Medical issues: pain, acupuncture, cannabis, cancer spread, hypothyroidism, hyperparathyroidism, hyperventilation, dizziness, cough syncope, fatigue, constipation, reflux, sleeping & medical errors

This section describes a variety of medical and treatment 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 medications, cannabis (see below), nerve blocks, acupuncture (see below), dry needling, 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, through a skin patch, and through inhalation. 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), carbamazepine ( an anticonvulsant), and gabapentin (a GABA analog), and cannabis. 

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 medications, 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 has shown positive results for acupuncture in controlling pain. However, studies in people with cancer are often too small and it is therefore  more difficult to be sure of their 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. Pain management services for treatment with narcotics and behavioral therapy are important assets in management of chronic pain. Acupuncture can provide significant reductions in pain, shoulder dysfunction, and dry mouth in head and neck cancer patients after neck dissection and radiation therapy. (See next section)

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 well-being, 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 effects.

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 acupuncturist. 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 10 to 30 minutes.

The degree of beneficial results from acupuncture treatment depends 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:

• Acute and chronic pain control
• Dry mouth (Xerostomia) after radiation
• Muscle spasms, tremors, tics, contractures
• Peripheral neuropathy (also after chemotherapy)
• Lymphedema after radiation (experimental at present)
• Anxiety, fright, panic
• Cancer and chemotherapy related tiredness
• Drug detoxification
• Neuralgias
• Certain functional gastro-intestinal disorders (nausea and vomiting after chemotherapy, esophageal spasm, hyperacidity, etc.)
• Headache, migraine, vertigo, tinnitus
• Frozen shoulder
• Cervical and lumbar spine syndromes
• Insomnia
• Anorexia
• Persistent hiccups
• Constipation

Acupuncture performed by professionally qualified practitioners is generally very safe and has very few side effects. The most common side 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. 

  

Cannabis use in cancer of the head and neck patients

The most studied and established roles for cannabis therapies include pain, chemotherapy-induced nausea and vomiting, and anorexia. Cannabinoids could be used to concurrently optimize the management of multiple symptoms, thereby reducing overall medications use. The use of cannabinoid therapies could be effective in improving quality of life and possibly modifying malignancy by virtue of direct effects and in improving compliance or adherence with chemotherapy and radiation therapy. 

Marijuana can also pose some harms to users. While the most common effect of marijuana is a feeling of euphoria ("high"), it also can lower the user’s control over movement, cause disorientation, and sometimes cause unpleasant thoughts or feelings of anxiety and paranoia.

Smoked marijuana delivers cannabinoids as well as harmful substances to users and those close by, including many of the same substances found in tobacco smoke. Marijuana smokers were found to have an elevated risk of oropharyngeal and a reduced risk of oral tongue cancer. 

Cannabis can trigger a suppression of the body's immune functions. Marijuana cannabinoids therefore present a double edged sword. At one hand, due to their immunosuppressive nature, they can cause increased susceptibility to some cancers and infections. However, further research of these compounds could provide opportunities to treat a large number of clinical disorders where suppressing the immune response is actually beneficial.

Because marijuana plants come in different strains with different levels of active compounds, it can make each user’s experience very hard to predict. The effects can also differ based on how deeply and for how long the user inhales. Likewise, the effects of ingesting marijuana orally can vary between people. Also, some chronic users can develop an unhealthy dependence on marijuana. https://www.cancer.org/treatment/treatments-and-side-effects/complementary-and-alternative-medicine/marijuana-and-cancer.html

Assessment of the potential risk against the benefit of the use of cannabis should be done by one’s physicians. 

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 one's 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

Head and neck cancers (including laryngeal cancer) 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 before, 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. Head and neck cancer survivors, like everyone else, need to watch for all types of cancers. Some are relatively easy to diagnose by regular examination and include breast, cervix, prostate, colon, and skin cancer.

Low thyroid hormone (hypothyroidism) and its treatment

High-dose irradiation can induce a variety of thyroid diseases, including thyroid dysfunction (hypothyroidism and hyperthyroidism) and thyroid cancer. Hypothyroidism is the most common consequence of high-dose irradiation. This is due to the effects of radiation and/or the removal of part or all of the thyroid gland during laryngectomy surgery. Small percentages of patients with thyroid autonomy or non-thyroidal malignant diseases treated with high-dose internal or external irradiation, respectively, can developing Graves’ hyperthyroidism or autoimmune thyroiditis. 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.

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, feeling down and depressed, 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 motility 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.

After starting therapy, the patient should be reevaluated and serum TSH, which is an excellent thyroid function-screening test, 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.

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.

