into my throat as I can. I then lean over the sink and drive my chin down into the lary tube and HME filter. This pushes the tube arrangement into my throat and acts as a flushing action pushing the old food up and out into the sink. It may sound a little indelicate, but it works for me. I repeat the water flush numerous times until nothing more is coming out. I have heard that some people can manually massage their throat and get the same effect. This approach may or may not work depending on the location of your pouch.
We are all different so we must cast about to discover what solution will work best for us.
Lary since 2010
articles from professionals
Excerpt from Questions for the Doctor, HeadLines 1999
We have a question about chronic problems with difficulty swallowing despite repeated dilations.
Let me give you my opinion about dilation. Basically, I don’t think it works. Let’s look at the problem. You have a round organ such as the esophagus. Around this circular organ you have scar tissue. The most basic thing that scar tissue does is to CONTRACT. When you have contracture around a circular organ you get narrowing or stricture. Now let’s look at what happens when you dilate something. What you do is forcibly break up the scar causing a new wound. This results in quess what? That’s right, more scar tissue. And what is scar going to do? CONTRACT!!! Therefore, you have set up a vicious cycle of scar, contracture, more scar and more contracture. Hence, no improvement. It is my feeling that to truly improve the situation, you have to bring in new tissue that is not affected by this cycle.
Glenn E. Peters M.D
Director, Division of Otolaryngology - Head and Neck Surgery
University of Alabama at Birmingham, Birmingham, AL
(from HeadLines December, 1998)
by William Carroll, M.D.
Some degree of difficulty swallowing (dysphagia) is common after most types of laryngectomy, whether total or partial. In most cases, the swallowing problems are not severe and tend to improve over time. The causes of swallowing difficulty differ depending on whether the laryngectomy has been partial (hemi-laryngectomy, or supraglottic laryngectomy) or total.
Let’s discuss the partial laryngectomy situation first. As you know, the production of sound or voice is not the most basic function of the larynx. The most basic function is to separate the food and the air which are both taken in through the mouth. The larynx acts as a gate or door. It closes by reflex action when a swallow occurs. It opens when air is inhaled, closes when food or liquid is swallowed. It keeps air moving toward the lungs and food moving toward the esophagus. Part of the larynx is removed during surgery and part of the normal nerve supply is interrupted. The reflexes that direct the larynx to open and close are often disrupted. The main problem that develops is aspiration, or food going into the breathing passage (trachea) instead of the swallowing passage (esophagus). Aspiration may be minor and cause nothing more than a little cough with swallowing or may be severe and cause pneumonia. Early after surgery, almost every patient has some degree of aspiration. Typically this situation improves with swallowing therapy and oral intake can be resumed. Unfortunately, there are occasions when the protective reflexes can never be fully regained and oral intake remains unsafe due to the risk of aspiration. This is rare but can require long-term feeding tube dependence.
In contrast, aspiration almost never occurs after a total laryngectomy because the breathing and swallowing passages are surgically separated. To understand the swallowing changes that occur after total laryngectomy, a little anatomy review would be helpful. The back wall of the larynx actually makes up the front wall of the pharynx or upper esophagus. When the larynx is removed, part of the front wall of the pharynx / esophagus is removed also. When the remaining portion of the pharynx is closed with sutures, the circular opening becomes smaller. Imagine a string tied in a circle. Cut out a piece of the string and toss it out. Now tie the remaining two ends back together. The new circle will always be smaller than the original circle. Just how much smaller depends on how much string was removed. Those patients who start with tumors confined to the inside of the larynx usually have plenty of pharynx left to make a very adequate swallowing passage. Some, however, not only have their larynx removed, but also have part of their esophagus or pharynx removed as well. For these patients, the new
“circle of string” can be quite tight. The extreme situation occurs when not only the larynx but also the entire pharynx or upper esophagus has to be removed. This is called a laryngo-pharngectomy. In these cases, the swallowing passage has to be completely reconstructed using small intestine, stomach or a ‘tubed’ skin flap.
Total laryngectomy also disrupts the nerve and muscle fibers that normally contract to help food move down the esophagus. Occasionally patients will have spasm of the remaining muscle, which makes the opening into the esophagus very tight. Plenty of tissue is present to allow easy swallowing, but the muscles are in spasm (hyper-contracted) and won’t allow food to pass. This situation can necessitate a surgical procedure called a myotomy (myo = muscle, tome = to cut) which divides the spastic muscle. The other factors that can lead to difficult swallowing are radiation before or after surgery, or a wound infection or fistula occurring after surgery. Both make the tissues of the pharynx and esophagus more stiff and less stretchy when food is trying to pass. Both processes can actually narrow the caliber of the opening into the esophagus as well.
Many of the same factors that effect swallowing so dramatically after laryngectomy can also effect the ability to use a voice prosthesis (Blom-Singer valve) or esophageal speech. We’ll save that topic for next time.
(William Carroll M.D., Otolaryngology, Kirklin Clinic, Birmingham, AL)
From HeadLines, April 2005
Dr. Lawrence F Johnson is a Professor of Medicine, University of Alabama at Birmingham where his specialty is Gastroenterology & Hepatology and his interests are esophageal and swallowing disorders; gastroenterology. The following is a summary of his presentation on a new dilation technique for strictures causing swallowing difficulties.
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
That's a Hard Pill to Swallow
© May 2004 Tammy L Wigginton; M.S., CCC/SLP, Milwaukee, WI
In three parts. This is a comprehensive article and a must read for anyone with swallowing problems. Written for VoicePoints in Whispers on the Web.
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