"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

Order a paperback or Kindle Edition or e-book of "The Laryngectomee Guide," the 170 page practical guide for laryngectomees. To obtain a free paperback copy fill this form and mail it to J. Harrison 11390 W. Theo W. Allis, WI 53214, or fax it to 414 227 9033. The Guide can also be requested by emailing to customersupport.us@atosmedical.com

Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Medical problems in head and neck cancer: pain management, acupuncture, cancer spread, hypothyroidism, dizziness, constipation, and prevention of medical errors

This section describes a variety of medical issues affecting laryngectomees and head and neck cancer patients.

See these pages to read about lymphedema and hypertension.




Pain management

General pain
Many cancer patients and survivors complain of pain. Pain can be one of the important signs of cancer and may even lead to its diagnosis. Thus, it should not be ignored and should be a sign to seek medical care. The pain associated with cancer can vary in intensity and quality. It can be constant, intermittent, mild, moderate or severe. It can also be aching, dull, or sharp.

The pain can be caused by a tumor pressing or growing into and destroying nearby tissues. As the tumor increases in size, it may cause pain by putting pressure on nerves, bones or other structures. Cancer of the head and neck can also erode the mucosa and expose it to saliva and mouth bacteria. Cancer that has spread or recurred is even more likely to cause pain.

Pain can result also from treatments for cancer. Chemotherapy, radiation and surgery are all potential source of pain. Chemotherapy can cause diarrhea, mouth sores, and nerve damage. Radiation of the head and neck may cause painful and burning sensations to the skin and mouth, muscle stiffness and nerve damage. Surgery also can be painful, may leave deformities and/or scars that take time to improve.

Cancer pain can be treated by various methods. Eliminating the source of the pain through radiation, chemotherapy, or surgery is best, if possible. However, if not possible, other treatments include pain oral medication, nerve blocks, acupuncture, acupressure, massage, physical therapy, meditation, relaxation, and even humor. Specialists in pain management can offer these treatments.

Pain medication can be administered as a tablet, dissolvable tablet, intravenously, intramuscularly, rectally or through a skin patch. Medication includes: analgesics (e.g., aspirin, acetaminophen), nonsteroidal anti-inflammatory drugs (e.g., ibuprofen), weak (e.g., codeine) and strong opioids (e.g., morphine, oxycodone, hydromorphone, fentanyl, methadone). Other medications include carbamazepine ( an anticonvulsant), and gabapentin (a GABA analog).

All these medications have side effects (i.e., constipation with codeine), and should be taken under medical supervision.

Sometimes patients do not receiving adequate treatment for cancer pain. The reasons for this include doctors’ reluctance to inquire about pain or offer treatments, patients' reluctance to speak about their pain, fear of addiction to medication, and fear of side effects.

Treating pain can both increase patients' well-being, as well as ease the hardship imposed on their caregivers. Patients should be encouraged to talk to their health care providers about their pain and seek treatment. Evaluation by a pain management specialist can be very helpful; all major cancer centers have pain management programs.

Recent research have shown positive results for acupuncture in controlling pain. However, studies in people with cancer are often small and it is more difficult to be sure of the results

Chronic head and neck pain
Chronic head or neck pain after treatment can be debilitating and occurs in about 15 % of patients. Shoulder and neck pain are particularly common in those who also underwent neck dissection. It can cause functional limitations and contribute to unemployment in survivors.
The condition can be treated with physical therapy and appropriate pain control. Medications such as gabapentin and carbamazepine may be prescribed. Acupuncture has been shown to decrease pain and shoulder dysfunction following neck dissectionPain management services for treatment with narcotics and behavioral therapy are important assets in management of chronic painAcupuncture can provide significant reductions in pain, dysfunction, and dry mouth in head and neck cancer patients after neck dissection.


The American Society of Clinical Oncology released the first set of practice guidelines to help clinicians manage chronic pain in adults with cancer In July 2016. The guidelines addresses screening and comprehensive assessment, treatment and care options - including pharmacologic and non-pharmacologic interventions - and paid special attention to the risks and benefits associated with opioid use.












Acupuncture in managing side effects of treatment of head and neck cancer


Acupuncture can help with some physical problems such as pain and feeling sick. It can also help to reduce symptoms such as anxiety and assists individuals in relaxing and improving their overall feeling of wellbeing.