  

Hypoparathyroidism following laryngectomy

Parathyroid hormone (PTH) is one of the major hormones that regulates serum calcium and is produced by the parathyroid glands. The surgical removal of some or all four parathyroid glands that are located around the thyroid gland can lead to permanent low levels of the parathyroid hormone (hypoparathyroidism). Hypoparathyroidism can occur in a significant number of patients after laryngectomy leading to the development of hypocalcemia and hyperphosphatemia. Low calcium levels due to hypoparathyroidism can cause a variety of clinical signs such as seizures, and heart failure.

Management includes the administration of calcium and Calcitriol (a vitamin D supplement). recombinant human PTH can be given to those with chronic hypoparathyroidism who cannot maintain even serum and urinary calcium concentration with calcium and Calcitriol.

Hyperventilation in neck breathers

Hyperventilation can occur in neck breathers including laryngectomees. Hyperventilation reduces the level of carbon dioxide in the blood. It can upset the acid-base balance in the blood making it more alkaline. The syndrome is characterized by repeated episodes of excessive ventilation in response to fear, anxiety or panic. It can also occur during an orgasm or intense sexual activity, as well as heavy physical activity.

Neck breathers are more prone to this condition because rapid breathing ventilate the lungs quicker than in non-neck breathers as the inhaled air enter the trachea through the stoma, bypassing the upper airways.

 

Symptoms can include:

• Fast or deep breathing
• Shortness of breath or the feeling that you can’t get enough air
• Anxiety, fear, panic, or strong feeling of dread or doom
• Generalized weakness
• Dizziness
• Fainting
• Chest pain or squeezing in the chest
• Fast, pounding, or skipping heartbeat
• Sweating
• Numbness or tingling around the mouth and in the fingers
• Muscle cramps in the hands or feet 

 

Management includes:

• Staying calm
• Holding breath for short periods
• Abdominal (diaphragmatic) breathing

 

Prevention includes:

• Breathing retraining education  
• Relaxation methods such as meditation or progressive muscle relaxation
• Regular exercise
• Counseling or medicines to help manage an anxiety or panic disorder

 

It is advisable to counsel one’s health provider to asses and treat this condition especially if it is recurrent.

Lightheadedness, and dizziness

Many head neck cancer patients suffer from dizziness. Enclosed are some of the most prevalent causes. Lightheadedness, a specific type of dizziness, can be caused by various factors. Here are the primary causes:

1. Dehydration: Inadequate fluid intake can lead to a decrease in blood volume, which lowers blood pressure and reduces the amount of blood that reaches the brain, causing lightheadedness.

2. Medication Side Effects: Certain medications, especially those that lower blood pressure or increase urination, can cause lightheadedness by reducing blood pressure too much.

3. Sudden Drops in Blood Pressure: Orthostatic hypotension, a sudden drop in blood pressure when standing up, can cause lightheadedness. This condition is more common in older adults and can be a long-term issue requiring medical treatment. Radiation to the head and neck can also be a cause of this condition( See below).

4. Low Blood Sugar: Insufficient blood sugar levels can deprive the brain of energy, leading to feelings of lightheadedness or confusion. Consuming something sugary can quickly alleviate these symptoms.

5. Heart Conditions: Serious conditions such as heart attacks or strokes can manifest as lightheadedness, often accompanied by other symptoms like chest pain, shortness of breath, and nausea.

6. Anxiety and Stress: High levels of stress and anxiety can disrupt the balance system (vestibular function), leading to lightheadedness.

These causes highlight the importance of understanding the underlying factors contributing to lightheadedness, as they range from benign issues like mild dehydration to more severe conditions such as heart attacks or strokes.

Laryngectomees can also 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. ( See side effects of radiation section) 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 compression stockings, exercises and by keeping well hydrated. It is best to consult one’s physician to prevent and treat this condition. Radiation can affect blood vessels in the head and neck region, potentially altering blood flow and contributing to dizziness.

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 (in voice prosthesis users).

Cough syncope: dizziness and fainting due to coughing

Fainting due to coughing is called cough syncope. It generally occurs with persistent, prolonged and severe episodes of coughing. It is more common in males than females. Because neck breathers including laryngectomees, experience recurrent coughing spells they are more likely to suffer from this condition. What occurs is that while coughing the autonomic nervous system reflexes connecting the brain, heart and the respiratory tract get stimulated. This causes a transitory drop in the blood pressure. Also, with severe coughing incidences, the pressure inside the chest surges further affecting the blood stream to and from the heart. Consequently, the heart rate slows down and with interrupted blood flow; the brain gets less oxygen, eventually causing one to faint.

 

Although passing out while coughing is a transient phase one should get medical help for prolonged, persistent cough immediately. One might have to take blood tests and an electrocardiogram to rule out other reasons for fainting. An X-ray may be needed to determine the cause of cough. A neurological examination may be vital to rule out other reasons for fainting associated with the central nervous system.

Fatigue: causes and management

Fatigue can result from medical and mental health conditions and can vary in severity from minimal to severe. Cancer related fatigue is often not relieved by rest. It can also be the result of lifestyle choices, such as inactivity or inadequate diet.

There are many potential causes of fatigue, which can be divided into three general categories:

Lifestyle issues: Over exertion, absence of physical activity, absence of sleep, obesity, emotional factors ( stress, grief, boredom, depression), medication side effects, alcoholism,  illicit drugs, inadequate diet.

Medical conditions: Hormonal issues ( e.g., hypothyroidism, hyperthyroidism, diabetes, Addison’s disease ), anorexia anemia, arthritis, fibromyalgia, infections, insomnia, chronic fatigue syndrome, anemia,  autoimmune disorders, cancer, congestive heart failure, emphysema, chronic obstructive pulmonary disease (COPD),and  kidney and liver diseases.

Mental health issues: Anxiety, depression, emotional exhaustion, and seasonal affective disorder.

If changes in life style do not alleviate the tiredness, or a medical or psychological issue(s) is suspected, it would be best to see a physician.  

Frequent urination

Laryngectomee need to consume large quantities of fluid to swallow solid food. They also tend to eat soft diet or other food items that contain liquid (i.e., yogurt, soup, blended food, cereal).  This makes them urinate very frequently throughout the day and night. This pattern can interfere with their sleep and lead to tiredness and irritability.

Consuming food that stays longer in the stomach (e.g., proteins such as white cheese, meat, nuts) can reduce the number of daily meals, thus reducing the need to drink liquids.

Learn how to eat without ingesting excessive amounts of liquid can be helpful. Relieving swallowing difficulties can also reduce the need to consume fluids, and consuming less liquids prior to bedtime can improve sleeping pattern.

Men with enlarged prostate also experience frequent urination.  The need to urinate frequently (in the day as well as night time) in these men can be reduced by taking medications such as alpha blocker or 5-alpha reductase inhibitor.

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 their lungs.  However, some straining is possible after occluding the stoma in those without a voice prosthesis. The straining is less effective in those with a voice prosthesis because some of the exhaled air goes through the voice prosthesis.

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), thus reducing dependency on laxatives
• Staying well hydrated by drinking plenty of fluids
• 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, calcium and iron supplements)
• Keeping active and exercise 

Severe constipation can be treated with glycerin suppositories, enema, and by prescribed medications. Occluding the stoma while exhaling can help pass the stool.

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. 

 

Gastroesophageal  reflux (GERD)

Most laryngectomees are prone or develop gastroesophageal reflux disease (GERD). 

There are two muscular bands or sphincters in the esophagus that prevent reflux. One is located where the esophagus enters the stomach and the other is behind the larynx at the beginning of the esophagus in the neck. The lower esophageal sphincter often becomes compromised when there is a hiatal hernia which may occur in more than 3/4 of people over 70. During laryngectomy the sphincter in the upper esophageal sphincter ( the cricopharyngeus ) which normally prevents food from returning to the mouth is removed. This leaves the upper part of the esophagus flaccid and always open which may result in the reflux of stomach contents up into the throat and mouth. Therefore, regurgitation of stomach acid and food, especially in the first hour or so after eating, can occur when bending forward or lying down. This can also occur after forceful exhalation when those who use a TEP try to speak.

Reflux in laryngectomized patients can lead to voice problems, tracheo-esophageal puncture problems and/or voice prosthesis problems. Reflux often contributes to early voice prosthesis's valve breakdown which may result in leakage through the TEP. It may also lead to tracheoesophageal puncture tissue changes, such as enlargement of the tract or granulation tissue, possibly leading to leakage around the prosthesis.

GERD can sometimes cause excessive belching by promoting increased swallowing. It can also cause loss of the dental enamel increasing the risk of tooth decay, increased incidence of postoperative pharyngocutaneous fistulae, and uncontrolled gastro esophageal reflux can limit the voice prosthesis life span. 

Taking medications that reduce stomach acidity, such as antacids and proton pump inhibitors (PPI), can alleviate some of the side effects of reflux, such as throat irritation, damage to the gums and bad taste. Not lying down after eating or drinking also helps prevent reflux. Eating small amounts of food multiple times causes less food reflux than eating large meals.

Food reflux from the stomach to the esophagus

Symptoms and treatment of gastroesophageal reflux: 

Acid reflux occurs when the acid that is normally in the stomach backs up into the esophagus. This condition is also called GERD.