Acupuncture works by stimulating nerves to release substances that can reduce symptoms. The substances can also change some of the body’s functions, such as muscle tension. A number of the body’s natural morphine like substances (endorphins) are released in the nervous system to relieve pain. Serotonin, a pain reliever that promotes a feeling of wellbeing, is also released by acupuncture.

There is no evidence that acupuncture helps in treating or curing cancer. It is, however, helpful in relieving some symptoms of cancer and the side effects of cancer treatment. It has sown to work in relieving chemotherapy related sickness, tiredness and cancer pain.  It can be very successful in treatment of some cancer-related pain and in reducing narcotic use and thereby minimizing their side.

Needling a variety of trigger and painful points, percutaneous electrical nerve stimulation, and osteo-puncture, along with whole body energetic acupuncture support, are approaches available to the acupuncturists. The practitioner puts fine, stainless steel, and disposable needles in different trigger points in the patient’s skin. Often, treatment starts with only a few needles but this may change depending on the response and the number of symptoms the patient manifests. The needles shouldn’t cause pain but might generate a tingling sensation. They are usually left in place for between 10 to 30 minutes.

The degree of beneficial results from acupuncture treatment is dependent on various clinical factors such as presenting symptoms, clinical staging, timing of the encounter in the course of the illness, and the areas of involvement.

Acupuncture is used to treat a wide range of pain conditions and some other symptoms. Some of the condition that acupuncture can be helpful that relate to head and neck cancer include:

Acupuncture performed by professionally qualified practitioners is generally very safe and has very few side effects. The most common effect is minor bleeding and bruising, which occurs in up to 3%of patients. An acupuncture qualified practitioner specialist can be found in the American Academy of Acupuncture web site



  




Symptoms and signs of new or recurring head and neck cancer

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 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, and 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 your voice (including hoarseness)
  •  Neck pain or swelling
  •  Difficulty 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


A self-examination guide is available.
Individuals with these symptoms should be examined by their otolaryngologists as soon as possible.
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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 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 local lymph glands have not revealed cancer the risk is lower.

Individuals who had cancer at one time may be more likely to develop another type of malignancy is 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, physical and mental health, be under good medical care and be examined on a regular basis. 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.









Low thyroid hormone (hypothyroidism) and its treatment

Most laryngectomees develop low levels of the thyroid hormone (hypothyroidism). This is due to the effects of radiation and/or the removal of part or all of the thyroid gland during laryngectomy surgery.

The symptoms of hypothyroidism vary; some individuals have no symptoms while others have dramatic or, rarely, life-threatening symptoms. The symptoms of hypothyroidism are nonspecific and mimic many normal changes of aging.

General symptoms - The thyroid hormone stimulates the body’s metabolism. Most symptoms of hypothyroidism are due to the slowing of metabolic processes. Systemic symptoms include fatigue, sluggishness, weight gain, and intolerance to cold temperatures.

Skin - Decreased sweating, dry and thick skin, coarse or thin hair, disappearance of eyebrows, and brittle nails. 

Eyes - Mild swelling around the eyes.

Cardiovascular system - Slowing of the heart rate and weakening of contractions, decreasing its overall function. These can cause fatigue and shortness of breath with exercise. Hypothyroidism can also cause mild hypertension and raise cholesterol levels.

Respiratory system - Respiratory muscles can weaken and lung function can decrease. Symptoms include fatigue, shortness of breath with exercise, and decreased ability to exercise. Hypothyroidism may lead to swelling of the tongue, hoarse voice, and sleep apnea (not in laryngectomees).

Gastrointestinal system - Slowing of the digestive tract actions, causing constipation.

Reproductive system - Menstrual cycle irregularities, ranging from absent or infrequent periods to very frequent and heavy periods

Thyroid deficiency can be corrected by taking synthetic thyroid hormone (Thyroxine). This should be taken on an empty stomach with a full glass of water 30 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 40 percent.

Several formulations of synthetic thyroxine are available, but there has been considerable controversy if they are similar in efficacy. In 2004, the US 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 TSH and sometimes throxine (T4) 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 approximately 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.


  



Lightheadedness, and dizziness

Laryngectomees can experience lightheadedness, and dizziness. It is often due to either side effects of radiation treatment and/or not inhaling enough air when speaking using trachea-esophageal voice prosthesis.