The symptoms of acid reflux include:

• Burning in the chest (heartburn)
• Burning or acid taste in the throat
• Bad breath
• Stomach or chest pain
• Difficulty in swallowing
• A raspy voice or a sore throat
• Unexplained cough (not in laryngectomees, unless their voice prosthesis leaks)
• In laryngectomees: granulation tissue forms around the voice prosthesis, voice prosthesis device life is shortened, voice problems

Measures to reduce and prevent acid reflux include:

• Losing weight (in those who are overweight)

• Reducing stress and practicing relaxation techniques

• Avoiding foods that worsen symptoms (e.g., coffee, chocolate, alcohol, peppermint, and fatty foods)

• Stopping smoking and passive exposure to smoke

• Eating small amounts of food several times a day rather than large meals

• Siting when eating and staying upright 30-60 minutes later

• Avoiding lying down for 2-3 hours after a meal

• Elevating the bed's head side by 6-8 inches (by putting blocks of wood under 2 legs of the bed or a wedge under the mattress), or by using a wedge or regular pillows to elevate the upper portion of the body by at least about 45 degrees
• If you sleep on the side, sleep on the left one
• Taking a medication that reduces the production of stomach acids, as prescribed by one's physician

• When bending down, bending the knees rather than bending the upper body 

                                                        Acid reflux wedge pillow

Medications for the treatment of gastroesophageal acid reflux:

There are three major types of medication that can help reduce acid reflux symptoms: antacids, histamine H2-receptor antagonists (also known as H2 blockers), and proton pump inhibitors. These drug classes work in different ways by reducing or blocking stomach acid.

Liquid antacids are generally more active than tablets, and are generally more active if taken after a meal or before going to bed, but they work only for a short time. H2 blockers (e.g., Pepcid, Tagamet, Zantac) work by reducing the amount of acid produced by the stomach. They last longer than antacids and can relieve mild symptoms. Most H2 blockers can be bought without a prescription.

Proton pump inhibitors (e.g., Prilosec, Nexium, Prevacid, Aciphex) are the most effective medicines in treating GERD and stopping the production of stomach acid. Some of these medicines are sold without a prescription. They may reduce the absorption of calcium. Monitoring the serum calcium levels is important; individuals taking these agents and those with low calcium levels may need to take calcium supplements. 

It is advisable to see a physician if the GERD symptoms are severe or last a long time and are difficult to control. GERD sufferers are more likely to develop significant health problems, including Barrett's esophagus and esophageal cancer.

Sleeping well as a laryngectomee

Sleeping well is very important, but may be challenging for laryngectomees.

It is important to continue to breath well at night, maintain good sputum quality, and preventing reflux of stomach contents. 

These are some of the steps that laryngctomees can take to get a good night sleep:

• Avoiding eating a large meal before lying down (to prevent reflux)
• Limiting the amount of consuming liquids prior to bedtime, especially those containing caffeine.  This can reduce frequent urination that can interfere with sleeping (especially in men with enlarged prostate)
• Elevating the beds' head side by 6-8 inches (by putting blocks of wood under 2 legs of the bed or a wedge under the mattress) or by using pillows to elevate the upper portion of the body by at least about 45 degrees (to prevent reflux and reduce nighttime urination by reducing the pressure on the bladder)

• Find the best body position to feel comfortable and able to breath. Many laryngectomees prefer to sleep facing straight up and avoid sleeping on the side or on their abdomen.

• Make sure that there is good access of air to the stoma by wearing adequate shirt, and avoiding covering it.
• Ensure the stoma is clean before bedtime to avoid blockages and discomfort during sleep.
• Maintain good humidity (40-50%) in the bedroom by using a humidifier, and or adjusting the air condition system.  
• Wear HME also at night to help humidify and filter the air. Some HMEs are approved for wear 24/7.  Provox Luna^R ( Atos Medical) is designed to be worn at nighttime by offering low breathing resistance.  It has side openings designed to prevent occlusion while sleeping. It is made of hydrogel that soothes the skin during the nighttime.

Other changes in daily routine can also help. These include: 

• Avoiding physical activity right before going to bed
• Keeping bedroom quiet and dark
• Keeping electronic devices ( i.e., TVs, computers, smart phones) out of the bedroom
• Reducing stress
• Taking care of sleep disorders, like sleep apnea or insomnia
• Avoiding smoking and alcohol which make sleeping harder
• Have an emergence plan in case of breathing difficulties during the night. Ensure that family members or caregivers are aware of this plan and know how to assist if needed. Consider using a medical alert system to quickly summon help if an emergency arises.

Regularly consult with your healthcare providers, including an ENT specialist and a respiratory therapist, for personalized advice and to address any issues that arise.  S

ome medications work better when taken at night (i.e, Lipitor) or on an empty stomach (i.e., Synthroid).  Some medications can interfere with falling asleep. These include theophylline, headache and pain medications that contain caffeine, corticosteroids, and sympathomimetic stimulants). Discuss with your doctor any medications you are taking that might affect your sleep and ask about possible alternatives if necessary.

By taking these measures, laryngectomees can improve their comfort and safety during sleep, leading to better overall rest and well-being.

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 year. The 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 and accompany one in the clinic
• 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 providers 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, their caregivers, and family members about the patient's' 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.