Radiation of the head and neck can damage the peripheral and autonomic nervous system. Dizziness usually occurs when standing up from sitting or lying position due to the development of low blood pressure (orthostatic or postural hypotension).  This can be prevented by standing up slowly, wearing of compression stockings, exercises and by keeping well hydrated. It is best to consult one’s physician to prevent and treat this condition.
Not inhaling enough air while speaking can deprive the brain of oxygen that causes dizziness and   lightheadedness.  Learning how to speak correctly with the assistance and guidance of a speech and language pathologist can prevent dizziness and lightheadedness.

Speech can be made easier and not lead to lightheadedness and dizziness when following these steps:


  • Speaking slowly
  • Taking breaks between sentences
  • Take breathes with the stoma not covered
  • Speaking slowly
  • Speaking only 4-5 words between each air exhalation
  • Using diaphragmatic breathing, 
  • Over articulating the words
  • Speaking by using low air pressure.





Constipation

Constipation is common in laryngectomees. This is mainly because they have difficulty in straining in order to have a natural bowel movement. Normally straining is done by closing the vocal cords and increasing the pressure in one’s chest by exhaling against the closed vocal cords.  The same thing happens when one strain to lift a heavy object. Without a larynx one can’t strain normally because the stoma does not allow a laryngectomee to restrict the outflow of air from the lungs.  However, some straining is possible after occluding the stoma in those without a TEP. The straining is less effective in those with a TEP because some of the exhaled air goes through the TEP.

What may also contribute to the development of constipation is that laryngectomees may consume less vegetables and fruits because of their swallowing difficulties.

Constipation can be prevented by:

  • Consuming a diet that will generate bulk and are high in fiber (fruits, vegetables and grain products)
  • Staying well hydrated by drinking plenty of fluids
  • Reducing dependency on laxatives
  • Defecating after meals, taking advantage of normal increases in colonic motility after eating especially in the morning
  • Taking a laxative. These include bulk forming laxatives (i.e., psyllium or Metamucil, methylcellulose or Citrucel); osmotic agents (polyethylene glycol or Miralax),  poorly absorbed or nonabsorbable sugar laxatives  (i.e., lactulose , sorbitol ), and saline laxatives (i.e., Magnesium citrate); and oral (e.g., Dulcolax, Senokot) and rectal stimulant laxatives (e.g., Dulcolax, bisacodyl).
  • If possible avoiding medications that cause constipation (i.e., codeine)

Severe constipation can be treated with glycerin suppositories, enema, and by prescribed medications.

Medical and psychological conditions can also induce constipation. These include: hypothyroidism, neuropathy, diabetes, irritable bowel syndrome, and depression. Some medications can also cause constipation. These include: antihistamines, antidepressants, antispasmodics, pain medications (opiates such as codeine), antihypertensives, antacids and calcium and iron supplements. 


It is advisable that one seeks medical evaluation and treatment by a physician for their constipation. 



 




Prevention of medical and surgical errors

Medical and surgical mistakes are very common and are the third leading cause of death in the US leading to 400,000 death a yearThe best way of preventing errors is for the patient to be his or her own advocate or to have a family member or friend serve as one's advocate. 

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 family or friends remain in the hospital
  • Getting a second opinion
  • Educating your medical provider about one's condition and needs (prior to and after surgery)
The occurrence of errors weakens patients' trust in their medical 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 medical provider are taking the mater seriously and that steps will be taken to make their hospital stays safer.

 
 

Patients after major surgery are more susceptible to medical errors

Not discussing mistakes with the patient and family increases their anxiety, frustration and anger, thus interfering with their recovery. And of course, such anger may also lead to malpractice suits.

Greater vigilance by the medical community can reduce errors. Obviously medical errors should be prevented as much as humanly possible; ignoring them can only lead to their repetition. Institutional policies should support and encourage healthcare professionals to disclose adverse events. Increased openness and honesty following adverse events can improve provider-patient relationships. There are important preventive steps that can be implemented by every institution and medical office. Educating the patient and their caregivers about the patients' condition and treatment plan is of utmost importance. Medical professionals can safeguard and prevent mistakes when they see deviations from the planned therapy.

These steps by the medical establishment can prevent errors: 
  •        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)

The Washington Post published a cover story in the Health Section on this topic which also includes my own experiences on May 7, 2013.


A Grand Rounds lecture entitled  "Preventing Medical Errors: a Physician's Personal Experience as a laryngeal Cancer" that was delivered to the Department of Medicine Louisiana State University on April 16, 2013, can be viewed in YouTube.